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. 2025 Jan 2;3(1):2.
doi: 10.1186/s44263-024-00118-6.

Monitoring for advanced disease in the universal test and treat era: trends in CD4 count testing in South Africa

Cornelius Nattey  1 , Dorina Onoya  2 , Khumbo Shumba  2 , Dickman Gareta  3 , William Macleod  2   4 , Matthew P Fox  2   4   5 , Adrian Puren  6 , Koleka Mlisana  6   7 , Jacob Bor  2   4   5
Affiliations

Monitoring for advanced disease in the universal test and treat era: trends in CD4 count testing in South Africa

Cornelius Nattey et al. BMC Glob Public Health. .

Abstract

Background: Under South Africa's Universal Test and Treat (UTT) policy, CD4 counts are no longer required to determine HIV treatment eligibility. However, CD4 count at presentation remains an important marker of disease progression. We assessed whether CD4 testing declined in the UTT era and, if so, by how much.

Methods: We analysed CD4 count data from the National Health Laboratory Service (NHLS) National HIV Cohort and TIER.Net database for individuals in HIV care across five South African provinces. "First CD4 count" was defined as the first CD4 test recorded for each patient. In TIER.Net, "date of presentation" was the earliest date of HIV testing, CD4 measurement, or clinic visit. Trends in first CD4 testing volumes (2004-2018) were analyzed, with interrupted time-series analyses assessing the impact of UTT (September 2016).

Results: Data included 5,274,218 (NHLS) and 2,265,557 (TIER.Net) individuals with a first CD4 count. In NHLS, first CD4 counts increased from 47,604 in 2004 to 383,705 in 2010 and then declined. Lower volumes were recorded in TIER.Net. Adjusting for prior trends, first CD4 counts increased slightly after UTT, by 32 individuals/day in NHLS (95% CI: - 6 to 61) and 88 individuals/day in TIER.Net (95% CI: 30 to 148). Among TIER.Net patients, the percentage with a CD4 count decreased by 4.3% (95% CI: - 5.2 to - 3.0%).

Conclusions: We found no major decline in CD4 testing at presentation following UTT, contrasting findings from resource-constrained settings with greater reliance on external donors.

Keywords: Advanced HIV disease; CD4 count testing; Interrupted time-series analysis; Trends in HIV care; Universal Test and Treat (UTT).

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: This study was approved by the Human Research Ethics Committee (HREC) of the University of Witwatersrand (ref. no. M200447) in South Africa and Boston University in the USA (IRB no. H-31968). No study participant recruitment took place since all data were collected as part of routine care in both databases. Data access for anonymized patient laboratory records in TIER.Net and NHLS were obtained from provincial departments of health as well as the NHLS. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Trends in number of individuals diagnosed with HIV in the public sector with first CD4 count by quarterly calendar period from January 2004 to March 2018 in NHLS and TIER.Net in four provinces of South Africa
Fig. 2
Fig. 2
Average number of new individuals (per day) with a first CD4 count in NHLS and TIER.Net databases from March 2015 to March 2018. The grey bar indicates the implementation of the Universal Test and Treat (UTT) policy in September 2016
Fig. 3
Fig. 3
Percent of patient records in TIER.Net that had a CD4 count recorded from March 2015 to March 2018. The grey bar indicates the implementation of the Universal Test and Treat (UTT) policy in September 2016
Fig. 4
Fig. 4
Adjusted percent of patient records in TIER.Net that had a CD4 count recorded from March 2015 to March 2018. The grey bar indicates the implementation of the Universal Test and Treat (UTT) policy in September 2016
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