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Donor support for CD4 testing has declined to prioritize access to VL monitoring. We examined trends in CD4 and VL testing among adults (\u226515\u00a0years of age) starting ART in Southern Africa.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      We analysed data from 14 HIV treatment programmes in Lesotho, Malawi, Mozambique, South Africa, Zambia and Zimbabwe in 2005 to 2018. We examined the frequency of CD4 and VL testing, the percentage of adults with CD4 or VL tests, and among those having a test, the percentage starting ART with advanced HIV disease (CD4 count &lt;200\u00a0cells\/mm\n                      <jats:sup>3<\/jats:sup>\n                      ) or failing to suppress viral replication (&gt;1000 HIV\u2010RNA copies\/mL) after ART initiation. We used mixed effect logistic regression to assess time trends adjusted for age and sex.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Among 502,456 adults, the percentage with CD4 testing at ART initiation decreased from a high of 78.1% in 2008 to a low of 38.0% in 2017; the probability declined by 14% each year (odds ratio (OR) 0.86; 95% CI 0.86 to 0.86). Frequency of CD4 testing also declined. The percentage starting ART with advanced HIV disease declined from 83.3% in 2005 to 23.5% in 2018; each year the probability declined by 20% (OR 0.80; 95% CI 0.80 to 0.81). VL testing after starting ART varied; 61.0% of adults in South Africa and 10.7% in Malawi were tested, but fewer than 2% were tested in the other four countries. The probability of VL testing after ART start increased only modestly each year (OR 1.06; 95% CI 1.05 to 1.06). The percentage with unsuppressed VL was 8.6%. There was no evidence of a decrease in unsuppressed VL over time (OR 1.00; 95% CI 0.99 to 1.01).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>CD4 cell counting declined over time, including testing at the start of ART, despite the fact that many patients still initiated ART with advanced HIV disease. Without CD4 testing and expanded VL testing many patients with advanced HIV disease and treatment failure may go undetected, threatening the effectiveness of ART in sub\u2010Saharan Africa.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1002\/jia2.25546","type":"journal-article","created":{"date-parts":[[2020,7,8]],"date-time":"2020-07-08T14:54:50Z","timestamp":1594220090000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":46,"title":["Trends in CD4 and viral load testing 2005 to 2018: multi\u2010cohort study of people living with HIV in Southern Africa"],"prefix":"10.1002","volume":"23","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1986-2359","authenticated-orcid":false,"given":"Elizabeth","family":"Zaniewski","sequence":"first","affiliation":[{"name":"Institute of Social and Preventive Medicine University of Bern Bern Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cam H","family":"Dao Ostinelli","sequence":"additional","affiliation":[{"name":"Institute of Social and Preventive Medicine University of Bern Bern Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8959-2724","authenticated-orcid":false,"given":"Fr\u00e9d\u00e9rique","family":"Chammartin","sequence":"additional","affiliation":[{"name":"Institute of Social and Preventive Medicine University of Bern Bern Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nicola","family":"Maxwell","sequence":"additional","affiliation":[{"name":"Centre for Infectious Disease Epidemiology and Research School of Public Health and Family Medicine University of Cape Town Cape Town South Africa"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8496-6475","authenticated-orcid":false,"given":"Mary\u2010Ann","family":"Davies","sequence":"additional","affiliation":[{"name":"Centre for Infectious Disease 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