During 2007–2012 in

TO THE EDITOR—We read with interest the study by Lahuerta et al [1] describing the change in CD4 count among those en-rolling into care and initiating antiretro-viral therapy (ART) in 4 countries in sub-Saharan Africa between 2006 and 2011, which suggests that increasing me-dian CD4 count at ART initiation may in part be due to the expansion of national CD4-based ART eligibility thresholds. We describe herein our experience with evolving eligibility criteria where we as-sessed the impact of changes to the South African guidelines on the numbers and characteristics of adult patients initi-ating ART in a large cohort in Khayelit-sha, South Africa, between 2007 and 2012. The 2010 World Health Organization (WHO) recommendations for ART initi-ation in adults revised the CD4 threshold from 200 to 350 cells/µL, along with ART for all patients coinfected with active tu-berculosis or hepatitis B virus. These guidelines were incrementally imple-mented in South Africa between April 2010 and August 2011. In Khayelitsha there is a high HIV burden (37 % antenatal prevalence, 2011 [2]) and estimated good ART coverage. The ART program was established in 2001 by Médecins Sans Frontières and government health services and compris-es 11 primary-level sites, largely nurse managed [3–6].A cross-sectional analysis was undertaken using routinely collected ART initiation data from 4 periods (2007–2012; Figure 1). Among 22 782 adults accessing AR