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Article History

Received: 28 October 2025

Accepted: 2 February 2026

First Online: 7 February 2026

Declarations

:

: Ethical approval, including a waiver of informed consent to participate, permitting the access to the data, was obtained from KwaZulu-Natal Biomedical Research Ethics Committee (BREC reference number: BE290/16). Permissions to access, analyze, and link patient-level TIER.Net data were obtained from the KwaZulu-Natal Provincial Department of Health (reference number:14/8/3/1 2250) and the National Health Laboratory Service through the Memorandum of Agreement entered between National Health Laboratory Service and Africa Health Research Institute. The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. The study utilized personal identifying information (PII) in the linkage process. The linkage was conducted by the lead author (who oversees all the data managed at AHRI which includes personal identifying information) within a secure, access-controlled environment under approved data governance protocols. PII data were used solely for the data linkage step and were never accessible to the analytic team; once linkage was completed, PII data were removed and replaced with encrypted study-specific identifiers. The process complied with the AHRI Data Access Policy, KwaZulu-Natal Biomedical Research Ethics Committee (BREC reference number: BE290/16) approval, South Africa’s Protection of Personal Information (POPI) act, and memoranda of agreement with South Africa’s National Department of Health and National Health Laboratory Service. No identifiable information was transferred outside the secure server environment, and all analyses were conducted on de-identified data.

: Not applicable.

: The authors declare no competing interests.