Background
Advanced HIV Disease (AHD) in individuals aged 5 and older is defined by a CD4 count below 200 cells/mm³ or World Health Organization (WHO) stage 3 or 4 conditions. Despite the global shift to a test-and-treat approach for people living with HIV, many in low- and middle-income countries still present with AHD at diagnosis, increasing their risk of opportunistic infections and mortality. CD4 testing is crucial for identifying AHD and ensuring proper management, and the WHO recommends routine CD4 testing for all starting or restarting antiretroviral therapy (ART). This study evaluated CD4 testing coverage and AHD prevalence at U.S. Agency for International Development (USAID) sites supported by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR).
Methods
The PEPFAR Monitoring, Evaluation, and Reporting (MER) framework introduced CD4 count disaggregation (<200, ≥200, Unknown) in October 2023. This study analyzed MER data from October 1, 2023, to June 30, 2024 from USAID implementing sites in 42 PEPFAR supported countries. High-risk clients were classified into two groups: those newly initiating ART (TX_NEW) and those reinitiating ART after a treatment interruption of ≥6 months (RTT-IIT). Descriptive statistics were used to assess CD4 testing rates and AHD prevalence based on HIV diagnosis, ART initiation, CD4 testing, and sex assigned at birth.
Results
The analysis included 645,342 high-risk clients, comprising 471,563 (73%) TX_NEW and 173,779 (27%) RTT-IIT. CD4 testing was reported for 267,948 (42%) high-risk clients, with a higher prevalence of CD4 counts <200 among TX_NEW (27%) compared to RTT-IIT (23%). AHD prevalence was higher among cisgender males (33% TX_NEW, 28% RTT-IIT) compared to females (23% TX_NEW, 20% RTT-IIT). Countries with CD4 testing coverage exceeding 50% had lower AHD prevalence (26% TX_NEW, 22% RTT-IIT) than those with coverage below 50% (28% TX_NEW, 31% RTT-IIT).
Conclusions
AHD continues to be a challenge for clients starting or reinitiating ART, particularly among men. Critical gaps in CD4 testing coverage for high-risk individuals exacerbate this issue. Even in countries with high CD4 testing rates, AHD prevalence remains elevated, highlighting the urgent need to enhance efforts toward earlier HIV diagnosis and rapid treatment initiation. Strengthening these efforts is crucial to improving clinical outcomes and achieving the goal of ending AIDS as a public health threat by 2030.
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