Background
Lesotho ranks second highest in national HIV prevalence globally. In April 2016, Lesotho was the first African country to adopt the World Health Organization (WHO) recommendation that all people with HIV (PWH) receive antiretroviral therapy (ART), regardless of clinical stage or CD4 cell count (CD4). Although CD4 is no longer used to guide treatment initiation, people with advanced HIV disease (AHD), defined as CD4 <200 cells/mm3, have a higher risk of mortality and may contribute to HIV transmission due to uncontrolled viremia. We describe population-level changes in AHD prevalence and examine changes in correlates of AHD since implementing the “treat-all” guidance.
Methods
Using data from Lesotho Population-Based HIV Impact Assessments (LePHIA) conducted in 2016-17 and 2019-20, we estimated the prevalence of AHD and examined sociodemographic, clinical, and treatment correlates of AHD. We fit multivariable logistic regression models of all covariates with an unadjusted p-value < 0.05. All analyses were performed with weighted data using SAS (version 9.4).
Results
Among 6,391 PWH (2016-17: n=3,159, 2019-20: n=3,232), the prevalence of AHD was 11.45% (95% CI:10.19,12.73) and 6.68% (95%CI:5.71,7.64) (X2 p value<0.0001), median CD4 count for all PWH/AHD was 477 (IQR:300-664)/ 132 (IQR:90-165) and 572 (IQR:382-783)/ 147 (IQR:105-175) (Wilcoxon rank sum p-value<0.0001/ p-value = 0.03) in 2016-17 and 2019-20, respectively. After statistical adjustment, covariates associated with AHD in both surveys (Figure) were male sex (aOR 2.07, 95% CI 1.68,2.55), older age (25-59 vs. 15-24 y, aOR 2.23, 95% CI 1.47,3.38), and viral non-suppression (viral load > 1000 copies/ml, aOR 11.00, 95% CI 8.21,14.74). In 2016-17 but not 2019-20, individuals reporting not currently being on ART had higher odds of AHD (aOR: 3.30, 95% CI:1.37,8.00) compared to those currently on ART.
Conclusions
Since implementing the treat-all policy in Lesotho, median CD4+ count increased among all PWH, and reported ART use was no longer associated with AHD. Correlates of AHD we report coincide with previous studies. The percent of PWH with AHD decreased by 40%, with unsuppressed viral load remaining associated with AHD. Last mile efforts should focus on reaching PWH who are men, older age, and experience viral non-suppression. The CD4 dynamics observed, highlight the need for continued CD4 monitoring to track remaining gaps in evidence on AHD and the HIV response.
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