Background
Advanced HIV disease (AHD) among adults is defined as a CD4 count <200 cells/mm³ or a World Health Organization HIV clinical stage 3 or 4. Data regarding trends in AHD prevalence in sub-Saharan Africa are limited.
Methods
We analysed population-based HIV impact assessment (PHIA) household surveys from Eswatini, Lesotho, Malawi, Uganda and Zimbabwe, each of which had two surveys available between 2015 and 2021. The period between both rounds of PHIA in each country was around five years. We assessed changes in the proportion of adults living with HIV with a CD4 count <200 cells/mm³ (i.e. AHD prevalence), stratified by demographic factors and the HIV treatment cascade.
Results
A total of 13,476 people living with HIV (PLHIV) were included in PHIA round 1 and 15,813 in PHIA round 2 across the five countries. During this period, the proportion of people who did not know their status decreased from 31 to 17%, and the proportion of people with suppressed viral load increased from 60 to 77%.
Pooled across the five countries, 10.4% (95% CI [CI] 9.8–11.0%) of PLHIV had a CD4 cell count <200cells/mm3 in PHIA round 1 and 6.8% (CI 6.2–7.4%) in PHIA round 2.
Stratified by the HIV treatment cascade, AHD prevalence remained similar among people who did not know their status (16.1%, CI 14.4–18.0%, to 12.7%, CI 10.5–15.2%), increased among people who knew their status but were not on ART (20.8%, CI 17.7–24.3% to 26.7%, CI 20.1–34%), but decreased across all other categories of the treatment cascade. Among people on ART who were not virally suppressed, AHD prevalence decreased from 36.7% (CI 34.0–41.4%) to 29.8% (CI 25.0–35.0%) and among people with viral suppression it almost halved from 6.4% (CI 5.7–7.1%) to 3.3% (CI: 2.8–3.8%, Figure). These effects were consistent across the five countries, were similar for men and women, and were more pronounced in urban than rural areas and among older ages. Among youth aged 15–24 years, AHD prevalence increased from 5.0% (CI 3.9–6.3%) to 6.1% (CI 4.3–8.2%).
Conclusions
The prevalence of AHD decreased across five countries, primarily due to advances in testing, knowledge of status and treatment. However, AHD persists among people with new HIV diagnosis, and among young people, which requires attention. Although household surveys underestimate AHD by excluding potential survey participants who are hospitalized, the need for continued CD4 count testing and the delivery of the package of care for people with AHD is clear.
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