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. Estimates of the burden of AHD in sub-Saharan Africa are still scarce.
Methods:
We analysed data from eleven Population-based HIV impact assessment (PHIA) household surveys conducted between 2015 and 2020 to determine the proportion of adults living with HIV who have a CD4 count <200 cells/mm[sup]3[/sup] stratified by demographic factors and the HIV treatment cascade. We then estimated the number of individuals with AHD in sub-Saharan Africa by combining these proportions with the latest HIV estimates from UNAIDS.
Results:
A total of 21,826 people living with HIV (PLHIV) were included in this study of which 15,012 (64%) were female and the median age was 38 years (interquartile range 30–46). Pooled across the eleven countries, 11.6% (95% CI 11–12.2%) of PLHIV had a CD4 cell count <200cells/mm3 – ranging from 6.1% in Côte d’Ivoire to 14.7% in Tanzania (Figure A). AHD was more common among males than females (15.6% versus 9.5%) and more common in urban than rural areas (12% versus 11.3%). Overall, 16.1% of people who did not know their HIV status had a CD4 count <200cells/mm3, as did 21.4% of people who knew their status but were not on ART, 35.6% of people who were on ART but not virally suppressed, and 5.1% of people who were virally suppressed. Among all people with a CD4 count <200cells/mm3, 26% (95%CI 23–28%) were virally suppressed (Figure B). Extrapolating these results to sub-Saharan Africa yielded an estimated 2.1 million people living with AHD (1.8–2.5 million); 1 million females and 1.1 million males.
Conclusions:
Despite advances in ART that have transformed HIV into a manageable chronic condition, a significant number of people continue to develop AHD, even as conservatively calculated from household surveys which do not capture data from health facilities. A considerable proportion of people with AHD have a suppressed viral load; this includes people who might have recently initiated ART or have re-engaged in ART care after treatment interruptions. These figures highlight the need for urgent and innovative programmatic improvements in monitoring, prevention and diagnosis of AHD in the context of well-established and maturing ART programmes.
