Decreasing adult prevalence of advanced HIV disease from two Population-based HIV Impact Assessments in Eswatini, Lesotho, Malawi, Tanzania, Uganda, Zambia, Zimbabwe, 2015–2023

Background Limited population data exist assessing trends in advanced HIV disease (AHD) in the test-and-treat era. We examined changes in AHD prevalence from 2015-17 (round 1) and 2019-23 (round 2) in seven African countries. Methods We pooled data from two rounds of the Population-based HIV Impact Assessment (PHIA) surveys from seven countries among persons with HIV (PWH) aged 15-59 years. AHD was defined as having an HIV-positive result and CD4 <200 cells/mm3. Awareness of HIV diagnosis and treatment status were based on self-report and detection of antiretrovirals. Weighted estimates between survey rounds were compared using complex survey methods. Results Across all countries, 13.2% and 6.8% of PWH met criteria for AHD during round 1 and 2, respectively. AHD prevalence among those aware of their HIV status and not on antiretroviral therapy (ART) increased by 31.7% (20.8% to 27.4%) but decreased by 17.7% (17.5% to 14.4%) among those unaware and not on ART, and decreased by 53.3% (10.5% to 4.9%) among those aware and on ART. The adjusted odds ratio for AHD comparing round 1 and 2 among those aware and on ART was 0.46 (95% CI: 0.39-0.53). Those who were aware and on ART accounted for the majority of PWH with AHD in both rounds (51.6%, round 1 and 58.8%, round 2). Conclusion These findings indicate substantial reductions in AHD prevalence among those on ART between 2015-17 and 2019-23. Continued efforts are warranted to ensure timely diagnoses and treatment adherence and reduce barriers to care reengagement which represent an increasingly important driver of AHD.