Three decades of HIV epidemic dynamics in The Gambia: a comprehensive analysis of prevalence, incidence, and mortality trends, 1990–2024

The Gambia has experienced major HIV epidemic shifts over three decades. As a low-prevalence country, understanding epidemic trends remains crucial for health planning and resource allocation. This study provides a comprehensive analysis of 35 years of HIV prevalence, incidence, and mortality trends in The Gambia from 1990 to 2024. We conducted epidemiological analysis using UNAIDS 2025 HIV estimates from 1990 to 2024. Temporal trends were examined across four phases. Log-linear regression estimated annual percent changes for people living with HIV (PLHIV), new infections, and AIDS deaths. Epidemic control was assessed using mortality-to-incidence and incidence-to-prevalence ratios. PLHIV increased 24-fold from 1,035 (95% CI 784–1,342) in 1990 to 25,247 (95% CI 20,945–30,216) in 2024. Adult prevalence rose from 0·18% to 1·29%. The early phase showed explosive growth (annual percent change + 30·46% for PLHIV), followed by declining incidence concurrent with treatment scale-up (− 4·40% annually 2010–2019; −7·37% annually 2020–2024). New infections peaked at 2,439 (2009), declining to 1,124 (2024). The mortality-to-incidence ratio exceeded 1·0 in 2023. Progressive feminization emerged: female-to-male prevalence ratio increased from 1·06 to 1·57 (β = 0·0133/year, p < 0·0001), with women comprising 61·3% of PLHIV. Treatment cascade performance fell substantially below 95-95-95 targets (63·7% diagnosed, 44·3% on ART, 34·9% virally suppressed), with pronounced gender gaps (men: 52·7%/27·2%/21·2% vs. women: 72·1%/55·4%/44·4%). Pediatric infections increased 284% (44→169 cases), representing 15·0% of 2024 infections. Despite declining incidence, The Gambia faces critical gaps in treatment cascade, particularly among men, epidemic feminization, and persistent vertical transmission, requiring urgent gender-responsive and pediatric interventions.