Authors: 

Jessica E Justman, Maureen Syowai

Abstract:

Antiretroviral treatment (ART) scale-up under the treat-all strategy has been the cornerstone of the global response to the HIV epidemic since 2015. Despite the subsequent increase in HIV treatment global coverage, reductions in AIDS-related mortality have lagged, likely because of advanced HIV disease (AHD).¹ AHD, defined as a CD4 count of less than 200 cells per mm3 or WHO stage of 3 or 4 in people living with HIV age 5 years or older,² has affected a persistent 30% of those initiating ART in clinical programmes since 2015, despite the ART scale-up.³ This 10-year plateau in AHD has been driven by shrinking CD4 testing resources⁴ and the growing problem of the cyclical cascade of engagement and disengagement.⁵ AHD fuels AIDS-related mortality¹ and, because many with AHD have a non-suppressed viral load, also contributes to the ongoing transmission of new infections. Paying more attention to AHD prevention and treatment might therefore be the missing piece of the global response puzzle. Most estimates of AHD prevalence have relied on routine clinical data and this has made it difficult to understand the absolute numbers, or burden, of AHD.