Confronting Advanced HIV Disease: Why It Still Matters
When we talk about HIV in 2025, the story we often hear is about progress: more people than ever are on treatment, new prevention methods are available, and the science of HIV cure is advancing. Yet, behind this progress lies a quieter crisis, Advanced HIV Disease (AHD).
What Is Advanced HIV Disease?
The World Health Organisation (WHO) defines Advanced
HIV Disease as when a person has a CD4 count below 200 cells/mm³ or is
in WHO clinical stage 3 or 4. For children younger than five years, any
HIV infection is considered advanced because of their high vulnerability.
People with AHD are extremely vulnerable to severe opportunistic infections
such as cryptococcal meningitis, tuberculosis, histoplasmosis, and
Pneumocystis pneumonia, alongside weight loss, persistent fevers, and other
life-threatening complications.
Why Does AHD Still Happen?
One might ask: If treatment is widely available, why are
people still reaching this stage? The reasons are complex:
- Late
diagnosis: WHO data show that at least one-third of people entering
HIV care present with advanced HIV disease, based on an analysis of
over 1.8 million individuals across 117 cohorts in 52 countries. In
sub-Saharan Africa, between 20% and 40% of people living with HIV
still present with AHD at the time of diagnosis or when re-engaging in
care.
- Treatment
interruption: Many people disengage from care due to stigma,
side-effects, migration, or health system failures, and return to care
much later.
- Health
system gaps: Not all facilities are equipped to provide the full “AHD
package of care,” including rapid diagnostics, access to life-saving
medicines, and appropriate hospital or palliative care.
- Social
and structural barriers: Poverty, gender inequality, discrimination,
and criminalisation of key populations often block people from accessing
services early.
The Human Cost
AHD is not just a clinical condition; it is a story of
human suffering. People often arrive in hospitals very ill, sometimes dying
within days of admission. Families face not only grief but also stigma and
financial strain. Globally, over 4 million adults are estimated to be living
with AHD, and in 2021 alone, there were around 650,000 HIV-related
deaths, most linked to advanced disease or complications that could have
been prevented with timely care.
What Needs to Be Done
The good news is that AHD is preventable and treatable,
if health systems respond effectively. Solutions include:
- Routine
screening and early intervention: Using CD4 testing and point-of-care
diagnostics to identify people at risk.
- The
AHD package of care: WHO recommends a combination of prophylaxis,
rapid diagnosis, and treatment for major opportunistic infections, plus
ART re-initiation.
- Stronger
hospital-to-community linkages: Many patients die after being
discharged because they are not properly followed up. Continuity of care
is essential.
- Integration
of palliative care: Beyond survival, people with AHD need relief from
pain and distress.
- Community
engagement: PLHIV networks and support groups must be central,
addressing stigma, offering peer navigation, and supporting adherence.
Why This Matters Now
As we celebrate advances in HIV prevention, treatment, and
cure research, we cannot forget those still being left behind. AHD reminds us
that equity is the unfinished business of the HIV response. Global
health leaders, governments, and communities must prioritise AHD, not as a remnant
of the past, but as an urgent challenge today.
The upcoming Lancet Commission on Advanced HIV Disease,
which I am honoured to support, offers an opportunity to shine a light on this
neglected crisis. By combining evidence, policy analysis, and community voices,
the Commission will help chart a path to reduce preventable suffering and
death.
A Call to Action
Ending AIDS is not only about reaching 95-95-95 targets, but
also about ensuring no one dies from preventable and treatable conditions.
We must invest in stronger health systems, community-centred care, and policies
that keep people from falling through the cracks.
Because until we end the suffering caused by Advanced HIV
Disease, the story of HIV is not complete.
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