Reducing HIV incidence and mortality: two sides of the same coin in the approach to ending AIDS

HIV programmes globally continue to face two persistent challenges: advanced HIV disease and high HIV incidence. These issues are often viewed separately, with advanced HIV disease viewed as a late-stage clinical failure and high HIV incidence as a failure of early prevention. However, these issues are closely linked at the individual and population level; both reflect the inability of current care models to engage and sustain viral suppression among a sizeable subgroup of people living with HIV who initiate antiretroviral therapy late or cycle in and out of care. In sub-Saharan Africa, where the HIV burden is highest, most individuals with advanced HIV disease are people who have previously initiated antiretroviral therapy and subsequently disengaged, often multiple times. This type of interruption in care has substantial implications for immune decline, viral rebound, and mortality. As donor funding decreases, there is a risk that global HIV responses will revert focus to maintaining aggregate antiretroviral therapy coverage, overlooking harder-to-reach populations with persistent viraemia.