One-year mortality among adults with advanced HIV in sub-Saharan Africa: a systematic review and meta-analysis

In sub-Saharan Africa (SSA), people with HIV continue to present with advanced HIV disease (AHD), putting them at high risk of life-threatening opportunistic diseases. We aimed to estimate mortality among this population.

We conducted a systematic review and meta-analysis of studies reporting one-year mortality among adults living with HIV and presenting to care with CD4 + cell count ≤200 cells/mm 3 in SSA. MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for studies (comprising >500 participants) published between January 1, 2016 and March 21, 2025. Screening and data extraction were done in duplicate. Pooled mortality proportions across CD4 + cell count and time strata were calculated using a generalized linear mixed model. Risk of bias was assessed using a modified Newcastle-Ottawa scale. The protocol is registered with PROSPERO, CRD42023451498.

Thirty-six studies with 313 362 participants were included. The weighted median age was 35 years, 64% were female, and 98.9% were antiretroviral therapy-naive. One-year mortality was 12% (95% CI 8-16) among people with CD4 + cell count ≤200 cells/mm 3 and increased with lower CD4 + cell count (≤100 cells/mm 3 , 15% (95% CI 11-19); ≤50 cells/mm 3 , 20% (95% CI 12-31)). Most deaths occurred within the first 3 months after AHD presentation. Heterogeneity was substantial. Risk of bias was high in 18 (50%) of 36 included studies.

There is high 1-year mortality among people presenting with AHD in SSA. It is a priority to identify AHD with CD4 + testing, improve retention in care, and evaluate additional interventions to reduce mortality in this population.