Epidemiologic Trends and Determinants of Advanced HIV Disease among People Living with HIV in Zimbabwe (2017-2024): Evidence to Inform an Optimisation Framework

Advanced HIV Disease (AHD) remains a leading cause of morbidity and mortality among people living with HIV (PLHIV) despite widespread antiretroviral therapy (ART) coverage. This study analysed epidemiologic trends and facility-level determinants of AHD in Zimbabwe to inform targeted programme optimisation strategies. A retrospective analysis of routine District Health Information System 2 (DHIS2) data was conducted across 16 health facilities in Harare and Mashonaland East from 2017 to 2024. AHD was defined in accordance with contemporaneous World Health Organization guidelines, and analyses included descriptive statistics, temporal trend assessment, geographic comparisons, correlation, and multivariable regression. Among 495,166 PLHIV on ART, 4,169 AHD cases were identified. AHD prevalence followed a U-shaped trend, declining from 20.31% in 2017 to 2.20% in 2020, before rising to 16.12% in 2024, reflecting programmatic shifts and COVID-19 disruptions. Rural Mashonaland East recorded significantly higher prevalence than urban Harare (16.53% vs. 9.71%, p=0.002). Facility-level variation was substantial (0.56%–40.23%), with district hospitals bearing a disproportionate burden (β = 15.24, p = 0.001). AHD was positively associated with cryptococcal meningitis (r = 0.419, p = 0.003) and mortality (r = 0.385, p = 0.007), while loss to follow-up was not strongly correlated. Despite strong retention outcomes, persistent challenges in early diagnosis and AHD identification remain. Geographic and facility-level inequities underscore the need for differentiated, equity-focused interventions. Strengthening decentralised screening, particularly for opportunistic infections such as cryptococcal disease and tuberculosis, is essential to reduce preventable mortality and improve clinical outcomes.