Abstract

Background: 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. Methods: 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 counts ≤200 cells/mm3 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 count and time strata were calculated using a generalised linear mixed model. Risk of bias was assessed using a modified Newcastle-Ottawa scale. The protocol is registered with PROSPERO, CRD42023451498. Results: 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 count ≤200 cells/mm3 and increased with lower CD4 counts (≤100 cells/mm3, 15% (95% CI 11 – 19); ≤50 cells/mm3, 20% (95% CI 12 – 31)). Most deaths occurred within the first three months after AHD presentation. Heterogeneity was substantial. Risk of bias was high in 18 (50%) of 36 included studies. Discussion: There is high one-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.