28.08.2025 Public Health

HIV diagnosis and management linked to national income

Infectious disease specialist Fernanda Fonseca, from the AIDS Healthcare Foundation, comments on a study that exposes inequalities in access to rapid HIV diagnosis and treatment.

Moura Leite Netto

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A study published in HIV Medicine analyzed 643 HIV treatment services in 37 countries across four continents, revealing significant disparities in the availability of diagnoses, treatment, and management of comorbidities in patients with advanced HIV.

The most striking gaps were found in Africa, Asia, and Latin America/the Caribbean, where low gross national income per capita is a determining factor.

In an interview with Science Arena, infectious disease specialist Dr. Fernanda Fernandes Fonseca, head of the AIDS Healthcare Foundation in Brazil and coauthor of the study, discussed the risks of late diagnosis, regional inequalities, and how this information can support more effective public policies.

Science Arena: Are there any countries that have efficiently overcome these resource challenges?

Fernanda Fonseca – The only region with adequate access to these resources is Europe, where per capita income is higher and the need for these resources is lower, given the reduced prevalence of people with advanced HIV/AIDS and late presenters. Recommendations to mitigate these challenges include targeted programs for under-served populations (including some supported by external funding) and local capacity building. Understanding and closing the gaps that restrict access to healthcare for this population can also help reduce the overall burden of HIV and AIDS.

What are the main consequences for patients without access to timely diagnostic tests and treatments, such as CD4 cell counts and prophylaxis for opportunistic infections?

People newly diagnosed with advanced HIV/AIDS and late presenters are at higher risk of adverse clinical outcomes than people diagnosed at earlier stages. Studies suggest that in low- and middle-income countries, 30% to 40% of people with HIV who start antiretroviral treatment have advanced HIV/AIDS. It is essential that every patient beginning or resuming HIV care has access to a baseline CD4 count. This allows for the identification of people with low CD4 counts who would benefit most from adequate resources to prevent and/or treat opportunistic infections in the first months of antiretroviral treatment, before immune recovery is established. Proper care can mitigate the morbidity and mortality associated with advanced HIV/AIDS.

How do stigma, discrimination, and lack of awareness contribute to high rates of late diagnosis?

Scientific studies suggest that factors associated with late presentation include being older, male, Latino, heterosexual, a migrant, with lower education, greater externalized stigma, and limited access to HIV testing.

How can the results of this study be used to influence public policy and improve the allocation of health resources?

Understanding and investigating public policies that remove barriers to healthcare for people living with HIV and who are receiving care later due to personal, community, and structural challenges will help mitigate the negative impacts of the global HIV/AIDS epidemic. The results of this analysis have been used to design and implement strategies for improving services at AHF-supported facilities, including by increasing the availability of rapid HIV testing and baseline CD4 counts for people starting or resuming treatment, allocating resources for the prevention and treatment of opportunistic infections, and continuing education for the clinical management of people with advanced HIV/AIDS. Ultimately, our findings can be used to inform future public health policies and other quality-improvement programs focused on comprehensive HIV care.

Resource availability is linked to national income:

• CD4 cell count testing: Available at 54% of services in low-income countries, 50% in lower-middle-income countries, 66% in upper-middle-income countries, and 100% in high-income countries.

• On-site viral load testing: Available at 60%, 49%, 67%, and 100% respectively.

• Genotyping for treatment failures: Available at 15%, 17%, 63%, and 100% respectively.

In the most affected regions:

• In Latin America, the BAAR test, essential for diagnosing tuberculosis, is available at only 67% of services.

• In Africa, only 24% of services offer chest X-rays, which are crucial for managing tuberculosis.

• Management of intracranial hypertension by lumbar puncture is performed at only 18% of services in Africa, 56% in Asia, and 38% in Latin America.

• Fundoscopy for the diagnosis of cytomegalovirus is available at less than half of the services in these regions.

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