Advanced HIV disease among newly diagnosed clients identified through community- and facility-based HIV testing services in Eswatini: a cross-sectional study

Background Despite the Kingdom of Eswatini surpassing the UNAIDS 95–95-95 targets, the persistence of Advanced HIV Disease (AHD) remains a clinical concern. Advanced HIV Disease increases morbidity and mortality. This study evaluated the rate of AHD among newly diagnosed clients aged ≥15 identified through the community-based testing in comparison to the facility-based testing. Methods A cross-sectional study was conducted in two groups (community and facility) of individuals newly diagnosed with HIV using secondary program data (October 2022–September 2025) to identify clients with WHO clinical stages 3 and 4 or defining disease which represent advanced HIV disease with severe immunosuppression or with a CD4 count <200 cells/mm 3 . Descriptive and comparative analyses were performed to compare AHD rates between the community and facility group. Bivariate and multivariable logistic regression analyses were utilized to identify associated factors of AHD for each group using STATA 19.5. Results The AHD rate was 19.0% ( n = 1,248) in the facility group and 16.7% ( n = 88) in the community group, with no statistically significant difference observed between the two groups ( p > 0.05). In facility group, factors associated with AHD included increase in age (aOR: 1.03 [1.01–1.05]; p < 0.001), male sex (aOR: 1.8 [1.5–2.1]; p < 0.001), and residing in Manzini (aOR: 1.6 [1.3–1.8]; p < 0.001). Conversely, age and sex were not significantly ( p > 0.05) associated with AHD in community-based testing setting. Delayed ART initiation (8–28 days) was associated with AHD in both groups, that is, community group (aOR: 3.2 [1.9–4.1]; p = 0.2) and facility group (aOR: 2.7 [2.1–3.3]; p < 0.001), reflecting the clinical complexity of stabilizing AHD prior to ART initiation. Conclusion Community testing did not demonstrate an advantage in early diagnosis of HIV in this study, but reached a younger, mobile population than facility testing. Hence community testing can be a complementary strategy for sub populations who often bypass facility-based care as well as used in addressing localized drivers of late presentation. Facility-based testing, meanwhile, remains essential for symptomatic late presenters and people returning to care.