Closing the "Missing Middle" in Advanced HIV Disease Care for Adolescents in Sub-Saharan Africa: Early Identification, Integrated Care, and Continuity After Discharge.

Adolescents remain insufficiently addressed in the response to advanced HIV disease (AHD) in sub-Saharan Africa. Despite progress in HIV testing and antiretroviral therapy, gaps remain in early identification, integrated care, and continuity of care for adolescents at risk of severe disease. This commentary describes adolescents as a "missing middle" between pediatric and adult HIV services. It highlights how treatment interruption, fragmented services, psychosocial challenges, and weak follow-up can increase their vulnerability. We propose an adolescent-responsive AHD pathway focused on three priorities: early identification of adolescents at risk, integration of clinical and psychosocial care, and continuity after hospitalization or treatment interruption. The approach should be adapted to the available workforce, financing, technology, and health-system capacity. Strengthening these areas may help reduce preventable illness and deaths and improve retention and recovery among adolescents living with HIV in sub-Saharan Africa.