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 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.