HIV Prognosis in Sub-Saharan Africa: A Narrative Review of Mortality Trends, Structural Determinants, and Policy Implications

Abstract

Background: HIV remains a significant public health problem in sub-Saharan Africa (SSA), where prognosis varies greatly within regions. Mortality continues to be a primary outcome of focus; however, little attention has been paid to studying it due to largely inequitable socio-structural factors, weak health systems, and limited evidence-based policy. Objective: This narrative review summarizes the peer-reviewed literature on HIV prognosis in SSA from 2015 to 2024, focusing on mortality as the principal outcome. It also characterizes structural, behavioral, and biomedical determinants and analyses how these factors provide a framework for policy recommendations. Methods: This study comprised 218 articles published in peer-reviewed journals. Eligible studies focused on mortality or mortality-related prognostic outcomes and contained sociodemographic, structural, behavioral, or biomedical determinants, and policy-relevant lessons. The findings were integrated to regionally evaluate the disparity, trend, and policy integration scope. Results: Results: Prognosis research is concentrated in southern and eastern Africa, while West and Central Africa remain underrepresented. Structural predictors such as healthcare access, economic inequality, and gender normsdominate the literature. Few studies have examined behavioral (e.g., alcohol use, counseling) or biomedical (e.g., viral load, CD4 count) predictors, despite their prognostic relevance. Only 43% of studies included actionable policy provisions. Conclusion: HIV prognosis in SSA reflects the impact of the dominant structural factors. However, comprehensive intervention is limited by the underutilization of behavioral and biomedical insights. Cross-regional expansion and interdisciplinary approaches are critical for addressing equity gaps and improving the effectiveness of the health system. Enhanced implementation pathways can improve evidence translation and reduce mortality.