The dust of the dry season swirled around Dr. Bosede Adebayo’s feet as she stepped out of the clinic into the harsh afternoon sun. Inside, the quiet hum of the few remaining machines was a constant reminder of what was missing. She thought of Joseph, a young man who had returned to her care in rural Kenya just a few weeks ago.
He had been on antiretrovirals (ARVs) years before, but life—a lost job, a move to a new village—had interrupted his treatment. When he came back, he looked tired but insisted he felt fine. Without a CD4 test, Bosede had to rely on symptomatic screening, a method she knew could miss up to half of the cases of advanced HIV disease (AHD).
Joseph was one of those missed cases. By the time his opportunistic infections became undeniable, his CD4 count was catastrophically low. He was fighting for his life, a battle that could have been prevented. Joseph’s story was not an isolated tragedy; it was a symptom of a larger, systemic failure.
A new, urgent policy brief from the Center for Global Health Policy & Politics and the Fight AIDS Coalition (FAC) lay on Bosede’s desk, its title a stark summary of her daily reality: “Reviving CD4 Monitoring to End AIDS Deaths”. The brief confirmed what she and clinicians across the continent already knew: the deliberate de-prioritization of CD4 testing was costing lives. Every minute, a person dies from an AHD-related illness, a grim statistic fueled by delayed diagnosis.
CD4 cells are the “alarm bells” of the immune system, the very cells that HIV targets and destroys. Monitoring their count is essential to gauge the health of a person living with HIV (PLHIV) and their risk of opportunistic infections. The World Health Organization (WHO) has long called CD4 testing the “gateway to AHD care”—the crucial first step to accessing a life-saving package of services, including screening for tuberculosis and cryptococcal meningitis, and preventive therapies.
Yet, this gateway was closing. The brief detailed a disturbing policy evolution. Following the WHO’s 2016 “Treat-All” recommendation, which advocated for starting everyone on ARVs regardless of their CD4 count, and a shift to using viral load (VL) testing to monitor treatment efficacy, resources were massively redirected.
This pivot, while well-intentioned, overlooked a critical reality: CD4 monitoring’s role had evolved, not become obsolete. Recent data showed that two-thirds of people with AHD were already on ARVs, and nearly half had suppressed viral loads. Adherence to ARVs alone cannot prevent AHD, making CD4 monitoring at key moments—like entering or re-entering care—absolutely vital.
The consequences were clear and devastating. In sub-Saharan Africa, CD4 testing coverage plummeted from 58–86% in 2005 to just 13–53% by 2019. In Uganda, baseline CD4 testing fell from 73% in 2013 to 21% in 2018. This decline in demand created a vicious cycle: stifled innovation and market exits by major diagnostic manufacturers like Abbott and BD, leading to fragile supply chains and frequent stockouts.
The policy brief, drawing on data from the HIV Policy Lab, painted a stark picture of policy adoption across sub-Saharan Africa. While 31 out of 33 countries had adopted baseline CD4 testing for individuals newly entering care, a staggering only 13 of these 31 countries had extended this essential testing to those returning to care—a population at incredibly high risk, with up to 60% re-entering with AHD. Even where strong policies existed on paper, implementation was weak, with coverage rates as low as 18% in some countries.
The situation on the ground, as detailed in country updates from Kenya and Malawi, was a testament to these statistics. In Kenya, a hub-and-spoke model for testing meant that machines were concentrated in high-volume facilities, creating a geographic lottery for patients.
Someone in the northern region might face an impossible journey to get a test. Compounding this, funding cuts from the U.S. government led to clinic closures and layoffs of trained healthcare workers, leaving a critical knowledge gap. Kenya’s CD4 testing rate stood at a dismal 6%.
Malawi faced similar struggles. Only 14% of its ART sites had CD4 testing platforms available. And while its overall coverage was higher at 67%, a steady decline in recent quarters pointed to systemic weaknesses, exacerbated by donor dependency and frequent stockouts.
This crisis is unfolding under the shadow of sharp reductions in international HIV funding. Even a brief interruption in support, as a modeling study warned, could set back the goal of ending AIDS as a public health threat by decades. The Global Fund, facing its own funding cuts, has classified CD4 testing as “Program Essential,” but advocates fear budget lines could be cut or buried, erasing visibility and accountability.
But as the brief powerfully argues, this grim scenario is not irreversible. The path forward lies in a concerted effort to revive CD4 monitoring, championed by a coalition of communities, clinicians, and governments who embody the “will to power” needed for change.
The policy brief doesn’t just diagnose the problem; it outlines a clear, actionable strategy to restore and sustain access to CD4 diagnostics. It echoes the call to action from the Nairobi Declaration, a landmark commitment signed by ministries of health, civil society organizations, and researchers from across Africa. The declaration lays out a comprehensive roadmap with immediate, medium-term, and long-term actions.
In the immediate term, the call is for national programs to mobilize domestic resources to counter the funding crisis, map their existing diagnostic networks, and for manufacturers to commit to sustainable pricing. In the medium-term, the focus is on scaling up testing, engaging with industry on service agreements, and establishing robust monitoring frameworks to track what gets measured—because what gets measured gets done. And in the long-term, the vision is for regional manufacturing, technology transfer for discontinued platforms, and the development of new, simplified, and affordable point-of-care tests.
Inspired by the success of the 95-95-95 targets for HIV treatment, advocates are now pushing for a new set of ambitious goals for AHD: by 2030, 95% of those at risk should receive a CD4 test; 95% of those eligible should be screened for major opportunistic infections; and 95% of those who test positive should receive treatment. The first target is the linchpin; without it, the others cannot be achieved.
For Dr. Adebayo, the brief was more than a document; it was a blueprint for hope. It was a call to fight for patients like Joseph by demanding that governments not only adopt but fully implement policies for CD4 testing at entry, reentry to care, and for anyone with treatment failure. It was a tool for civil society to hold donors and governments accountable, using data from platforms like CHAI’s CD4 Needs Calculator to ensure that demand is accurately forecasted and met.
Leaving the clinic, Bosede felt a renewed sense of purpose. The challenges were immense—fragile supply chains, funding cuts, political inertia. But the solution was clear. It was time to revive CD4 monitoring, to reopen the gateway to care, and to ensure that no more lives are needlessly lost to a preventable and treatable condition. The fight to end AIDS deaths had a new, urgent frontline, and it began with a simple, essential test.
