Advancing Toward the UNAIDS 95‑95‑95 Targets in Sierra Leone: A Narrative Review of Progress, Persistent Gaps, and Policy Priorities

Review rationale and objectives

This narrative review summarizes Sierra Leone’s progress toward UNAIDS 95‑95‑95 indicators using standard definitions, analyzes structural/programmatic bottlenecks, identifies research and implementation gaps, and proposes prioritized policy actions.

Conceptual framework

A cascade‑oriented framework positioned inputs (governance, financing, commodities, workforce, data systems) as determinants of outputs (testing, ART initiation, retention, VL coverage, suppression) and outcomes (reduced transmission/mortality). Stigma and rights contexts were cross‑cutting modifiers [1, 3–11].

Information sources

Data were sourced from peer‑reviewed literature (PubMed, Google Scholar), National AIDS Secretariat (NAS) strategic reports (2013–2024), PEPFAR (President’s Emergency Plan for AIDS Relief) Country Operational Plan summaries, Global Fund performance reports, UNAIDS updates, WHO guidelines, UNICEF briefs, and World Bank indicators. The search period spanned January 2013 to 30 June 2024 (final search). 2023 cascade indicators (e.g., PLHIV estimates, diagnosis, ART coverage, VL suppression) were derived from UNAIDS global updates and PEPFAR summaries, which aggregate data from Sierra Leone’s NAS, Ministry of Health (MoH) surveillance, and spectrum modelling for prevalence/incidence estimates. These secondary sources compile primary programme and facility data, with methodologies detailed in respective reports [1, 5].

Eligibility and synthesis

Inclusion focused on documents with quantitative or qualitative data on Sierra Leone’s HIV cascade or systemic determinants, and regionally relevant (West/Central Africa) evidence from 2013 to 2024. Exclusions were non‑English sources, purely clinical trials, conference presentations, and editorials without empirical content. Extracted variables included PLHIV estimates, diagnosis/treatment/suppression rates, VL coverage, stockouts, stigma, drug resistance surveillance, and financing shares. Narrative synthesis grouped determinants, distinguishing observed data from modelled estimates. Potential biases (e.g., model uncertainty, incomplete VL ascertainment, stigma under‑reporting) were considered, with extrapolations from regional evidence explicitly framed [10–21]. Detailed search strategies and data extraction matrices are available in a supplementary file to maintain brevity.

Epidemiological overview

As of 2023, Sierra Leone had an estimated 82,000 PLHIV, with prevalence stable at 1.5–1.7% per 2019 Demographic and Health Surveys (DHS), though more recent UNAIDS estimates are prioritized for cascade analysis [1–3]. Of these, 80% (65,600) knew their status, 87% of diagnosed (57,072) were on ART, and 44% of those on ART (47,945) achieved viral suppression (<1000 copies/mL). VL testing covered 68% of ART patients (38,812), with 88% of tested (34,154) conditionally suppressed, suggesting underestimation of population‑level suppression if untested patients have poorer outcomes [1–3]. Table 1 provides detailed UNAIDS 95‑95‑95 cascade data for Sierra Leone in 2023.

Key populations (e.g., female sex workers, men who have sex with men) face elevated rates (12–15%), while adolescent girls and vertical transmission contribute to paediatric cases due to gaps in the elimination of mother‑to‑child transmission programme, including early infant diagnosis [2, 3, 12, 13]. Modelled incidence shows a gradual decline, but slow prevention scale‑up (e.g., pre‑exposure prophylaxis (PrEP), condom promotion) limits faster progress [3]. Compared to West African peers (e.g., Nigeria ~1.3%, Côte d’Ivoire ~2.4%), Sierra Leone’s burden is modest, yet 95‑95‑95 progress lags, especially in diagnosis and VL coverage [1–3, 8].

Figure 1 illustrates HIV prevalence and 95‑95‑95 progress by district alongside key VL testing facilities (e.g., Western Area Urban, Bo, Kenema, Makeni, Koidu), highlighting regional disparities [2, 3]. Data granularity is limited for some districts [1–3].

Figure 1

The GeneXpert platform is a rapid, automated molecular diagnostic system that utilizes polymerase chain reaction (PCR) technology to detect and monitor diseases, including HIV. It is designed for near‑point‑of‑care testing, offering quick turnaround times for VL monitoring, which is critical for managing HIV treatment and ensuring viral suppression. The cobas® 5800 System, developed by Roche Diagnostics, is an advanced automated molecular diagnostic instrument specifically engineered for both quantitative and qualitative nucleic acid testing. It provides high‑throughput capabilities for VL testing, enabling precise measurement of HIV RNA levels in patient samples, which is essential for assessing treatment efficacy and disease progression. In the context of the Table 2, the presence of these platforms at various hospitals across Sierra Leone indicates the capacity for VL testing, with only Makeni Government Hospital and PCMH/ODCH equipped with both GeneXpert and cobas® 5800 systems, while most facilities rely solely on the GeneXpert platform. Regional disparities persist, with Western regions showing a higher prevalence than Northern/Eastern areas.

Progress and gaps across 95‑95‑95

First 95 (Diagnosis): Nationally, 80% of PLHIV (65,600/82,000) are diagnosed, the lowest indicator and critical for epidemic control. Disparities exist by sex (women 92%, men 85%) and age (15–24: 77%, 50+: 94%), with young males least aware. Barriers include stigma, test kit stockouts, and rural access gaps; opportunities lie in self‑testing and community outreach [1–3, 22]. Provider‑initiated testing in antenatal and TB clinics nears saturation (e.g., > 98% TB patients tested), but index testing and male engagement lag [3–5, 8]. (See Supplementary Table 1 for detailed progress toward 95‑95‑95 targets by sex and age group). (See Supplementary Table 2 for principal barriers and opportunities across the 95‑95‑95 cascade).

Second 95 (Treatment): Of those diagnosed, 87% (57,072/65,600) are on ART, with women (86%) and older adults (89%) outperforming adolescents and young people (15–24 years) (70%). ART scale‑up, aligned with test‑and‑treat and dolutegravir rollout, reduces pre‑ART attrition, yet retention is challenged by transport costs, disclosure issues, and stockouts. Differentiated service delivery (DSD), including three‑month dispensing (all districts) and pilot six‑month multi‑month dispensing (MMD), improves adherence, though rural scale‑up is limited [1, 3, 15, 23]. Peer support aids retention but faces stipend discontinuity [14–16].

Third 95 (Suppression): Of those on ART, 44% (25,112/57,072) are suppressed, though only 68% received a VL test, with 88% of those tested suppressed. This discrepancy suggests underestimation if untested patients fare worse. VL platforms (six total) are urban‑concentrated, with delays in sample transport and result turnaround. Adolescents and young people (46% suppression among tested) and rural areas lag, necessitating near point‑of‑care solutions [1–3, 8, 24].

Key populations and equity

Key populations face heightened risks. Female sex workers (prevalence ~11%) encounter inconsistent condom use and economic pressures, with peer‑led testing increasing uptake, but retention is challenged by mobility and harassment [11, 14, 25]. Men who have sex with men, lacking robust data, avoid facilities due to layered stigma, needing discreet self‑testing and safe clinics [11, 14]. Adolescents and young people struggle with confidentiality and transition to adult care, showing lower diagnosis (77%) and suppression (46%), requiring adolescents and young people to be responsive to DSD [12, 13, 25]. Pregnant women benefit from antenatal testing but face postpartum retention gaps, while orphans and vulnerable children risk adherence lapses due to caregiver instability [3, 12, 26]. Data on mobile/mining workers is sparse, warranting targeted outreach [3, 4]. (See Supplementary Table 3 for current data availability and priority interventions for key populations.)

Key systemic barriers

Systemic challenges constrain Sierra Leone’s HIV response. Stigma, spanning anticipated and enacted forms, deters service uptake, especially among key populations, with limited monitoring or grievance mechanisms [11, 14, 26]. Workforce shortages and uneven urban–rural distribution limit service quality, despite task‑shifting to nurses and other cadres of healthcare workers [27]. Fragmented data systems without universal patient identifiers hinder cascade tracking and cohort analysis [28, 29]. Supply chain gaps, including forecasting inaccuracies and stockouts, disrupt commodity availability, exacerbated by poor real‑time visibility [30]. Donor‑dependent financing (e.g., PEPFAR, Global Fund) risks sustainability amid fiscal constraints, with potential post‑2024 drawdowns beyond this review’s scope (data up to June 2024); a domestic funding roadmap is urgent [31, 32]. Past shocks (Ebola, COVID‑19, Mpox) exposed resilience gaps, though MMD mitigated some disruptions [32]. Addressing these requires integrated logistics systems, stigma reduction tools, digital interoperability, and sustainable financing strategies [34–35].

Strategic policy implications

Service delivery: Shift from expansion to optimization by prioritizing diagnosis (first 95) through scaled self‑testing via pharmacies, academic institutions, and community networks, supported by peer navigators [22, 28]. Universalize six‑month MMD for stable adults, decongesting clinics, and integrate adolescent‑responsive hours to narrow retention gaps [15, 32].

Laboratory and supply chain: Optimize VL access with hub‑and‑spoke networks and near point‑of‑care devices for priority groups (e.g., pregnant women, adolescents, and young people), supported by barcode tracking and maintenance contracts [8, 24, 33]. Deploy integrated logistics systems for stock visibility to prevent stockouts [30].

Stigma and rights: Institutionalize stigma reduction via facility sensitizations, confidential grievance systems, and community dialogues with faith leaders, monitoring impact with validated scales [14, 25].

Financing and data: Develop a medium‑term domestic financing roadmap to mitigate donor transition risks, leveraging DSD efficiencies [31]. Harmonize unique patient identifiers and interoperable electronic records for accurate cascade tracking [26, 29]. (See Supplementary Table 5 for detailed systems bottlenecks, priority actions, indicators, and timelines.)

Limitations of this narrative review

This review synthesizes heterogeneous sources with variability in indicator definitions and data quality, limiting comparability. Reliance on 2019 DHS for some prevalence data may not reflect current trends, though 2023 UNAIDS/PEPFAR figures are prioritized [1–3]. Non‑systematic search methods may omit grey literature, and national aggregates obscure district‑level disparities. Sparse data on key populations, adolescent and young people adherence, and post‑June 2024 events (e.g., 2025 donor funding changes) restrict analysis; future research should address these gaps. Absence of real‑time drug resistance data limits assessment of dolutegravir resistance patterns [16, 18]. (See Supplementary Table 4 for prioritized research and implementation evidence gaps, including drug resistance surveillance and cost‑effectiveness studies.)