More than four decades into the global HIV epidemic, one of the most sobering findings in modern HIV medicine remains how late many patients still arrive at the clinic. A new prospective cohort study from Ibn Rochd University Hospital in Casablanca, published in BMC Infectious Diseases, offers a detailed snapshot of who is being diagnosed with HIV in Morocco today, how sick they are when the diagnosis is finally made, and what happens to them during the critical first six months of antiretroviral therapy. The picture that emerges is one of persistent late presentation, a heavy burden of tuberculosis coinfection, and early deaths that are tightly linked to advanced immunosuppression at the moment of diagnosis.
The research team, led by Ahd Ouladlahsen of the Faculté de Médecine et de Pharmacie at Hassan II University and the infectious diseases service of CHU Ibn Rochd, enrolled 396 consecutive adults newly diagnosed with HIV between January 1 and December 31, 2023. Unlike retrospective chart reviews, this was a prospective cohort: demographic, clinical, laboratory, and treatment outcome data were systematically collected as patients moved through care. The investigators then used multivariable logistic and Cox regression models to identify independent predictors of three key outcomes: advanced HIV disease at presentation, virological failure at six months, and all-cause mortality. The study was approved by the Ethics Committee of the Faculty of Medicine in Rabat and conducted in accordance with the Declaration of Helsinki, with informed consent obtained from all participants.
The demographic profile of the cohort reflects a mixture of social vulnerability and mobility. The median age was 34 years, with a range spanning 18 to 74, and men made up 55 percent of newly diagnosed patients. Most participants were single, 60.1 percent, and nearly half, 46.1 percent, were unemployed. Perhaps the most striking socioeconomic figure is that 83.6 percent of patients had no health insurance, a factor that shapes both access to testing and the ability to remain in care. Nearly one in five patients, 19.9 percent, were of Sub-Saharan African origin, underscoring the role of migration corridors in the regional epidemiology of HIV and the need for screening strategies that reach migrant populations effectively.
Transmission patterns in the cohort were dominated by heterosexual contact, which accounted for 72.0 percent of new diagnoses. That figure matters for public health planning because it signals that HIV in this setting is not confined to networks traditionally classified as key populations; it is embedded in the general adult population. At the same time, the way patients entered care is perhaps the most consequential finding of the entire study: symptoms prompted the diagnosis in 58.9 percent of cases. In other words, the majority of people were not identified through proactive, voluntary testing but because something was already clinically wrong, which almost by definition implies that the virus had been replicating, and the immune system deteriorating, for a considerable period before anyone looked for it.
The immunological data confirm just how far disease had progressed by the time of diagnosis. The median baseline CD4 count was 186 cells per cubic millimeter, well below the 200-cell threshold that defines one of the classic boundaries of severe immunosuppression, and 60.6 percent of patients presented with CD4 counts below that mark. Under the Centers for Disease Control and Prevention staging system, 41.4 percent of patients were already at stage C, the stage corresponding to AIDS-defining illness. Tuberculosis was the leading opportunistic infection, affecting 35.1 percent of the cohort. This convergence of low CD4 counts, advanced clinical staging, and rampant tuberculosis coinfection paints a portrait of an epidemic in which the virus is being discovered only after it has done most of its damage, a pattern that global health authorities have repeatedly identified as one of the chief obstacles to ending AIDS as a public health threat.
Treatment outcomes at six months tell a more nuanced story. On the positive side, 75.0 percent of patients achieved viral suppression within half a year of starting therapy, a respectable figure for a cohort in which most patients began treatment profoundly immunocompromised. The backbone of modern first-line therapy in the region is dolutegravir-based antiretroviral therapy, and the suppression rate suggests that when patients reach care and start the recommended regimens, the drugs largely do their job. However, 10.0 percent of patients experienced virological failure at six months, and overall mortality in the cohort reached 8.3 percent. An early death rate approaching one in twelve among newly diagnosed patients is a direct consequence of late presentation: people who arrive with CD4 counts below 200 cells per cubic millimeter and active tuberculosis face a fundamentally different prognosis than those identified early.
The regression analyses sharpen these associations into a hierarchy of risk. For mortality, four independent predictors emerged: a CD4 count below 200 cells per cubic millimeter carried an adjusted hazard ratio of 3.67, by far the strongest signal in the model; age of 40 years or older carried an adjusted hazard ratio of 1.62; active tuberculosis carried an adjusted hazard ratio of 2.56; and higher baseline viral load carried an adjusted hazard ratio of 1.18. Each of these factors is, in principle, addressable. CD4 nadir and viral load at diagnosis are proxies for how long infection went undetected; tuberculosis coinfection can be prevented or caught earlier through integrated TB/HIV screening; and age is a reminder that testing strategies must not neglect middle-aged and older adults who are rarely the focus of HIV awareness campaigns.
Advanced HIV disease at presentation was itself predicted by a distinct cluster of characteristics: age of 40 or older, Sub-Saharan African origin, unemployment, divorced or widowed status, and tuberculosis. Read together, these predictors describe patients who sit at the intersection of biological and social risk. Unemployment and lack of insurance limit both the incentive and the means to seek voluntary testing, while marital status may affect disclosure, support, and health-seeking behavior. For migrants, language barriers, documentation concerns, and discontinuous access to health systems can delay entry into care for years. The finding that virological failure at six months was independently predicted by advanced HIV disease at baseline, with an adjusted odds ratio of 1.85, higher baseline viral load, with an adjusted odds ratio of 1.92 per log10 increase, and receipt of non-TDF/3TC/DTG regimens, with an adjusted odds ratio of 1.89, adds a therapeutic dimension: patients who start treatment with very high viral burdens and non-standard regimens are the ones most likely to fail, reinforcing the case for prompt diagnosis and rapid initiation of preferred first-line therapy.
The authors are careful about the limits of their work. This was a single-center study at a tertiary referral hospital in Casablanca, which means the cohort may overrepresent complicated cases referred from elsewhere while underrepresenting people diagnosed and managed entirely in primary care. Some analyses were restricted to subsets of patients: the advanced disease model included 236 patients with available CD4 data, and the virological failure model included 280 patients with six-month viral load measurements. The investigators themselves call for multi-center validation with extended follow-up, noting that six months captures early treatment outcomes but not the longer arc of retention, adherence, and survival.
Even with those caveats, the policy implications are difficult to ignore. The study argues for expanded community-based screening so that diagnoses are driven by testing rather than by symptoms, integrated TB/HIV services capable of detecting coinfection at or before the moment of HIV diagnosis, socioeconomic support for unemployed and uninsured patients whose life circumstances compete with clinic attendance, and enhanced, culturally competent screening for migrant populations. Dolutegravir-based therapy has already proven capable of suppressing the virus in three-quarters of newly diagnosed patients within six months; the remaining losses, the deaths, the failures, the late presentations, are largely problems of timing and access rather than of pharmacology. In that sense, the Casablanca cohort is less a story about the virus than about the systems that fail to intercept it, and a reminder that in 2023, in a Moroccan tertiary care center, the median person diagnosed with HIV had a CD4 count of 186 cells per cubic millimeter, a number that should be an anachronism but is not.
Subject of Research: Epidemiological and clinical profile of newly diagnosed HIV patients in Morocco
Article Title: Epidemiological and clinical profile of newly diagnosed HIV patients at a moroccan tertiary care center in 2023
Article References: Ouladlahsen, A., Lkhider, M., Haddaji, A., Bensghir, R., Badi, H., Sodqi, M., Ihbibane, F., Marih, L., Ezzikouri, S., & El Filali, K. M. (2026). Epidemiological and clinical profile of newly diagnosed HIV patients at a moroccan tertiary care center in 2023. BMC Infectious Diseases. https://doi.org/10.1186/s12879-026-14422-z
Image Credits: AI Generated
DOI: 10.1186/s12879-026-14422-z
Keywords: HIV, late diagnosis, Morocco, tuberculosis, antiretroviral therapy, dolutegravir, CD4 count, virological suppression, opportunistic infections, Sub-Saharan migrants, public health, Casablanca
News Source: Ophelia Keating. (October 6, 2026). Late HIV Diagnosis Persists in Morocco as TB Coinfection and Early Deaths Mount. Scienmag.
