System-level barriers to HIV service delivery in five African countries: a comparative policy analysis for health systems strengthening

Background: Despite substantial progress in expanding HIV prevention, testing, and treatment services, sub-Saharan Africa continues to bear a disproportionate share of the global HIV burden. Progress toward epidemic control remains uneven, with persistent gaps in service delivery linked to broader health system constraints. Objectives: This study provides a comparative, policy-oriented analysis of health system barriers affecting HIV responses in five African countries, Central African Republic, Comoros, Guinea, Madagascar, and Burkina Faso, and identifies cross-cutting structural constraints and priority areas for health systems strengthening. Methods: The study was conducted as a comparative policy-oriented evidence synthesis drawing on purposively selected peer-reviewed studies and programmatic reports published between 2018 and 2025. Sources were identified through iterative searches of bibliographic databases and institutional repositories, including reports from global health agencies. Evidence was selected based on relevance to HIV service delivery and health system performance in the five study countries. Findings were analysed using a framework-based thematic approach guided by the World Health Organization health system building blocks. The analysis focused on identifying recurrent system-level barriers, cross-country patterns, and interactions between health system components affecting HIV programme implementation. Results: Evidence from 60 sources consistently identified interrelated barriers affecting HIV service delivery across the five countries. Key constraints included limited HIV testing coverage in rural and underserved populations, delayed treatment initiation, inadequate laboratory capacity for viral load monitoring, supply chain disruptions affecting diagnostics and antiretroviral medicines, and persistent stigma affecting service uptake. Weak health information systems and shortages of trained health workers further constrained programme performance. These barriers were observed across multiple countries, indicating shared structural weaknesses in core health system functions rather than isolated national challenges. Conclusions: Persistent gaps in HIV service delivery across diverse African settings are driven by interconnected health system constraints rather than programme-specific failures. Strengthening laboratory infrastructure, improving supply chain management, expanding community-based HIV testing strategies, and addressing stigma-related barriers are critical to accelerating progress toward epidemic control in resource-constrained settings. These findings highlight the need for coordinated, system-level reforms to improve HIV service delivery in resource-constrained settings and provide policy-relevant insights for governments and global health partners.