Abstract
Background: Sierra Leone, with a low adult HIV prevalence (~1.6-1.7%), faces uneven progress toward the UNAIDS 95-95-95 targets, with significant gaps in diagnosis, viral load (VL) coverage, and key population reach. Methods: A narrative review (January 2013-June 2024; final search 30 June 2024) synthesized national reports and peer-reviewed articles on Sierra Leone's HIV cascade and systemic determinants. Data focused on diagnosis, treatment, suppression, and cross-cutting issues (e.g., stigma, supply chain). Results: In 2023, of an estimated 82,000 people living with HIV (PLHIV), 80% (65,600) were diagnosed. Of those diagnosed, 87% (57,072) were on antiretroviral therapy (ART), and 44% of those on ART (25,112) were virally suppressed. VL testing covered 68% of ART patients (38,812), suggesting incomplete coverage may underestimate true population-level suppression if untested patients are less likely to be suppressed. Key bottlenecks include limited VL platforms, commodity stockouts of antiretrovirals, stigma (especially for female sex workers), adolescent retention gaps, absent drug resistance surveillance, fragmented data systems, and donor-dependent financing. Conclusions: Progress is tangible but fragile. Prioritizing detection (first 95) through scaled testing, alongside VL network strengthening, differentiated service delivery (e.g., six-month multi-month dispensing), stigma monitoring, drug resistance surveillance, and sustainable financing roadmaps, is essential. Targeted research on implementation and cost-effectiveness will support equitable attainment of HIV 2030 goals.