Constructed wetlands offer a promising low-cost solution for wastewater management in water-scarce regions, yet the role of macrophyte planting density in treatment performance remains insufficiently characterized. This study investigates the effect of Phragmites australis planting density on treatment efficiency in horizontal subsurface flow constructed wetlands under semi-arid conditions in Aghmat, Morocco. Three pilot-scale units, planted at low density (5 stems m⁻²), high density (9 stems m⁻²), and an unplanted control, were monitored over 120 days. Planted systems significantly outperformed the unplanted control across all parameters, achieving removal efficiencies of approximately 92% for chemical oxygen demand, 73–78% for total suspended solids, 60% for nitrogen, up to 77% for phosphorus, and over 90% for pathogenic indicators. No significant difference between density treatments was observed for physicochemical or bacteriological parameters; however, density-specific effects emerged for plant growth and microbial activity: high-density planting enhanced shoot development and nitrification, while low-density planting favored greater aboveground biomass and soil enzyme activity. These results indicate that macrophyte presence is the main driver of treatment efficiency, while planting density plays a secondary yet functionally important role in plant–microbe interactions. Overall, the findings provide practical guidance for designing and optimizing nature-based wastewater treatment systems in arid and semi-arid regions.