Abstract
BACKGROUND: In sub-Saharan Africa, 20-40% of people living with HIV present with advanced HIV disease (AHD), which can be diagnosed, treated, and prevented using a package of care recommended by WHO. We aimed to project the cost-effectiveness and budget impact of the WHO-recommended AHD package in Malawi. METHODS: Using the Cost-Effectiveness of Preventing AIDS Complications-International model, we simulated a cohort of non-hospitalised people living with HIV (aged >19 years) initiating antiretroviral therapy (ART), 25% of whom had AHD (CD4 count <200 cells per μL and/or WHO stage 3 or 4 disease). We assessed 13 increasingly comprehensive strategies, ranging from ART only to the WHO-recommended AHD package, including tuberculosis diagnostics (ie, sputum Xpert and urine lipoarabinomannan), tuberculosis preventive therapy, serum cryptococcal antigen (CrAg) screening with pre-emptive fluconazole treatment if CrAg-positive, and co-trimoxazole to prevent bacterial infections. Model outcomes included 1 year survival, life expectancy, costs, and incremental cost-effectiveness ratios (ICERs, US$ per quality-adjusted life-year [QALY]); we considered a strategy cost-effective if the ICER was less than $600 per QALY (based on 2023 Malawi per capita gross domestic product). FINDINGS: ART only resulted in life expectancy of 17·45 undiscounted QALYs and discounted lifetime costs of $1450. All other strategies would increase both QALYs and costs. The WHO-recommended AHD package would result in the greatest life expectancy (19·30 undiscounted QALYs) and be cost-effective (ICER $580 per QALY). AHD prevalence and intervention efficacy had the greatest influence on ICERs; however, the WHO-recommended AHD package would remain cost-effective over a wide range of estimates. INTERPRETATION: The WHO-recommended AHD package of care at ART initiation would provide substantial clinical benefits and be cost-effective in Malawi. This package for AHD should be made widely available in Malawi and similar settings. FUNDING: WHO, the HIV Modelling Consortium within the Institute for Global Health at University College London, the Bill & Melinda Gates Foundation, the National Institute of Allergy and Infectious Diseases, the Massachusetts General Hospital Jerome and Celia Reich Endowed Scholar in HIV/AIDS Research Award, and the Steve and Deborah Gorlin Massachusetts General Hospital Research Scholars Award. TRANSLATION: For the Chichewa translation of the abstract see Supplementary Materials section.