Clinical impact and cost-effectiveness of the WHO-recommended advanced HIV disease package of care

Emily P. Hyle, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA; Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA. Electronic address: ehyle@mgh.harvard.edu.
Thulani Maphosa, Elizabeth Glaser Pediatric AIDS Foundation Malawi, Lilongwe, Malawi.
Ajay Rangaraj, Department of Global HIV, Hepatitis, and Sexually Transmitted Diseases, World Health Organization, Geneva, Switzerland.
Mary Feser, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.
Geoffrey C. Singini, Elizabeth Glaser Pediatric AIDS Foundation Malawi, Lilongwe, Malawi.
Prakriti Shrestha, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.
Amir Shroufi, HIV Team, The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland.
Krishna P. Reddy, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA; Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
Eddie Matiya, Elizabeth Glaser Pediatric AIDS Foundation Malawi, Lilongwe, Malawi.
Rosalia Dambe, Elizabeth Glaser Pediatric AIDS Foundation Malawi, Lilongwe, Malawi.
Virginia R. Talbot, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.
Rachel Chamanga, Elizabeth Glaser Pediatric AIDS Foundation Malawi, Lilongwe, Malawi.
C Robert Horsburgh, Department of Epidemiology, Biostatistics, Global Health and Medicine, Boston University, Boston, MA, USA.
Milton C. Weinstein, Department of Health Policy and Management, Harvard T H Chan School of Public Health, Boston, MA, USA.
Rose K. Nyirenda, Division of HIV and AIDS, Ministry of Health, Government of Malawi, Lilongwe, Malawi.
Nathan Ford, Department of Global HIV, Hepatitis, and Sexually Transmitted Diseases, World Health Organization, Geneva, Switzerland; Centre for Integrated Data and Epidemiological Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
Appolinaire Tiam, Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, USA; Department of Epidemiology, The George Washington University Milken Institute School of Public Health, Washington, DC, USA.
Andrew Phillips, HIV Modelling Consortium, Institute for Global Health, University College London, London, UK.
Kenneth A. Freedberg, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA; Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA; Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Department of Health Policy and Management, Harvard T H Chan School of Public Health, Boston, MA, USA.

Document Type

Journal Article

Publication Date

8-1-2025

Journal

The Lancet. Global health

Volume

13

Issue

8

DOI

10.1016/S2214-109X(25)00190-1

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.

Department

Epidemiology

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