Impact of a phased transition model on Advanced HIV Disease outcomes: A pre- and post-implementation evaluation study...

To promote sustainability and strengthen national ownership of Advanced HIV Disease (AHD) services, a transition was implemented across 22 health facilities in Central Malawi. This transition involved shifting responsibility for key AHD program elements from partner-led implementation to full Ministry of Health (MoH) leadership. This evaluation assessed the impact of this transition on diagnostic coverage, TB preventive therapy (TPT) uptake, and 12-month survival outcomes. A retrospective cohort study included all children and adults enrolled in AHD care during the pre-MoH transition (January 2020-December 2021) and post-MoH transition (January 2023-December 2024) periods. Eligibility was defined by national AHD criteria: CD4 count <200 cells/mm³, WHO stage 3 or 4 disease, or age < 5 years. Data were abstracted from clinical records and routine facility registers. Kaplan-Meier survival curves, Cox proportional hazards, and Fine and Gray competing risk models were used to evaluate 6 and 12-month mortality and retention as primary outcomes. A total of 1,044 AHD clients were included (553 pre-transition; 491 post-transition). Median age increased post-transition (35.9 to 38.5 years, p < 0.001). CD4 testing uptake declined (80.7% to 46.0%, p < 0.001), while WHO staging and TB diagnostic coverage improved. TB diagnoses decreased (44.5% to 31.2%, p = 0.002). TPT uptake dropped from 46.4% to 31.6% (p < 0.001). Twelve-month mortality declined significantly from 9.4% to 5.5% (adjusted hazard ratio [aHR] = 0.59, 95% CI: 0.37-0.94, p = 0.026). Retention in care remained stable (HR = 0.86, 95% CI: 0.62-1.20, p = 0.384). Transitioning AHD services to MoH leadership was associated with sustained key program outcomes and a significant reduction in mortality. Continued mentorship and government ownership appeared to support these outcomes, although the pre-post design precludes causal inference. Declines in CD4 testing and TPT coverage highlight the need to strengthen diagnostics and integrate preventive care. These findings support scaling nationally led AHD models in high-burden HIV settings.