Impact of a Phased Transition Model on Advanced HIV Disease Outcomes: A Pre- and Post-Implementation Evaluation Study in Malawi

BackgroundTo 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, including clinical service delivery, diagnostics, provider mentorship, and reporting systems, from implementing 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. MethodsA retrospective cohort study was conducted involving 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 followed national AHD criteria: CD4 count <200 cells/mm3, WHO stage 3 or 4 illness, or age <5 years. AHD clients data were abstracted from clinical records and linked across routine facility registers to assess diagnostic and treatment indicators. 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. ResultsA total of 1,044 AHD clients were included (553 pre-transition; 491 post-transition) in the evaluation. Median age increased post-transition (35.9 to 38.5 years, p<0.001). CD4 testing declined (80.7% to 46.0%, p<0.001) testing uptake, 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 significantly declined 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). ConclusionsTransitioning AHD services to MoH leadership sustained key program outcomes and significantly reduced mortality. Continued mentorship and government ownership were key drivers of success. However, declines in CD4 testing and TPT coverage highlight the need for strengthened diagnostics and preventive care integration. These findings support scaling nationally-led AHD models in high-burden HIV settings.