{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,23]],"date-time":"2026-10-23T17:41:47Z","timestamp":1792777307976,"version":"4.5.0"},"reference-count":22,"publisher":"Public Library of Science (PLoS)","issue":"10","license":[{"start":{"date-parts":[[2026,10,23]],"date-time":"2026-10-23T00:00:00Z","timestamp":1792713600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Bill & Melinda Gates Foundation","award":["INV-004547"],"award-info":[{"award-number":["INV-004547"]}],"id":[{"id":"https:\/\/ror.org\/0456r8d26","id-type":"ROR","asserted-by":"crossref"}]}],"content-domain":{"domain":["www.plosglobalpublichealth.org"],"crossmark-restriction":false},"short-container-title":["PLOS Glob Public Health"],"abstract":"<jats:p>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\u2013December 2021) and post-MoH transition (January 2023\u2013December 2024) periods. Eligibility was defined by national AHD criteria: CD4 count &lt;200 cells\/mm\u00b3, WHO stage 3 or 4 disease, or age\u2009&lt;\u20095 years. Data were abstracted from clinical records and routine facility registers. Kaplan\u2013Meier 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\u2009&lt;\u20090.001). CD4 testing uptake declined (80.7% to 46.0%, p\u2009&lt;\u20090.001), while WHO staging and TB diagnostic coverage improved. TB diagnoses decreased (44.5% to 31.2%, p\u2009=\u20090.002). TPT uptake dropped from 46.4% to 31.6% (p\u2009&lt;\u20090.001). Twelve-month mortality declined significantly from 9.4% to 5.5% (adjusted hazard ratio [aHR] = 0.59, 95% CI: 0.37\u20130.94, p\u2009=\u20090.026). Retention in care remained stable (HR\u2009=\u20090.86, 95% CI: 0.62\u20131.20, p\u2009=\u20090.384). 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.<\/jats:p>","DOI":"10.1371\/journal.pgph.0006348","type":"journal-article","created":{"date-parts":[[2026,10,23]],"date-time":"2026-10-23T17:33:41Z","timestamp":1792776821000},"page":"e0006348","update-policy":"https:\/\/doi.org\/10.1371\/journal.pgph.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["Impact of a phased transition model on Advanced HIV Disease outcomes: A pre- and post-implementation evaluation study in Malawi"],"prefix":"10.1371","volume":"6","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-5164-8913","authenticated-orcid":true,"given":"Thulani","family":"Maphosa","sequence":"first","affiliation":[{"name":"Elizabeth Glaser Pediatric AIDS Foundation","place":["Lilongwe, Malawi"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rhoderick","family":"Machekano","sequence":"additional","affiliation":[{"name":"Elizabeth Glaser Pediatric AIDS Foundation","place":["Washington, District of Columbia, United States of America"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lise Denoeud","family":"Ndam","sequence":"additional","affiliation":[{"name":"Elizabeth Glaser Pediatric A.I.D.S. Foundation","place":["Geneva, Switzerland"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4646-3425","authenticated-orcid":true,"given":"Lucky","family":"Makonokaya","sequence":"additional","affiliation":[{"name":"Elizabeth Glaser Pediatric AIDS Foundation","place":["Lilongwe, Malawi"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lloyd","family":"Chilikutali","sequence":"additional","affiliation":[{"name":"Elizabeth Glaser Pediatric AIDS Foundation","place":["Lilongwe, Malawi"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Louiser Upile","family":"Kalitera","sequence":"additional","affiliation":[{"name":"Elizabeth Glaser Pediatric AIDS Foundation","place":["Lilongwe, Malawi"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eddington","family":"Matiya","sequence":"additional","affiliation":[{"name":"Elizabeth Glaser Pediatric AIDS Foundation","place":["Lilongwe, Malawi"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Allan","family":"Mayi","sequence":"additional","affiliation":[{"name":"Elizabeth Glaser Pediatric AIDS Foundation","place":["Washington, District of Columbia, United States of America"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0622-2195","authenticated-orcid":true,"given":"Reuben","family":"Musarandega","sequence":"additional","affiliation":[{"name":"Elizabeth Glaser Pediatric AIDS Foundation","place":["Washington, District of Columbia, United States of America"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-1202-0524","authenticated-orcid":true,"given":"Bilal Wilson","family":"Matola","sequence":"additional","affiliation":[{"name":"Elizabeth Glaser Pediatric AIDS Foundation","place":["Lilongwe, Malawi"]},{"name":"Ministry of Health","place":["Lilongwe, Malawi"],"department":["Department of HIV and AIDS"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aida Yemane","family":"Berhan","sequence":"additional","affiliation":[{"name":"Elizabeth Glaser Pediatric AIDS Foundation","place":["Washington, District of Columbia, United States of America"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Allan","family":"Ahimbisibwe","sequence":"additional","affiliation":[{"name":"Elizabeth Glaser Pediatric AIDS Foundation","place":["Lilongwe, Malawi"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Appolinaire","family":"Tiam","sequence":"additional","affiliation":[{"name":"Elizabeth Glaser Pediatric AIDS Foundation","place":["Washington, District of Columbia, United States of America"]},{"name":"George Washington University","place":["Washington, District of Columbia, United States of America"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,10,23]]},"reference":[{"issue":"12","key":"pgph.0006348.ref001","doi-asserted-by":"crossref","DOI":"10.1002\/hsr2.70285","article-title":"Prevalence, Predictors, and Outcomes of HIV Care in HIV-Positive Clients Entering HIV Care With Advanced HIV Disease in Sub-Saharan Africa 2010-2022: Systematic Review and Meta-Analysis","volume":"7","author":"S Haumba","year":"2024","journal-title":"Health Sci Rep"},{"key":"pgph.0006348.ref002","unstructured":"WHO. Identifying common opportunistic infections among people with advanced HIV disease. 2023."},{"issue":"1","key":"pgph.0006348.ref003","doi-asserted-by":"crossref","first-page":"40","DOI":"10.1186\/s12981-020-00296-x","article-title":"Addressing advanced HIV disease and mortality in global HIV programming","volume":"17","author":"AT Boyd","year":"2020","journal-title":"AIDS Res Ther"},{"issue":"9","key":"pgph.0006348.ref004","doi-asserted-by":"crossref","first-page":"2500","DOI":"10.1093\/cid\/ciaa265","article-title":"The Enduring Burden of Advanced Human Immunodeficiency Virus Disease","volume":"71","author":"N Ford","year":"2020","journal-title":"Clin Infect Dis"},{"issue":"3","key":"pgph.0006348.ref005","doi-asserted-by":"crossref","first-page":"283","DOI":"10.1056\/NEJMe1707598","article-title":"The Enduring Challenge of Advanced HIV Infection","volume":"377","author":"N Ford","year":"2017","journal-title":"N Engl J Med"},{"issue":"8","key":"pgph.0006348.ref006","doi-asserted-by":"crossref","first-page":"1683","DOI":"10.1093\/cid\/ciz485","article-title":"Cryptococcal-related Mortality Despite Fluconazole Preemptive Treatment in a Cryptococcal Antigen Screen-and-Treat Program","volume":"70","author":"RM Wake","year":"2020","journal-title":"Clin Infect Dis"},{"issue":"15","key":"pgph.0006348.ref007","doi-asserted-by":"crossref","first-page":"2311","DOI":"10.1097\/QAD.0000000000003695","article-title":"Factors associated with CD4 + cell count recovery among males and females with advanced HIV disease","volume":"37","author":"CryptoART Study team","year":"2023","journal-title":"AIDS"},{"key":"pgph.0006348.ref008","article-title":"Prevalence and factors associated with advanced HIV disease among young people aged 15 - 24 years in a national referral hospital in Sierra Leone: A cross-sectional study","author":"M Baldeh","year":"2023","journal-title":"medRxiv"},{"issue":"1","key":"pgph.0006348.ref009","doi-asserted-by":"crossref","first-page":"244","DOI":"10.1186\/s12913-024-10700-1","article-title":"Understanding health systems challenges in providing Advanced HIV Disease (AHD) care in a hub and spoke model: a qualitative analysis to improve AHD care program in Malawi","volume":"24","author":"T Maphosa","year":"2024","journal-title":"BMC Health Serv Res"},{"issue":"1","key":"pgph.0006348.ref010","doi-asserted-by":"crossref","first-page":"2382","DOI":"10.1186\/s12889-023-17384-y","article-title":"Understanding gender differences of people with HIV newly diagnosed or returning to care with advanced HIV disease in Malawi: a qualitative study","volume":"23","author":"L Katirayi","year":"2023","journal-title":"BMC Public Health"},{"issue":"1","key":"pgph.0006348.ref011","doi-asserted-by":"crossref","first-page":"2802","DOI":"10.1186\/s12889-025-24157-2","article-title":"Impact of an optimized care model for advanced HIV disease: a non-randomized cluster study in Malawi","volume":"25","author":"T Maphosa","year":"2025","journal-title":"BMC Public Health"},{"issue":"6","key":"pgph.0006348.ref012","doi-asserted-by":"crossref","DOI":"10.1136\/bmjgh-2024-018190","article-title":"Supporting local ownership of transition processes: a key pathway to sustaining the HIV response","volume":"10","author":"LM Murphy","year":"2025","journal-title":"BMJ Glob Health"},{"issue":"1","key":"pgph.0006348.ref013","doi-asserted-by":"crossref","first-page":"16","DOI":"10.5334\/aogh.3532","article-title":"Implementing Advanced HIV Disease Care for Inpatients in a Referral Hospital in Malawi - Demand, Results and Cost Implications","volume":"88","author":"T Heller","year":"2022","journal-title":"Ann Glob Health"},{"key":"pgph.0006348.ref014","doi-asserted-by":"crossref","unstructured":"Neel AH, Rodriguez DC, Sikazwe I, Pillay Y, Barron P, Pereira SK, et al. HIV programme sustainability in Southern and Eastern Africa and the changing role of external assistance for health. Health Policy Plan. 2024;39(Supplement_1):i107\u2013i17.","DOI":"10.1093\/heapol\/czad091"},{"key":"pgph.0006348.ref015","first-page":"20499361241251936","article-title":"Prevalence of advanced HIV disease and associated factors among antiretroviral therapy na\u00efve adults enrolling in care at public health facilities in Kampala, Uganda","volume":"11","author":"B Ainembabazi","year":"2024","journal-title":"Ther Adv Infect Dis"},{"issue":"1","key":"pgph.0006348.ref016","doi-asserted-by":"crossref","first-page":"10","DOI":"10.1186\/s12981-022-00433-8","article-title":"Advanced HIV disease management practices within inpatient medicine units at a referral hospital in Zambia: a retrospective chart review","volume":"19","author":"N Mbewe","year":"2022","journal-title":"AIDS Res Ther"},{"issue":"1","key":"pgph.0006348.ref017","doi-asserted-by":"crossref","DOI":"10.1128\/JCM.01238-18","article-title":"Cryptococcal Meningitis Diagnostics and Screening in the Era of Point-of-Care Laboratory Testing","volume":"57","author":"R Rajasingham","year":"2019","journal-title":"J Clin Microbiol"},{"issue":"1","key":"pgph.0006348.ref018","doi-asserted-by":"crossref","first-page":"1015","DOI":"10.1186\/s12913-023-10009-5","article-title":"Barriers and facilitators to implementing advanced HIV disease screening at a secondary referral hospital -Malawi: a convergent parallel study","volume":"23","author":"B Mithi","year":"2023","journal-title":"BMC Health Serv Res"},{"key":"pgph.0006348.ref019","doi-asserted-by":"crossref","first-page":"137460","DOI":"10.1155\/2012\/137460","article-title":"Strengthening Health Systems for Chronic Care: Leveraging HIV Programs to Support Diabetes Services in Ethiopia and Swaziland","volume":"2012","author":"M Rabkin","year":"2012","journal-title":"J Trop Med"},{"issue":"3","key":"pgph.0006348.ref020","doi-asserted-by":"crossref","first-page":"131","DOI":"10.3390\/tropicalmed6030131","article-title":"Implementation of an Effective Decentralised Programme for Detection, Treatment and Prevention of Tuberculosis in Children","volume":"6","author":"JP Dongo","year":"2021","journal-title":"Trop Med Infect Dis"},{"key":"pgph.0006348.ref021","unstructured":"WHO. Consolidated guidelines on tuberculosis: module 1: prevention: tuberculosis preventive treatment. Geneva: WHO. 2019."},{"key":"pgph.0006348.ref022","doi-asserted-by":"crossref","first-page":"1353760","DOI":"10.3389\/fepid.2024.1353760","article-title":"Determinants of tuberculosis among adult people living with HIV on antiretroviral therapy at public hospitals in Hawassa City, South Ethiopia","volume":"4","author":"A Asefa","year":"2024","journal-title":"Front Epidemiol"}],"container-title":["PLOS Global Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pgph.0006348","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,23]],"date-time":"2026-10-23T17:33:46Z","timestamp":1792776826000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pgph.0006348"}},"subtitle":[],"editor":[{"given":"Everton","family":"Falc\u00e3o de Oliveira","sequence":"first","affiliation":[{"name":"Federal University of Mato Grosso do Sul","place":["BRAZIL"]}],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2026,10,23]]},"references-count":22,"journal-issue":{"issue":"10","published-online":{"date-parts":[[2026,10,23]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pgph.0006348","relation":{},"ISSN":["2767-3375"],"issn-type":[{"value":"2767-3375","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,10,23]]}}}