Health, workforce, and cost trade-offs of HIV programme prioritization strategies in Malawi

BACKGROUND: Malawi has achieved substantial progress towards HIV epidemic control, reaching the UNAIDS 95-95-95 targets. However, declining external financing and health-workforce constraints threaten sustainability. Programme reconfiguration is being considered to reduce resource use. METHODS: We used the Thanzi La Onse (TLO) individual-based health system simulation model to evaluate HIV programme changes in Malawi from 2025 to 2050. HIV testing, treatment monitoring, prevention interventions, and tuberculosis preventive therapy (TPT) were assessed individually and in combination, and compared against a Status Quo scenario with service delivery fixed at end-2024 levels. RESULTS: Changes that weakened diagnosis or treatment monitoring produced the largest adverse effects. Reducing HIV testing by 50% increased HIV/AIDS deaths by 55 200 (95% uncertainty interval 35 100-78 000) and disability-adjusted life years (DALYs) by 3.28 million (2.41-4.54 million), while releasing 26.45 million healthcare-worker-hours and reducing total programme costs, including human resources for health and consumables, by USD 538.9 million. Removing viral load monitoring increased HIV/AIDS deaths by 21 460 (12 400-31 700) and DALYs by 1.17 million (0.58-1.69 million), with little change in workforce requirements but cost savings of USD 108.9 million. Reducing prevention services produced smaller savings with uncertain effects on mortality or DALYs. Combining reductions in testing, monitoring and prevention generated the largest cost savings (USD 812.0 million) but increased HIV infections by 1070 (990-1160), HIV/AIDS DALYs by 4.56 million (3.67-5.37 million) and AIDS deaths by 80 960 (66 240-93 640). CONCLUSION: Reducing HIV diagnosis or treatment monitoring risks undermining epidemic control. These services should be maintained if HIV programmes are reconfigured.