Opportunities and costs in the early treatment period of people living with HIV

Despite global advances in HIV treatment, the first six months after antiretroviral therapy (ART) initiation remains a critical phase marked by high risk of treatment interruptions. This thesis investigates the economic and epidemiological dimensions of HIV service delivery during this early treatment period, with a focus on sub-Saharan Africa. It comprises three interrelated parts.
Part one reports a cost-outcomes analysis of differentiated service delivery (DSD) models in Zimbabwe, demonstrating community-based multi-month dispensing to be potentially cost-saving and non-inferior to facility-based care.
Part two consists of an evaluation of prior ART exposure among clients initiating or reinitiating treatment. It reveals that up to 45% of clients presenting for treatment initiation have prior treatment experience, often undisclosed, and evaluates methods to accurately identify these individuals.
The third section reports two studies that characterize patterns of care engagement in South Africa and Zambia respectively, using large-scale electronic medical record data. Both studies showed that engagement is not binary and that multiple trajectories of how clients engage in care exist.
By using a combination of economic evaluation, diagnostic accuracy metrics, and longitudinal engagement analysis, this thesis provides actionable insights for improving retention and outcomes in HIV care to policy makers. It advocates for earlier access to DSD models and enhanced systems for identifying prior treatment experience to better support long-term engagement and viral suppression.