BACKGROUND Malawi is progressing towards UNAIDS and WHO End TB Strategy targets to eliminate HIV/AIDS and tuberculosis. We aimed to assess the prospective effect of achieving these goals on the health and health system of the country and the influence of consumable constraints. METHODS In this modelling study, we used the Thanzi la Onse (Health for All) model, which is an individual-based multi-disease simulation model that simulates HIV and tuberculosis transmission, alongside other diseases (eg, malaria, non-communicable diseases, and maternal diseases), and gates access to essential medicines according to empirical estimates of availability. The model integrates dynamic disease modelling with health system engagement behaviour, health system use, and capabilities (ie, personnel and consumables). We used 2018 data on the availability of HIV and tuberculosis consumables (for testing, treatment, and prevention) across all facility levels of the country to model three scenarios of HIV and tuberculosis programme scale-up from Jan 1, 2023, to Dec 31, 2033: a baseline scenario, when coverage remains static using existing consumable constraints; a constrained scenario, in which prioritised interventions are scaled up with fixed consumable constraints; and an unconstrained scenario, in which prioritised interventions are scaled up with maximum availability of all consumables related to HIV and tuberculosis care. FINDINGS With uninterrupted medical supplies, in Malawi, we projected HIV and tuberculosis incidence to decrease to 26 (95% uncertainty interval [UI] 19-35) cases and 55 (23-74) cases per 100 000 person-years by 2033 (from 152 [98-195] cases and 123 [99-160] cases per 100 000 person-years in 2023), respectively, with programme scale-up, averting a total of 12·21 million (95% UI 11·39-14·16) disability-adjusted life-years. However, the effect was compromised by restricted access to key medicines, resulting in approximately 58 700 additional deaths (33 400 [95% UI 22 000-41 000] due to AIDS and 25 300 [19 300-30 400] due to tuberculosis) compared with the unconstrained scenario. Between 2023 and 2033, eliminating HIV treatment stockouts could avert an estimated 12 100 deaths compared with the baseline scenario, and improved access to tuberculosis prevention medications could prevent 5600 deaths in addition to those achieved through programme scale-up alone. With programme scale-up under the constrained scenario, consumable stockouts are projected to require an estimated 14·3 million extra patient-facing hours between 2023 and 2033, mostly from clinical or nursing staff, compared with the unconstrained scenario. In 2033, with enhanced screening, 188 000 (81%) of 232 900 individuals projected to present with active tuberculosis could start tuberculosis treatment within 2 weeks of initial presentation if all required consumables were available, but only 8600 (57%) of 15 100 presenting under the baseline scenario. INTERPRETATION Ignoring frailties in the health-care system, in particular the potential non-availability of consumables, in projections of HIV and tuberculosis programme scale-up might risk overestimating potential health impacts and underestimating required health system resources. Simultaneous health system strengthening alongside programme scale-up is crucial, and should yield greater benefits to population health while mitigating the strain on a heavily constrained health-care system. FUNDING Wellcome and UK Research and Innovation as part of the Global Challenges Research Fund.

中文翻译：

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评估卫生系统资源对马拉维艾滋病毒和结核病规划的影响：一项模型研究。


背景 马拉维正在朝着联合国艾滋病规划署和世界卫生组织终止结核病战略的目标取得进展，以消除艾滋病毒/艾滋病和结核病。我们的目的是评估实现这些目标对国家卫生和卫生系统的预期影响以及消耗品限制的影响。方法 在这项建模研究中，我们使用了 Thanzi la Onse（全民健康）模型，这是一个基于个体的多疾病模拟模型，可以模拟艾滋病毒和结核病的传播以及其他疾病（例如疟疾、非传染性疾病、和孕产妇疾病），并根据对可用性的经验估计来控制基本药物的获取。该模型将动态疾病建模与卫生系统参与行为、卫生系统使用和能力（即人员和消耗品）相结合。我们使用 2018 年全国所有设施级别的艾滋病毒和结核病耗材（用于检测、治疗和预防）的可用性数据来模拟 2023 年 1 月 1 日至 12 月 31 日期间艾滋病毒和结核病项目扩大的三种情景。 2033 年：基线情景，使用现有消耗品限制覆盖范围保持不变；受限情景，其中优先干预措施在固定消耗品限制下扩大；在不受限制的情况下，优先干预措施将得到扩大，最大限度地提供与艾滋病毒和结核病护理相关的所有消耗品。 结果 凭借不间断的医疗供应，我们预计到 2033 年，马拉维的艾滋病毒和结核病发病率将降至每 10 万人年 26 例（95% 不确定区间 [UI] 19-35）例和 55 例（23-74 例）（从到 2023 年，每 10 万人年分别有 152 [98-195] 例和 123 [99-160] 例），随着计划规模的扩大，总共避免了 12·21 百万例（95% UI 11·39-14 ·16) 伤残调整生命年。然而，由于关键药物的获取受到限制，这一效果受到影响，导致大约 58 700 人额外死亡（33 400 人 [95% UI 22 000-41 000] 死于艾滋病，25 300 人 [19 300-30 400] 死于肺结核）与无约束场景相比。 2023 年至 2033 年间，与基线情景相比，消除艾滋病毒治疗缺货预计可避免 12 100 人死亡，而除了仅通过扩大计划规模实现的死亡之外，改善结核病预防药物的获取可避免 5,600 人死亡。随着受限场景下计划规模的扩大，与无受限场景相比，预计 2023 年至 2033 年间耗材缺货将需要额外增加 14·300 万小时的面对患者的时间，其中大部分来自临床或护理人员。到 2033 年，通过加强筛查，预计出现活动性结核病的 232 900 名患者中，如果拥有所有必需的耗材，则有 188 000 名患者（81%）可以在初次就诊后 2 周内开始结核病治疗，但 15 100 名患者中只有 8 600 名患者（57%）可以开始结核病治疗在基线情景下呈现。 解释 在艾滋病毒和结核病规划扩大规模的预测中，忽视卫生保健系统的脆弱性，特别是可能无法获得消耗品，可能会高估潜在的健康影响并低估所需的卫生系统资源。在扩大计划的同时加强卫生系统至关重要，这应该会给人口健康带来更大的好处，同时减轻严重受限的卫生保健系统的压力。作为全球挑战研究基金的一部分，资助惠康和英国研究与创新。