INTRODUCTION: The Temprano and START trials provided evidence to support early ART initiation recommendations. We projected long-term clinical and economic outcomes of immediate ART initiation in Cote d'Ivoire. METHODS: We used a mathematical model to compare three potential ART initiation criteria: 1) CD4 <350/muL (ART<350/muL); 2) CD4 <500/muL (ART<500/muL); and 3) ART at presentation (Immediate ART). Outcomes from the model included life expectancy, 10-year medical resource use, incremental cost-effectiveness ratios (ICERs) in /yearoflifesaved(YLS),and5−yearbudgetimpact.WesimulatedpeoplewithHIV(PWH)incare(meanCD4:259/muL,SD198/muL)andtransmittedcases.Keyinputparameterstotheanalysisincludedfirst−lineARTefficacy(8090/person-year). We assessed cost-effectiveness relative to Cote d'Ivoire's 2017 per capita annual gross domestic product (1,600).RESULTS:ImmediateARTincreasedlifeexpectancyby0.34yearscomparedtoART<350/muLand0.17yearscomparedtoART<500/muL.ImmediateARTresultedin4,500fewer10−yeartransmissionsper170,000PWHcomparedtoART<350/muL.Incost−effectivenessanalysis,ImmediateARThada10−yearICERof680/YLS compared to ART<350/muL, ranging from cost-saving to an ICER of 1,440/YLSastransmissionratesvaried.ART<500/muLwas"dominated"(aninefficientuseofresources),comparedwithImmediateART.ImmediateARTincreasedthe5−yearHIVcarebudgetfrom801.9M to $812.6M compared to ART<350/muL. CONCLUSIONS: In Cote d'Ivoire, immediate compared to later ART initiation will increase life expectancy, decrease HIV transmission, and be cost-effective over the long-term, with modest budget impact. Immediate ART initiation is an appropriate, high-value standard of care in Cote d'Ivoire and similar settings