In the United States (US), there are high levels of disengagement along the HIV care continuum. We sought to characterize the heterogeneity in research studies and interventions to improve care engagement among people living with diagnosed HIV infection. We performed a systematic literature search for interventions to improve HIV linkage to care, retention in care, reengagement in care and adherence to antiretroviral therapy (ART) in the US published from 2007-mid 2015. Study designs and outcomes were allowed to vary in included studies. We grouped interventions into categories, target populations, and whether results were significantly improved. We identified 152 studies, 7 (5%) linkage studies, 33 (22%) retention studies, 4 (3%) reengagement studies, and 117 (77%) adherence studies. ‘Linkage’ studies utilized 11 different outcome definitions, while ‘retention’ studies utilized 39, with very little consistency in effect measurements. The majority (59%) of studies reported significantly improved outcomes, but this proportion and corresponding effect sizes varied substantially across study categories. This review highlights a paucity of assessments of linkage and reengagement interventions; limited generalizability of results; and substantial heterogeneity in intervention types, outcome definitions, and effect measures. In order to make strides against the HIV epidemic in the US, care continuum research must be improved and benchmarked against an integrated, comprehensive framework.

Structured Summary Background The recently updated White House National HIV/AIDS Strategy (NHAS) includes specific progress indicators for improving the HIV care continuum, but the economic and epidemiological impact of achieving those indicators remains unclear. Methods We constructed a dynamic transmission model of HIV progression and care engagement to project HIV incidence, prevalence, mortality, and costs among adults in the United States over ten years. We specifically considered achievement of the 2020 targets set forth in NHAS progress indicator 1 (90% awareness of serostatus), indicator 4 (85% linkage within one month), and indicator 5 (90% of diagnosed individuals in care). Finding At current rates of engagement in the HIV care continuum, we project 524,000 (95% Uncertainty Range 442,000 – 712,000) new HIV infections and 375,000 deaths (364,000 – 578,000) between 2016 and 2025. Achieving NHAS progress indicators 1 and 4 has modest epidemiologic impact (new infections reduced by 2·0% and 3·9%, respectively). By contrast, increasing the proportion of diagnosed individuals in care (indicator 5) averts 52% (47-56%) of new infections. Achieving all NHAS targets resulted in a 58% reduction (52%-61%) in new infections and 128,000 lives saved (106,000-223,000) at an incremental health system cost of $105 billion dollars. Interpretation Achievement of NHAS progress indicators for screening, linkage, and particularly improving retention in care, can substantially reduce the burden of HIV in the United States.

SUMMARY BACKGROUND India has a high burden of active tuberculosis (TB) and human immunodeficiency virus (HIV) infection. Pregnancy increases the risks of developing TB in HIV-infected women. Isoniazid preventive therapy (IPT) reduces progression to TB, but may increase costs and hepatotoxicity. The cost-effectiveness of IPT for HIV-infected pregnant women in India is unknown. DESIGN We evaluated the cost-effectiveness of ante-partum IPT among HIV-infected women in India using a decision-analytic model. We compared current practice (no IPT) with: Intervention 1 (IPT regardless of CD4 count) and Intervention 2 (IPT for those with CD4 count ≤ 200 cells/μl). We modeled IPT irrespective of tuberculin skin test (TST) status and TST-driven strategies. Primary outcomes were anticipated costs, disability-adjusted life-years (DALYs) and TB cases. RESULTS Both IPT interventions are highly cost-effective compared to no IPT at current willingness-to-pay thresholds (respectively US$178.00 and US$201.00 per DALY averted for Interventions 1 and 2). However, providing IPT irrespective of CD4 count results in the greatest health benefits (21 TB cases averted/1000 patients) compared to current practice. IPT irrespective of TST status was also highly cost-effective compared to TST-driven IPT (respectively US$1027.00 and US$1154.00/DALY averted for Interventions 1 and 2). CONCLUSION Antepartum IPT for HIV-infected women is highly cost-effective for TB prevention compared to current practices in India.