Ending the HIV epidemic in the USA: an economic modelling study in six cities

Abstract

Background The HIV epidemic in the USA is a collection of diverse local microepidemics. We aimed to identify optimal combination implementation strategies of evidence-based interventions to reach 90% reduction of incidence in 10 years, in six US cities that comprise 24•1% of people living with HIV in the USA. MethodsIn this economic modelling study, we used a dynamic HIV transmission model calibrated with the best available evidence on epidemiological and structural conditions for six US cities: Atlanta (GA), Baltimore (MD), Los Angeles (CA), Miami (FL), New York City (NY), and Seattle (WA). We assessed 23 040 combinations of 16 evidence-based interventions (ie, HIV prevention, testing, treatment, engagement, and re-engagement) to identify combination strategies providing the greatest health benefit while remaining cost-effective. Main outcomes included averted HIV infections, quality-adjusted life-years (QALYs), total cost (in 2018 US$), and incremental cost-effectiveness ratio (ICER; from the health-care sector perspective, 3% annual discount rate). Interventions were implemented at previously documented and ideal (90% coverage or adoption) scale-up, and sustained from 2020 to 2030, with outcomes evaluated until 2040. Findings Optimal combination strategies providing health benefit and cost-effectiveness contained between nine (Seattle) and 13 (Miami) individual interventions. If implemented at previously documented scale-up, these strategies could reduce incidence by between 30•7% (95% credible interval 19•1-43•7; Seattle) and 50•1% (41•5-58•0; New York City) by 2030, at ICERs ranging from cost-saving in Atlanta, Baltimore, and Miami, to $95 416 per QALY in Seattle. Incidence reductions reached between 39•5% (26•3-53•8) in Seattle and 83•6% (70•8-87•0) in Baltimore at ideal implementation. Total costs of implementing strategies across the cities at previously documented scale-up reached $559 million per year in 2024; however, costs were offset by long-term reductions in new infections and delayed disease progression, with Atlanta, Baltimore, and Miami projecting cost savings over the 20 year study period.Interpretation Evidence-based interventions can deliver substantial public health and economic value; however, complementary strategies to overcome social and structural barriers to HIV care will be required to reach national targets of the ending the HIV epidemic initiative by 2030.

What the HIV Pandemic Experience Can Teach the United States About the COVID-19 Response

“…At best, models can help understand epidemic drivers, predict and assess intervention impact, and optimally allocate funding. 130 , 131 However, they can also be inaccurate, which can lead to erroneous policy decisions. An analysis of 10 HIV models for South Africa 132 found that all projected lower prevalence compared with a subsequent household survey in 2012 and may have been overly optimistic about the impact of ART on HIV transmission.…”

“…Strategies required for ending the HIV epidemic in Atlanta, where the most vulnerable to HIV infection are young Black MSM will differ from rural US counties hard hit by rising rates of injecting drug use and HIV. 130 , 135 Disparities in health care access by race will continue to fuel disparities in HIV incidence unless directly addressed. 130 Decentralized and integrated HIV prevention and care can increase access to services among underserved populations and provide synergistic benefits.…”

“… 130 , 135 Disparities in health care access by race will continue to fuel disparities in HIV incidence unless directly addressed. 130 Decentralized and integrated HIV prevention and care can increase access to services among underserved populations and provide synergistic benefits. 136 …”

Contact Tracing for COVID-19: An Opportunity to Reduce Health Disparities and End the Human Immunodeficiency Virus/AIDS Epidemic in the United States

“…We [BN, CDR] have recently written that for six of the largest US cities comprising nearly 1 in 4 people living with HIV/AIDS in the US, implementing a wide range of interventions to diagnose, treat and protect against infection at even near-ideal levels would fall short of the EHE targets [15]. We excluded contact tracing because of the relatively limited experimental evidence supporting its effectiveness in HIV and the uncertainty regarding the potential scale this type of effort could actually reach.…”

Human Immunodeficiency Virus in the State of Texas of the United States: Past Reflections, Present Shortcomings, and Future Needs of the Public Health Response

“…Table 1 shows a comparison of Harris County with select other EHE priority jurisdictions, in terms of core [ 79 ] and other indicators [ 28 ] from the following areas [ 56 ]: policy and legal, socioeconomic, and service availability. Based on modeled forecasts, EHE scale-up of interventions is likely to be cost-saving in Houston/Harris County similar to other Southern hotspots such as Atlanta, Baltimore, and Miami [ 80 ]. However, augmented scale-up [ 81 , 82 ] and differentiated service delivery [ 83 , 84 ] will be required for optimal results.…”