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

• Authors: Bohdan Nosyk, BC Centre for Excellence in HIV/AIDS; Xiao Zang, BC Centre for Excellence in HIV/AIDS; Emanuel Krebs, BC Centre for Excellence in HIV/AIDS; Benjamin Enns, BC Centre for Excellence in HIV/AIDS; Jeong E Min, BC Centre for Excellence in HIV/AIDS; Czarina N Behrends, Weill Cornell Medical College; Carlos del Rio, Emory University; Julia C Dombrowski, University of Washington; Daniel J Feaster, University of Miami; Matthew Golden, University of Washington; Brandon DL Marshall, Brown University; Shruti H Mehta, Johns Hopkins University; Lisa R Metsch, Columbia University; Ankur Pandya, Harvard TH Chan Sch Publ Hlth; Bruce R Schackman, Weill Cornell Med Coll; Steven Shoptaw, University of California Los Angeles; Steffanie A Strathdee, University of California San Diego
• Journal Title: LANCET HIV
• Volume: Volume 7, Number 7
• Publisher: ELSEVIER INC | 2020-07-01, Pages E491-E503
• Type of Work: Article | Post-print: After Peer Review
• Publisher DOI: http://doi.org/10.1016/S2352-3018(20)30033-3
• Subjects: Health Sciences, Epidemiology; Health Sciences, Public Health; Health Sciences, Health Care Management
• Keywords: Science & Technology; Life Sciences & Biomedicine; Immunology; Infectious Diseases; PREEXPOSURE PROPHYLAXIS; COST-EFFECTIVENESS; UNITED-STATES; INJECT DRUGS; HEALTH; INFECTION; INTERVENTION; DISPARITIES; SERVICES; RISK

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. Methods: In 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. Funding: National Institutes of Health.