Developing a dynamic HIV transmission model for 6 U.S. cities: An evidence synthesis

Estimating the potential value of MSM-focused evidence-based implementation interventions in three Ending the HIV Epidemic jurisdictions in the United States: a model-based analysis

INTRODUCTION

Improving the delivery of existing evidence-based interventions to prevent and diagnose HIV is key to Ending the HIV Epidemic in the United States. Structural barriers in the access and delivery of related health services require municipal or state-level policy changes; however, suboptimal implementation can be addressed directly through interventions designed to improve the reach, effectiveness, adoption or maintenance of available interventions. Our objective was to estimate the cost-effectiveness and potential epidemiological impact of six real-world implementation interventions designed to address these barriers and increase the scale of delivery of interventions for HIV testing and pre-exposure prophylaxis (PrEP) in three US metropolitan areas.

METHODS

We used a dynamic HIV transmission model calibrated to replicate HIV microepidemics in Atlanta, Los Angeles (LA) and Miami. We identified six implementation interventions designed to improve HIV testing uptake ("Academic detailing for HIV testing," "CyBER/testing," "All About Me") and PrEP uptake/persistence ("Project SLIP," "PrEPmate," "PrEP patient navigation"). Our comparator scenario reflected a scale-up of interventions with no additional efforts to mitigate implementation and structural barriers. We accounted for potential heterogeneity in population-level effectiveness across jurisdictions. We sustained implementation interventions over a 10-year period and evaluated HIV acquisitions averted, costs, quality-adjusted life years and incremental cost-effectiveness ratios over a 20-year time horizon (2023-2042).

RESULTS

Across jurisdictions, implementation interventions to improve the scale of HIV testing were most cost-effective in Atlanta and LA (CyBER/testing cost-saving and All About Me cost-effective), while interventions for PrEP were most cost-effective in Miami (two of three were cost-saving). We estimated that the most impactful HIV testing intervention, CyBER/testing, was projected to avert 111 (95% credible interval: 110-111), 230 (228-233) and 101 (101-103) acquisitions over 20 years in Atlanta, LA and Miami, respectively. The most impactful implementation intervention to improve PrEP engagement, PrEPmate, averted an estimated 936 (929-943), 860 (853-867) and 2152 (2127-2178) acquisitions over 20 years, in Atlanta, LA and Miami, respectively.

CONCLUSIONS

Our results highlight the potential impact of interventions to enhance the implementation of existing evidence-based interventions for the prevention and diagnosis of HIV.

Estimating the epidemiological impact of reaching the objectives of the Florida integrated HIV prevention and care plan in Miami-Dade County

Background

The US Ending the HIV Epidemic (EHE) initiative aims to reduce national HIV incidence 90% by 2030 and to address the disproportionate burden of HIV among different racial/ethnic populations. Florida's state-wide 2022-2026 Integrated HIV Prevention and Care Plan outlines objectives for reaching EHE goals. In Miami-Dade County, we determined the epidemiological impact of achieving the integrated plan's objectives individually and jointly.

Methods

We adapted an HIV transmission model calibrated to Miami-Dade County adjusting access to HIV testing, pre-exposure prophylaxis (PrEP) and antiretroviral treatment to model the effects of each objective between 2022 and 2030. We compared two service scale-up approaches: (a) scale-up proportionally to existing racial/ethnic group access levels, and (b) scale-up according to new diagnoses across racial/ethnic groups (equity-oriented). We estimated reductions in new HIV infections by each objective and approach, compared to the EHE's incidence reduction target.

Findings

The single most influential strategy was reducing new HIV diagnoses in Hispanic/Latinx men who have sex with men through increased PrEP uptake, resulting in 907/2444 (37.1%) fewer annual new HIV infections in 2030. Achieving all objectives jointly would result in 1537/2444 (62.9%) and 1553/2444 (63.5%) fewer annual new HIV infections with the proportional and equity-oriented approaches, respectively.

Interpretation

Achieving the goals of Florida's integrated care plan would significantly reduce HIV incidence in Miami-Dade County; however, further efforts are required to achieve EHE targets. Structural changes in service delivery and a focus on effective implementation of available interventions to address racial/ethnic disparities will be crucial to ending the HIV epidemic.

Funding

This work was supported by the National Institutes of Health/National Institute on Drug Abuse grant no. R01-DA041747.

Toward Best Practices for Economic Evaluations of Tumor-Agnostic Therapies: A Review of Current Barriers and Solutions

OBJECTIVES

Cancer therapies targeting tumor-agnostic biomarkers are challenging traditional health technology assessment (HTA) frameworks. The high prevalence of nonrandomized single-arm trials, heterogeneity, and small benefiting populations are driving outcomes uncertainty, challenging healthcare decision making. We conducted a structured literature review to identify barriers and prioritize solutions to generating economic evidence for tumor-agnostic therapies.

METHODS

We searched MEDLINE and Embase for English-language studies conducting economic evaluations of tumor-agnostic treatments or exploring related challenges and solutions. We included studies published by December 2022 and supplemented our review with Canadian Agency for Drugs and Technologies in Health and National Institute for Health and Care Excellence technical reports for approved tumor-agnostic therapies. Three reviewers abstracted and summarized key methodological and empirical study characteristics. Challenges and solutions were identified through authors' statements and categorized using directed content analysis.

RESULTS

Twenty-six studies met our inclusion criteria. Studies spanned economic evaluations (n = 5), reimbursement reviews (n = 4), qualitative research (n = 1), methods validations (n = 3), and commentaries or literature reviews (n = 13). Challenges encountered related to (1) the treatment setting and clinical trial designs, (2) a lack of data or low-quality data on clinical and cost parameters, and (3) an inability to produce evidence that meets HTA guidelines. Although attempted solutions centered on analytic approaches for managing missing data, proposed solutions highlighted the need for real-world evidence combined with life-cycle HTA to reduce future evidentiary uncertainty.

CONCLUSIONS

Therapeutic innovation outpaces HTA evidence generation and the methods that support it. Existing HTA frameworks must be adapted for tumor-agnostic treatments to support future economic evaluations enabling timely patient access.

Impact of subgroup-specific heterogeneities and dynamic changes in mortality rates on forecasted population size, deaths, and age distribution of persons receiving antiretroviral treatment in the United States: a computer simulation study

PURPOSE

Model-based forecasts of population size, deaths, and age distribution of people with HIV (PWH) are helpful for public health and clinical services planning but are influenced by subgroup-specific heterogeneities and changes in mortality rates.

METHODS

Using an agent-based simulation of PWH in the United States, we examined the impact of distinct approaches to parametrizing mortality rates on forecasted epidemiology of PWH on antiretroviral treatment (ART). We first estimated mortality rates among (1) all PWH, (2) sex-specific, (3) sex-and-race/ethnicity-specific, and (4) sex-race/ethnicity-and-HIV-acquisition-risk-specific subgroups. We then assessed each scenario by (1) allowing unrestricted reductions in age-specific mortality rates over time and (2) restricting the mortality rates among PWH to subgroup-specific mortality thresholds from the general population.

RESULTS

Among the eight scenarios examined, those lacking subgroup-specific heterogeneities and those allowing unrestricted reductions in future mortality rates forecasted the lowest number of deaths among all PWH and 9 of the 15 subgroups through 2030. The forecasted overall number and age distribution of people with a history of injection drug use were sensitive to inclusion of subgroup-specific mortality rates.

CONCLUSIONS

Our results underscore the potential risk of underestimating future deaths by models lacking subgroup-specific heterogeneities in mortality rates, and those allowing unrestricted reductions in future mortality rates.

Translating and disseminating a localised economic model to support implementation of the 'Ending the HIV Epidemic' initiative to public health policymakers

Background

Despite significant progress in HIV treatment and prevention, the US remains far from its goal of 'Ending the HIV Epidemic' by 2030. Economic models using local data can synthesise the evidence to help policymakers allocate HIV resources efficiently, but persistent research-to-practice gaps remain. Little is known about how to facilitate the use of economic modelling data among local public health policymakers in real-world settings.

Aims and objectives

To explore the dissemination of results from a locally-calibrated economic model for HIV prevention and treatment and identify the factors influencing potential uptake of the model for public health decision making at the local level.

Methods

Four virtual focus groups with 26 local health department policymakers in Baltimore, Miami, Seattle, and New York City were held between July 2020 and May 2021. Qualitative content analysis of transcripts identified key themes around using the localised economic model in policy decisions.

Results

Participants were interested in using local data in their decisions to allocate resources for HIV prevention/treatment. Six themes emerged: 1) importance of understanding local policy context; 2) health equity considerations; 3) using evidence to support current priorities; 4) difficulty of changing strategies, even incrementally; 5) bang for the incremental buck (efficiency) vs. previous impact; and 6) community values.

Conclusion and relevance

To optimise acceptance and use of results from economic models, researchers should engage with local community members and public health decision makers early to understand budgetary and community priorities. Participants prioritised evidence that supports their existing strategies, considers budgets and funding streams, and improves health equity; however, real-world budget constraints and conflicting interests serve as barriers to implementing model recommendations and reaching national goals.

Framework for determining the optimal course of action when efficiency and affordability measures differ by perspective in cost-effectiveness analysis-with an illustrative case of HIV treatment in Mozambique

BACKGROUND

Cost-effectiveness analysis (CEA) is a standard tool for evaluating health programs and informing decisions about resource allocation and prioritization. Most CEAs evaluating health interventions in low- and middle-income countries adopt a health sector perspective, accounting for resources funded by international donors and country governments, while often excluding out-of-pocket expenditures and time costs borne by program beneficiaries. Even when patients' costs are included, a companion analysis focused on the patient perspective is rarely performed. We view this as a missed opportunity.

METHODS

We developed methods for assessing intervention affordability and evaluating whether optimal interventions from the health sector perspective also represent efficient and affordable options for patients. We mapped the five different patterns that a comparison of the perspective results can yield into a practical framework, and we provided guidance for researchers and decision-makers on how to use results from multiple perspectives. To illustrate the methodology, we conducted a CEA of six HIV treatment delivery models in Mozambique. We conducted a Monte Carlo microsimulation with probabilistic sensitivity analysis from both patient and health sector perspectives, generating incremental cost-effectiveness ratios for the treatment approaches. We also calculated annualized patient costs for the treatment approaches, comparing the costs with an affordability threshold. We then compared the cost-effectiveness and affordability results from the two perspectives using the framework we developed.

RESULTS

In this case, the two perspectives did not produce a shared optimal approach for HIV treatment at the willingness-to-pay threshold of 0.3 × Mozambique's annual GDP per capita per DALY averted. However, the clinical 6-month antiretroviral drug distribution strategy, which is optimal from the health sector perspective, is efficient and affordable from the patient perspective. All treatment approaches, except clinical 1-month distributions of antiretroviral drugs which were standard before Covid-19, had an annual cost to patients less than the country's annual average for out-of-pocket health expenditures.

CONCLUSION

Including a patient perspective in CEAs and explicitly considering affordability offers decision-makers additional insights either by confirming that the optimal strategy from the health sector perspective is also efficient and affordable from the patient perspective or by identifying incongruencies in value or affordability that could affect patient participation.

Five point initiative: a community-informed bundled implementation strategy to address HIV in Black communities

BACKGROUND

Black individuals in the U.S. remain the most disproportionately impacted by new HIV diagnoses, represent the highest portion of individuals living with HIV, and have the highest morbidity rates. Structural inequities and historical oppression are the primary drivers. Such drivers limit access to HIV prevention tools that need to be delivered with culturally congruent and community-informed approaches.

METHODS

The Five Point Initiative (FPI) is a community-informed bundled implementation strategy developed and piloted between September 2019 and March 2020 in Miami, Florida in communities heavily impacted by HIV. Key components of the strategy included community consultants/experts, five categories (hence the "Five Point") of community businesses (e.g., corner stores, beauty supply stores, laundromats, mechanics, barbershops), local health organizations, an academic research program engrossed in community engaged research, and community residents who provided ongoing feedback throughout. Outcomes of FPI included (a) survey information (e.g., knowledge of and access to PrEP, barriers to care) and pilot data (acceptability and feasibility), (b) expansion of reach to Black individuals in HIV high impact zip codes in Miami, (c) insights on our bundled implementation strategy, (d) condom distribution, and (e) HIV testing.

RESULTS

Over the course of six months FPI carried out 10 outreach events, partnered with 13 community businesses and 5 health organizations, engaged 677 community residents, collected health information via a survey, distributed 12,434 condoms, provided information on PrEP, and offered voluntary HIV testing (131 completed). FPI's ability to reach residents who are not being reached (e.g., 68.8% never heard of PrEP, 8% no HIV testing ever, 65.9% no primary care provider), positive feedback from residents (e.g., 70% very satisfied, 21% satisfied; 62% strongly agree and 25% agree they would participate again) and qualitative interviews with businesses provide evidence of acceptability and feasibility. Further, survey data provided insights on factors such as socio-demographics, discrimination experiences, barriers to care, social-structural factors, physical and sexual health, and mental health and substance use.

CONCLUSIONS

The FPI bundled implementation strategy shows promise to deliver health prevention/intervention for HIV and other health conditions to communities facing health inequities and for whom the current system for delivering care is insufficient.

Evaluating the sensitivity of jurisdictional heterogeneity and jurisdictional mixing in national level HIV prevention analyses: context of the U.S. ending the HIV epidemic plan

BACKGROUND

The U.S. Ending the HIV epidemic (EHE) plan aims to reduce annual HIV incidence by 90% by 2030, by first focusing interventions on 57 regions (EHE jurisdictions) that contributed to more than 50% of annual HIV diagnoses. Mathematical models that project HIV incidence evaluate the impact of interventions and inform intervention decisions. However, current models are either national level, which do not consider jurisdictional heterogeneity, or independent jurisdiction-specific, which do not consider cross jurisdictional interactions. Data suggests that a significant proportion of persons have sexual partnerships outside their own jurisdiction. However, the sensitivity of these jurisdictional interactions on model outcomes and intervention decisions hasn't been studied.

METHODS

We developed an ordinary differential equations based compartmental model to generate national-level projections of HIV in the U.S., through dynamic simulations of 96 epidemiological sub-models representing 54 EHE and 42 non-EHE jurisdictions. A Bernoulli equation modeled HIV-transmissions using a mixing matrix to simulate sexual partnerships within and outside jurisdictions. To evaluate sensitivity of jurisdictional interactions on model outputs, we analyzed 16 scenarios, combinations of a) proportion of sexual partnerships mixing outside jurisdiction: no-mixing, low-level-mixing-within-state, high-level-mixing-within-state, or high-level-mixing-within-and-outside-state; b) jurisdictional heterogeneity in care and demographics: homogenous or heterogeneous; and c) intervention assumptions for 2019-2030: baseline or EHE-plan (diagnose, treat, and prevent).

RESULTS

Change in incidence in mixing compared to no-mixing scenarios varied by EHE and non-EHE jurisdictions and aggregation-level. When assuming jurisdictional heterogeneity and baseline-intervention, the change in aggregated incidence ranged from - 2 to 0% for EHE and 5 to 21% for non-EHE, but within each jurisdiction it ranged from - 31 to 46% for EHE and - 18 to 109% for non-EHE. Thus, incidence estimates were sensitive to jurisdictional mixing more at the jurisdictional level. As a result, jurisdiction-specific HIV-testing intervals inferred from the model to achieve the EHE-plan were also sensitive, e.g., when no-mixing scenarios suggested testing every 1 year (or 3 years), the three mixing-levels suggested testing every 0.8 to 1.2 years, 0.6 to 1.5 years, and 0.6 to 1.5 years, respectively (or 2.6 to 3.5 years, 2 to 4.8 years, and 2.2 to 4.1 years, respectively). Similar patterns were observed when assuming jurisdictional homogeneity, however, change in incidence in mixing compared to no-mixing scenarios were high even in aggregated incidence.

CONCLUSIONS

Accounting jurisdictional mixing and heterogeneity could improve model-based analyses.

Trace the History of HIV and Predict Its Future through Genetic Sequences

Traditional methods of quantifying epidemic spread are based on surveillance data. The most widely used surveillance data are normally incidence data from case reports and hospital records, which are normally susceptible to human error, and sometimes, they even can be seriously error-prone and incomplete when collected during a destructive epidemic. In this manuscript, we introduce a new method to study the spread of infectious disease. We gave an example of how to use this method to predict the virus spreading using the HIV gene sequences data of China. First, we applied Bayesian inference to gene sequences of two main subtypes of the HIV virus to infer the effective reproduction number (GRe(t)) to trace the history of HIV transmission. Second, a dynamic model was established to forecast the spread of HIV medication resistance in the future and also obtain its effective reproduction number (MRe(t)). Through fitting the two effective reproduction numbers obtained from the two separate ways above, some crucial parameters for the dynamic model were obtained. Simply raising the treatment rate has no impact on lowering the infection rate, according to the dynamics model research, but would instead increase the rate of medication resistance. The negative relationship between the prevalence of HIV and the survivorship of infected individuals following treatment may be to blame for this. Reducing the MSM population’s number of sexual partners is a more efficient strategy to reduce transmission per the sensitivity analysis.

The Impact of Churn on HIV Outcomes in a Southern United States Clinical Cohort

Background

Persons with human immunodeficiency virus (PWH) may experience a cycle of engaging and disengaging in care referred to as “churn.” While human immunodeficiency virus (HIV) churn is predicted to be more prevalent in the southern United States (US), it has not been well characterized in this region.

Methods

We conducted a retrospective cohort study involving PWH newly establishing care at a large urban clinic in Atlanta, Georgia, from 2012 to 2017, with follow-up data collected through 2019. The primary exposure was churn, defined as a ≥12-month gap between routine clinic visits or viral load (VL) measurements. We compared HIV metrics before and after churn and assessed the risk of future churn or loss to follow-up.

Results

Of 1303 PWH newly establishing care, 81.7% were male and 84.9% were Black; 200 (15.3%) experienced churn in 3.3 years of median follow-up time. The transmissible viremia (TV) rate increased from 28.6% prechurn to 66.2% postchurn (P < .0001). The 122 PWH having TV on reengagement had delayed time to subsequent viral suppression (adjusted hazard ratio, 0.59 [95% confidence interval {CI}, .48–.73]), and PWH returning to care contributed disproportionately to the community viral load (CVL) (proportion of CVL/proportion of patients, 1.96). Churn was not associated with an increased risk of subsequent churn (adjusted odds ratio [aOR], 1.53 [95% CI, .79–2.97]) or loss to follow-up (aOR, 1.04 [95% CI, .60–1.79]).

Conclusions

The rate of churn in a southern US clinic was high, and those who experienced churn had increased TV at reentry and disproportionately contributed to the CVL and likely contributing to ongoing HIV transmission.

Mechanisms of phosphatidylserine influence on viral production: A computational model of Ebola virus matrix protein assembly

Ebola virus (EBOV) infections continue to pose a global public health threat, with high mortality rates and sporadic outbreaks in Central and Western Africa. A quantitative understanding of the key processes driving EBOV assembly and budding could provide valuable insights to inform drug development. Here, we use a computational model to evaluate EBOV matrix assembly. Our model focuses on the assembly kinetics of VP40, the matrix protein in EBOV, and its interaction with phosphatidylserine (PS) in the host cell membrane. It has been shown that mammalian cells transfected with VP40-expressing plasmids are capable of producing virus-like particles (VLPs) that closely resemble EBOV virions. Previous studies have also shown that PS levels in the host cell membrane affects VP40 association with the plasma membrane inner leaflet and that lower membrane PS levels result in lower VLP production. Our computational findings indicate that PS may also have a direct influence on VP40 VLP assembly and budding, where a higher PS level will result in a higher VLP budding rate and filament dissociation rate. Our results further suggest that the assembly of VP40 filaments follow the nucleation-elongation theory, where initialization and oligomerization of VP40 are two distinct steps in the assembly process. Our findings advance the current understanding of VP40 VLP formation by identifying new possible mechanisms of PS influence on VP40 assembly. We propose that these mechanisms could inform treatment strategies targeting PS alone or in combination with other VP40 assembly steps.

M2HepPrEP: study protocol for a multi-site multi-setting randomized controlled trial of integrated HIV prevention and HCV care for PWID

Background

Opioid use is escalating in North America and comes with a multitude of health consequences, including HIV and hepatitis C virus (HCV) outbreaks among persons who inject drugs (PWID). HIV pre-exposure prophylaxis (PrEP) and HCV treatment regimens have transformative potential to address these co-occurring epidemics. Evaluation of innovative multi-modal approaches, integrating harm reduction, opioid agonist therapy (OAT), PrEP, and HCV treatment is required. The aim of this study is to assess the effectiveness of an on-site integrated care model where delivery of PrEP and HCV treatment for PWID takes places at syringe service programs (SSP) and OAT programs compared with referring PWID to clinical services in the community through a patient navigation model and to examine how structural factors interact with HIV prevention adherence and HCV treatment outcomes.

Methods

The Miami-Montreal Hepatitis C and Pre-Exposure Prophylaxis trial (M²HepPrEP) is an open-label, multi-site, multi-center, randomized, controlled, superiority trial with two parallel treatment arms. A total of 500 persons who injected drugs in the prior 6 months and are eligible for PrEP will be recruited in OAT clinics and SSP in Miami, FL, and Montréal, Québec. Participants will be randomized to either on-site care, with adherence counseling, or referral to off-site clinics assisted by a patient navigator. PrEP will be offered to all participants and HCV treatment to those HCV-infected. Co-primary endpoints will be (1) adherence to pre-exposure prophylaxis medication at 6 months post-randomization and (2) HCV sustained virological response (SVR) 12 weeks post-treatment completion among participants who were randomized within the HCV stratum. Up to 100 participants will be invited to participate in a semi-structured interview regarding perceptions of adherence barriers and facilitators, after their 6-month assessment. A simulation model-based cost-effectiveness analysis will be performed to determine the comparative value of the strategies being evaluated.

Discussion

The results of this study have the potential to demonstrate the effectiveness and cost-effectiveness of offering PrEP and HCV treatment in healthcare venues frequently attended by PWID. Testing the intervention in two urban centers with high disease burden among PWID, but with different healthcare system dynamics, will increase generalizability of findings.

Trial registration

Clinicaltrials.gov NCT03981445. Trial registry name: Integrated HIV Prevention and HCV Care for PWID (M2HepPrEP). Registration date: June 10, 201.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06085-3.

Cost and Cost-Effectiveness of Incentives for Viral Suppression in People Living with HIV

Only 63% of people living with HIV in the United States are achieving viral suppression. Structural and social barriers limit adherence to antiretroviral therapy which furthers the HIV epidemic while increasing health care costs. This study calculated the cost and cost-effectiveness of a contingency management intervention with cash incentives. People with HIV and detectable viral loads were randomized to usual care or an incentive group. Individuals could earn up to $3650 per year if they achieved and maintained an undetectable viral load. The average 1-year intervention cost, including incentives, was $4105 per patient. The average health care costs were $27,189 per patient in usual care and $35,853 per patient in the incentive group. We estimated a cost of $28,888 per quality-adjusted life-year (QALY) gained, which is well below accepted cost-per-QALY thresholds. Contingency management with cash incentives is a cost-effective intervention for significantly increasing viral suppression.

Human Immunodeficiency Virus transmission by HIV Risk Group and Along the HIV Care Continuum: A Contrast of 6 US Cities

BACKGROUND

Understanding the sources of HIV transmission provides a basis for prioritizing HIV prevention resources in specific geographic regions and populations. This study estimated the number, proportion, and rate of HIV transmissions attributable to individuals along the HIV care continuum within different HIV transmission risk groups in 6 US cities.

METHODS

We used a dynamic, compartmental HIV transmission model that draws on racial behavior-specific or ethnic behavior-specific and risk behavior-specific linkage to HIV care and use of HIV prevention services from local, state, and national surveillance sources. We estimated the rate and number of HIV transmissions attributable to individuals in the stage of acute undiagnosed HIV, nonacute undiagnosed HIV, HIV diagnosed but antiretroviral therapy (ART) naïve, off ART, and on ART, stratified by HIV transmission group for the 2019 calendar year.

RESULTS

Individuals with undiagnosed nonacute HIV infection accounted for the highest proportion of total transmissions in every city, ranging from 36.8% (26.7%-44.9%) in New York City to 64.9% (47.0%-71.6%) in Baltimore. Individuals who had discontinued ART contributed to the second highest percentage of total infections in 4 of 6 cities. Individuals with acute HIV had the highest transmission rate per 100 person-years, ranging from 76.4 (58.9-135.9) in Miami to 160.2 (85.7-302.8) in Baltimore.

CONCLUSION

These findings underline the importance of both early diagnosis and improved ART retention for ending the HIV epidemic in the United States. Differences in the sources of transmission across cities indicate that localized priority setting to effectively address diverse microepidemics at different stages of epidemic control is necessary.

Costs and Consequences of Eliminating a Routine, Point-Of-Care HIV Screening Program in a High-Prevalence Jail

INTRODUCTION

This study aims to assess the public health impact of eliminating a longstanding routine HIV screening program and replacing it with targeted testing. In addition, costs, outcomes, and cost effectiveness of routine screening are compared with those of targeted testing in the Fulton County Jail, Atlanta, Georgia.

METHODS

A published mathematical model was used to assess the cost effectiveness and public health impact of routine screening (March 2013-February 2014) compared with those of targeted testing (January 2018-December 2018) from a health system perspective. Costs, outcomes, and other model inputs were derived from the testing programs and the published literature, and the cost effectiveness analysis was conducted from 2019 to 2020.

RESULTS

Routine screening identified 74 more new HIV infections over 1 year than targeted testing, resulting in an estimated 10 HIV transmissions averted and 45 quality-adjusted life-years saved, and was cost saving. The missed opportunity to diagnose infections because routine screening was eliminated resulted in an estimated 8.4 additional HIV transmissions and $3.7 million in additional costs to the healthcare system.

CONCLUSIONS

Routine HIV screening in high-prevalence jails is cost effective and has a larger impact on public health than targeted testing. Prioritizing sustained funding for routine, jail-based HIV screening programs in high-prevalence areas may be important to realizing the national HIV prevention goals.

Attributing health benefits to preventing HIV infections versus improving health outcomes among people living with HIV: an analysis in six US cities

OBJECTIVE

Combination strategies generate health benefits through improved health outcomes among people living with HIV (PLHIV) and prevention of new infections. We aimed to determine health benefits attributable to improved health among PLHIV versus HIV prevention for a set of combination strategies in six US cities.

DESIGN

A dynamic HIV transmission model.

METHODS

Using a model calibrated for Atlanta, Baltimore, Los Angeles, Miami, New York City (NYC) and Seattle, we assessed the health benefits of city-specific optimal combinations of evidence-based interventions implemented at publicly documented levels and at ideal (90% coverage) scale-up (2020-2030 implementation, 20-year study period). We calculated the proportion of health benefit gains (measured as quality-adjusted life-years) resulting from averted and delayed HIV infections; improved health outcomes among PLHIV; and improved health outcomes due to medication for opioid use disorder (MOUD).

RESULTS

The HIV-specific proportion of total benefits ranged from 68.3% (95% credible interval: 55.3-80.0) in Seattle to 98.5% (97.5-99.3) in Miami, with the rest attributable to MOUD. The majority of HIV-specific health benefits in five of six cities were attributable HIV prevention, and ranged from 33.1% (26.1-41.1) in NYC to 83.1% (79.6-86.6) in Atlanta. Scaling up to ideal service levels resulted in three to seven-fold increases in additional health benefits, mostly from MOUD, with HIV-specific health gains primarily driven by HIV prevention.

CONCLUSION

Optimal combination strategies generated a larger proportion of health benefits attributable to HIV prevention in five of six cities, underlining the substantial benefits of antiretroviral therapy engagement for the prevention of HIV transmission through viral suppression. Understanding to whom benefits accrue may be important in assessing the equity and impact of HIV investments.

Improving health equity and ending the HIV epidemic in the USA: a distributional cost-effectiveness analysis in six cities

BACKGROUND

In the USA, Black and Hispanic or Latinx individuals continue to be disproportionately affected by HIV. Applying a distributional cost-effectiveness framework, we estimated the cost-effectiveness and epidemiological impact of two combination implementation approaches to identify the approach that best meets the dual objectives of improving population health and reducing racial or ethnic health disparities.

METHODS

We adapted a dynamic, compartmental HIV transmission model to characterise HIV micro-epidemics in six US cities: Atlanta, Baltimore, Los Angeles, Miami, New York, and Seattle. We considered combinations of 16 evidence-based interventions to diagnose, treat, and prevent HIV transmission according to previously documented levels of scale-up. We then identified optimal combination strategies for each city, with the distribution of each intervention implemented according to existing service levels (proportional services approach) and the racial or ethnic distribution of new diagnoses (between Black, Hispanic or Latinx, and White or other ethnicity individuals; equity approach). We estimated total costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios of strategies implemented from 2020 to 2030 (health-care perspective; 20-year time horizon; 3% annual discount rate). We estimated three measures of health inequality (between-group variance, index of disparity, Theil index), incidence rate ratios, and rate differences for the selected strategies under each approach.

FINDINGS

In all cities, optimal combination strategies under the equity approach generated more QALYs than those with proportional services, ranging from a 3·1% increase (95% credible interval [CrI] 1·4-5·3) in New York to more than double (101·9% [75·4-134·6]) in Atlanta. Compared with proportional services, the equity approach delivered lower costs over 20 years in all cities except Los Angeles; cost reductions ranged from $22·9 million (95% CrI 5·3-55·7 million) in Seattle to $579·8 million (255·4-940·5 million) in Atlanta. The equity approach also reduced incidence disparities and health inequality measures in all cities except Los Angeles.

INTERPRETATION

Equity-focused HIV combination implementation strategies that reduce disparities for Black and Hispanic or Latinx individuals can significantly improve population health, reduce costs, and drive progress towards Ending the HIV Epidemic goals in the USA.

FUNDING

National Institute on Drug Abuse.

The healthier healthcare management models for COVID-19

The worldwide pandemic situation of COVID-19 generates a situation in which healthcare resources such as diagnostic kits, drugs and basic healthcare infrastructure were on shortage throughout the period, along with negative impact on socio-economic system. Standardized public healthcare models were missing in pandemic situation, covering from hospitalized patient care to local resident's healthcare managements in terms of monitoring, assess to diagnosis and medicines. This exploratory and intervention-based study with the objective of proposing COVID-19 Care Management Model representing comprehensive care of society including patients (COVID-19 and other diseases) and healthy subjects under integrated framework of healthier management model. Shifting policy towards technology-oriented models with well-aligned infrastructure can achieve better outcomes in COVID-19 prevention and care. The planned development of technical healthcare models for prognosis and improved treatment outcomes that take into account not only genomics, proteomics, nanotechnology, materials science perspectives but also the possible contribution of advanced digital technologies is best strategies for early diagnosis and infections control. In view of current pandemic, a Healthier Healthcare Management Model is proposed here as a source of standardized care having technology support, medical consultation, along with public health model of sanitization, distancing and contact less behaviours practices. Effective healthcare managements have been the main driver of healthier society where, positive action at identified research, technology and management segment more specifically public health, patient health, technology selection and political influence has great potential to enhanced the global response to COVID-19. The implementation of such practices will deliver effective diagnosis and control mechanism and make healthier society.

The Potential Epidemiological Impact of Coronavirus Disease 2019 (COVID-19) on the Human Immunodeficiency Virus (HIV) Epidemic and the Cost-effectiveness of Linked, Opt-out HIV Testing: A Modeling Study in 6 US Cities

Background

Widespread viral and serological testing for SARS-CoV-2 may present a unique opportunity to also test for HIV infection. We estimated the potential impact of adding linked, opt-out HIV testing alongside SARS-CoV-2 testing on HIV incidence and the cost-effectiveness of this strategy in six US cities.

Methods

Using a previously-calibrated dynamic HIV transmission model, we constructed three sets of scenarios for each city: (1) sustained current levels of HIV-related treatment and prevention services (status quo); (2) temporary disruptions in health services and changes in sexual and injection risk behaviours at discrete levels between 0%-50%; and (3) linked HIV and SARS-CoV-2 testing offered to 10%-90% of the adult population in addition to scenario (2). We estimated cumulative HIV infections between 2020-2025 and incremental cost-effectiveness ratios of linked HIV testing over 20 years.

Results

In the absence of linked, opt-out HIV testing, we estimated a total of 16.5% decrease in HIV infections between 2020-2025 in the best-case scenario (50% reduction in risk behaviours and no service disruptions), and 9.0% increase in the worst-case scenario (no behavioural change and 50% reduction in service access). We estimated that HIV testing (offered at 10%-90% levels) could avert a total of 576-7,225 (1.6%-17.2%) new infections. The intervention would require an initial investment of $20.6M-$220.7M across cities; however, the intervention would ultimately result in savings in health care costs in each city.

Conclusions

A campaign in which HIV testing is linked with SARS-CoV-2 testing could substantially reduce HIV incidence and reduce direct and indirect health care costs attributable to HIV.

"Ending the Epidemic" Will Not Happen Without Addressing Racial/Ethnic Disparities in the United States Human Immunodeficiency Virus Epidemic

We estimated human immunodeficiency virus incidence and incidence rate ratios (IRRs) for black and Hispanic vs white populations in 6 cities in the United States (2020-2030). Large reductions in incidence are possible, but without elimination of disparities in healthcare access, we found that wide disparities persisted for black compared with white populations in particular (lowest IRR, 1.69 [95% credible interval, 1.19-2.30]).

Ending the HIV Epidemic Among Persons Who Inject Drugs: A Cost-Effectiveness Analysis in Six US Cities

BACKGROUND

Persons who inject drugs (PWID) are at a disproportionately high risk of HIV infection. We aimed to determine the highest-valued combination implementation strategies to reduce the burden of HIV among PWID in 6 US cities.

METHODS

Using a dynamic HIV transmission model calibrated for Atlanta, Baltimore, Los Angeles, Miami, New York City, and Seattle, we assessed the value of implementing combinations of evidence-based interventions at optimistic (drawn from best available evidence) or ideal (90% coverage) scale-up. We estimated reduction in HIV incidence among PWID, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) for each city (10-year implementation; 20-year horizon; 2018 $ US).

RESULTS

Combinations that maximized health benefits contained between 6 (Atlanta and Seattle) and 12 (Miami) interventions with ICER values ranging from $94 069/QALY in Los Angeles to $146 256/QALY in Miami. These strategies reduced HIV incidence by 8.1% (credible interval [CI], 2.8%-13.2%) in Seattle and 54.4% (CI, 37.6%-73.9%) in Miami. Incidence reduction reached 16.1%-75.5% at ideal scale.

CONCLUSIONS

Evidence-based interventions targeted to PWID can deliver considerable value; however, ending the HIV epidemic among PWID will require innovative implementation strategies and supporting programs to reduce social and structural barriers to care.

Development and dissemination of infectious disease dynamic transmission models during the COVID-19 pandemic: what can we learn from other pathogens and how can we move forward?

The current COVID-19 pandemic has resulted in the unprecedented development and integration of infectious disease dynamic transmission models into policy making and public health practice. Models offer a systematic way to investigate transmission dynamics and produce short-term and long-term predictions that explicitly integrate assumptions about biological, behavioural, and epidemiological processes that affect disease transmission, burden, and surveillance. Models have been valuable tools during the COVID-19 pandemic and other infectious disease outbreaks, able to generate possible trajectories of disease burden, evaluate the effectiveness of intervention strategies, and estimate key transmission variables. Particularly given the rapid pace of model development, evaluation, and integration with decision making in emergency situations, it is necessary to understand the benefits and pitfalls of transmission models. We review and highlight key aspects of the history of infectious disease dynamic models, the role of rigorous testing and evaluation, the integration with data, and the successful application of models to guide public health. Rather than being an expansive history of infectious disease models, this Review focuses on how the integration of modelling can continue to be advanced through policy and practice in appropriate and conscientious ways to support the current pandemic response.

Prioritizing Additional Data Collection to Reduce Decision Uncertainty in the HIV/AIDS Response in 6 US Cities: A Value of Information Analysis

OBJECTIVES

The ambitious goals of the US Ending the HIV Epidemic initiative will require a targeted, context-specific public health response. Model-based economic evaluation provides useful guidance for decision making while characterizing decision uncertainty. We aim to quantify the value of eliminating uncertainty about different parameters in selecting combination implementation strategies to reduce the public health burden of HIV/AIDS in 6 US cities and identify future data collection priorities.

METHODS

We used a dynamic compartmental HIV transmission model developed for 6 US cities to evaluate the cost-effectiveness of a range of combination implementation strategies. Using a metamodeling approach with nonparametric and deep learning methods, we calculated the expected value of perfect information, representing the maximum value of further research to eliminate decision uncertainty, and the expected value of partial perfect information for key groups of parameters that would be collected together in practice.

RESULTS

The population expected value of perfect information ranged from $59 683 (Miami) to $54 108 679 (Los Angeles). The rank ordering of expected value of partial perfect information on key groups of parameters were largely consistent across cities and highest for parameters pertaining to HIV risk behaviors, probability of HIV transmission, health service engagement, HIV-related mortality, health utility weights, and healthcare costs. Los Angeles was an exception, where parameters on retention in pre-exposure prophylaxis ranked highest in contributing to decision uncertainty.

CONCLUSIONS

Funding additional data collection on HIV/AIDS may be warranted in Baltimore, Los Angeles, and New York City. Value of information analysis should be embedded into decision-making processes on funding future research and public health intervention.

Can the 'Ending the HIV Epidemic' initiative transition the USA towards HIV/AIDS epidemic control?

: Using a dynamic HIV transmission model calibrated for six USA cities, we projected HIV incidence from 2020 to 2040 and estimated whether an established UNAIDS HIV epidemic control target could be met under ideal implementation of optimal combination strategies previously defined for each city. Four of six cities (Atlanta, Baltimore, New York City and Seattle) were projected to achieve epidemic control by 2040 and we identified differences in reaching epidemic control across racial/ethnic groups.

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

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.

The impact of localized implementation: determining the cost-effectiveness of HIV prevention and care interventions across six United States cities

OBJECTIVE

Effective interventions to reduce the public health burden of HIV/AIDS can vary in their ability to deliver value at different levels of scale and in different epidemiological contexts. Our objective was to determine the cost-effectiveness of HIV treatment and prevention interventions implemented at previously documented scales of delivery in six US cities with diverse HIV microepidemics.

DESIGN

Dynamic HIV transmission model-based cost-effectiveness analysis.

METHODS

We identified and estimated previously documented scale of delivery and costs for 16 evidence-based interventions from the US CDC's Compendium of Evidence-Based Interventions and Best Practices for HIV Prevention. Using a model calibrated for Atlanta, Baltimore, Los Angeles, Miami, New York City and Seattle, we estimated averted HIV infections, quality-adjusted life years (QALY) gained and incremental cost-effectiveness ratios (healthcare perspective; 3% discount rate, 2018$US), for each intervention and city (10-year implementation) compared with the status quo over a 20-year time horizon.

RESULTS

Increased HIV testing was cost-saving or cost-effective across cities. Targeted preexposure prophylaxis for high-risk MSM was cost-saving in Miami and cost-effective in Atlanta ($6123/QALY), Baltimore ($18 333/QALY) and Los Angeles ($86 117/QALY). Interventions designed to improve antiretroviral therapy initiation provided greater value than other treatment engagement interventions. No single intervention was projected to reduce HIV incidence by more than 10.1% in any city.

CONCLUSION

Combination implementation strategies should be tailored to local epidemiological contexts to provide the most value. Complementary strategies addressing factors hindering access to HIV care will be necessary to meet targets for HIV elimination in the United States.

Development and Calibration of a Dynamic HIV Transmission Model for 6 US Cities

Background. Heterogeneity in HIV microepidemics across US cities necessitates locally oriented, combination implementation strategies to prioritize resources. We calibrated and validated a dynamic, compartmental HIV transmission model to establish a status quo treatment scenario, holding constant current levels of care for 6 US cities. Methods. Built off a comprehensive evidence synthesis, we adapted and extended a previously published model to replicate the transmission, progression, and clinical care for each microepidemic. We identified a common set of 17 calibration targets between 2012 and 2015 and used the Morris method to select the most influential parameters for calibration. We then applied the Nelder-Mead algorithm to iteratively calibrate the model to generate 2000 best-fitting parameter sets. Finally, model projections were internally validated with a series of robustness checks and externally validated against published estimates of HIV incidence, while the face validity of 25-year projections was assessed by a Scientific Advisory Committee (SAC). Results. We documented our process for model development, calibration, and validation to maximize its transparency and reproducibility. The projected outcomes demonstrated a good fit to calibration targets, with a mean goodness-of-fit ranging from 0.0174 (New York City [NYC]) to 0.0861 (Atlanta). Most of the incidence predictions were within the uncertainty range for 5 of the 6 cities (ranging from 21% [Miami] to 100% [NYC]), demonstrating good external validity. The face validity of the long-term projections was confirmed by our SAC, showing that the incidence would decrease or remain stable in Atlanta, Los Angeles, NYC, and Seattle while increasing in Baltimore and Miami. Discussion. This exercise provides a basis for assessing the incremental value of further investments in HIV combination implementation strategies tailored to urban HIV microepidemics.

Ending the Epidemic in America Will Not Happen if the Status Quo Continues: Modeled Projections for Human Immunodeficiency Virus Incidence in 6 US Cities

We estimated 10-year (2020-2030) trajectories for human immunodeficiency virus incidence in 6 US cities. Estimated incidence will only decrease in 2 of 6 cities, with the overall population-weighted incidence decreasing 3.1% (95% credible interval [CrI], -1.0% to 8.5%) by 2025, and 4.3% (95% CrI, -2.6% to 12.7%) by 2030 across cities. Targeted, context-specific combination implementation strategies will be necessary to meet the newly established national targets.