Bohdan Nosyk1, Xiao Zang2, Emanuel Krebs3, Benjamin Enns3, Jeong E Min3, Czarina N Behrends4, Carlos Del Rio5, Julia C Dombrowski6, Daniel J Feaster7, Matthew Golden6, Brandon D L Marshall8, Shruti H Mehta9, Lisa R Metsch10, Ankur Pandya11, Bruce R Schackman4, Steven Shoptaw12, Steffanie A Strathdee13. 1. British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada; Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada. Electronic address: bnosyk@cfenet.ubc.ca. 2. British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada; Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada. 3. British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada. 4. Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, USA. 5. Rollins School of Public Health and Emory School of Medicine, Emory University, Atlanta, GA, USA. 6. Department of Medicine, Division of Allergy and Infectious Disease, University of Washington, Seattle, WA, USA. 7. Department of Public Health Sciences, Leonard M Miller School of Medicine, University of Miami, Miami, FL, USA. 8. School of Public Health, Brown University, Providence, RI, USA. 9. Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA. 10. Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY, USA. 11. Department of Health Policy and Management, Harvard T H Chan School of Public Health, Boston, MA, USA. 12. School of Medicine, University of California Los Angeles, Los Angeles, CA, USA. 13. School of Medicine, University of California San Diego, La Jolla, CA, USA.
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 $559 million per year in 2024; however, costs were offset by long-term reductions in new infections and delayed disease progression, with Atlanta, Baltimore, and Miami projecting cost savings over the 20 year study period. INTERPRETATION: Evidence-based interventions can deliver substantial public health and economic value; however, complementary strategies to overcome social and structural barriers to HIV care will be required to reach national targets of the ending the HIV epidemic initiative by 2030. FUNDING: National Institutes of Health.
BACKGROUND: The HIV epidemic in the USA is a collection of diverse local microepidemics. We aimed to identify optimal combination implementation strategies of evidence-based interventions to reach 90% reduction of incidence in 10 years, in six US cities that comprise 24·1% of people living with HIV in the USA. METHODS: In this economic modelling study, we used a dynamic HIV transmission model calibrated with the best available evidence on epidemiological and structural conditions for six US cities: Atlanta (GA), Baltimore (MD), Los Angeles (CA), Miami (FL), New York City (NY), and Seattle (WA). We assessed 23 040 combinations of 16 evidence-based interventions (ie, HIV prevention, testing, treatment, engagement, and re-engagement) to identify combination strategies providing the greatest health benefit while remaining cost-effective. Main outcomes included averted HIV infections, quality-adjusted life-years (QALYs), total cost (in 2018 US$), 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.
Authors: Curt G Beckwith; Amy Nunn; Sharon Baucom; Asresahegn Getachew; Akin Akinwumi; Bruce Herdman; Phil DiBartolo; Susan Spencer; Devon Brown; Henry Lesansky; Irene Kuo Journal: Am J Public Health Date: 2012-03-08 Impact factor: 9.308
Authors: William E Cunningham; Robert E Weiss; Terry Nakazono; Mark A Malek; Steve J Shoptaw; Susan L Ettner; Nina T Harawa Journal: JAMA Intern Med Date: 2018-04-01 Impact factor: 21.873
Authors: Xiao Zang; Emanuel Krebs; Jeong E Min; Ankur Pandya; Brandon D L Marshall; Bruce R Schackman; Czarina N Behrends; Daniel J Feaster; Bohdan Nosyk Journal: Med Decis Making Date: 2019-12-22 Impact factor: 2.583
Authors: Cora L Bernard; Margaret L Brandeau; Keith Humphreys; Eran Bendavid; Mark Holodniy; Christopher Weyant; Douglas K Owens; Jeremy D Goldhaber-Fiebert Journal: Ann Intern Med Date: 2016-04-26 Impact factor: 51.598
Authors: Ethan D Borre; Emily P Hyle; A David Paltiel; Anne M Neilan; Paul E Sax; Kenneth A Freedberg; Milton C Weinstein; Rochelle P Walensky Journal: J Infect Dis Date: 2017-10-17 Impact factor: 7.759
Authors: Xiao Zang; Emanuel Krebs; Cassandra Mah; Jeong E Min; Brandon D L Marshall; Daniel J Feaster; Bruce R Schackman; Lisa R Metsch; Steffanie A Strathdee; Czarina N Behrends; Bohdan Nosyk Journal: AIDS Date: 2020-12-01 Impact factor: 4.177
Authors: Anthony Todd Fojo; Melissa Schnure; Parastu Kasaie; David W Dowdy; Maunank Shah Journal: Ann Intern Med Date: 2021-09-21 Impact factor: 25.391
Authors: Jean B Nachega; Ethan D Borre; David W Dowdy; Pascalina Chanda-Kapata; Susan Cleary; Elvin H Geng Journal: Lancet Glob Health Date: 2021-03-12 Impact factor: 26.763
Authors: Cari van Schalkwyk; Rob E Dorrington; Thapelo Seatlhodi; Claudia Velasquez; Ali Feizzadeh; Leigh F Johnson Journal: Sci Rep Date: 2021-03-11 Impact factor: 4.379
Authors: Amanda My Linh Quan; Cassandra Mah; Emanuel Krebs; Xiao Zang; Siyuan Chen; Keri Althoff; Wendy Armstrong; Czarina Navos Behrends; Julia C Dombrowski; Eva Enns; Daniel J Feaster; Kelly A Gebo; William C Goedel; Matthew Golden; Brandon D L Marshall; Shruti H Mehta; Ankur Pandya; Bruce R Schackman; Steffanie A Strathdee; Patrick Sullivan; Hansel Tookes; Bohdan Nosyk Journal: Lancet HIV Date: 2021-08-06 Impact factor: 16.070