Emanuel Krebs1, Xiao Zang1,2, Benjamin Enns1, Jeong E Min1, Czarina N Behrends3, Carlos Del Rio4,5, Julia C Dombrowski6, Daniel J Feaster7, Kelly A Gebo8, Brandon D L Marshall9, Shruti H Mehta10, Lisa R Metsch11, Ankur Pandya12, Bruce R Schackman3, Steffanie A Strathdee13, Bohdan Nosyk1,2. 1. British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada. 2. Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada. 3. Department of Healthcare Policy and Research, Weill Cornell Medical College, New York City, New York, USA. 4. Rollins School of Public Health, Emory University, Atlanta, Georgia, USA. 5. School of Medicine, Emory University, Atlanta, Georgia, USA. 6. Department of Medicine, Division of Allergy and Infectious Disease, University of Washington, Seattle, Washington, USA. 7. Department of Public Health Sciences, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida, USA. 8. School of Medicine, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA. 9. School of Public Health, Brown University, Providence, Rhode Island, USA. 10. Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA. 11. Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York City, New York, USA. 12. Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA. 13. School of Medicine, University of California San Diego, La Jolla, California, USA.
Abstract
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.
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.
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