Amanda My Linh Quan1, Cassandra Mah2, Emanuel Krebs3, Xiao Zang4, Siyuan Chen2, Keri Althoff5, Wendy Armstrong6, Czarina Navos Behrends7, Julia C Dombrowski8, Eva Enns9, Daniel J Feaster10, Kelly A Gebo11, William C Goedel12, Matthew Golden8, Brandon D L Marshall12, Shruti H Mehta11, Ankur Pandya13, Bruce R Schackman7, Steffanie A Strathdee14, Patrick Sullivan15, Hansel Tookes16, Bohdan Nosyk17. 1. Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada. 2. Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada. 3. Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada; BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada. 4. Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada; Department of Epidemiology, School of Public Health, Brown University, Providence, RI, USA. 5. Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. 6. Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA. 7. Department of Population Health Sciences, Weill Cornell Medical College, New York, NY, USA. 8. Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA; HIV/STD Program, Public Health-Seattle & King County, Seattle, WA, USA. 9. Division of Health Policy and Management, University of Minnesota, Minneapolis, MN, USA. 10. Department of Public Health Sciences, Leonard M Miller School of Medicine, University of Miami, Miami, FL, USA. 11. Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA. 12. Department of Epidemiology, School of Public Health, Brown University, Providence, RI, USA. 13. T H Chan School of Public Health, Harvard University, Boston, MA, USA. 14. School of Medicine, University of California San Diego, La Jolla, CA, USA. 15. Department of Epidemiology, Emory University, Atlanta, GA, USA. 16. Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA. 17. Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada; BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada. Electronic address: bnosyk@sfu.ca.
Abstract
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.
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.
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