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. 2020 Sep 2;222(Suppl 5):S301-S311.
doi: 10.1093/infdis/jiaa130.

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

Emanuel Krebs  1 , Xiao Zang  1   2 , Benjamin Enns  1 , Jeong E Min  1 , Czarina N Behrends  3 , Carlos Del Rio  4   5 , Julia C Dombrowski  6 , Daniel J Feaster  7 , Kelly A Gebo  8 , Brandon D L Marshall  9 , Shruti H Mehta  10 , Lisa R Metsch  11 , Ankur Pandya  12 , Bruce R Schackman  3 , Steffanie A Strathdee  13 , Bohdan Nosyk  1   2 ; Localized HIV Modeling Study Group
Collaborators, Affiliations

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

Emanuel Krebs et al. J Infect Dis. .

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.

Keywords: HIV; cost-effectiveness; dynamic HIV transmission mode; injection drug use; interventions; localized HIV microepidemics.

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Figures

Figure 1.
Figure 1.
City-level health production functions for evidence-based prevention and care interventions targeted to persons who inject drugs and men who have sex with men who inject drugs. Abbreviations: MOUD, medication for opioid use disorder; PrEP, preexposure prophylaxis; QALY, quality-adjusted life-year; SSP, syringe service program.
Figure 2.
Figure 2.
Interventions composing the health-maximizing cost-effective combinations. Abbreviations: ART, antiretroviral therapy; ARTAS, Antiretroviral Treatment Access Study; EMR, electronic medical records; MOUD, medication for opioid use disorder; MSMWID, men who have sex with men who inject drugs; PrEP, preexposure prophylaxis; PWID, persons who inject drugs; RAPID, Rapid ART Program for Individuals with an HIV Diagnosis.
Figure 3.
Figure 3.
Projected reductions in HIV incidence among persons who inject drugs and men who have sex with men who inject drugs.
See this image and copyright information in PMC

References

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