Modeling an integrated HIV prevention and care continuum to achieve the Ending the HIV Epidemic goals

Abstract

Objective: We sought to evaluate, which combinations of HIV prevention and care activities would have the greatest impact towards reaching the US Ending the HIV Epidemic (EHE) plan goals of HIV incidence reduction.

Design: A stochastic network-based HIV transmission model for men who have sex with men (MSM), calibrated to surveillance estimates in the Atlanta area, a focal EHE jurisdiction.

Methods: Model scenarios varied HIV screening rates under different assumptions of how HIV-negative MSM would be linked to PrEP initiation, and rates of HIV care linkage and retention for those screening positive.

Results: A ten-fold relative increase in HIV screening rates (to approximately biannual screening for black and Hispanic MSM and quarterly for white MSM) would lead to 43% of infections averted if integrated with PrEP initiation. Improvements focused only on black MSM would achieve nearly the same outcome (37% of infections averted). Improvements to HIV care retention would avert 41% of infections if retention rates were improved ten-fold. If both screening and retention were jointly improved ten-fold, up to 74% of cumulative infections would be averted. Under this scenario, it would take 4 years to meet the 75% EHE goal and 12 years to meet the 90% goal for Atlanta MSM.

Conclusion: Reaching the EHE 75% incidence reduction goals by their target dates will require immediate and substantial improvements in HIV screening, PrEP, and ART care retention. Meeting these EHE goals in target jurisdictions like Atlanta will be possible only by addressing the HIV service needs of black MSM.

Figure 1.

Percent of cumulative infections averted (PIA) over 10 years as a function of relative improvements to HIV screening rates and HIV care retention rates, under a scenario where the offer of PrEP is linked to screening negative (left panel) or that the offer of PrEP occurs as a separate activity with no linkage to HIV screening (right panel). The maximum PIA achieved (upper right corners of each panel) were 73.9% and 57.9%, respectively.

Figure 2.

HIV incidence rate per 100 person-years at risk (PYAR) over 50 years comparing a scenario in which the HIV prevention and care continuum was fixed (Reference Model) to a scenario in which there were 10-fold increases in rates of HIV screening (with linked PrEP) and care retention (10x10 Model). The EHE target of a 75% reduction in the incidence rate is achieved in the 10x10 Model in year 2024 (4 years post-intervention initiation) and the 90% incidence reduction target is achieved in 2032 (12 years post-intervention initiation).