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. 2021 Jan;111(1):150-158.
doi: 10.2105/AJPH.2020.305965. Epub 2020 Nov 19.

Optimal Allocation of Societal HIV Prevention Resources to Reduce HIV Incidence in the United States

Stephanie L Sansom  1 , Katherine A Hicks  1 , Justin Carrico  1 , Evin U Jacobson  1 , Ram K Shrestha  1 , Timothy A Green  1 , David W Purcell  1
Affiliations

Optimal Allocation of Societal HIV Prevention Resources to Reduce HIV Incidence in the United States

Stephanie L Sansom et al. Am J Public Health. 2021 Jan.

Abstract

Objectives. To optimize combined public and private spending on HIV prevention to achieve maximum reductions in incidence.Methods. We used a national HIV model to estimate new infections from 2018 to 2027 in the United States. We estimated current spending on HIV screening, interventions that move persons with diagnosed HIV along the HIV care continuum, pre-exposure prophylaxis, and syringe services programs. We compared the current funding allocation with 2 optimal scenarios: (1) a limited-reach scenario with expanded efforts to serve eligible persons and (2) an ideal, unlimited-reach scenario in which all eligible persons could be served.Results. A continuation of the current allocation projects 331 000 new HIV cases over the next 10 years. The limited-reach scenario reduces that number by 69%, and the unlimited reach scenario by 94%. The most efficient funding allocations resulted in prompt diagnosis and sustained viral suppression through improved screening of high-risk persons and treatment adherence support for those infected.Conclusions. Optimal allocations of public and private funds for HIV prevention can achieve substantial reductions in new infections. Achieving reductions of more than 90% under current funding will require that virtually all infected receive sustained treatment.

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Figures

FIGURE 1—
FIGURE 1—
Diagram of How HIV Prevention Interventions Relate to HIV and the HIV Care Continuum: United States Note. ART = antiretroviral therapy; PrEP = pre-exposure prophylaxis; PWID = persons who inject drugs; SSP = syringe services programs; VLS = viral load suppression.
FIGURE 2—
FIGURE 2—
Annual Allocations to HIV Care–Continuum Interventions Under Current and Optimal Allocation Scenarios and Associated Cumulative Number of HIV Infections: United States, 2018–2027 Note. ART = antiretroviral therapy; LTC = linkage to care; MSM = men who have sex with men; PrEP = pre-exposure prophylaxis; PWID = persons who inject drugs. The same total prevention funding was applied in the 3 scenarios, but the allocations differed. Allocations to screening, PrEP, and interventions that increase linkage to care and support adherence to care and treatment represented allocations across subpopulations. Screening, for instance, included high- and low-risk MSM, high- and low-risk heterosexuals, and all PWID; PrEP included allocations to high-risk MSM, high-risk heterosexuals, and all PWID; linkage-to-care interventions influenced linkage at and after diagnosis; and interventions that support adherence to care and treatment included allocations to both achieve and maintain viral suppression. The dots on the solid black line indicate the 10-year cumulative incidence of HIV associated with a 10-year allocation of current funding and the 2 consecutive 5-year allocations under the 2 optimal distributions.
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