Projecting the Potential Clinical and Economic Impact of HIV Prevention Resource Reallocation in Tennessee

Abstract

Background: In 2023, Tennessee replaced $6.2 M in US Centers for Disease Control and Prevention (CDC) human immunodeficiency virus (HIV) prevention funding with state funds to redirect support away from men who have sex with men (MSM), transgender women (TGW), and heterosexual Black women (HSBW) and to prioritize instead first responders (FR), pregnant people (PP), and survivors of sex trafficking (SST).

Methods: We used a simulation model of HIV disease to compare the clinical impact of Current, the present allocation of condoms, preexposure prophylaxis (PrEP), and HIV testing to CDC priority risk groups (MSM/TGW/HSBW); with Reallocation, funding instead increased HIV testing and linkage of Tennessee-determined priority populations (FR/PP/SST). Key model inputs included baseline condom use (45%-49%), PrEP provision (0.1%-8%), HIV testing frequency (every 2.5-4.8 years), and 30-day HIV care linkage (57%-65%). We assumed Reallocation would reduce condom use (-4%), PrEP provision (-26%), and HIV testing (-47%) in MSM/TGW/HSBW, whereas it would increase HIV testing among FR (+47%) and HIV care linkage (to 100%/90%) among PP/SST.

Results: Reallocation would lead to 166 additional HIV transmissions, 190 additional deaths, and 843 life-years lost over 10 years. HIV testing reductions were most influential in sensitivity analysis; even a 24% reduction would result in 287 more deaths compared to Current. With pessimistic assumptions, we projected 1359 additional HIV transmissions, 712 additional deaths, and 2778 life-years lost over 10 years.

Conclusions: Redirecting HIV prevention funding in Tennessee would greatly harm CDC priority populations while conferring minimal benefits to new priority populations.

Keywords: HIV; HIV prevention; HIV prevention resource allocation; Health policy; Tennessee HIV prevention.

Figure 1.

Cumulative HIV transmissions among the modeled populations at 10 y in the Current and Reallocation strategies. This figure depicts the number of HIV transmissions over 10 y resulting from the Current (dark shade) and Reallocation (light shade) strategies for each modeled subpopulation. Primary HIV transmissions among the simulated risk groups are included. Secondary transmissions arising from these primary transmissions were not considered. Abbreviation: HIV, Human immunodeficiency virus.

Figure 2.

HIV care continuum outcomes among modeled people with HIV for the Current and Reallocation strategies at 10 y. Figure shows the proportion of simulated people with HIV who are diagnosed, linked to care, and virologically suppressed at year 10 in the Current (dark shade) and Reallocation (light shade) strategies. Of note, these results are for populations simulated in the present study, defined in the Methods, and include only people in Tennessee with undiagnosed or unlinked HIV at model initiation, or incident HIV over the 10-y time horizon of the simulation. Under Current, there are fewer people with HIV overall because of decreased HIV transmissions; there are also greater proportions of people with HIV who are diagnosed, linked to care, and virologically suppressed. Abbreviation: HIV, Human immunodeficiency virus.

Figure 3.

Number of simulated people with HIV in Tennessee who have undiagnosed HIV, compared to people who have diagnosed HIV and are virologically suppressed at 10 y. Figure presents the projected number of people with HIV across each risk group who are undiagnosed (patterned) compared to those who are diagnosed and virologically suppressed (solid) at 10 y under the Current (dark shade) and Reallocation (light shade) scenarios. Under Current, there are fewer total people with undiagnosed HIV and more people with diagnosed HIV at year 10 compared with Reallocation. Reallocation does increase the number of people with HIV who are virologically suppressed among first responders, pregnant people, and survivors of sex trafficking; however, the increase is relatively small compared to the decrease in virologic suppression among men who have sex with men, transgender women, and heterosexual Black women. *Survivors of sex trafficking are assumed to be diagnosed when freed from sex trafficking in Current and Reallocation, but in Reallocation the linkage to HIV care is assumed to increase from 56% to 90%. Abbreviation: HIV, human immunodeficiency virus.

Figure 4.

Change in key clinical outcomes across scenario analyses. This figure shows the impact of varying selected input parameters across their plausible ranges on estimated additional HIV transmissions, deaths, and life-years lost under Reallocation compared with Current. Each row is a single scenario analysis where either 1 parameter, or multiple parameters, were varied from their base case value. The numerical impact of the parameter change on the clinical outcomes is shown on the right, and the color gradient depicts whether the projected outcome under the given scenario analysis has better (blue) or worse (red) outcomes in that sensitivity analysis compared to the base case reallocation value. The pessimistic case scenario included changing 6 combined parameters: increase in transmissions from PWH with viremia, retention in care to 62% at 2 y in reallocation, HIV testing change to 71%, linkage to care reduction in reallocation by 25%, reduction in condom use to 6% and PrEP use to 38%, and condom and PrEP efficacy to 91% and 95%. Abbreviations: HIV, Human immunodeficiency virus; PrEP, preexposure prophylaxis; PWH, people with HIV.