Healio Special Report: Health Care and Politics

Healio Special Report: Health Care and Politics

Perspective from Brandon Pollak, MD
Disclosures: Fojo reports receiving support from the National Institute of Mental Health. Linas reports receiving grant support from the National Institute on Drug Abuse and the National Institute of Allergy and Infectious Diseases. Please see the study for all authors' relevant financial disclosures.
September 20, 2021
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Ending HIV epidemic by 2030 requires community-specific interventions

Perspective from Brandon Pollak, MD
Disclosures: Fojo reports receiving support from the National Institute of Mental Health. Linas reports receiving grant support from the National Institute on Drug Abuse and the National Institute of Allergy and Infectious Diseases. Please see the study for all authors' relevant financial disclosures.
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Large reductions in HIV incidence can be achieved with substantial investments and sustained, community-specific interventions, according to a modeling study published in the Annals of Internal Medicine.

However, the Ending the HIV Epidemic (EHE) goal of reducing incidence by 90% over the next 10 years will be difficult to accomplish, Anthony Todd Fojo, MD, MHS, a general internal medicine fellow at Johns Hopkins University School of Medicine, and colleagues wrote. Reaching the EHE goal would “require a level of intervention that is likely beyond the reach of most local jurisdiction,” they added.

Predicted reductions in HIV incidence by 2030.
Fojo AT, et al. Ann Int Med. 2021;doi:10.7326/M21-1501.

Fojo and colleagues simulated HIV transmission in 32 priority metropolitan statistical areas (MSAs) in the U.S. from 2020 to 2030 using the Johns Hopkins HIV Economic-Epidemiologic Mathematical Model. The model estimated likely HIV infections by age, race, ethnicity, sex and sexual behavior after implementing a combination of varying intensities of transmission reduction strategies from the EHE. The three primary EHE interventions analyzed included HIV screening, viral suppression among persons with HIV infection and preventive measures.

Modest vs. large-scale interventions

In 2020, the projected level of preexposure prophylaxis (PrEP) coverage for men who have sex with men (MSM) in all MSAs was 3% to 12%.

Without any interventions implemented, the rate of HIV incidence was modeled to decrease 19% by 2030 in the 32 MSAs. However, with a 1.25-fold annual increase in testing, a 5-percentage point increase in PrEP coverage and a 10-percentage point increase in viral suppression were predicted to achieve incidence reductions of 34% to 67%. In addition, average testing of twice a year, 25% PrEP coverage and 90% viral suppression among Black and Hispanic MSM were predicted to achieve incidence reductions of 13% to 68%.

If these interventions were expanded to include all MSM and those who inject drugs, incidence reduction could be reduced by 48% to 90%, according to Fojo and colleagues. However, large-scale interventions that include heterosexuals were modeled to achieve incidence reductions of greater than 90% by 2030 in 13 of the 32 MSAs.

In specific MSAs, the researchers estimated that HIV incidence could be reduced by up to 16% in communities that expanded needle exchange programs. The interventions most associated with incidence reductions involved targeting HIV transmission among Black heterosexuals and the “degree to which viral suppression increased in the future absent intervention,” according to Fojo and colleagues.

Still, interventions like increasing testing, PrEP coverage and viral suppression require “substantial investments at the local level,” they wrote.

Extra $30 billion per year needed to end HIV

In a related editorial, Benjamin P. Linas, MD, MPH, a professor at Boston University’s School of Medicine and School of Public Health and an infectious disease physician at Boston Medical Center, emphasized the need for national investments to end the HIV epidemic and discussed how current efforts are lacking.

“The WHO, U.S. Department of Health and Human Services, CDC and National Institutes of Health all endorse the goal of eliminating HIV transmission and ending the HIV epidemic by

the year 2030,” Linas wrote. “Yet, although tools exist to end the HIV epidemic, the incidence of HIV in the U.S. has been stubbornly flat. In some groups, the incidence of HIV is even increasing.”

Without more interventions and investments, the HIV epidemic will not end, according to Linas. While officials recognize that the challenge of ending the HIV epidemic necessitates localized and comprehensive strategies, it requires “an all-in response that arguably does not currently exist,” he wrote.

To implement this approach, Linas said the U.S. needs to invest an additional $30 billion per year.

“In the scope of the $6.6 trillion U.S. federal budget, plus an approximately $2.2 trillion spent by states, $30 billion represents an additional 0.3% of our total resources every year (2% of federal discretionary spending),” he wrote. “We can end the HIV epidemic in America. Are we ready to commit one-third of 1%?”

References:

Fojo AT, et al. Ann Int Med. 2021;doi:10.7326/M21-1501.

Linas BP. Ann Int Med. 2021;doi:10.7326/M21-3607.