Ending HIV epidemic by 2030 requires community-specific interventions
Click Here to Manage Email Alerts
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.
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.
Perspective
Back to Top
Brandon Pollak, MD
There has been a recent resurgence in efforts to EHE, with lofty goals of decreasing rates of new HIV infections by 90% over the next 10 years. The HIV epidemic continues to highlight the inequities of the health care system and the impacts and intersectionality of institutional racism, homophobia and transphobia, with continued disproportionate rates of new HIV infections in marginalized populations. Interventions such as increasing HIV screening, improving viral suppression of those who are aware of their HIV diagnosis and providing broad access to HIV prevention services like PrEP and needle exchange programs have been identified as key targets to achieving this goal.
Fojo and colleagues have created a compartmental model to examine the impact of these different interventions at various intensities and their impact on decreasing HIV rates at a metropolitan statistical level based on previous epidemiological data. They also identified three key populations in their model:
- Black and Hispanic MSM younger than 35 years.
- Non-Black and Hispanic MSM younger than 35 years; Black and Hispanic MSM older than 35 years; and all people who inject drugs.
- All heterosexual persons.
This novel HIV transmission model predicts outcomes ranging from a 19% reduction in HIV incidence by 2030 without intervention to reductions of 34% to 67% overall with modest increases in testing, PrEP uptake and viral suppression, although outcomes vary widely across MSAs. Models such as this one allow local leaders to invest and create programs with the highest potential impact on decreasing the new HIV infection rate. It is clear that to achieve these goals, rapidly expanding funding and community-specific interventions are needed to ultimately end the HIV epidemic.
Areas of highest priority include comprehensive mental health treatment, substance use treatment (specifically for methamphetamines), highly potent long-acting antiretroviral medications and new case management models to help people at highest risk for acquiring HIV. These efforts will need to extend beyond the traditional models of HIV care to include other settings such as the ED, primary care and mental health centers to achieve these goals. Although our efforts will likely fall short of the EHE goals by 2030, this model highlights that ending the HIV epidemic is possible.
Collapse
Read more about
Click Here to Manage Email Alerts