Background: In the USA, Black and Hispanic or Latinx individuals continue to be disproportionately affected by HIV. Applying a distributional cost-effectiveness framework, we estimated the cost-effectiveness and epidemiological impact of two combination implementation approaches to identify the approach that best meets the dual objectives of improving population health and reducing racial or ethnic health disparities. Methods: We adapted a dynamic, compartmental HIV transmission model to characterise HIV micro-epidemics in six US cities: Atlanta, Baltimore, Los Angeles, Miami, New York, and Seattle. We considered combinations of 16 evidence-based interventions to diagnose, treat, and prevent HIV transmission according to previously documented levels of scale-up. We then identified optimal combination strategies for each city, with the distribution of each intervention implemented according to existing service levels (proportional services approach) and the racial or ethnic distribution of new diagnoses (between Black, Hispanic or Latinx, and White or other ethnicity individuals; equity approach). We estimated total costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios of strategies implemented from 2020 to 2030 (health-care perspective; 20-year time horizon; 3% annual discount rate). We estimated three measures of health inequality (between-group variance, index of disparity, Theil index), incidence rate ratios, and rate differences for the selected strategies under each approach. Findings: In all cities, optimal combination strategies under the equity approach generated more QALYs than those with proportional services, ranging from a 3·1% increase (95% credible interval [CrI] 1·4–5·3) in New York to more than double (101·9% [75·4–134·6]) in Atlanta. Compared with proportional services, the equity approach delivered lower costs over 20 years in all cities except Los Angeles; cost reductions ranged from $22·9 million (95% CrI 5·3–55·7 million) in Seattle to $579·8 million (255·4–940·5 million) in Atlanta. The equity approach also reduced incidence disparities and health inequality measures in all cities except Los Angeles. Interpretation: Equity-focused HIV combination implementation strategies that reduce disparities for Black and Hispanic or Latinx individuals can significantly improve population health, reduce costs, and drive progress towards Ending the HIV Epidemic goals in the USA. Funding: National Institute on Drug Abuse.
Bibliographical noteFunding Information:
KA reports grants from the US National Institutes of Health (NIH), personal fees from The All of Us Research Program (NIH), personal fees from TrioHealth, and non-financial support from Cumming School of Medicine, University of Calgary, outside the submitted work. CNB reports grants from the National Institute on Drug Abuse, during the conduct of the study. EE reports personal fees from ViiV Healthcare, outside the submitted work. KAG reports personal fees from Simon Fraser University, during the conduct of the study. SHM reports personal fees from Gilead Sciences, outside the submitted work. MG reports research support from Hologic, outside the submitted work. SAS reports grants from NIH, outside the submitted work. HT reports grants from Gilead Sciences, outside the submitted work. BN reports grants from NIH, during the conduct of the study. All other authors declare no competing interests.
This study was funded by the NIH National Institute on Drug Abuse (grant number R01DA041747 to BN). The funding agreement ensured the authors’ independence in designing the study, interpreting the data, writing, and publishing the report.
© 2021 Elsevier Ltd
PubMed: MeSH publication types
- Journal Article
- Research Support, N.I.H., Extramural