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Shi F, Zhang J, Chen S, Yang X, Li Z, Weissman S, Olatosi B, Li X. Association of Racial Residential Segregation and Other Social Determinants of Health with HIV Late Presentation. AIDS Behav 2024:10.1007/s10461-024-04535-4. [PMID: 39414717 DOI: 10.1007/s10461-024-04535-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2024] [Indexed: 10/18/2024]
Abstract
Understanding social determinants of HIV late presentation with advanced disease (LPWA) beyond individual-level factors could help decrease LPWA and improve population-level HIV outcomes. This study aimed to examine county-level social determinants of health (SDOH) with HIV late presentation. We aggregated datasets for analysis by linking statewide HIV diagnosis data from the South Carolina (SC) Enhanced HIV/AIDS Reporting System and multiple social contextual datasets (e.g., the American Community Survey). All adult (18 years and older) people with HIV diagnosed from 2014 to 2019 in SC were included. Linear mixed models with forward selection were employed to explore the association of county-level SDOH with the county-level three-year moving average percentage of LPWA and average delay time from HIV infection to diagnosis. Around 30% of new HIV diagnoses were LPWA in SC, and the mean delay time for people with LPWA was approximately 13 years. Counties with more racial residential segregation had longer average delay time (Adjusted beta = 5.079, 95% CI: 0.268 ~ 9.889). Regarding other SDOH, the increased percentage of LPWA was associated with fewer Ryan White centers per 100,000 population (Adjusted beta = -0.006, 95% CI: -0.011~-0.001) and higher percentages of the population with less than a high school education (Adjusted beta = 0.008, 95% CI: 0 ~ 0.015). Reducing county-level disparities in LPWA requires multifaceted interventions addressing multiple dimensions of SDOH. Targeted interventions are needed for counties with more Black residential segregation, fewer Ryan White centers, and higher percentages of less than high school education.
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Affiliation(s)
- Fanghui Shi
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, South Carolina SmartState Center for Healthcare Quality, University of South Carolina, 915 Greene Street, Columbia, SC, 29208, USA.
- Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, 29208, USA.
| | - Jiajia Zhang
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, South Carolina SmartState Center for Healthcare Quality, University of South Carolina, 915 Greene Street, Columbia, SC, 29208, USA
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC, 29208, USA
| | - Shujie Chen
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, South Carolina SmartState Center for Healthcare Quality, University of South Carolina, 915 Greene Street, Columbia, SC, 29208, USA
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC, 29208, USA
| | - Xueying Yang
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, South Carolina SmartState Center for Healthcare Quality, University of South Carolina, 915 Greene Street, Columbia, SC, 29208, USA
- Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, 29208, USA
| | - Zhenlong Li
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, South Carolina SmartState Center for Healthcare Quality, University of South Carolina, 915 Greene Street, Columbia, SC, 29208, USA
- Department of Geography, College of Earth and Mineral Sciences, The Pennsylvania State University, University Park, PA, 16802, USA
| | - Sharon Weissman
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, South Carolina SmartState Center for Healthcare Quality, University of South Carolina, 915 Greene Street, Columbia, SC, 29208, USA
- Department of Internal Medicine, School of Medicine, University of South Carolina, Columbia, SC, 29208, USA
| | - Bankole Olatosi
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, South Carolina SmartState Center for Healthcare Quality, University of South Carolina, 915 Greene Street, Columbia, SC, 29208, USA
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, SC, 29208, USA
| | - Xiaoming Li
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, South Carolina SmartState Center for Healthcare Quality, University of South Carolina, 915 Greene Street, Columbia, SC, 29208, USA
- Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, 29208, USA
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GOYAL R, HOTCHKISS J, GILMAN B, KLEIN PW, MILLS RJ, STARLING J, MARTIN NK, PATTON T, COHEN SM, CHEEVER L. The health equity implications of the Health Resources and Services Administration's Ryan White HIV/AIDS Program. AIDS 2024; 38:1025-1032. [PMID: 38691049 PMCID: PMC11063458 DOI: 10.1097/qad.0000000000003836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
OBJECTIVE Investigate the role of the Ryan White HIV/AIDS Program (RWHAP) - which funds services for vulnerable and historically disadvantaged populations with HIV - in reducing health inequities among people with HIV over a 10-year horizon. DESIGN We use an agent-based microsimulation model to incorporate the complexity of the program and long-time horizon. METHODS We use a composite measure (the Theil index) to evaluate the health equity implications of the RWHAP for each of four subgroups (based on race and ethnicity, age, gender, and HIV transmission category) and two outcomes (probability of being in care and treatment and probability of being virally suppressed). We compare results with the RWHAP fully funded versus a counterfactual scenario, in which the medical and support services funded by the RWHAP are not available. RESULTS The model indicates the RWHAP will improve health equity across all demographic subgroups and outcomes over a 10-year horizon. In Year 10, the Theil index for race and ethnicity is 99% lower for both outcomes under the RWHAP compared to the non-RWHAP scenario; 71-93% lower across HIV transmission categories; 31-44% lower for age; and 73-75% lower for gender. CONCLUSION Given the large number of people served by the RWHAP and our findings on its impact on equity, the RWHAP represents an important vehicle for achieving the health equity goals of the National HIV/AIDS Strategy (2022-2025) and the Ending the HIV Epidemic Initiative goal of reducing new infections by 90% by 2030.
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Affiliation(s)
- Ravi GOYAL
- Division of Infectious Diseases & Global Public Health, University of California San Diego, La Jolla, CA
| | | | | | - Pamela W. KLEIN
- HIV/AIDS Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services, 5600 Fishers Lane, Rockville, MD 20857
| | - Robert J. MILLS
- HIV/AIDS Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services, 5600 Fishers Lane, Rockville, MD 20857
| | | | - Natasha K. MARTIN
- Division of Infectious Diseases & Global Public Health, University of California San Diego, La Jolla, CA
| | - Thomas PATTON
- Division of Infectious Diseases & Global Public Health, University of California San Diego, La Jolla, CA
| | - Stacy M. COHEN
- HIV/AIDS Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services, 5600 Fishers Lane, Rockville, MD 20857
| | - Laura CHEEVER
- HIV/AIDS Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services, 5600 Fishers Lane, Rockville, MD 20857
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Cummins B, Johnson K, Schneider JA, Del Vecchio N, Moshiri N, Wertheim JO, Goyal R, Skaathun B. Leveraging social networks for identification of people with HIV who are virally unsuppressed. AIDS 2024; 38:245-254. [PMID: 37890471 PMCID: PMC10843229 DOI: 10.1097/qad.0000000000003767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 10/06/2023] [Accepted: 10/12/2023] [Indexed: 10/29/2023]
Abstract
OBJECTIVES This study investigates primary peer-referral engagement (PRE) strategies to assess which strategy results in engaging higher numbers of people with HIV (PWH) who are virally unsuppressed. DESIGN We develop a modeling study that simulates an HIV epidemic (transmission, disease progression, and viral evolution) over 6 years using an agent-based model followed by simulating PRE strategies. We investigate two PRE strategies where referrals are based on social network strategies (SNS) or sexual partner contact tracing (SPCT). METHODS We parameterize, calibrate, and validate our study using data from Chicago on Black sexual minority men to assess these strategies for a population with high incidence and prevalence of HIV. For each strategy, we calculate the number of PWH recruited who are undiagnosed or out-of-care (OoC) and the number of direct or indirect transmissions. RESULTS SNS and SPCT identified 256.5 [95% confidence interval (CI) 234-279] and 15 (95% CI 7-27) PWH, respectively. Of these, SNS identified 159 (95% CI 142-177) PWH OoC and 32 (95% CI 21-43) PWH undiagnosed compared with 9 (95% CI 3-18) and 2 (95% CI 0-5) for SPCT. SNS identified 15.5 (95% CI 6-25) and 7.5 (95% CI 2-11) indirect and direct transmission pairs, whereas SPCT identified 6 (95% CI 0-8) and 5 (95% CI 0-8), respectively. CONCLUSION With no testing constraints, SNS is the more effective strategy to identify undiagnosed and OoC PWH. Neither strategy is successful at identifying sufficient indirect or direct transmission pairs to investigate transmission networks.
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Affiliation(s)
- Breschine Cummins
- Department of Mathematical Sciences, Montana State University, Bozeman, MT
| | - Kara Johnson
- Department of Mathematical Sciences, Montana State University, Bozeman, MT
| | - John A. Schneider
- Department of Medicine, University of Chicago
- Department of Public Health Sciences, University of Chicago, Chicago, IL
| | | | | | - Joel O. Wertheim
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Ravi Goyal
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Britt Skaathun
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California, San Diego, La Jolla, CA, USA
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Goyal R, Carnegie N, Slipher S, Turk P, Little SJ, De Gruttola V. Estimating contact network properties by integrating multiple data sources associated with infectious diseases. Stat Med 2023; 42:3593-3615. [PMID: 37392149 PMCID: PMC10825904 DOI: 10.1002/sim.9816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 05/09/2023] [Accepted: 05/19/2023] [Indexed: 07/03/2023]
Abstract
To effectively mitigate the spread of communicable diseases, it is necessary to understand the interactions that enable disease transmission among individuals in a population; we refer to the set of these interactions as a contact network. The structure of the contact network can have profound effects on both the spread of infectious diseases and the effectiveness of control programs. Therefore, understanding the contact network permits more efficient use of resources. Measuring the structure of the network, however, is a challenging problem. We present a Bayesian approach to integrate multiple data sources associated with the transmission of infectious diseases to more precisely and accurately estimate important properties of the contact network. An important aspect of the approach is the use of the congruence class models for networks. We conduct simulation studies modeling pathogens resembling SARS-CoV-2 and HIV to assess the method; subsequently, we apply our approach to HIV data from the University of California San Diego Primary Infection Resource Consortium. Based on simulation studies, we demonstrate that the integration of epidemiological and viral genetic data with risk behavior survey data can lead to large decreases in mean squared error (MSE) in contact network estimates compared to estimates based strictly on risk behavior information. This decrease in MSE is present even in settings where the risk behavior surveys contain measurement error. Through these simulations, we also highlight certain settings where the approach does not improve MSE.
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Affiliation(s)
- Ravi Goyal
- Division of Infectious Diseases and Global Public, University of California San Diego, San Diego, California, USA
| | | | - Sally Slipher
- Department of Mathematical Sciences, Montana State University, Bozeman, Montana, USA
| | - Philip Turk
- Department of Data Science, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Susan J Little
- Division of Infectious Diseases and Global Public, University of California San Diego, La Jolla, California, USA
| | - Victor De Gruttola
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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Economic benefits of the United States’ AIDS drug assistance Program: A systematic review of cost analyses to guide research and policy priorities. Prev Med Rep 2022; 29:101969. [PMID: 36161113 PMCID: PMC9502648 DOI: 10.1016/j.pmedr.2022.101969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 08/26/2022] [Accepted: 08/27/2022] [Indexed: 11/24/2022] Open
Abstract
The AIDS Drug Assistance Program (ADAP) is a $2.4 billion a year program. Little formal economic analysis of the ADAP in the literature. The few economic analyses of ADAP use 2008 or older data. ADAP programs’ healthcare delivery have changed substantially since 2008. Updated person-centered cost effectiveness models assessing ADAP are needed.
As part of the Ryan White HIV/AIDs Program, the federally-funded, state-administered AIDS Drug Assistance Program (ADAP) provides prescription drug medications, including antiretroviral therapy, for people with HIV (PWH) who are uninsured/underinsured and have a low income. ADAP expenditures are ∼$2.4 billion annually, but there is a dearth of formal economic analysis supporting the societal perspective. We conducted a systematic review of economic analyses of the United States’ AIDS Drug Assistance Program to establish future research priorities based on gaps in knowledge. We searched six electronic databases for articles published before January 2022 that met inclusion criteria. We used the 2022 Consolidated Health Economic Evaluation Reporting Standards to assess the quality of reporting of the economic evaluations. We extracted data into categories to assess gaps and needs for future economic evaluation. Seven studies met inclusion criteria. Two used the same modeling approaches but were published with slightly different outcomes. The few economic analyses that focused solely on ADAP were conducted using 2008 or older data. The most recent study modeled the net cost per quality-adjusted life-year (QALY) secondary to reducing new HIV cases among those virally suppressed, but did not include the economic or health benefits for PWH. ADAP programs’ delivery of antiretroviral therapy has shifted from primarily direct provision to subsidizing insurance plans. None of the models take these shifts into account. Updated person-centered cost effectiveness models assessing ADAP are needed on a national and state-by-state level to guide policy decisions and coverage determinations.
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Goyal R, Luca D, Klein PW, Morris E, Mandsager P, Cohen SM, Hu C, Hotchkiss J, Gao J, Jones A, Addison W, O'Brien-Strain M, Cheever LW, Gilman B. Cost-Effectiveness of HRSA's Ryan White HIV/AIDS Program? J Acquir Immune Defic Syndr 2021; 86:174-181. [PMID: 33093330 DOI: 10.1097/qai.0000000000002547] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 09/28/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND With an annual budget of more than $2 billion, the Health Resources and Services Administration's Ryan White HIV/AIDS Program (RWHAP) is the third largest source of public funding for HIV care and treatment in the United States, yet little analysis has been done to quantify the long-term public health and economic impacts of the federal program. METHODS Using an agent-based, stochastic model, we estimated health care costs and outcomes over a 50-year period in the presence of the RWHAP relative to those expected to prevail if the comprehensive and integrated system of medical and support services funded by the RWHAP were not available. We made a conservative assumption that, in the absence of the RWHAP, only uninsured clients would lose access to these medical and support services. RESULTS The model predicts that the proportion of people with HIV who are virally suppressed would be 25.2 percentage points higher in the presence of the RWHAP (82.6 percent versus 57.4 percent without the RWHAP). The number of new HIV infections would be 18 percent (190,197) lower, the number of deaths among people with HIV would be 31 percent (267,886) lower, the number of quality-adjusted life years would be 2.7 percent (5.6 million) higher, and the cumulative health care costs would be 25 percent ($165 billion) higher in the presence of the RWHAP relative to the counterfactual. Based on these results, the RWHAP has an incremental cost-effectiveness ratio of $29,573 per quality-adjusted life year gained compared with the non-RWHAP scenario. Sensitivity analysis indicates that the probability of transmitting HIV via male-to-male sexual contact and the cost of antiretroviral medications have the largest effect on the cost-effectiveness of the program. CONCLUSIONS The RWHAP would be considered very cost-effective when using standard guidelines of less than the per capita gross domestic product of the United States. The results suggest that the RWHAP plays a critical and cost-effective role in the United States' public health response to the HIV epidemic.
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Affiliation(s)
| | | | - Pamela W Klein
- HIV/AIDS Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services; and
| | | | - Paul Mandsager
- HIV/AIDS Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services; and
| | - Stacy M Cohen
- HIV/AIDS Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services; and
| | | | | | | | | | | | | | - Laura W Cheever
- HIV/AIDS Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services; and
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