What Will It Take to End HIV in the United States? : A Comprehensive, Local-Level Modeling Study

Persistence With Human Immunodeficiency Virus Pre-exposure Prophylaxis in an Active-Duty Military Population

There is limited data on Human Immunodeficiency Virus Pre-exposure Prophylaxis (PrEP) use and persistence in the military. Despite universal access to care, there is concern that PrEP persistence may be lower in military populations due to logistical challenges and perceived stigma. This study evaluated the persistence rates as well as reasons for PrEP discontinuation in a military cohort. This study evaluated all active-duty service members who received PrEP between 2020 and 2022 at a large military infectious diseases clinic. All charts were examined to determine patient characteristics. Patients who discontinued PrEP were contacted to determine the reason for discontinuation and invited to restart PrEP. In total, 112 service members received PrEP during the study period. The cohort was predominantly male (99%) with a median age 30 [IQR: 26-34] and a median of 2 years [IQR: 0-3] receiving PrEP. The most common indication was multiple sexual partners with less than 100% condom use (88%). At the end of the study, most (79%) patients were still receiving PrEP including 33 (37%) at other facilities. Of the twenty-four service members who were no longer receiving PrEP, 18 (75%), were able to be contacted. No patients contacted were interested in restarting PrEP. In this cohort with universal access to care, PrEP persistence rates were greater than seen in other populations. While the most common reason for discontinuation was changes in sexual behavior, systemic factors still contributed to PrEP discontinuation. Future studies should elucidate the challenges to PrEP care in the military.

Potential contribution of PrEP uptake by adolescents 15-17 years old to achieving the "Ending the HIV Epidemic" incidence reduction goals in the US South

BACKGROUND

The "Ending the HIV Epidemic" (EHE) initiative seeks to reduce new HIV infections in the U.S. by prioritizing federal resources towards highly impacted populations. Antiretroviral therapy (ART) and pre-exposure prophylaxis (PrEP) are essential for reaching EHE goals. Adolescents are often at increased risk for HIV because they may lack agency in negotiating their sexual partnerships and may not have the same access to treatment and prevention as adults. This study estimates the potential contribution of expanded PrEP coverage among adolescents ages 15-17 to achieving the EHE goals in the South.

METHODS

An HIV-transmission model was built to simulate the HIV epidemic in the South. Increased ART and PrEP uptake were systematically varied with and without PrEP eligibility including individuals age<18.

RESULTS

Prioritizing PrEP for adolescents had a negligible impact on incidence. At 50% uptake among eligible adolescents and 90% ART coverage, including adolescents only improved the percentage of infections averted from 80.1% to 80.3%. In 10 of 15 scenarios explored, there was no reduction in new infections when PrEP eligibility was expanded to include adolescents age<18. At 95% ART coverage at the population-level incidence among adolescents declined by over 80%, but PrEP uptake among adolescents did not contribute to additional declines in incidence among adolescents.

CONCLUSIONS

Prioritizing PrEP for adolescents did not significantly contribute to reaching EHE incidence reductions goal. Focusing resources to specific adolescent populations at risk, such sexual minority males in high incidence settings, will remain an important public health goal outside the context of EHE.

Estimating the epidemiological impact of reaching the objectives of the Florida integrated HIV prevention and care plan in Miami-Dade County

Background

The US Ending the HIV Epidemic (EHE) initiative aims to reduce national HIV incidence 90% by 2030 and to address the disproportionate burden of HIV among different racial/ethnic populations. Florida's state-wide 2022-2026 Integrated HIV Prevention and Care Plan outlines objectives for reaching EHE goals. In Miami-Dade County, we determined the epidemiological impact of achieving the integrated plan's objectives individually and jointly.

Methods

We adapted an HIV transmission model calibrated to Miami-Dade County adjusting access to HIV testing, pre-exposure prophylaxis (PrEP) and antiretroviral treatment to model the effects of each objective between 2022 and 2030. We compared two service scale-up approaches: (a) scale-up proportionally to existing racial/ethnic group access levels, and (b) scale-up according to new diagnoses across racial/ethnic groups (equity-oriented). We estimated reductions in new HIV infections by each objective and approach, compared to the EHE's incidence reduction target.

Findings

The single most influential strategy was reducing new HIV diagnoses in Hispanic/Latinx men who have sex with men through increased PrEP uptake, resulting in 907/2444 (37.1%) fewer annual new HIV infections in 2030. Achieving all objectives jointly would result in 1537/2444 (62.9%) and 1553/2444 (63.5%) fewer annual new HIV infections with the proportional and equity-oriented approaches, respectively.

Interpretation

Achieving the goals of Florida's integrated care plan would significantly reduce HIV incidence in Miami-Dade County; however, further efforts are required to achieve EHE targets. Structural changes in service delivery and a focus on effective implementation of available interventions to address racial/ethnic disparities will be crucial to ending the HIV epidemic.

Funding

This work was supported by the National Institutes of Health/National Institute on Drug Abuse grant no. R01-DA041747.

Impact of subgroup-specific heterogeneities and dynamic changes in mortality rates on forecasted population size, deaths, and age distribution of persons receiving antiretroviral treatment in the United States: a computer simulation study

PURPOSE

Model-based forecasts of population size, deaths, and age distribution of people with HIV (PWH) are helpful for public health and clinical services planning but are influenced by subgroup-specific heterogeneities and changes in mortality rates.

METHODS

Using an agent-based simulation of PWH in the United States, we examined the impact of distinct approaches to parametrizing mortality rates on forecasted epidemiology of PWH on antiretroviral treatment (ART). We first estimated mortality rates among (1) all PWH, (2) sex-specific, (3) sex-and-race/ethnicity-specific, and (4) sex-race/ethnicity-and-HIV-acquisition-risk-specific subgroups. We then assessed each scenario by (1) allowing unrestricted reductions in age-specific mortality rates over time and (2) restricting the mortality rates among PWH to subgroup-specific mortality thresholds from the general population.

RESULTS

Among the eight scenarios examined, those lacking subgroup-specific heterogeneities and those allowing unrestricted reductions in future mortality rates forecasted the lowest number of deaths among all PWH and 9 of the 15 subgroups through 2030. The forecasted overall number and age distribution of people with a history of injection drug use were sensitive to inclusion of subgroup-specific mortality rates.

CONCLUSIONS

Our results underscore the potential risk of underestimating future deaths by models lacking subgroup-specific heterogeneities in mortality rates, and those allowing unrestricted reductions in future mortality rates.

The Testing Imperative: Why the US Ending the Human Immunodeficiency Virus (HIV) Epidemic Program Needs to Renew Efforts to Expand HIV Testing in Clinical and Community-Based Settings

Data from several modeling studies demonstrate that large-scale increases in human immunodeficiency virus (HIV) testing across settings with a high burden of HIV may produce the largest incidence reductions to support the US Ending the HIV Epidemic (EHE) initiative's goal of reducing new HIV infections 90% by 2030. Despite US Centers for Disease Control and Prevention's recommendations for routine HIV screening within clinical settings and at least yearly screening for individuals most at risk of acquiring HIV, fewer than half of US adults report ever receiving an HIV test. Furthermore, total domestic funding for HIV prevention has remained unchanged between 2013 and 2019. The authors describe the evidence supporting the value of expanded HIV testing, identify challenges in implementation, and present recommendations to address these barriers through approaches at local and federal levels to reach EHE targets.

Achieving the "Ending the HIV Epidemic in the U.S." incidence reduction goals among at-risk populations in the South

INTRODUCTION

Antiretroviral medication coverage remains sub-optimal in much of the United States, particularly the Sothern region, and Non-Hispanic Black or African American persons (NHB) continue to be disproportionately impacted by the HIV epidemic. The "Ending the HIV Epidemic in the U.S." (EHE) initiative seeks to reduce HIV incidence nationally by focusing resources towards the most highly impacted localities and populations. This study evaluates the impact of hypothetical improvements in ART and PrEP coverage to estimate the levels of coverage needed to achieve EHE goals in the South.

METHODS

We developed a stochastic, agent-based network model of 500,000 individuals to simulate the HIV epidemic and hypothetical improvements in ART and PrEP coverage.

RESULTS

New infections declined by 78.6% at 90%/40% ART/PrEP and 94.3% at 100%/50% ART/PrEP. Declines in annual incidence rates surpassed 75% by 2025 with 90%/40% ART/PrEP and 90% by 2030 with 100%/50% ART/PrEP coverage. Increased ART coverage among NHB MSM was associated with a linear decline in incidence among all MSM. Declines in incidence among Hispanic/Latino and White/Other MSM were similar regardless of which MSM race group increased their ART coverage, while the benefit to NHB MSM was greatest when their own ART coverage increased. The incidence rate among NHB women declined by over a third when either NHB heterosexual men or NHB MSM increased their ART use respectively. Increased use of PrEP was associated with a decline in incidence for the groups using PrEP. MSM experienced the largest absolute declines in incidence with increasing PrEP coverage, followed by NHB women.

CONCLUSIONS

Our analysis indicates that it is possible to reach EHE goals. The largest reductions in HIV incidence can be achieved by increasing ART coverage among MSM and all race groups benefit regardless of differences in ART initiation by race. Improving ART coverage to > 90% should be prioritized with a particular emphasis on reaching NHB MSM. Such a focus will reduce the largest number of incident cases, reduce racial HIV incidence disparities among both MSM and women, and reduce racial health disparities among persons with HIV. NHB women should also be prioritized for PrEP outreach.

Leveraging mHealth and Patient Supporters for African Americans' and Latinxs' Engagement in HIV Care (LEAN): Protocol for a Randomized, Controlled, Effectiveness-Implementation Trial

BACKGROUND

Despite substantial investments in ending the HIV epidemic, disparities in HIV care persist, and there is an urgent need to evaluate novel and scalable approaches to improving HIV care engagement and viral suppression in real-world settings.

OBJECTIVE

This paper aims to describe a study protocol for a pragmatic type II hybrid effectiveness-implementation randomized controlled trial comparing existing standard of care clinic HIV linkage, adherence, and retention (LAR) protocols to a mobile health (mHealth)-enhanced linkage, adherence, and retention (mLAR) intervention.

METHODS

The study will enroll 450 participants from clinics in Baltimore City. Eligibility criteria include being ≥18 years of age, having a new HIV diagnosis or being HIV-positive and out of care, or being HIV-positive and deemed by clinic staff as someone who could benefit from linkage and retention services. Participants randomized to the intervention receive mHealth-supported patient navigation for 12 months. Participants in the control group receive the referring clinic's standard of care patient support. The primary outcome is HIV virologic suppression at 12 months. A subset of participants will be interviewed at 12 months to learn about their HIV care experiences and, for those in the intervention arm, their experiences with the mLAR intervention. This protocol was developed in collaboration with the Baltimore City Health Department (BCHD) and the Maryland Department of Health (MDH) and with input from a community advisory board.

RESULTS

Enrollment began on February 25, 2020. As of August 11, 2022, 411 of the 450 target participants had been enrolled.

CONCLUSIONS

Pragmatic implementation science trials designed with input from key stakeholders, including health departments and community members, can help evaluate the evidence for mHealth interventions to reduce HIV health disparities.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03934437; https://clinicaltrials.gov/ct2/show/NCT03934437.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/42691.

Evaluating the sensitivity of jurisdictional heterogeneity and jurisdictional mixing in national level HIV prevention analyses: context of the U.S. ending the HIV epidemic plan

BACKGROUND

The U.S. Ending the HIV epidemic (EHE) plan aims to reduce annual HIV incidence by 90% by 2030, by first focusing interventions on 57 regions (EHE jurisdictions) that contributed to more than 50% of annual HIV diagnoses. Mathematical models that project HIV incidence evaluate the impact of interventions and inform intervention decisions. However, current models are either national level, which do not consider jurisdictional heterogeneity, or independent jurisdiction-specific, which do not consider cross jurisdictional interactions. Data suggests that a significant proportion of persons have sexual partnerships outside their own jurisdiction. However, the sensitivity of these jurisdictional interactions on model outcomes and intervention decisions hasn't been studied.

METHODS

We developed an ordinary differential equations based compartmental model to generate national-level projections of HIV in the U.S., through dynamic simulations of 96 epidemiological sub-models representing 54 EHE and 42 non-EHE jurisdictions. A Bernoulli equation modeled HIV-transmissions using a mixing matrix to simulate sexual partnerships within and outside jurisdictions. To evaluate sensitivity of jurisdictional interactions on model outputs, we analyzed 16 scenarios, combinations of a) proportion of sexual partnerships mixing outside jurisdiction: no-mixing, low-level-mixing-within-state, high-level-mixing-within-state, or high-level-mixing-within-and-outside-state; b) jurisdictional heterogeneity in care and demographics: homogenous or heterogeneous; and c) intervention assumptions for 2019-2030: baseline or EHE-plan (diagnose, treat, and prevent).

RESULTS

Change in incidence in mixing compared to no-mixing scenarios varied by EHE and non-EHE jurisdictions and aggregation-level. When assuming jurisdictional heterogeneity and baseline-intervention, the change in aggregated incidence ranged from - 2 to 0% for EHE and 5 to 21% for non-EHE, but within each jurisdiction it ranged from - 31 to 46% for EHE and - 18 to 109% for non-EHE. Thus, incidence estimates were sensitive to jurisdictional mixing more at the jurisdictional level. As a result, jurisdiction-specific HIV-testing intervals inferred from the model to achieve the EHE-plan were also sensitive, e.g., when no-mixing scenarios suggested testing every 1 year (or 3 years), the three mixing-levels suggested testing every 0.8 to 1.2 years, 0.6 to 1.5 years, and 0.6 to 1.5 years, respectively (or 2.6 to 3.5 years, 2 to 4.8 years, and 2.2 to 4.1 years, respectively). Similar patterns were observed when assuming jurisdictional homogeneity, however, change in incidence in mixing compared to no-mixing scenarios were high even in aggregated incidence.

CONCLUSIONS

Accounting jurisdictional mixing and heterogeneity could improve model-based analyses.

Projected Impact of Expanded Long-Acting Injectable PrEP Use Among Men Who Have Sex With Men on Local HIV Epidemics

BACKGROUND

Pre-exposure prophylaxis (PrEP) is a key component in helping to reduce HIV incidence in the United States. Long-acting injectable (LAI) PrEP is a new alternative to oral PrEP; its potential to affect local HIV epidemics remains unclear.

METHODS

The Johns Hopkins HIV Economic Epidemiological model (JHEEM) is a dynamic model of HIV transmission in 32 US urban areas. We used JHEEM to project the HIV incidence among men who have sex with men (MSM) from 2020 to 2030 under a range of interventions aimed at increasing PrEP use.

RESULTS

In the absence of any intervention (ie, current levels of oral PrEP and HIV care engagement), we projected a 19% reduction (95% credible interval, CrI 1% to 36%) in HIV incidence among MSM from 2020 to 2030 across all 32 cities. Adding 10% LAI PrEP uptake (above a base case of all oral PrEP) reduced the incidence by 36% (95% CrI 23% to 50%) by year 2030. This effect varied between cities, ranging from 22% in Atlanta to 51% in San Francisco. At 25% additional LAI PrEP uptake, this incidence reduction increased to 54% (95% CrI 45% to 64%). Reductions in incidence after introducing LAI PrEP were driven primarily by increased uptake and sustained usage rather than increased efficacy.

CONCLUSIONS

LAI PrEP has the potential to substantially reduce HIV incidence among MSM, particularly if it increases PrEP uptake and continued use beyond existing levels. Because potential effects vary by city, the effectiveness of expanding PrEP use is dependent on local dynamics.

Potential Effects of the Coronavirus Disease 2019 (COVID-19) Pandemic on Human Immunodeficiency Virus (HIV) Transmission: A Modeling Study in 32 US Cities

BACKGROUND

The degree to which the 2019 novel coronavirus disease (COVID-19) pandemic will affect the US human immunodeficiency virus (HIV) epidemic is unclear.

METHODS

We used the Johns Hopkins Epidemiologic and Economic Model to project HIV infections from 2020 to 2025 in 32 US metropolitan statistical areas (MSAs). We sampled a range of effects of the pandemic on sexual transmission (0-50% reduction), viral suppression among people with HIV (0-40% reduction), HIV testing (0-50% reduction), and pre-exposure prophylaxis use (0-30% reduction), and indexed reductions over time to Google Community Mobility Reports.

RESULTS

Simulations projected reported diagnoses would drop in 2020 and rebound in 2021 or 2022, regardless of underlying incidence. If sexual transmission normalized by July 2021 and HIV care normalized by January 2022, we projected 1161 (1%) more infections from 2020 to 2025 across all 32 cities than if COVID-19 had not occurred. Among "optimistic" simulations in which sexual transmission was sharply reduced and viral suppression was maintained we projected 8% lower incidence (95% credible interval: 14% lower to no change). Among "pessimistic" simulations where sexual transmission was largely unchanged but viral suppression fell, we projected 11% higher incidence (1-21% higher). MSA-specific projections are available at www.jheem.org?covid.

CONCLUSIONS

The effects of COVID-19 on HIV transmission remain uncertain and differ between cities. Reported diagnoses of HIV in 2020-2021 are likely to correlate poorly with underlying incidence. Minimizing disruptions to HIV care is critical to mitigating negative effects of the COVID-19 pandemic on HIV transmission.