Localized Economic Modeling to Support Implementation of the “Ending the HIV Epidemic in America” Initiative

Bohdan Nosyk, PhD, MA
Simon Fraser University

ABSTRACT:
Rather than a homogeneous national epidemic, the HIV epidemic in the US is a collection of diverse local microepidemics concentrated primarily in the South, hotspot counties, and large urban centers, with fundamental differences in health system infrastructure, funding and HIV-related laws and policies. Recognizing these facts, the US launched the ambitious ‘Ending the HIV Epidemic (EHE) initiative in February 2019. The plan called for an initial focus on 48 of the most-affected counties plus Washington, DC, San Juan, Puerto Rico and seven southern states to reduce new infections by 75% within 5 years and by 90% within 10 years. These goals are now challenged by the onset of the global COVID-19 pandemic, which may have severe consequences for people living with HIV and on HIV microepidemics across the US. A value-based approach, accounting for the pervasive racial/ethnic inequities in healthcare access and explicating key elements of the implementation process are now more critical than ever in reaching the ambitious targets of the EHE initiative.

In 2016 our investigative team began a project aiming to identify optimal combination implementation strategies to reduce the public health burden of HIV/AIDS in six US cities (NIH-DA-041747). These six cities, all subsequently included in the EHE initiative, comprised 12 of 48 EHE-targeted counties and 24.1% of people living with HIV/AIDS in the nation. Considering the impact of 16 evidence-based interventions to Diagnose, Treat and Protect against HIV/AIDS, we found unique combination implementation strategies provided the greatest health benefits in each city; no two cities featured the same mix of interventions in their ‘optimal’ strategy. Moreover, we found the EHE goals were attainable in three of six cities. The biomedical interventions we considered would however have to be delivered at ideal levels of implementation, which would require additional efforts to reduce barriers in access to care and explicitly focus on reducing disparities in healthcare access among Black and Hispanic communities. We argue that promoting health equity is key to bridging this implementation gap and propose an approach to establish an equitable distribution of resources to maximize the impact of the EHE initiative.