Novel Modeling Approach Improves Health Equity in HIV

An abstract presented at IAS 2021, this year's virtual annual meeting of the International AIDS Society, addressed reducing health care disparities that persist among persons living with HIV via a modeling approach. The goal of the investigators was to improve health equity and close care gaps.

The authors examined HIV-related health equity in 6 US cities: Atlanta, Georgia; Baltimore, Maryland; Los Angeles, California; Miami, Florida; New York, New York; and Seattle, Washington. Patients aged 15 to 64 years were stratified by sex, race/ethnicity, sexual risk level, risk behavior type, pre-exposure prophylaxis use (yes or no) and opioid agonist treatment. Outcomes were projected for 2020 through 2040 for health care interventions implemented from 2020 through 2030.

“We adapted a dynamic HIV transmission model to characterize HIV microepidemics and considered combinations of 16 evidence-based interventions to diagnose, treat, and prevent HIV transmission, implemented by race/ethnicity” the authors noted, comparing their results against existing service levels and new diagnoses distribution among Black, Hispanic/Latinx, and White/other individuals.

Between 2014 and 2018, per 100,000 population, Black/African American individuals accounted for 45.4 cases of HIV, followed by 22.4 among Hispanic/Latinx individuals, 19.3 among multiracial persons, 10.4 among American Indians/Alaskan Natives, 5.2 among Whites, and 3.9 among Asians, the authors noted.

The interventions investigated were either a single combination or a bundle of up to 16 interventions that “produced the greatest health benefit at an incremental cost-effectiveness ratio below $100,000 per quality-adjusted life-year (QALY),” and the study authors used 2 scale-up approaches to gauge the potential impact of each: a proportional services approach (using publicly documented data) and an equity approach (using data on HIV diagnoses by race/ethnicity).

The equity approach produced superior results in all 6 cities, vs the proportional services approach, when looking at HIV incidence reductions:

• Seattle: 36.4% vs 34.1%
• Los Angeles: 36.5% vs 30.8%
• New York: 54.4% vs 52.8%
• Miami: 59.7% vs 57.8%
• Atlanta: 68.9% vs 34.0%
• Baltimore: 80.7% vs 57.8%

Compared with continuing on with the status quo approach, implementing an equity-based approach to HIV care also resulted in incremental cost reductions of $968.1M, $781.4M, and $185.0M in 3 of the 6 cities (Miami, Atlanta, and Baltimore, respectively) and lowered costs over 20 years in 4 of the 6 cities, ranging from $74.0M (95% CI, $6.9-164.6) in Miami to $574.3 (95% CI, $252.3-$934.6) in Atlanta.

The equity approach also produced incremental QALY gains higher in every city evaluated vs the proportional services model:

• Los Angeles: 31,586 vs 24,767
• New York: 27,921 vs 27,081
• Miami: 24,728 vs 23,313
• Atlanta: 16,497 vs 8169
• Baltimore: 9155 vs 6129
• Seattle: 3498 vs 2981

These QALY gains represent increases ranging from 3.1% (95% CI, 1.4%-5.3%) in New York to 101.9% (95% CI, 75.4%-134.6%) in Atlanta.

“Our results have demonstrated that in this context, equity-driven combination implementation policies can generate greater health benefits at lower costs and reduce inequalities in HIV,” concluded presenting author Amanda My Link Quan, MPH, Dalla Lana School of Public Health, University of Toronto. “Our study provides an economic argument for targeting resources and efforts to reducing racial/ethnic health disparities in HIV and suggests that contrary to belief, there are no trade-offs between maximizing health and improving equity.”

IAS began July 18 and ends Wednesday.

Reference

Quan AML, Mah C, Krebs E, et al. Improving health equity and ending the HIV epidemic in the United States: a distributional cost-effectiveness analysis in six cities. Presented at: IAS 2021; July 18, 2021. Accessed July 20, 2021. https://conference.ias2021.org/media-638-improving-health-equity-and-ending-the-hiv-epidemic-in-the-united-states-a-distributional-