The Impact of Localized Implementation

Determining the Cost-effectiveness of HIV Prevention and Care Interventions Across Six United States Cities

Emanuel Krebs; Xiao Zang; Benjamin Enns; Jeong E. Min; Czarina N. Behrends; Carlos del Rio; Julia C. Dombrowski; Daniel J. Feaster; Kelly A. Gebo; Matthew Golden; Brandon D.L. Marshall; Lisa R. Metsch; Bruce R. Schackman; Steven Shoptaw; Steffanie A. Strathdee; Bohdan Nosyk


AIDS. 2020;34(3):447-458. 

In This Article

Abstract and Introduction


Objective: Effective interventions to reduce the public health burden of HIV/AIDS can vary in their ability to deliver value at different levels of scale and in different epidemiological contexts. Our objective was to determine the cost-effectiveness of HIV treatment and prevention interventions implemented at previously documented scales of delivery in six US cities with diverse HIV microepidemics.

Design: Dynamic HIV transmission model-based cost-effectiveness analysis.

Methods: We identified and estimated previously documented scale of delivery and costs for 16 evidence-based interventions from the US CDC's Compendium of Evidence-Based Interventions and Best Practices for HIV Prevention. Using a model calibrated for Atlanta, Baltimore, Los Angeles, Miami, New York City and Seattle, we estimated averted HIV infections, quality-adjusted life years (QALY) gained and incremental cost-effectiveness ratios (healthcare perspective; 3% discount rate, 2018$US), for each intervention and city (10-year implementation) compared with the status quo over a 20-year time horizon.

Results: Increased HIV testing was cost-saving or cost-effective across cities. Targeted preexposure prophylaxis for high-risk MSM was cost-saving in Miami and cost-effective in Atlanta ($6123/QALY), Baltimore ($18 333/QALY) and Los Angeles ($86 117/QALY). Interventions designed to improve antiretroviral therapy initiation provided greater value than other treatment engagement interventions. No single intervention was projected to reduce HIV incidence by more than 10.1% in any city.

Conclusion: Combination implementation strategies should be tailored to local epidemiological contexts to provide the most value. Complementary strategies addressing factors hindering access to HIV care will be necessary to meet targets for HIV elimination in the United States.


The President of the United States recently announced the intention to eliminate domestic HIV epidemic within 10 years.[1] To achieve this ambitious goal, healthcare providers and public health departments will need to overcome political, legal and structural barriers, and make efficient use of current and future funding.[2] A number of efficacious biomedical, behavioural, and structural interventions are available; however, there is a paucity of evidence on real-world implementation of many of these interventions,[3] including the population base reached, their adoption across diverse care delivery settings and how long they are sustained.[4]

This paucity of evidence challenges decisions on how interventions should be implemented to make the best use of available funding,[4] which are further complicated by the fact that the HIV epidemic in the United States is a collection of distinct regional microepidemics, dispersed predominantly across large urban centers.[5] Anderson et al.[6] in 2014 demonstrated that a regionally focused public health response to HIV can provide substantially greater public health benefits compared with a uniform, national strategy for the same investment level. The heterogeneity of HIV microepidemics across the United States suggests that focused, locally oriented strategies in treating and preventing HIV will be required to end the HIV epidemic.

More than ever, simulation modeling is playing a critical role in priority setting for HIV treatment and prevention.[7] Dynamic HIV transmission models can provide a unified framework to quantify the health and economic value of different strategies to address the HIV epidemic while accounting for microepidemic context and the synergistic effects of different combinations of public health interventions.[8] The context in which healthcare services are delivered can influence the cost-effectiveness of interventions[9] and dynamic HIV transmission models using best-available localized data that capture the heterogeneity across settings are uniquely positioned to offer guidance on contextually efficient strategies to implement.[10]

Ending the HIV epidemic will require an understanding of the population-level impact of HIV interventions, as they may vary substantially in their ability to deliver value at different levels of scale and in different microepidemics. Our objective was to determine the cost-effectiveness of HIV treatment and prevention interventions, offered at previously documented levels of scale in six US cities with diverse HIV microepidemics.