A computer model developed by Johns Hopkins health care delivery specialists predicts that strengthening a handful of efforts to keep people with HIV in lifetime care, along with more rigorous testing, would potentially avert a projected 752,000 new HIV infections and 276,000 AIDS deaths in the United States alone over the next 20 years.
In a report on their HIV epidemic-economic model, published online in October by the journal Clinical Infectious Diseases, the researchers say that efforts to encourage people with HIV to follow up regularly with their provider and maintain long-term drug therapy may be more fruitful in preventing HIV transmission than efforts to increase HIV testing alone. Encouraging patient engagement with care is known as retention in care. Combining increased retention among those diagnosed with increased HIV screening and rapid enrollment into care among high-risk groups would have even greater impact.
Such comprehensive improvements would cost an estimated $96 billion, according to the model, but could reduce HIV incidence in the U.S. by 54 percent and the mortality rate by 64 percent, at a cost-effectiveness ratio of $45,300 per quality-adjusted life year, or QALY, a standard economic measure of the value of a medical intervention. Spending $50,000 or less per QALY is widely considered a good value, the Johns Hopkins team reports.
By contrast, the model predicts that continuing the current levels of HIV “care engagement” in the U.S. would lead to 1.39 million new HIV infections and 435,000 AIDS deaths, at a cost of $256 billion over the next two decades.
“Despite having good treatments available, current reports suggest that fewer than half of individuals who need therapy are actually getting appropriate HIV medicine to control their virus, leading to more transmission of disease,” says lead study author Maunank Shah, M.D., Ph.D., an assistant professor of medicine at the Johns Hopkins University School of Medicine. “The engagement in care of individuals infected with HIV is not what it could or should be.”
Shah noted that public health experts recently have placed efforts on increased screening, particularly among those at high risk of HIV, such as men who have sex with men, people who inject drugs and heterosexuals ages 15 to 24.
“However,” Shah says, “while continued HIV screening in high-risk groups is extremely important, our model suggests that you get the most bang for your buck targeting retention in care.” Spending more resources that way, he says, “could transform our HIV epidemic, potentially reducing our future cases by more than 50 percent and saving thousands of lives every year.”
For the study, Shah and his colleagues designed a computer model based on currently published HIV epidemiological data from scientific literature and national surveillance reports from a number of institutions, including the Centers for Disease Control and Prevention, the U.S. Census Bureau, and the U.S. Department of Health and Human Services. The model simulates HIV transmission and HIV care in the U.S., estimates the economic and epidemiologic consequences of incomplete or intermittent care, and explores the potential impact of different interventions versus the status quo in care. They estimated health care costs, HIV incidence, AIDS mortality rate and QALYs over a 20-year time period.