Cost-utility of HIV Testing Programs Among Men Who Have Sex with Men in the United States.

Few groups in the United States (US) are as heavily affected by HIV as men who have sex with men (MSM), yet many MSM remain unaware of their infection. HIV diagnosis is important for decreasing onward transmission and promoting effective treatment for HIV, but the cost-effectiveness of testing programs is not well-established. This study reports on the costs and cost-utility of the MSM Testing Initiative (MTI) to newly diagnose HIV among MSM and link them to medical care. Cost and testing data in 15 US cities from January 2013 to March 2014 were prospectively collected and combined to determine the cost-utility of MTI in each city in terms of the cost per Quality Adjusted Life Years (QALY) saved from payer and societal perspectives. The total venue-based HIV testing costs ranged from $18,759 to $564,284 for nine to fifteen months of MTI implementation. The cost-saving threshold for HIV testing of MSM was $20,645 per new HIV diagnosis. Overall, 27,475 men were tested through venue-based MTI, of whom 807 (3 %) were newly diagnosed with HIV. These new diagnoses were associated with approximately 47 averted HIV infections. The cost per QALY saved by implementation of MTI in each city was negative, indicating that MTI venue-based testing was cost-saving in all cities. The cost-utility of social network and couples testing strategies was, however, dependent on whether the programs newly diagnosed MSM. The cost per new HIV diagnosis varied considerably across cities and was influenced by both the local cost of MSM testing implementation and by the seropositivity rate of those reached by the HIV testing program. While the cost-saving threshold for HIV testing is highly achievable, testing programs must successfully reach undiagnosed HIV-positive individuals in order to be cost-effective. This underscores the need for HIV testing programs which target and engage populations such as MSM who are most likely to have undiagnosed HIV to maximize programmatic benefit and cost-utility.

Cost-Utility Analysis of Three U.S. HIV Linkage and Re-engagement in Care Programs from Positive Charge.

Linking and retaining people living with HIV in ongoing, HIV medical care is vital for ending the U.S. HIV epidemic. Yet, 41-44 % of HIV+ individuals are out of care. In response, AIDS United initiated Positive Charge, a series of five HIV linkage and re-engagement projects around the U.S. This paper investigates whether three Positive Charge programs were cost effective and calculates a return on investment for each program. It uses standard methods of cost utility analysis and WHO-CHOICE thresholds. All three projects were found to be cost effective, and two were highly cost effective. Cost utility ratios ranged from $4439 to $137,271. These results suggest that HIV linkage to care programs are a productive and efficient use of public health funds.

Positive Charge: Filling the Gaps in the U.S. HIV Continuum of Care.

Adequate engagement in HIV care is necessary for the achievement of optimal health outcomes and for the reduction of HIV transmission. Positive Charge (PC) was a national HIV linkage and re-engagement in care program implemented by AIDS United. This study describes three PC programs, the characteristics of their participants, and the continuum of engagement in care for their participants. Eighty-eight percent of participants were engaged in care post PC enrollment. Sixty-nine percent were retained in care, and 46 % were virally suppressed at follow-up. Older participants were more likely to be engaged, retained, and virally suppressed. Differences by race and gender in HIV care and treatment varied across PC programs, reflecting the diverse target populations, locations, and strategies employed by the PC grantees. There is an urgent need for programs that promote HIV care and treatment among vulnerable populations, including young people living with HIV. There is also an urgent need for additional research to test the effectiveness of promising linkage and retention in care strategies, such as peer navigation.

Individual-Level and Partner-Level Predictors of Newly Diagnosed HIV Infection Among Black and White Men Who Have Sex with Men in Baltimore, MD.

Black MSM continue to be the group most disproportionately impacted by HIV in the United States. This study assesses the relationship between partner-level and respondent-level characteristics and newly diagnosed HIV infection among a sample of MSM. Ego-centric data were gathered using venue-based time-space sampling on 335 men who reported on a total of 831 male anal sex partners. In multivariate analyses, age of partner, HIV status of partner, and respondent having had an STD in the past twelve months were associated with a newly diagnosed HIV infection among black MSM. Efforts for black MSM are needed that aim to increase HIV and STD testing, foster open communication between partners about HIV status, and address social determinants of health.

Retention in HIV care among female sex workers in the Dominican Republic: implications for research, policy and programming.

There are clear benefits of retention in HIV care, yet millions of people living with HIV are sub-optimally retained. This study described factors from Andersen's behavioral model that were associated with retention in HIV care among 268 female sex workers (FSWs) living with HIV in the Dominican Republic using two measures of retention: a 6-month measure of HIV clinic attendance and a measure that combined clinic attendance and missed visits. FSWs who ever attended HIV care reported high rates (92 %) of 6-month attendance, but 37 % reported missed visits. Using the combined retention measure, the odds of being retained in HIV care were higher among FSWs with more positive perceptions of HIV service providers [adjusted odds ratio (AOR) 1.17; 95 % confidence interval (CI) 01.09, 1.25] and lower among women who reported recent alcohol consumption (AOR 0.50; 95 % CI 0.28, 0.92) and self-stigmatizing beliefs related to sex work (AOR 0.93; 95 % CI 0.88, 0.98). These findings support the hypothesis that retention in HIV care may be best determined through a combined measure as missed visits are an important mechanism to identify in-care patients who require additional support.

Cost and threshold analysis of positive charge, a multi-site linkage to HIV care program in the United States.

Positive Charge (PC) is a linkage to HIV care initiative implemented by AIDS United with sites in New York, Chicago, Louisiana, North Carolina, and the San Francisco/Bay Area. This study employed standard methods of cost and threshold analyses, as recommended by the US Panel on Cost-effectiveness in Health and Medicine, to calculate cost-saving and cost effective thresholds of the initiative. The overall societal cost of the linkage to care programs ranged from $48,490 to $370,525. The study found that PC's five unique evidence-based linkage to care programs have relatively low costs per client served and highly achievable cost-saving and cost-effectiveness thresholds. The findings from this study suggest that HIV linkage to care programs have the potential to be a highly productive use of public health resources.

HIV among Black men who have sex with men (MSM) in the United States: a review of the literature.

In 2006, Millett published a seminal literature review that examined 12 hypotheses to explain the high rates of HIV among black MSM. This paper augments Millett's article by reviewing the recent literature on behavioral, biomedical, structural, social contextual, psychosocial, and social network factors that affect HIV rates among black MSM. We searched three databases: PubMed, Scopus, and Google Scholar. First we searched all articles that included black or African American and MSM and HIV. We then searched the following terms for each area: behavioral (drug use during sex, crack cocaine use, and serosorting); biomedical (circumcision, STDs, and STIs); structural (access to care, HIV care, ART, HAART, patient-provider communication, HIV quality of care); social contextual (stigma, discrimination, internalized homophobia, internalized heterosexism, medical mistrust, social isolation, and incarceration); psychosocial (peer support and mental health); and social network (sexual mixing, partner characteristics, and social networks) factors. We identified 39 articles to include in this review. We found inconclusive evidence that incarceration, stigma, discrimination, social isolation, mental health disparities, or social networks explain the elevated rates of HIV among black MSM. We found evidence that the differences in rates of HIV between black and white MSM may be explained by differences in STIs, undiagnosed seropositivity, access to care and treatment services, and use of HAART. There is an overwhelming need for HIV testing, linkage to care, retention in care, and adherence programs for black MSM.

Unmet HIV service needs among Black men who have sex with men in the United States.

The National HIV/AIDS Strategy (NHAS) clearly emphasized the need to provide services to black men who have sex with men (MSM). However, there are no estimates of the unmet HIV-related service delivery needs among black MSM. We estimate that of 195,313 black MSM living with HIV in the US, 50,196 were not yet diagnosed, and 145,118 were aware of their seropositivity (of whom 67,625 were not linked to care and 77,493 were linked to care). Also, of those already diagnosed, ~43,390 had undetectable viral load and 101,728 had detectable viral load. Approximately 19,545 of diagnosed black MSM engage in unprotected risk behavior in serostatus-discordant partnerships. The cost of delivering services needed to meet the NHAS goals is ~$2.475 billion in 2011 U.S. dollars. Mathematical modeling suggests that provisions of these services would avert 6213 HIV infections at an economically favorable cost of $20,032 per quality-adjusted life year saved.

A systematic review of HIV interventions for black men who have sex with men (MSM).

BACKGROUND: Black men who have sex with men (MSM) are disproportionately burdened by HIV/AIDS. Despite this burden there has been a shortage of research on HIV interventions for black MSM. This article provides a comprehensive review of the literature on interventions for black MSM to identify effective HIV prevention intervention strategies for black MSM. METHODS: We searched 3 databases: Pubmed, Scopus, and Google Scholar to identify peer-reviewed articles and used the following search terms: African American or black; MSM or men who have sex with men and women (MSMW); HIV; program or intervention; and evaluation or intervention science or implementation research. We included research articles that assessed interventions for black men who have sex with men. We included studies that used an experimental, quasi-experimental, or pre-post test design as well as formative research studies. We also searched the CDC and NIH websites to identify planned and on-going intervention studies. We identified a total of 23 studies to include in the review. RESULTS: We identified 12 completed studies of interventions for black MSM. Eight of these 12 interventions aimed to reduce HIV risk behaviors and 5 found a significant reduction in HIV risk behavior over time. We identified 4 health service intervention studies for young black MSM. CONCLUSIONS: Behavior change interventions are effective at reducing HIV risk behaviors among black MSM. However, relying only on behavioral interventions that aim to reduce HIV risk behavior will most likely not have a population-level effect on HIV infection among black MSM. There is a compelling and urgent need to develop and test comprehensive HIV testing, linkage to care, retention in care and adherence interventions for black MSM.

Costs, consequences and feasibility of strategies for achieving the goals of the National HIV/AIDS strategy in the United States: a closing window for success?

Three key policy questions are explored here: Is it still epidemiologically feasible to attain the incidence and transmission rate reduction goals of the U.S. National HIV/AIDS Strategy (NHAS) by 2015? If so, what costs will be incurred in necessary program expansion, and will the investment be cost-effective? Would substantial expansion of prevention services for persons living with HIV (PLWH) augment the other strategies outlined in the NHAS in terms of effectiveness and cost-effectiveness? Eight policy scenarios were constructed based on three factors (two levels each): expansion (or not) of HIV diagnostic services; assumptions regarding levels of effectiveness of HIV treatment in achieving suppressed viral load; and possible levels of expansion of prevention services for PLWH. All scenarios assumed that the NHAS goal of 85 % linkage to HIV care would be fully achieved by 2015. Standard methods of economic evaluation and epidemiologic modeling were employed. Each of the eight policy scenarios was compared to a flat transmission rate comparison condition; then, key policy dyads were compared pairwise. Without expansion of diagnostic services and of prevention services for PLWH, scaling up coverage of HIV care and treatment alone in the U.S. will not achieve the incidence and transmission rate reduction goals of the NHAS. However, timely expansion of testing and prevention services for PLWH does allow for the goals to still be achieved by 2015, and does so in a highly cost-effective manner.

Behavioral factors in assessing impact of HIV treatment as prevention.

The recent NIH HPTN 052 study of using HIV treatment to prevent HIV transmission in serostatus discordant heterosexual partnerships has garnered much attention. In subsequent discussions, however, the topic of HIV-related risk behavior has been nearly absent. Here, we identify the critical roles that HIV-related risk behavior plays in determining the unmet needs, optimal targeting, and ultimate impact of treatment as prevention. We describe the size of the population at risk of HIV and three subgroups of persons living with HIV (PLWH) based on awareness of serostatus and risk behavior, and the corresponding HIV transmission rates to seronegative partners. For each of the subgroups of PLWH, we identify which approach is most relevant ("testing and linkage to care," "treatment as prevention," and/or "treatment as clinical care"). We observe that the impact of "treatment as prevention" on HIV incidence will depend heavily on which subgroup of PLWH is targeted for services.

Partner characteristics and undiagnosed HIV seropositivity among men who have sex with men only (MSMO) and men who have sex with men and women (MSMW) in Baltimore.

This study examined the relationship between HIV risk behaviors, partner characteristics, and undiagnosed seropositivity among men who have sex with men and women (MSMW) and men who have sex with men only (MSMO). BESURE-MSM2 is a venue-based cross-sectional HIV surveillance study conducted among MSM in 2008. Stratified log-binomial regression was used to assess adjusted prevalence ratios of undiagnosed seropositivity among 103 MSMW and 296 MSMO (N = 399). Among MSMO, race/ethnicity, age, having had a sexually transmitted infection, concurrency, and having a black/African American male partner were associated with undiagnosed seropositivity. Among MSMW, having five or more male partners, having a main male partner, and having a main female partner were associated with undiagnosed seropositivity. Our findings underscore the importance of partner characteristics in understanding HIV transmission. HIV programs for men with both male and female partners are needed to address the unique partnership dynamics of MSMW.

Extending access to care across the rural US south: Preliminary results from the Alabama eHealth programme.

PURPOSE: Using a mixed-methods formative evaluation, the purpose of this study was to provide a broad overview of the Alabama eHealth programme set-up and initial patient outcomes. The Alabama eHealth programme uses telemedicine to provide medical care to people living with HIV in rural Alabama. It was led by a community-based organisation, Medical Advocacy and Outreach (MAO), and supported by AIDS United and the Corporation for National Community Service's Social Innovation Fund with matching support from non-federal donors. METHODS: We conducted and transcribed in-depth interviews with Alabama eHealth staff and then performed directed content analysis. We also tracked patients' ( n = 240) appointment attendance, CD4 counts, and viral loads. FINDINGS: Staff described the steps taken to establish the programme, associated challenges (e.g., costly, inadequate broadband in rural areas), and technology enabling this programme (electronic medical records, telemedicine equipment). Of all enrolled patients, 76% were retained in care, 88% had antiretroviral therapy and 75% had a suppressed viral load. Among patients without missing data, 96% were retained in care, 97% used antiretroviral therapy and 93% had suppressed viral loads. There were no statistically significant demographic differences between those with and without missing data. CONCLUSIONS: Patients enrolled in a telemedicine programme evaluation successfully moved through the HIV continuum of care.

Barriers and Facilitators to the Implementation of a National HIV Linkage, Re-Engagement, and Retention in Care Program.

The 2020 National HIV AIDS Strategy (NHAS) sets a target of 90% of diagnosed people living with HIV (PLWH) retained in HIV care. Access to Care (A2C) was a national HIV linkage, re-engagement, and retention in care program funded by AIDS United with support from the Corporation for National and Community Service that aimed to link and retain the most vulnerable PLWH into high-quality HIV care. This study explores the barriers and facilitators of implementing the A2C program from the perspective of program staff. Ninety-eight qualitative interviews were conducted with staff at implementing organizations over the 5 years of the project. Barriers included challenges with recruiting and retaining participants, staffing and administration, harmonizing partnerships, and addressing the basic and psychosocial needs of participants. Facilitators included strong relationships with partner organizations, flexible program models, and the passion and dedication of staff. Findings will inform the development of future programs and policy.

Exploring Changes in Interagency Collaboration Following AIDS United's Positive Charge: A Five-Site HIV Linkage and Retention in Care Program.

BACKGROUND: Many out-of-care people living with HIV have unmet basic needs and are served by loosely connected agencies. Prior research suggests that increasing agencies' coordination may lead to higher quality and better coordinated care. This study examines four U.S. interagency networks in AIDS United's HIV linkage and retention in care program. This study explores changes in the networks of implementing agencies. METHODS: Each network included a lead agency and collaborators. One administrator and service provider per agency completed an online survey about collaboration prior to and during Positive Charge. We measured how many organizations were connected to one another through density, or the proportion of reported connections out of all possible connections between organizations. Network centralization was measured to investigate whether this network connectivity was due to one or more highly connected organizations or not. To compare collaboration by type, density and centralization were calculated for any collaboration and specific collaboration types: technical assistance, shared resources, information exchange, and boosting access. To characterize the frequency of collaboration, we examined how often organizations interacted by "monthly or greater" versus "less than monthly." RESULTS: Density increased in all networks. Density was highest for information exchange and referring clients. When results were restricted to "monthly or greater," the densities of all networks were lower. CONCLUSIONS: This study suggests that a targeted linkage to care initiative may increase some collaboration types among organizations serving people living with HIV. It also provides insights to policy makers about how such networks may evolve.

Using Resource Allocation Modeling to Inform HIV Prevention Priority Setting for Baltimore-Towson, Maryland.

PROBLEM: In 2010, the Centers for Disease Control and Prevention (CDC) launched the "Enhanced Comprehensive HIV Prevention Planning" initiative, which targeted funding to the 12 U.S. metropolitan statistical areas (MSAs) with the most severe epidemics of human immunodeficiency virus infection to a) develop a plan to align each MSA's HIV prevention plan with the National HIV/AIDS Strategy (NHAS) and b) identify and implement the optimal combination of prevention services to reduce new infections. PURPOSE: This paper describes how the Maryland Department of Health and Mental Hygiene (DHMH) partnered with the Johns Hopkins Bloomberg School of Public Health (JHSPH) to conduct mathematical modeling and economic analyses to inform local planning for resource allocation and intervention design for the Baltimore-Towson MSA. KEY POINTS: The paper outlines the steps of building and implementing that analytic partnership, illustrates how results were discussed with other key stakeholders, and shows how the findings informed local priority setting. CONCLUSION: The paper demonstrates how health departments, academia, and community partners can jointly use policy modeling to improve resource allocation and address urgent public health challenges.

Unpacking Linkage and Reengagement in HIV Care: A Day in the Life of a Positive Charge Care Coordinator.

UNLABELLED: AIDS United's Positive Charge (PC) was a multiorganizational HIV linkage to care program implemented in five U.S. LOCATIONS: To better understand the process of linkage and reengagement in care, we conducted interviews with care coordinators and program supervisors at 20 PC implementing agencies. Though linkage to care is often considered a single column in the HIV continuum of care, we found that it contains several underlying and often complex steps. The steps described are: identifying individuals in need of services; contacting those individuals through a variety of means; assessing and addressing needs and barriers to care; initial engagement (or reengagement) in HIV primary care; and provision of ongoing support to promote retention. We highlight strategies used to complete these steps. These findings will be of utility to other HIV interventions that aim to improve linkage and engagement in HIV care.

The development and implementation of the national evaluation strategy of Access to Care, a multi-site linkage to care initiative in the United States.

The Access to Care (A2C) is a multi-site initiative that seeks to increase the access to and retention in effective HIV healthcare and support services by people living with HIV across the United States. As the initiative implemented evidence-based programs in new settings with diverse populations, it was important to document these innovative efforts to contribute to the evidence base for best practices. In a partnership between Johns Hopkins University, AIDS United, and the A2C sites, a national evaluation strategy was developed and implemented to build knowledge about how linkage to care interventions could be most effectively implemented within the context of local, real-world settings. This article provides an overview of the efforts to develop and implement a national monitoring and evaluation strategy for a multi-site initiative. The findings may be of utility for other HIV interventions that are seeking to incorporate a monitoring and evaluation component into their efforts.

Employing resource allocation modeling to inform HIV prevention planning for the state of Iowa.

In fiscal year (FY) 2012, the Centers for Disease Control and Prevention (CDC) reallocated their HIV prevention funding to U.S. states, territories, and some cities so as to be more highly correlated with 2008 HIV prevalence. A jurisdiction's HIV prevention funding could drop as low as $750,000 for FY 2016. Iowa was one state that experienced a substantial funding drop, and it chose to undertake a mathematical modeling exercise to inform the following questions: (a) Given current HIV prevention funding for the state, what is the optimal allocation of resources to maximize infections averted? (b) With this "optimal" resource allocation, how many (and what percentage of) HIV infections in the state can be averted? (c) Is the optimal resource allocation sufficient to achieve the National HIV/AIDS Strategy goal of 25% reduction in HIV incidence? and (d) With the "optimal" resource allocation, is the return on the investment such that it might be considered cost-effective? Here, we describe the results of the policy analysis, and the uses of the results.