JAIDS Journal of Acquired Immune Deficiency Syndromes

HIV treatment can suppress viral load and prevent transmission between sex partners, a strategy known as treatment as prevention (TasP). TasP is key for ending the HIV epidemic, and it is important to understand its adoption among priority populations. We examined the TasP adoption cascade using cross-sectional survey data from 1443 U.S. men and transgender, gender-nonconforming, and nonbinary individuals who reported having sex with men. Most participants (82.4%; n = 1189/1443) reported prior awareness of TasP, but only 52.6% of them (n = 625/1189) perceived it as effective at preventing HIV transmission. Of those, 83.8% (n = 524/625) indicated being willing to rely on TasP, among whom 30.2% (n = 158/524) reported having recently done so. Among participants aware of TasP, we compared those who perceived it as effective to those who did not. Participants who did not have HIV and never used PrEP were less likely to agree with TasPs effectiveness than those who had used PrEP or had HIV. Those who had learned about TasP from a sex partner or who had a partner of different HIV status were more likely to perceive it as effective. TasP promotion appears to have achieved broad awareness, but future efforts should aim at increasing the understanding of its effectiveness, especially among those not connected to HIV-related services, organizations, or communities. Public Health SignificanceTasP is an important tool to end the HIV epidemic. Examining stages of its adoption can inform tailored promotion among priority populations. In our study, many participants were aware of TasP, but fewer perceived it as effective. Monitoring uptake over time will allow for responsive promotion strategies as attitudes continue to evolve.

BackgroundAs social and economic conditions are key determinants of HIV, the National HIV/AIDS Strategy (NHAS), in addition to care and treatment metrics, aims to address mental health, unemployment, food insecurity, and housing instability, as a strategic plan for the Ending the HIV Epidemic initiative. Mechanistic models of HIV play a key role in identifying cost-effective intervention strategies, however, social conditions are typically not part of the modeling framework. HIV projections are typically simulated by modeling care and sexual behaviors, and transmissions as functions of those behaviors. MethodsWe developed a methodological framework, using Markov random field model to estimate joint probability distributions between social conditions and behaviors, to incorporate in a mechanistic model to simulate behaviors as functions of social conditions and HIV transmissions as a function of behaviors. As demonstration, we conducted two numerical applications in a national-level agent-based network model, Progression and Transmission of HIV (PATH 4.0). The first modeled care behavior (using viral suppression as proxy) as a function of depression, neighborhood, housing, poverty, education, insurance, and employment status. The second modeled sexual behaviors (number of partners and condom-use) as functions of employment, housing, poverty, and education status, using exchange sex as a mediator. Both simulated HIV transmissions and disease progression as functions of behaviors. We conducted what-if intervention analyses to estimate the impact of an ideal 100% efficacious intervention strategy. ResultsIf we intervene on HIV infected persons with the social needs modeled here, such that their care behavior increases to become equal to that among persons who do not have those social needs, the overall viral suppression in persons with diagnosed HIV infection increases from 65.5% to 80% (79% to 83%), resulting in a 10-year cumulative national incidence reduction of 29% (20% to 41%). If we address the social needs modeled here among persons who exchange sex, such that their sexual behavior becomes equal to that among those who do not exchange sex, we can expect a 10-year cumulative national incidence reduction of 6% (2.5% to 14%). ConclusionsWe developed a methodological framework for modeling social conditions into intervention decision-analytic models, using the limited data to present two demonstrative applications. Routinely monitoring quantitative data on associations between social conditions and HIV risk behaviors, and efficacy of structural interventions can help develop a comprehensive mechanistic model to identify cost-effective intervention combinations and inform public health strategic plans.

BackgroundMen who have sex with men (MSM) who experience sexual violence are at increased risk for HIV. Pre-exposure prophylaxis (PrEP) is effective in preventing HIV infection. Associations between sexual violence and PrEP discussion or PrEP use among MSM are not well-understood. MethodsNational HIV Behavioral Surveillance used venue-based sampling methods to recruit and interview MSM in 23 U.S. urban areas in 2017. We estimated the prevalence of sexual violence and examined associations between sexual violence and PrEP discussion with a health care provider (HCP) or PrEP use among HIV-negative MSM in the past 12 months. We reported weighted percentages and 95% confidence intervals (CI). Adjusted prevalence ratios (aPR) with 95% CIs were calculated using logistic regression with predicted margins to compare groups. ResultsAmong 7,121 HIV-negative MSM, 4.2% (95% CI: 3.6%-4.8%) experienced sexual violence in the past 12 months. Sexual violence was not independently associated with PrEP discussion with HCP (47.6% vs. 40.0%; aPR = 1.16, 95% CI: 0.98-1.37). MSM who experienced sexual violence were more likely to use PrEP than those who did not experience sexual violence, even after adjusting for demographic differences (34.9% vs. 25.7%; aPR = 1.34, 95% CI: 1.07-1.67). ConclusionsOverall PrEP discussion and PrEP use were low among HIV-negative MSM. PrEP use was higher among MSM who experienced sexual violence. Supportive patient-provider relationships that foster PrEP discussion and sexual violence screening in healthcare settings may be important to identifying HIV risk and PrEP needs while assessing MSMs safety.

Structured AbstractO_ST_ABSImportanceC_ST_ABSPre-exposure prophylaxis (PrEP) is a proven effective intervention to reduce risk for HIV infection, but changes in policies that lead to increased out of pocket PrEP costs or that decrease access to convenient PrEP locations could reduce PrEP coverage, resulting in excess HIV infections and costs. ObjectiveTo estimate the impacts of federal policy changes on PrEP coverage, new HIV infections and costs associated with new HIV infections DesignEstimation of excess HIV infections under different policy impacts were conducted using parameters from a previously published ecological model of the relationship between PrEP coverage and new HIV infections. Costs were estimated for the treatment of infections not averted under different scenarios. SettingUnited States ParticipantsThere was no individual participation in research activities; population-based data sources were used to describe the population-level PrEP use and new diagnoses under different hypothetical changes in PrEP coverage. ExposuresPercent of people with indications for PrEP who are taking PrEP Main Outcome and MeasuresEstimated change in new HIV infections under different assumptions of change in PrEP coverage; costs of treatment for avoidable HIV infections and net costs of avoidable infections after accounting for costs of PrEP medications. ResultsEven modest reductions in PrEP coverage would result in thousands of avoidable HIV infections. An absolute 3.3% annual reduction in PrEP coverage over the next decade would result in 8,618 avoidable HIV infections, with lifetime medical costs of over $3.6 billion (discounted) for treatment of the unaverted HIV infections. Conclusions and RelevanceChanges in policy that reduce PrEP uptake would result in avoidable HIV infections and increased costs for HIV treatment. Maintaining policies and programs that support PrEP uptake offers benefits for health and is estimated to result in net cost savings. Key pointsO_ST_ABSQuestionC_ST_ABSWhat are the likely impacts on HIV transmissions and healthcare costs if policy changes result in decreased PrEP utilization in the United States? FindingsUnder assumptions of even modest reductions in PrEP use, we estimated thousands of HIV infections would fail to be averted over the next decade, and billions of dollars of additional treatment costs would accrue to the healthcare system. Results of the studyWe used historical descriptive data on the US HIV epidemic to quantify the relationship between PrEP coverage and trends in HIV diagnoses and to estimate future trends in HIV infections if PrEP coverage were to be rolled back. If PrEP use declines modestly - about 3% annually - we estimate that 8,618 new infections would fail to be averted in a decade because of lowered PrEP uptake, and the estimated lifetime medical costs of these unaverted infections would be $3.6 billion (discounted) and $9.3 billion (undiscounted). MeaningChanges in healthcare priorities and policies, especially those that increase out of pocket costs of PrEP or reduce the convenience of engaging in PrEP care, risk rolling back our progress in ending the HIV epidemic, accruing avertable HIV infections, and incurring increased costs for medical care of people whose HIV infections were avoidable.

Objective(s)To examine associations between Index of Concentration at the Extremes (ICE) measures for economic and racial segregation and HIV outcomes in the United States (U.S.) and Puerto Rico. MethodsCounty-level HIV testing data from CDCs National HIV Prevention Program Monitoring and Evaluation and census tract-level HIV diagnoses, linkage to HIV medical care, and viral suppression data from the National HIV Surveillance System were used. Three ICE measures of spatial polarization were obtained from the U.S. Census Bureaus American Community Survey: ICEincome (income segregation), ICErace (Black-White racial segregation), and ICEincome+race (Black-White racialized economic segregation). Rate ratios (RRs) for HIV diagnoses and prevalence ratios (PRs) for HIV testing, linkage to care within 1 month of diagnosis, and viral suppression within 6 months of diagnosis were estimated with 95% confidence intervals (CIs) to examine changes across ICE quintiles using the most privileged communities (Quintile 5, Q5) as the reference group. ResultsPRs and RRs showed a higher likelihood of testing and adverse HIV outcomes among persons residing in Q1 (least privileged) communities compared with Q5 (most privileged) across ICE measures. For HIV testing percentages and diagnosis rates, PRs and RRs were consistently greatest for ICErace. For linkage to care and viral suppression, PRs were consistently lower for ICEincome+race. ConclusionsIncome, racial, and economic segregation--as measured by ICE--might contribute to poor HIV outcomes and disparities by unfairly concentrating certain groups (i.e., Black persons) in highly segregated and deprived communities that experience a lack of access to quality, affordable health care. Expanded efforts are needed to address the social/economic barriers that might impede access to HIV care among Black persons. Increased partnerships between government agencies and the private sector are needed to change policies that promote and sustain racial and income segregation.

BackgroundMajor geopolitical events and structural shocks are thought to play a significant role in shaping HIV epidemics by influencing individual behaviours, reshaping social networks, and impacting HIV prevention and treatment programs. Here, we describe individual-level measures of estimated time since HIV infection (ETI) from viral next generation sequencing data among female sex workers and their clients in relation to significant geopolitical events in Ukraine. MethodsThe Dynamics study, is a cross-sectional integrated biological and behavioural survey conducted among female sex workers and their clients in Dnipro, Ukraine (December 2017 to March 2018). We were able to successfully sequence a portion of the HIV pol gene on dried blood spot specimens among n = 5/9 clients and n = 5/16 female sex workers who tested positive for HIV (total n = 10/25) using an in-house drug resistance genotyping assay. The "HIV EVO" Intrapatient HIV Evolution web-based tool (https://biozentrum.unibas.ch/) was used to infer ETI from viral diversity. ResultsThe median ETI for female sex workers and their clients was 5.4 years (IQR = 2.9, 6.6) and 6.5 years (IQR = 5.4, 10.8) respectively. Nearly all HIV acquisition events (n=7/10; 70%) were estimated to have occurred between the Great Recession (2008 - 2009) and the War in Donbas (May 2014 - February 2022). In general, ETI suggests that HIV acquisition occurred earlier among clients (2012 [IQR = 2007, 2013]) compared to sex workers (2013 [IQR = 2012, 2016]). ConclusionOur findings suggest that most HIV acquisition in this small subset of female sex workers and clients living with HIV, occurred during periods of economic decline. Molecular studies on timing of HIV acquisition against timing of major geopolitical events offer a novel way to contextualize how such events may shape transmission patterns.

Substance use remains a robust predictor of HIV infection, as well as a serious impediment to progress across the HIV care continuum for people living with HIV. As such, the careful design and implementation of interventions uniquely tailored to target substance use and HIV care behaviors remain paramount. A necessary step in these efforts is to understand the extent to which HIV care interventions have been efficacious in helping people who use substances progress across the HIV care continuum. Using PubMed and ProQuest databases, we performed a systematic review of randomized trials of HIV care continuum interventions among people who use substances published between 2011 and 2021, the treatment-as-prevention era. Existing systematic reviews and studies in which less than half of those sampled reported substance use were excluded. We identified ten studies (total N=5410; range: 210-1308), nine of which intentionally targeted substance-using populations. Four of these studies involved use of at least one of several substances, including alcohol, opioids, stimulants, and/or marijuana, among others; three involved injection drug use only; one involved methamphetamine use only; and one involved alcohol use only. One study targeted a population with incidental substance use, which involved use of alcohol, injection drug use, and non-injection drug use. Viral suppression was targeted in 8/10 studies, followed by uptake/initiation of antiretroviral therapy (ART; 6/10), ART adherence (6/10), retention to care (4/10), and linkage to care (3/10). For each outcome, intervention effects were found in roughly half of the studies in which a given outcome was assessed. Mediated (2/10) and moderated (2/10) effects were minimally examined. The diversity of substances used in and across studies, as well as other characteristics that varied across studies, prevented broad deductions or conclusions about the amenability of specific substances to intervention. Moreover, study quality was mixed due to varying attrition and assessment measures (self-report vs biological/clinical). More coordinated, comprehensive, and targeted efforts are needed to disentangle intervention effects on HIV care continuum outcomes among populations using diverse substances.

BackgroundInequalities in the antiretroviral therapy (ART) cascade across subpopulations remain an ongoing challenge in the global HIV response. Eswatini achieved the UNAIDS 95-95-95 targets by 2020, with differentiated programs to minimize inequalities across subpopulations, including for female sex workers (FSW) and their clients. We sought to estimate additional HIV infections expected in Eswatini if cascade scale-up had not been equal, and under which epidemic conditions these inequalities could have the largest influence. MethodsDrawing on population-level and FSW-specific surveys in Eswatini, we developed a compartmental model of heterosexual HIV transmission which included eight subpopulations and four sexual partnership types. We calibrated the model to stratified HIV prevalence, incidence, and ART cascade data. Taking observed cascade scale-up in Eswatini as the basecase -- reaching 95-95-95 in the overall population by 2020 -- we defined four counterfactual scenarios in which the population overall reached 80-80-90 by 2020, but where FSW, clients, both, or neither were disproportionately left behind, reaching only 60-40-80. We quantified relative additional cumulative HIV infections by 2030 in counterfactual vs base-case scenarios. We further estimated linear effects of viral suppression gap among FSW and clients on additional infections by 2030, plus effect modification by FSW/client population sizes, rates of turnover, and HIV prevalence ratios. ResultsCompared with the base-case scenario, leaving behind neither FSW nor their clients led to the fewest additional infections by 2030: median (95% credible interval) 14.9 (10.4, 18.4) % vs 26.3 (19.7, 33.0) % if both were left behind -- a 73 (40, 149) % increase. The effect of lower cascade on additional infections was larger for clients vs FSW, and both effects increased with population size and relative HIV incidence. ConclusionsInequalities in the ART cascade across subpopulations can undermine the anticipated prevention impacts of cascade scale-up. As Eswatini has shown, addressing inequalities in the ART cascade, particularly those that intersect with high transmission risk, could maximize incidence reductions from cascade scale-up.

Objective(s)To predict the burden of HIV in the United States (US) nationally and by region, transmission type, and race/ethnicity through 2030. MethodsUsing publicly available data from the CDC NCHHSTP AtlasPlus dashboard, we generated 11-year prospective forecasts of incident HIV diagnoses nationally and by region (South, non-South), race/ethnicity (White, Hispanic/Latino, Black/African American), and transmission type (Injection-Drug Use, Male-to-Male Sexual Contact (MMSC), and Heterosexual Contact (HSC)). We employed weighted (W) and unweighted (UW) n-sub-epidemic ensemble models, calibrated using 12 years of historical data (2008-2019), and forecasted trends for 2020-2030. We compared results to identify persistent, concerning trends across models. ResultsWe projected substantial decreases in incident HIV diagnoses nationally (W: 27.9%, UW: 21.9%), and in the South (W:18.0%, UW: 9.2%) and non-South (W: 21.2%, UW: 19.5%) from 2019 to 2030. However, concerning non-decreasing trends were observed nationally in key sub-populations during this period: Hispanic/Latino persons (W: 1.4%, UW: 2.6%), Hispanic/Latino MMSC (W: 9.0%, UW: 9.9%), people who inject drugs (PWID) (W: 25.6%, UW: 9.2%), and White PWID (W: 3.5%, UW: 44.9%). The rising trends among Hispanic/Latino MMSC and overall PWID were consistent across the South and non-South regions. ConclusionsAlthough the forecasted national-level decrease in the number of incident HIV diagnoses is encouraging, the US is unlikely to achieve the Ending the HIV Epidemic in the U.S. goal of a 90% reduction in HIV incidence by 2030. Additionally, the observed increases among specific subpopulations highlight the importance of a targeted and equitable approach to effectively combat HIV in the US.

BackgroundAlthough the number of new HIV diagnoses among men who have sex with men (MSM) in the Netherlands has declined considerably, the recent plateau suggests ongoing transmission. In 2024, 29% of new diagnoses among MSM were in a late HIV stage, showing that the time between infection and diagnosis can still be substantially reduced. In low-incidence settings, infections introduced through immigration are increasingly important in sustaining transmission, highlighting the need to re-evaluate current testing guidelines. We assess targeted testing strategies among MSM in the Netherlands addressing these considerations. MethodsWe used an agent-based model of HIV transmission among MSM in the Netherlands, incorporating infections acquired domestically and abroad. For 2024 - 2040, we simulated testing interventions targeting different subgroups, including offering an HIV test to immigrants upon entry, increasing testing rates among MSM residing in the Netherlands, and combinations of these approaches. ResultsOffering HIV testing to immigrating MSM at the entry averted up to 94 (95-th % quantile interval, 95% QI -128 - 328) new infections over 15 years if at least 50% take the test. Increasing testing to every 7 months in the general MSM population achieved the largest reduction, with up to 508 (95% QI 292 - 900) infections averted. The same testing rate in MSM with more than 5 partners within the previous six months resulted in 340 (95% QI 132-592) infections averted. Combining testing at entry with 7-months testing among general resident MSM averted the most infections, 534 (95% QI 308 - 884). ConclusionsCombination of offering HIV test to immigrating MSM at the entry with 7-month testing frequency in the general resident MSM population can substantially reduce HIV infections. The difference in impact between targeting general MSM and those with relatively high recent partner numbers suggests that criteria for being at risk of having HIV need to expand. 1 Author summaryWhile HIV transmission among MSM in the Netherlands has decreased substantially over the last decade, it is still ongoing. In 2024, 29% of new HIV diagnoses in MSM were in individuals in late-stage of HIV infection, suggesting that the time between HIV acquisition and diagnosis should be shortened further. Additionally, in a low-incidence setting such as MSM in the Netherlands, introduction of HIV infections through immigration becomes more important. We evaluated several HIV testing strategies for this context, considering both immigrating MSM and resident MSM. While offering HIV test at entry point can avert many HIV infections, increasing testing rate in resident MSM to on average every seven months can avert substantially more HIV infections. The greatest impact is achieved when these approaches are combined: targeting both immigrating MSM and those already living in the country. This combined strategy requires the fewest additional tests per infection averted. Importantly, our simulations show that there are MSM living with undiagnosed HIV who do not necessarily meet the traditional criteria for being at risk. Improved testing strategies can help reach these individuals earlier, benefiting both public and their personal health.

Despite significant gains and successes in many areas, progress in HIV prevention and treatment is uneven, highlighted in the 2022 UNAIDS report In Danger, and certain populations are being left behind. In particular, men and adolescent girls and young women (AGYW) are among the groups in danger of not reaching epidemic control targets. Among other calls for utilizing scientific innovations, PEPFARs Office of the Global AIDS Coordinator and Health Diplomacy recently highlighted the need to expand the use of innovative methods from behavioral science in HIV programs. One of these innovative, but underused, approaches is behavioral economics (BE), which leverages our predictable cognitive biases and mental shortcuts to both diagnose behavioral factors and positively influence behavior. The tools used by BE to change behavior are frequently called nudges, which tend to be low-cost and easy-to-implement interventions. This scoping review identified nudges applied to select client and provider behaviors along the HIV prevention, testing, and care and treatment continuum. It maps them to the commonly used EAST Framework, a simplified way to classify nudges for program design and highlights those that shifted behavior. The EAST Framework groups nudges into Easy, Attractive, Social, and Timely categories. This scoping review identified that Easy nudges were commonly applied as changes to the structure of HIV programs, influencing individual behavior through program changes. Nudges that directly targeted individuals most commonly fell into the Attractive and Social categories. Many of the individual-focused nudges in the Attractive and Social categories changed behavior, along with Easy nudges. Additionally, the mapping highlighted the dearth of nudges applied to provider behavior in the Low and Middle Income (LMIC) HIV space. Further integration of nudges into HIV programs and their evaluation using implementation science may help move the needle to end the HIV epidemic as a public health threat by 2030.

Introduction Understanding provider preferences for the design of HIV treatment packages could enhance the implementation of programs to support the adoption of long-acting injectable antiretroviral therapy (LAI ART) by people living with HIV who are interested in initiating this treatment modality. Methods We recruited providers from New York City (NYC), Rockland, Putman, and Westchester County Ryan White Part A Medical Case Management (MCM) programs to complete a discrete choice experiment (DCE) containing twelve tasks with two alternatives and an opt-out option, with additional survey questions about implementation readiness and choice motivations. The alternatives included four attributes--Type of ART Medication (monthly or bimonthly LAI ART), Service Location and Mode, Support for Clients, and Rewards for Clients--with 2-4 levels each. We ran latent class multinomial logit analyses (LCA) with 1-5 classes to estimate preferences and explore hypothesis-free preference heterogeneity. We estimated attribute influence using relative importances and preferences using zero-centered part-worth utilities for each level. Results One hundred seventy-seven providers completed the survey (July 2022-January 2023). About half (52%) were 40-59 years old, 72% identified as women, and the plurality (41%) identified as Latino/a. We chose the two-group LCA solution. Bimonthly LAI ART was preferred over monthly LAI ART overall and in both groups. Group 1 (n=45) preferred more traditional adherence supports (e.g., injections at the clinic by appointment, injection appointment reminders) whereas Group 2 (n=132) preferred more client-centered supports (e.g., injections at home by appointment, free transportation to injection appointments if at a clinic). Both groups preferred higher monetary value gift cards for clients for every on-time injection. The top-ranking motivations indicated that participants prioritized patient convenience over job satisfaction and administrative or financial feasibility for the agency. The scores for all implementation measures indicate readiness to implement LAI ART in both groups. Conclusions Our implementation science-focused study suggests that providers of MCM services in NYC and surrounding counties are motivated to offer services to support clients' access and adherence to LAI ART. More work is needed to understand how programs have, in fact, integrated supports for LAI ART into their services.

BackgroundIn the US, transgender and gender-diverse (TGD) individuals, particularly trans feminine individuals, experience a disproportionately high burden of HIV relative to their cisgender counterparts. While engagement in the HIV Care Continuum (e.g., HIV care visits, antiretroviral (ART) prescribed, ART adherence) is essential to reduce viral load, HIV transmission, and related morbidity, the extent to which TGD people engage in one or more steps of the HIV Care Continuum at similar levels as cisgender people is understudied on a national level and by gendered subgroups. Methods and FindingsWe used Medicare Fee-for-Service claims data from 2009 to 2017 to identify TGD (trans feminine and non-binary (TFN), trans masculine and non-binary (TMN), unclassified gender) and cisgender (male, female) beneficiaries with HIV. Using a retrospective cross-sectional design, we explored within- and between-gender group differences in the predicted probability (PP) of engaging in one or more steps of the HIV Care Continuum. TGD individuals had a higher predicted probability of every HIV Care Continuum outcome compared to cisgender individuals [HIV Care Visits: TGD PP=0.22, 95% Confidence Intervals (CI)=0.22-0.24; cisgender PP=0.21, 95% CI=0.21-0.22); Sexually Transmitted Infection (STI) Screening (TGD PP=0.12, 95% CI=0.11-0.12; cisgender PP=0.09, 95% CI=0.09-0.10); ART Prescribed (TGD PP=0.61, 95% CI=0.59-0.63; cisgender PP=0.52, 95% CI=0.52-0.54); and ART Persistence or adherence (90% persistence: TGD PP=0.27, 95% CI=0.25-0.28; 95% persistence: TGD PP=0.13, 95% CI=0.12-0.14; 90% persistence: cisgender PP=0.23, 95% CI=0.22-0.23; 95% persistence: cisgender PP=0.11, 95% CI=0.11-0.12)]. Notably, TFN individuals had the highest probability of every outcome (HIV Care Visits PP =0.25, 95% CI=0.24-0.27; STI Screening PP =0.22, 95% CI=0.21-0.24; ART Prescribed PP=0.71, 95% CI=0.69-0.74; 90% ART Persistence PP=0.30, 95% CI=0.28-0.32; 95% ART Persistence PP=0.15, 95% CI=0.14-0.16) and TMN people or cisgender females had the lowest probability of every outcome (HIV Care Visits: TMN PP =0.18, 95% CI=0.14-0.22; STI Screening: Cisgender Female PP =0.11, 95% CI=0.11-0.12; ART Receipt: Cisgender Female PP=0.40, 95% CI=0.39-0.42; 90% ART Persistence: TMN PP=0.15, 95% CI=0.11-0.20; 95% ART Persistence: TMN PP=0.07, 95% CI=0.04-0.10). The main limitation of this research is that TGD and cisgender beneficiaries were included based on their observed care, whereas individuals who did not access relevant care through Fee-for-Service Medicare at any point during the study period were not included. Thus, our findings may not be generalizable to all TGD and cisgender individuals with HIV, including those with Medicare Advantage or other types of insurance. ConclusionsAlthough TGD beneficiaries living with HIV had superior engagement in the HIV Care Continuum than cisgender individuals, findings highlight notable disparities in engagement for TMN individuals and cisgender females, and engagement was still low for all Medicare beneficiaries, independent of gender. Interventions are needed to reduce barriers to HIV care engagement for all Medicare beneficiaries to improve treatment outcomes and reduce HIV-related morbidity and mortality in the US.

ImportanceEstimating the medical complexity of people aging with HIV can inform clinical programs and policy to meet future healthcare needs. ObjectiveTo project the prevalence of comorbidities and multimorbidity among people with HIV (PWH) using antiretroviral therapy (ART) in the US through 2030. DesignAgent-based simulation model SettingHIV clinics in the United States in the recent past (2020) and near future (2030) ParticipantsIn 2020, 674,531 PWH were using ART; 9% were men and 4% women with history of injection drug use; 60% were men who have sex with men (MSM); 8% were heterosexual men and 19% heterosexual women; 44% were non-Hispanic Black/African American (Black); 32% were non-Hispanic White (White); and 23% were Hispanic. Exposure(s)Demographic and HIV acquisition risk subgroups Main Outcomes and MeasuresProjected prevalence of anxiety, depression, stage [≥]3 chronic kidney disease (CKD), dyslipidemia, diabetes, hypertension, cancer, end-stage liver disease (ESLD), myocardial infarction (MI), and multimorbidity ([≥]2 mental or physical comorbidities, other than HIV). ResultsWe projected 914,738 PWH using ART in the US in 2030. Multimorbidity increased from 58% in 2020 to 63% in 2030. The prevalence of depression and/or anxiety was high and increased from 60% in 2020 to 64% in 2030. Hypertension and dyslipidemia decreased, diabetes and CKD increased, MI increased steeply, but there was little change in cancer and ESLD. Among Black women with history of injection drug use (oldest demographic subgroup in 2030), CKD, anxiety, hypertension, and depression were most prevalent and 93% were multimorbid. Among Black MSM (youngest demographic subgroup in 2030), depression was highly prevalent, followed by hypertension and 48% were multimorbid. Comparatively, 67% of White MSM were multimorbid in 2030 (median age in 2030=59 years) and anxiety, depression, dyslipidemia, CKD, and hypertension were highly prevalent. Conclusion and relevanceThe distribution of multimorbidity will continue to differ by race/ethnicity, gender, and HIV acquisition risk subgroups, and be influenced by age and risk factor distributions that reflect the impact of social disparities of the health on women, people of color, and people who use drugs. HIV clinical care models and funding are urgently required to meet the healthcare needs of people with HIV in the next decade. KEY POINTS QuestionHow will the prevalence of multimorbidity change among people with HIV (PWH) using antiretroviral therapy in the US from 2020 to 2030? FindingsIn this agent-based simulation study using data from the NA-ACCORD and the CDC, multimorbidity ([≥]2 mental/physical comorbidities other than HIV) will increase from 58% in 2020 to 63% in 2030. The composition of comorbidities among multimorbid PWH vary by race/ethnicity, gender, and HIV acquisition risk group. MeaningHIV clinical programs and policy makers must act now to identify resources and care models to meet the increasingly complex medical needs of PWH over time, particularly mental healthcare needs.

BackgroundState AIDS Drug Assistance Programs (ADAPs) provide HIV medication access for people with HIV (PWH) with low incomes in the United States (US). We quantified the proportion of viral suppression (VS) that is from ADAP clients for 2015-2022. MethodsFor 2015-2022, we obtained viral load (VL) test results and VS data from publicly available, jurisdiction-level data on ADAP clients and PWH. We report descriptive statistics including the proportion of PWH with a VL who had VS and were supported by ADAPs. ResultsAfter excluding jurisdictions with missing data, PWH who were included in the analysis for each year was 63.7-96.4%. VS for PWH each year was 60-66.3%. VS for ADAP clients was 81.2%-91.4%. In all years, compared to all PWH, a lower proportion of ADAP clients had a reported VL and a higher proportion had VS. Over 2015-2022, the average proportion of PWH who were ADAP clients was 23.1%, the proportion of PWH with VLs who were ADAP clients was 22.2%, and the proportion of PWH with VS who were ADAP clients was 30.8%. ConclusionsAlmost a third of the entire VS rate was from ADAP clients, despite ADAP serving less than 25% of PWH. A much higher proportion of ADAP clients achieved VS, compared to PWH. ADAPs impact is not due to ADAP clients being over represented among PWH with reported VLs. ADAP does not directly receive any federal Ending the HIV Epidemic (EHE) Initiative funding. Policymakers should examine how ADAPs can support the EHE Initiative. SummaryDespite state AIDS Drug Assistance Programs (ADAPs) serving less than a quarter of people with HIV, almost a third of the viral suppression in the United States can be attributed to ADAPs. ADAPs are essential for ending the HIV epidemic.

BackgroundDespite progress in HIV prevention and treatment, resulting in overall incidence reductions in the United States, large racial/ethnic (r/e) disparities in HIV incidence remain due to stigma, discrimination, racism, poverty, and other social and structural factors. SettingWe used the HIV Optimization and Prevention Economics (HOPE) model to analyze which intervention strategies provide the most effective path towards eliminating r/e disparities in HIV incidence. MethodsWe considered four intervention scenarios for 2023-2035, which focused on eliminating r/e disparities by 2027 in the HIV care continuum only, HIV prevention services only, both continuum and prevention services, and a final scenario where prevention and care levels for Black and Hispanic/Latino were set to maximum feasible levels. The primary outcome is the incidence-rate-ratio (IRR) for Black and Hispanic/Latino populations compared to Other populations (of whom 89% are White) with the goal of IRRs [≤] 1 by 2035. ResultsAll scenarios reduced IRRs but only Maximum Feasible eliminated HIV incidence disparities by 2035, with respective IRRs of 0.9 and 1.1 among the Black and Hispanic/Latino populations, compared to 6.5 and 4.1 in the baseline scenario. Continuum-only was more effective at reducing disparities (2035 IRRs of 4.7 for Black and 3.1 for Hispanic/Latino populations) than Prevention-only (6.1 and 3.7 respectively). ConclusionsWith no prioritized changes, our simulation showed that r/e disparities in HIV incidence persist through 2035. Elimination of r/e incidence disparities by 2035 is only possible if maximum HIV prevention and care levels for Black and Hispanic/Latino populations can be realized by 2027.

BackgroundRapid Start results in persons with HIV (PWH) initiating antiretroviral therapy (ART) in less than seven days. Benefits associated with Rapid Start include linkage to medical care and starting ART on the same day as diagnosis. These PWH were better retained in medical care and likely to achieve virologic suppression, in a shorter time, than those who did not have access to Rapid Start. Despite recommendations to initiate ART less than seven days after diagnosis, slow uptake of Rapid Start, in New Jersey were noted. ObjectiveIdentify knowledge, structural barriers and attitudes to Rapid Start, among New Jersey providers. MethodsAn electronic survey using Qualtrics consisting of 33 questions with the following domains: provider and practice characteristics (11), knowledge (1), structural barriers (9) and attitudes to diverse patient types was administered to New Jersey providers. The results were analyzed using descriptive statistics due to small numbers over strata. Approval to conduct this survey was obtained from the William Paterson University Institutional Review Board. ResultsThe respondents were less than 55 years old (36/56, 64%), female (44/60, 73%), heterosexual (50/59, 85%), and nurse practitioners or physician assistants (41/59, 69%). Those who identified as internal medicine (9, 47%) or infectious disease (6, 60%) providers or worked in Ryan White (3, 30%) and non-Ryan White (6, 55%) practices correctly identified that integrase inhibitors had the lowest prevalence of transmitted resistance, when compared to those in private and other clinical settings. Newly diagnosed patients were referred for medical care in 37 (65%) of the medical sites. However, only providers from Ryan White (federally funded clinics for HIV patients) (64%) and non-Ryan White (73%) public sites reported co-located HIV testing sites. Seventy percent of medical sites reported that they offered same-day medical appointments. However, a lower proportion of private (62%), public Ryan White (55%), and other medical sites (36%) offered same-day appointments compared to public non-Ryan White sites (82%). Despite having staff available 40 hours per week (91%), only 55% of Ryan White sites offered extended office hours in the early morning, evenings, or on Saturdays. When compared to providers in public Ryan White sites, a higher proportions of providers in non-Ryan White sites were comfortable doing Rapid Start either on the day of or within one week of diagnosis, 72% and 82%, respectively, or starting ART before genotype results were available, 46% and 55%, respectively. Providers in public non-Ryan White sites were comfortable with Rapid Start for the following diverse groups of patients: with untreated mental illness (64%), engaging in unprotected sex (73%), with multiple partners (91%), actively using illicit drugs (91%), without health insurance (91%), homeless (100%), and with acute infection (82%). ConclusionsPolicy and administrative decisions are needed to eliminate structural barriers at the clinic level. Education on guideline recommendations and with diverse groups of patients will increase comfort with Rapid Start.

ObjectivesTo estimate the increase in HIV infections in 11 US states if Ryan White services are interrupted or ended. MethodsWe applied a population-level model of HIV transmission to 11 states. We represented the proportion of people with HIV receiving Ryan White AIDS Drug Assistance, Outpatient Health services, or Support services, and simulated a loss of suppression in each category if services permanently end or return after delays of 1.5 or 3.5 years. ResultsCessation of Ryan White services in 2025 was projected to result in 69,695 additional infections from 2025-2030 (95% credible interval 18,943 to 123,628) - 68% (18% to 118%) more than if Ryan White were continued. Temporary interruptions of 1.5 and 3.5 years resulted in 26,951 (7,341 to 47,534) and 53,594 (14,645 to 94,860) additional infections, respectively. Excess infections varied across states, from a 45% increase in Texas to 126% in Missouri. ConclusionsProjected increases in HIV infections due to disruptions of Ryan White services threaten the progress made in curtailing the US HIV epidemic, illustrating the critical role Ryan White plays in preventing HIV transmission.

PurposeWe developed metrics to estimate the number of people who could benefit from PrEP using clinical, behavioral, and economic considerations. MethodsWe estimated the distribution of annual HIV acquisition risk in the U.S. population and the number who would benefit from PrEP based on HIV acquisition risk thresholds. Estimates were generated for men who have sex with men (MSM), men who have sex with women (MSW), women who have sex with men (WSM), and people who inject drugs (PWID). Populations were stratified by state, age, and race and ethnicity. Adult PWID were stratified by state and sex. We also derived a measure anchored on a willingness-to-pay threshold to gain one quality-adjusted life year (QALY). ResultsWe estimated 31-57% of MSM could benefit from PrEP by HIV acquisition risk thresholds, and 30% when using the cost-per-QALY threshold. For PWID, estimates ranged from 7% (cost-per-QALY) to 60% (highest risk threshold). MSW and WSM had the lowest proportions estimated to benefit (0-11%), but the absolute number of individuals remained large due to the size of these populations. DiscussionThese estimates provide a broader framework in which to examine need for PrEP at the population and program level in the United States.

Lack of adherence to antiretroviral therapy (ART) and poor retention in care are significant barriers to ending HIV epidemics. Treatment adherence support (TAS) effectiveness may be constrained by limited awareness and understanding of the benefits of ART, particularly the concepts of treatment as prevention and Undetectable=Untransmittable (U=U), for which substantial knowledge gaps persist. We used mixed methods to evaluate a straightforward visual and tactile tool, the B-OK Bottles ("B-OK"), that incorporates human-centered design and behavioral economics principles and is designed to change and strengthen mental models about HIV disease progression and transmission. We enrolled 118 consenting adults living with HIV who were clients of medical case managers at one of four case management agencies in Philadelphia. All participants completed a pre-intervention survey, a B-OK intervention, and a post-intervention survey. A subset (N=52) also completed qualitative interviews before (N=20) or after (N=32) B-OK. Participants had a median age of 55 years (IQR 47-60), about two-thirds were male sex (N=77, 65%), nearly three-quarters identified as non-Hispanic Black (N=85, 72%), and almost all reported receiving ART (N=116, 98%). Exposure to B-OK was associated with improved awareness and understanding of HIV terminology, changes in attitudes about HIV treatment, and increased intention to rely on HIV treatment for transmission prevention. Insights from qualitative interviews aligned with the quantitative findings as respondents expressed a better understanding of U=U and felt that B-OK clearly explained concepts of HIV treatment and prevention. These findings provide a strong rationale to further evaluate the potential for B-OK to improve TAS for PLWH.