Background
The Ending the HIV Epidemic (EHE) program was launched in 2019 with the goal of reducing HIV transmission in the US by 75% by 2025 and 90% by 2030. Men who have sex with men (MSM) are a priority population in this effort. Our objective was to model the impact of improvements across the HIV prevention and care continuum on HIV transmissions and to quantify the improvements needed to reach EHE goals among MSM.
Methods
We used the CEPAC model of HIV disease to assess the scale of prevention, diagnosis, linkage, retention, and virologic suppression needed to meet EHE goals for MSM in the US. We projected HIV transmissions over time given the current HIV care continuum (Status quo) and for 11 individual and combination intervention strategies with improvements in HIV testing frequency, 30-day linkage, virologic suppression, retention in care, and/or PrEP coverage. MSM were stratified into higher (HR MSM) and lower (LR MSM) HIV transmission risk groups using published data. Status quo inputs included HIV testing frequency (mean every 6.8y), 30-day HIV care linkage (77%), ART virologic suppression (81%, first-line), 2y retention in care (78%), and PrEP coverage (57% for HR MSM and 7.5% for LR MSM). Outcomes included annual HIV transmissions through 2030 and % reduction in transmissions compared to 2017. In sensitivity analysis, we examined the % of population achieving virologic suppression and % PrEP coverage for HR MSM.
Results
We estimated 24,278 transmissions to have occurred in 2017, matching CDC estimates. In Status quo, transmissions would be reduced 33% by 2030 (n=16,285). Improving retention in care to 98% at 2 years had the largest individual impact on transmissions, with 63% reduction by 2030. Combined testing and treatment interventions at very high levels (HIV testing every 6 months, 30-day linkage of 98%, retention in care at 2y of 98%, and ART effectiveness of 98%) would decrease transmissions 85% by 2030 (n=3,763). Adding expanded PrEP for HR MSM (PrEP coverage 90%/effectiveness 96%), would decrease transmissions 90% by 2030 (n=2,530, Figure). In sensitivity analysis, increasing the % of all MSM with virologic suppression had a greater impact on transmissions than increasing PrEP coverage in HR MSM.
Conclusions
With substantial and rapid improvements across the HIV testing, treatment, and prevention continuum, meeting EHE goals for MSM in the US would be possible. Improving retention in care is especially important for reducing transmissions and moving towards EHE goals.
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