Improving health equity and ending the HIV epidemic in the USA: a distributional cost-effectiveness analysis in six cities,The Lancet HIV

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Improving health equity and ending the HIV epidemic in the USA: a distributional cost-effectiveness analysis in six cities
The Lancet HIV ( IF 16.1 ) Pub Date : 2021-08-06 , DOI: 10.1016/s2352-3018(21)00147-8
Amanda My Linh Quan ₁ , Cassandra Mah ₂ , Emanuel Krebs ₃ , Xiao Zang ₄ , Siyuan Chen ₂ , Keri Althoff ₅ , Wendy Armstrong ₆ , Czarina Navos Behrends ₇ , Julia C Dombrowski ₈ , Eva Enns ₉ , Daniel J Feaster ₁₀ , Kelly A Gebo ₁₁ , William C Goedel ₁₂ , Matthew Golden ₈ , Brandon D L Marshall ₁₂ , Shruti H Mehta ₁₁ , Ankur Pandya ₁₃ , Bruce R Schackman ₇ , Steffanie A Strathdee ₁₄ , Patrick Sullivan ₁₅ , Hansel Tookes ₁₆ , Bohdan Nosyk ₃ ,

Affiliation

Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada.
Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada.
Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada; BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada.
Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada; Department of Epidemiology, School of Public Health, Brown University, Providence, RI, USA.
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.
Department of Population Health Sciences, Weill Cornell Medical College, New York, NY, USA.
Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA; HIV/STD Program, Public Health-Seattle & King County, Seattle, WA, USA.
Division of Health Policy and Management, University of Minnesota, Minneapolis, MN, USA.
Department of Public Health Sciences, Leonard M Miller School of Medicine, University of Miami, Miami, FL, USA.
Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
Department of Epidemiology, School of Public Health, Brown University, Providence, RI, USA.
T H Chan School of Public Health, Harvard University, Boston, MA, USA.
School of Medicine, University of California San Diego, La Jolla, CA, USA.
Department of Epidemiology, Emory University, Atlanta, GA, USA.
Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA.

Background

In the USA, Black and Hispanic or Latinx individuals continue to be disproportionately affected by HIV. Applying a distributional cost-effectiveness framework, we estimated the cost-effectiveness and epidemiological impact of two combination implementation approaches to identify the approach that best meets the dual objectives of improving population health and reducing racial or ethnic health disparities.

Methods

We adapted a dynamic, compartmental HIV transmission model to characterise HIV micro-epidemics in six US cities: Atlanta, Baltimore, Los Angeles, Miami, New York, and Seattle. We considered combinations of 16 evidence-based interventions to diagnose, treat, and prevent HIV transmission according to previously documented levels of scale-up. We then identified optimal combination strategies for each city, with the distribution of each intervention implemented according to existing service levels (proportional services approach) and the racial or ethnic distribution of new diagnoses (between Black, Hispanic or Latinx, and White or other ethnicity individuals; equity approach). We estimated total costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios of strategies implemented from 2020 to 2030 (health-care perspective; 20-year time horizon; 3% annual discount rate). We estimated three measures of health inequality (between-group variance, index of disparity, Theil index), incidence rate ratios, and rate differences for the selected strategies under each approach.

Findings

In all cities, optimal combination strategies under the equity approach generated more QALYs than those with proportional services, ranging from a 3·1% increase (95% credible interval [CrI] 1·4–5·3) in New York to more than double (101·9% [75·4–134·6]) in Atlanta. Compared with proportional services, the equity approach delivered lower costs over 20 years in all cities except Los Angeles; cost reductions ranged from $22·9 million (95% CrI 5·3–55·7 million) in Seattle to $579·8 million (255·4–940·5 million) in Atlanta. The equity approach also reduced incidence disparities and health inequality measures in all cities except Los Angeles.

Interpretation

Equity-focused HIV combination implementation strategies that reduce disparities for Black and Hispanic or Latinx individuals can significantly improve population health, reduce costs, and drive progress towards Ending the HIV Epidemic goals in the USA.

Funding

National Institute on Drug Abuse.

中文翻译：

在美国改善健康公平并结束艾滋病毒流行：六个城市的分布成本效益分析

背景

在美国，黑人和西班牙裔或拉丁裔人继续受到 HIV 的不成比例的影响。应用分布成本效益框架，我们估计了两种组合实施方法的成本效益和流行病学影响，以确定最能满足改善人口健康和减少种族或民族健康差异的双重目标的方法。

方法

我们采用了一个动态的、区域性的 HIV 传播模型来描述美国六个城市的 HIV 微流行病：亚特兰大、巴尔的摩、洛杉矶、迈阿密、纽约和西雅图。我们根据先前记录的扩大规模考虑了 16 种基于证据的干预措施的组合，以诊断、治疗和预防 HIV 传播。然后，我们确定了每个城市的最佳组合策略，根据现有服务水平（按比例服务方法）和新诊断的种族或民族分布（在黑人、西班牙裔或拉丁裔以及白人或其他种族个体之间）实施每项干预措施的分布; 公平法）。我们估计了从 2020 年到 2030 年实施的战略的总成本、质量调整生命年 (QALY) 和增量成本效益比（医疗保健视角；20年的时间跨度；3% 年折现率）。我们估计了每种方法下所选策略的健康不平等的三个衡量标准（组间方差、差异指数、泰尔指数）、发病率比率和比率差异。

发现

在所亚特兰大的两倍 (101·9% [75·4–134·6])。与比例服务相比，公平方法在 20 年内在除洛杉矶以外的所有城市都提供了更低的成本；成本降低范围从西雅图的 22·900 万美元（95% CrI 5·3–55·7 百万）到亚特兰大的 579·800 万美元（255·4–940·500 万）。公平方法还减少了除洛杉矶以外所有城市的发病率差异和健康不平等措施。