Cost-Effectiveness and the Role of Socioeconomic Support Services in Ending the HIV/AIDS Epidemic in the United States

Abstract

There is still no cure for human immunodeficiency virus (HIV), meaning infected individuals must remain on lifelong treatment. While the United States has made substantial progress on HIV prevention, there are still more than 1.2 million people living with HIV (PLWH) in the U.S. and prevalence continues to increase. Treatment not only extends life expectancy and improves quality of life for PLWH, it also reduces the risk of HIV transmission by suppressing HIV viral loads to undetectable levels. However, only 58% of diagnosed PLWH in the U.S. were retained in care and only 66% were virally suppressed in 2019, which is well-below the National HIV/AIDS Strategy goal of reaching 95% viral suppression and ending the HIV epidemic by 2030. This dissertation summarizes existing evidence on the cost-effectiveness of improving retention in HIV care. It then presents new findings on the potential costs, benefits, and cost-effectiveness of socioeconomic support services funded by the U.S. Ryan White HIV/AIDS Program (RWHAP), the largest federally funded program focused on HIV care for low-income populations. Specific aims are to: 1) Systematically review evidence on the cost-effectiveness of HIV retention and re-engagement interventions. A systematic review of literature published in the past 10 years on retention interventions in high-income settings was conducted. Findings on methods, cost-effectiveness, quality, and overall strength of evidence were summarized. 2) Estimate the impact of support services on sustained viral suppression among low-income PLWH. Five years (2015-2019) of RWHAP data from the Minneapolis-St. Paul region was analyzed. Logistic and linear regressions using generalized estimating equations and propensity scores to adjust for the probability of service use were used to estimate the causal effect of support service use on sustained viral suppression. 3) Investigate the barriers, opportunities, and potential costs of expanding HIV socioeconomic support services. Semi-structured interviews were conducted with service providers in Minneapolis-St. Paul to explore current barriers, potential opportunities, estimated costs, and anticipated outcomes of program expansion for food, financial, transportation, and housing support services for low-income people living with HIV. 4) Evaluate the potential cost-effectiveness of expanding food aid vouchers to fill unmet need. An individual-based microsimulation model of post-diagnosis HIV care was developed and parameterized to reflect the RWHAP client population in the Minneapolis-St. Paul region. Using results from Aims 2 and 3, the model was used to estimate the potential cost-effectiveness of expanding food aid vouchers. Preliminary results from the base case and relevant sensitivity and scenario analyses are reported. Outcomes from this project provide support for continued funding of programs that address socioeconomic challenges for PLWH and can be used to inform local resource allocation decisions for HIV care. Socioeconomic support programs such as food aid, financial assistance, housing, and transportation could be integrated into multifaceted strategies aimed at improving HIV outcomes and achieving national HIV treatment goals.