Modeling an Integrated HIV Prevention and Care Continuum to Achieve the Ending the HIV Epidemic Goals

Background: The goal of the US Ending the HIV Epidemic (EHE) plan is to reduce HIV incidence by 75% by 2025 and 90% by 2030. This initiative will scale-up prevention and care activities in high-need areas like the Southeast United States. It is unknown what interventions, alone or in combination, will have the greatest impact towards reaching the EHE targets. Methods: We developed a stochastic HIV transmission model for men who have sex with men (MSM), calibrated to local surveillance estimates of HIV prevalence, PrEP utilization, and HIV care continuum levels in the Atlanta area. Model scenarios varied HIV screening rates relative to empirical levels, under two assumptions of how HIV-negative persons would be linked to PrEP initiation, and also considered relative improvements to HIV care linkage and care retention for those screening positive. We estimated both the proportion of cumulative infections averted over 10 years and the reduction in incidence rates relative to EHE targets. Results: A ten-fold relative increase in HIV screening rates (to approximately biannual screening for black and Hispanic MSM and quarterly for white MSM) would lead to 41% of infections averted under the assumption of integrated linkage to PrEP, with prevention through both increased PrEP coverage and increased HIV viral suppression. At the same relative increase in screening but under the assumption of no PrEP linkage, only 9.9% of infections would be averted, with prevention only through increased viral suppression. Improvements to HIV care retention would avert 33.5% of infections if retention rates were improved 10-fold. If both screening and retention were jointly improved 10-fold, 66.6% and 48.5% of cumulative infections would be averted under assumptions of PrEP linkage and no-linkage, respectively. Under the joint 10-fold PrEP-linked scenario, it would take 7.3 years to meet the 75% EHE target and 30.4 years to meet the 90% target for MSM in Atlanta. Conclusions: Interventions to improve HIV screening linked with PrEP for those screening negative, and HIV care retention would have a substantial impact on HIV prevention through reduction of HIV acquisition and transmission rates. However, additional interventions beyond these substantial improvements to HIV screening, PrEP coverage, and HIV care retention will be necessary to reach the EHE target of a 90% reduction in incidence for Atlanta MSM by 2030.