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Test and treat DC: modeling the impact of a comprehensive HIV strategy in the US Capitol
R.P. Walensky1,2,3, A.D. Paltiel4, E. Losina1,2,5, B.L. Morris1, C. Scott1, G.R. Seage, III6, K.A. Freedberg1,3,5,6
1Massachusetts General Hospital, Boston, United States, 2Brigham and Women's Hospital, Boston, United States, 3Harvard Medical School, Boston, United States, 4Yale School of Medicine, New Haven, United States, 5Boston University School of Public Health, Boston, United States, 6Harvard School of Public Health, Boston, United States
Objective: Washington DC has the worst reported HIV epidemic (3% prevalence) in the US. We examine both patient outcomes and population transmission effects of a comprehensive HIV screening and early treatment strategy in DC.
Methods: Using a mathematical model of HIV disease, screening, treatment, and transmission, we project the impact of combination “test and treat” strategies: 1) background screening only, screening every 5 years, or screening annually, and 2) ART initiation at CD4 < 350/µl or immediately upon detection. Inputs include mean age 34 years, HIV prevalence/annual incidence 3%/1.2%, and mean CD4 of prevalence cases 332/µl. Baseline test offer, acceptance, and linkage to care rates are assumed to be 80%, 60% and 80%.
Results: Compared to background screen and ART at < 350/µl (current standard, bold), annual testing with immediate ART increases HIV+ life expectancy by 2.8 years and decreases secondary cases by 26% over 10 years.
| Screen frequency | ART initation | Life expectancy for HIV+ persons (yrs) | Follow-up time (yrs, %) with >3,000 copies/ml HIV RNA over 10y | % change in 2° cases of HIV at 10yrs | | Background screen | No ART | 26.6 | 1,116,931 (75%) | +14% | | Background screen | CD4 ≤ 350/μl | 34.8 | 942,222 (53%) | -- | | Every 5y | CD4 ≤ 350/μl | 35.8 | 904,699 (49%) | -3% | | Annual | CD4 ≤ 350/μl | 37.0 | 845,925 (45%) | -8% | | Background screen | Immediately | 35.7 | 830,180 (45%) | -9% | | Every 5y | Immediately | 36.6 | 773,646 (41%) | -14% | | Annual | Immediately | 37.6 | 649,870 (34%) | -26% |
In sensitivity analysis, annual testing and immediate ART, coupled with 90% offer, 100% acceptance and 90% linkage, increases HIV+ life expectancy to 38.5 yrs and decreases the secondary cases by 36%.
Conclusions: We estimated that a comprehensive test and treat strategy in Washington DC would improve HIV+ life expectancy by several years and decrease secondary HIV cases by 26% compared to current strategies. Efforts to increase test offering, acceptance, and linkage would further improve outcomes.
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