CROI 2020 Abstract eBook

Abstract eBook

Poster Abstracts

1091 OUT-OF-POCKET SPENDING ON HEALTH FOR PEOPLE LIVING WITH HIV IN CÔTE D’IVOIRE Rachel Stelmach 1 , Miriam Rabkin 2 , Kouame Abo 3 , Irma Ahoba 4 , Mahena G. Anago 2 , Rodrigo Boccanera 5 , Hermann Brou 2 , Rebecca M. Flueckiger 1 , Kieran Hartsough 2 , Martin Msukwa 2 , Jennifer M. Zech 2 , Rachel Nugent 1 1 RTI International, Research Triangle Park, NC, USA, 2 ICAP at Columbia University, New York, NY, USA, 3 Ministère de la santé et de l’hygiène publique, Abidjan, Côte d'Ivoire, 4 National AIDS and STD Control Programme, Abidjan, Côte d'Ivoire, 5 HRSA HIV/AIDS Bureau, Rockville, MD, USA Background: In Côte d’Ivoire (CI), out-of-pocket (OOP) spending on health services is a barrier to care and risk for impoverishment. Although people living with HIV receive free antiretroviral therapy (ART), OOP spending on other direct and indirect health costs may impede them from engaging with HIV treatment services. Methods: A convenience sample of 400 HIV+ adults at 10 health facilities in rural and urban CI completed a tablet-based survey on health status, ART adherence, missed appointments, and OOP health spending. Participants (ppts) had been on ART for >1 year (yr) and missed >1 HIV appointment (appt) in the past yr. We performed descriptive statistics and simple linear regression analyses with bootstrapped 95% confidence intervals using the bias-corrected and accelerated method to test associations between OOP spending and number of missed HIV and chronic non-communicable diseases (NCD) appts. Results Ppts were 77% female, 87% formally employed, and a median of 39 yrs old (IQR 33-49). Median time on ART was 4.7 yrs (IQR 2.8-7.4). 365 ppts (91%) reported OOP spending on HIV care, with a median of $16/yr (IQR 5-48). 34% of ppts reported direct costs –medications, tests, hospitalization, gloves– with a median of $2/yr (IQR 1-41). No ppts reported paying user fees on HIV services. 87% of ppts reported indirect costs –often on transportation, but also lost wages and childcare– with a median of $17/yr (IQR 7-41). 102 ppts (26%) reported having HIV and >1 NCD, most commonly hypertension or lung disease. Of these, 80 (78%) reported OOP spending on NCD care, with a median of $50/yr (IQR 6-107). In contrast to ppts with HIV only, 76 ppts (95%) with both HIV & NCDs reported direct costs and 48% reported paying user fees on NCD services. Ppts had missed a median of 2 HIV appts in the past yr (IQR 2-3). When asked for reasons for missing HIV appts, cost was the 6th most-common cause, cited by 7% of ppts. Higher OOP costs were not associated with number of HIV appts missed. 66% reported they or a household member used savings to pay for health care, while 30% borrowed money and 6% sold assets. 21% of ppts reported spending >10% of household income on HIV and/or NCD care. This result was similar whether OOP spending was on HIV, NCD or both. Conclusion: Despite free ART, most ppts reported OOP spending. OOP costs were higher for ppts with co-morbid NCD, contributing to financial distress.

We calibrated the model using 10,000 simulations against CDC-reported new HIV diagnoses and persons living with HIV from 2010-2017 in the Baltimore metropolitan statistical area. We ran each simulation multiple times from 2020-2030 under a range of potential interventions, targeting HIV testing frequency, proportion of HIV-diagnosed individuals virally suppressed, and proportion of at-risk individuals prescribed and adherent to PrEP. Interventions were targeted at different combinations of high-risk subgroups. For each intervention and target group, we estimated the reduction in total Baltimore incidence that could be achieved between 2020 and 2030. We calculated 95% uncertainty ranges (UR) by weighting simulations according to howwell they fit the observed data from 2010-2017. Results: Continuing testing, suppression, and PrEP at current levels projected a reduction in incidence of 13% [95%UR: 2-35%] from 2020-2030. Interventions targeted to Baltimore’s highest-risk subgroups, black MSM and injection drug users, could achieve reductions of 57% [39-67%] (Table) with yearly testing, 90% suppression among people with diagnosed HIV, and 50% adherence to PrEP, and reductions up to 60% [42-71%] with 75% adherence to PrEP. Achieving close to 90% reduction in incidence from 2020 to 2030 among our tested interventions required expanding these interventions across the entire population. Conclusion: Ending the HIV epidemic in Baltimore will be challenging, and will require several, broadly targeted interventions to achieve high levels of HIV suppression among diagnosed individuals with HIV as well as high uptake of PrEP and frequent screening across multiple subgroups.

Poster Abstracts

1093 WHAT WILL IT TAKE TO "END THE HIV EPIDEMIC"? AN ECONOMIC MODELING STUDY IN 6 CITIES Bohdan Nosyk 1 , Xiao Zang 1 , Emanuel Krebs 1 , Czarina N. Behrends 2 , Carlos del Rio 3 , Julia C. Dombrowski 4 , Daniel J. Feaster 5 , Matthew R. Golden 4 , Brandon D. Marshall 6 , Shruti H. Mehta 7 , Lisa R. Metsch 8 , Bruce R. Schackman 2 , Steven Shoptaw 9 , Steffanie A.Strathdee 10 , for the Localized Economic Modeling Study Group 1 British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada, 2 Weill Cornell Medicine, New York, NY, USA, 3 Emory University, Atlanta, GA, USA, 4 University of Washington, Seattle, WA, USA, 5 University of Miami, Miami, FL, USA, 6 Brown University, Providence, RI, USA, 7 Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA, 8 Columbia University, New York, NY, USA, 9 University of California Los Angeles, Los Angeles, CA, USA, 10 University of California San Diego, La Jolla, CA, USA Background: The HIV epidemic in the US is a collection of diverse local microepidemics. Targeted strategies have been proposed to reduce HIV incidence by 90%within 10 years. We aimed to identify optimal combination implementation strategies of evidence-based interventions to reach these targets in six cities, comprising 24.1% of people living with HIV/AIDS in the US. Methods: Using a dynamic HIV transmission model calibrated with the best-available evidence on epidemiological and structural conditions for Atlanta, Baltimore, Los Angeles (LA), Miami, New York City (NYC) and Seattle, we assessed 16 evidence-based interventions (HIV prevention, testing, antiretroviral therapy (ART) engagement and re-engagement) to identify strategies providing the greatest health benefit while remaining cost-effective. Outcomes included averted HIV infections, quality-adjusted life-years (QALYs), total costs and incremental cost-effectiveness ratios (ICERs) (healthcare perspective; 3% annual discount rate; 2018$US). Interventions were implemented at previously-documented and ideal (90% coverage/adoption) scale-up, and sustained from 2020 to 2030, with outcomes evaluated until 2040. Results: We assessed 23,040 combinations, with optimal strategies containing between eleven (NYC, Seattle) and thirteen (Atlanta, LA, Miami) interventions.

1092 ENDING THE HIV EPIDEMIC IN BALTIMORE: A MODELING STUDY Anthony T. Fojo 1 , Parastu Kasaie 2 , David Dowdy 2 , Maunank Shah 1

1 Johns Hopkins University School of Medicine, Baltimore, MD, USA, 2 Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA Background: Last year, the US government announced a plan to reduce HIV incidence by 90% by 2030 through the “90-90-90” target. However, it is not clear how these targets will perform in local epidemics, such as the one in Baltimore City, driven by heterogeneities in HIV transmission and access to care. Methods: We extended the Johns Hopkins HIV economic-epidemic model (JHEEM), a validated compartmental model of HIV transmission, to represent population by sex (male/female), race/ethnicity (black, non-black), age strata (13-24, 25-34, 35-44,45-54, 55+ years old), and CDC risk groups (MSM, injection drug users, heterosexuals), and to include pre-exposure prophylaxis (PrEP).

CROI 2020 411