Projected Life Expectancy Gains From Improvements in HIV Care in Black and White Men Who Have Sex With Men

This decision analytical model evaluates the projected life expectancy gains from improvements in HIV care in men who have sex with men.


Introduction
2][3][4][5][6] Black PWH are less likely to receive prompt diagnosis, consistently receive HIV care, and achieve virologic suppression than White PWH. 2 These inequities are particularly evident between Black men who have sex with men (MSM) and White MSM.Less than 85% of Black MSM with HIV receiving care were virologically suppressed in 2021 compared with more than 90% of White MSM with HIV; virologic nonsuppression increases morbidity, mortality, and HIV transmission. 18][9] Inequities in access to health care have continued to persist in large part due to people being uninsured and underinsured, which disproportionately affects Black communities. 102][13] This initiative aligns with growing calls for local and national programs to set HIV care goals that promote health equity, or the attainment of the highest level of health for all people. 14,15In contrast, goals that aim for similar increments in improvement in care across subpopulations, rather than setting identical outcome goals, allow racial inequities to persist.
To achieve health equity, investments must be made in interventions that address multilevel factors driving racial inequities, as well as evaluations of public health goals to determine effective strategies.We used simulation modeling to assess the potential implications of different HIV care continuum goals by examining which strategies would reduce gaps in life expectancy and improve outcomes among Black MSM and White MSM with HIV.Although prevention efforts, such as preexposure prophylaxis (PrEP), are essential to comprehensive care, we explicitly focused this study on improving care among MSM living with HIV to guide efforts toward strengthening the care continuum for individuals with HIV.

Analytic Overview
The Cost-Effectiveness of Preventing AIDS Complications (CEPAC) microsimulation model was used to project survival for non-Hispanic Black MSM with HIV and non-Hispanic White MSM with HIV given 7 different HIV care continuum goals.First, we populated the status quo care strategy with racespecific national estimates of testing frequency, the proportion of MSM with diagnosed HIV receiving care, and the proportion with virological suppression.We then simulated 2 equal improvements in care goals, which would attain equal absolute improvements in care between Black MSM and White MSM: (1) 10-point increased receipt of care and (2) 5-point increased virologic suppression (eFigure 1 in Supplement 1).We next simulated 3 equity-centered goals, in which equity between Black MSM and White MSM is achieved in 1 step of the HIV care continuum: (1) annual HIV testing for earlier diagnosis, (2) 95% receiving HIV care among MSM with diagnosed HIV, and (3) 95% virologic suppression among MSM receiving HIV care (eFigure 2 in Supplement 1).Last, we simulated an equitable care continuum that achieves annual HIV testing, 95% receiving HIV care, and 95% virologic suppression. 16These goals align with recommendations from the National HIV/AIDS Strategy and the US Centers for Disease Control and Prevention (CDC). 11,17,18To examine the association between racial inequities within the HIV care continuum and HIV care outcomes, we projected the mean age at death and compared the mean years of life gained (YLG) from attaining each HIV care continuum goal for Black MSM and White MSM with HIV.

JAMA Network Open | Equity, Diversity, and Inclusion
Improved HIV Care and Life Expectancy in Black and White Men Who Have Sex With Men

The CEPAC Model
0][21] Simulated individuals experience clinical events, including HIV infection, diagnosis, and virologic suppression (eAppendix and eFigure 3 in Supplement 1).Research projects using the CEPAC model are approved by the Mass General Brigham human research committee; we used the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) reporting guidelines.The need for informed consent was waived in this study as no individual-level data were used.All data used in this study to create model parameters were either aggregate data from the US Centers for Disease Control and Prevention or from peer-reviewed literature.

HIV Acquisition, HIV Diagnosis, and ART Initiation
Following infection with HIV, individuals experience a monthly decline in CD4 count while not receiving antiretroviral therapy (ART), as well as CD4-stratified risks of opportunistic infections and HIV-related mortality.HIV diagnosis is determined by a race-specific monthly probability of testing.
After diagnosis, an individual can initiate ART with an integrase strand transfer inhibitor-based regimen. 22While on ART, individuals have a rise in CD4 count and a decreased risk of opportunistic infections and other HIV-related mortality.

ART Adherence and Outcomes for HIV Care
Higher ART adherence results in a lower risk of disengaging from care and a greater probability of virologic suppression. 23Individuals disengaged from care have a decline in CD4 count; they also have a monthly probability of returning to HIV care. 24

Mortality
HIV-related mortality depends on an individual's CD4 count.Individuals are assigned age-specific and race-specific non-HIV-related mortality rates derived from national life tables, adjusted for smoking prevalence. 25

Model Input Parameters
We populated the status quo strategy with race-specific estimates of the 2021 HIV care continuum using national data from the CDC HIV Surveillance Reports (Table ). 1,26We estimated the mean time from HIV infection until diagnosis among Black MSM and White MSM, given reported CD4 counts at diagnosis (eTable 1 in Supplement 1). 1,26,27We subtracted the mean diagnostic delay from the mean age at HIV diagnosis to estimate the mean (SD) age at HIV infection: 27.0 (10.8) years for Black MSM and 35.5 (13.6) years for White MSM (Table ).We calibrated the frequency of HIV testing among Black MSM (every 4.9 years) and White MSM (every 4.6 years) to the estimated time until HIV diagnosis. 27 calibrated the model to achieve race-specific estimates of receipt of care and virologic suppression: 75.3% (Black MSM) and 80.3% (White MSM) with diagnosed HIV received HIV care in 2021, and 83.6% (Black MSM) and 92.4% (White MSM) receiving care were virologically suppressed (eTable 2 and eTable 3 in Supplement 1). 1,26,28We defined receipt of care as documentation of 1 or more CD4 or viral load tests during 2021 and virologic suppression as a viral load level less than 200 copies/mL. 1 derived the age-stratified monthly non-HIV-related mortality rates from non-Hispanic Black and White male US national life tables. 29Given the higher prevalence of tobacco smoking among PWH compared with the general adult population, we adjusted these estimates for excess mortality attributable to tobacco smoking among MSM with HIV according to race-specific tobacco smoking prevalence (Table ; eTable 4 in Supplement 1). 25,30

Sensitivity and Scenario Analyses
We conducted deterministic, 1-way sensitivity analyses to examine the outcomes of differences in age at HIV infection by simulating a cohort of Black MSM who acquire HIV at the same age as White MSM (35.5 years).We additionally performed 1-way sensitivity analyses by varying the proportion of MSM who never, formerly, and currently smoke tobacco, using reported 95% CIs of estimated smoking prevalence (eTable 5 in Supplement 1). 25,30 examined the implications of equal improvements in care goals and equity-centered goals in 1-way scenario analyses.For equal improvements in care goals, we simulated absolute improvements in receipt of care of 5 or 15 percentage points (vs base case of 10-point increased receipt of care).In additional 1-way scenario analyses, we examined YLG with attaining equitycentered goals compared with different status quo scenarios, which reflect the wide range of current access to care among different regions and demographic groups in the US. 31,32We varied the frequency of HIV testing in status quo to every 6 years and compared YLG if annual testing were attained.We next varied the status quo strategy receipt of care (75%-90%) and compared YLG attained with 95% receiving HIV care.We then varied status quo virologic suppression (75%-90%) and compared YLG with 95% virologic suppression.
Last, we conducted multiway scenario analyses to estimate YLG with attaining an equitable care continuum in regions with different status quo HIV care continuums (eTable 6 in Supplement 1).We varied status quo receipt of care and virologic suppression (each from 75% to 95%) at 4 status quo HIV testing frequencies: every 6 years, at base case frequency, annually, and every 6 months.We used Excel version 16.0 (Microsoft) to summarize model outcomes.Data were analyzed from July 2021 to October 2023.

Base Case
We projected mean age at death to be 68.8 years among Black MSM and 75.6 years among White MSM with HIV who receive status quo HIV care, a difference of 6.8 years (Figure 1).With the 10-point increased receipt of care goal, Black MSM would gain 0.5 life-years and White MSM would gain 0.9 life-years.The 5-point increased virologic suppression goal would result in 0.5 YLG for Black MSM  suppression (from 90% to 75%), we projected that achieving 95% virologic suppression would result in 0.3 to 1.7 YLG for Black MSM and 0.3 to 1.5 YLG for White MSM.

Multiway Scenario Analyses
We projected YLG if an equitable care continuum was attained compared with different status quo HIV care continuums.In regions with infrequent HIV testing (every 6 years), projected outcomes with an equitable care continuum would result in 0.7 to 4.2 YLG for Black MSM and 0.5 to 4.0 YLG for White MSM if status quo receipt of care and virologic suppression were both 95% or 75%, respectively (Figure 2).An equitable care continuum would result in 0.6 to 4.0 YLG for Black MSM and 0.5 to 3.7 YLG for White MSM in regions with status quo HIV testing frequency (Black MSM, every 4.9 years; White MSM, every 4.6 years), and receipt of care and virologic suppression were both 95% or 75%, respectively (Figure 2).In regions with annual HIV testing in status quo but 75% receiving care and 75% virologically suppressed, attaining an equitable care continuum would result in up to 3.4 YLG for Black MSM and 3.2 YLG for White MSM (Figure 3).Further improvements in care (HIV testing every 6 months, 95% receiving HIV care, and 95% virologic suppression) would result in an additional 0.2 YLG (Black MSM) and 0.3 YLG (White MSM) compared with an equitable care continuum and annual HIV testing (Figure 3).

Discussion
We assessed existing inequities across the HIV care continuum and projected the potential outcomes of attaining different goals in the HIV care continuum to address racial inequities, using a decision analytical model.We projected a 6.8-year difference in age at death between Black MSM and White MSM with HIV in the US, according to the current HIV care continuum.Attaining equal improvements in care goals would maintain or worsen existing inequities.In contrast, the equity-centered goal of 95% virologic suppression would result in 0.7 more life-years gained for Black MSM compared with White MSM and thus reduce but not eliminate existing inequities.The greatest potential benefits We varied the HIV testing frequency (status quo testing [every 4.9 for Black men who have sex with men (MSM) and 4.6 for White MSM] and every 6 years), percentage receiving care (x-axis), and percentage virologically suppressed (y-axis) among non-Hispanic Black MSM (left, blue) and White MSM (right, gray) with HIV in the status quo care continuum.
We then projected age at death with the equitable care continuum (annual HIV testing, 95% receiving HIV care, and 95% virologically suppressed) and quantified the years of life gained compared with status quo.Darker shades represent greater potential years of life gained when status quo includes less frequent HIV testing (top rows), lower receipt of care (x-axis, left), or lower virologic suppression (y-axis, bottom).The boxes in yellow represent the base case status quo national HIV care continuum.
would occur with an equitable care continuum, particularly among Black MSM, who would gain 3.5 life-years.These model-based results emphasize how an equity-centered approach across the HIV care continuum is critical to improve care outcomes and reduce racial inequities in HIV care.
When examining scenarios that focus on individual steps in the care continuum, we found that improving receipt of care would result in more years of life gained than achieving national goals for improving HIV testing or virologic suppression.These findings are likely due to the larger gap between current and goal levels of receiving HIV care compared with testing and virologic suppression.Additionally, synergies exist in the HIV care continuum; more people can attain virologic suppression if more people receive HIV care.
Although interventions to increase receipt of HIV care will improve clinical outcomes, our findings highlight that a combination of equity-centered strategies is critical.A combination of more frequent HIV testing, improved receipt of care, and increased virologic suppression would result in at least twice the gain in life-years than would occur with achieving an improvement goal in any 1 of the care continuum steps.
4][35][36] For example, it is essential to address structural issues due to health care infrastructure (eg, dearth of HIV practitioners, lack of Medicaid expansion, and medical mistrust) that are associated with a higher burden of HIV in the US South and to develop tailored interventions focused on the community and cultural context for Black MSM residing in the US South.Such interventions are also likely to provide benefits to the community at large by reducing forward transmission of HIV (eg, treatment as prevention) among other benefits. 3,37e importance of equity-centered initiatives, with explicit, longitudinal engagement of disproportionately affected communities, has been recognized at both the local and federal level. 38,39For example, the National Institutes of Health have funded the E2i Initiative 5,38,40,41 Figure shows mean age at HIV acquisition, mean age at HIV diagnosis, and mean time lived with diagnosed HIV in the 7 simulated HIV care scenarios.Each bar represents model-projected outcomes for a different HIV care continuum goal.The lighter portions of the bar (left) represent years spent without HIV.The yellow highlighted boxes represent time spent with undiagnosed HIV; the left border of the yellow box represents the mean age at HIV acquisition, and the right border represents the mean age at time of HIV diagnosis.The darker portions of the bars (right) represent time spent with diagnosed HIV, during which the simulated individual could be receiving or disengaged from HIV care.

Figure 2 .
Figure 2. Model-Projected Years of Life Gained With an Equitable Care Continuum of HIV Care Compared With a Range of Status Quo Scenarios, Including Less Frequent HIV Testing Rates Non-Hispanic Black MSM Testing every 6 y

Table . Model
Input Parameters and Calibration Targets for Simulated Populations of Black and White Men Who Have Sex With Men (MSM) With HIV 0.5 YLG for White MSM.Equal improvements in care goals would maintain or worsen inequities in age at death between Black MSM and White MSM.With the first equity-centered goal (annual HIV testing), the mean diagnostic delay would be reduced to 0.9 years for both Black MSM and White MSM.With annual HIV testing, Black MSM and White MSM would gain 0.5 life-years (Figure1).With 95% receiving HIV care, Black MSM would gain 1.7 life-years, and White MSM would gain 1.3 life-years compared with status quo.With 95% virologic suppression, Black MSM would gain 1.1 life-years, and White MSM 0.4 life-years compared with status quo.With attainment of an equitable care continuum, Black MSM would gain 3.5 life-years from status quo, whereas White MSM would gain 2.1 life-years, narrowing the gap in age at death to 5.4 years from 6.8 years.When simulating a cohort of Black MSM who acquire HIV at a mean (SD) age of 35.5 (16.4) years, age at death would be 71.2 years (White MSM age at death, 75.6 years).When varying smoking prevalence, age at death would range between 68.4 and 69.3 years among Black MSM and between 75.6 and 76.0 years among White MSM.With varying smoking prevalence, model-projected outcomes would change by 0.1 YLG or less compared with the base case.The differences in age at death between Black MSM and White MSM were 7.2 years and 6.7 years under the scenarios of more and less prevalent smoking, respectively.If receipt of care improved by 5 to 15 percentage points in the equal improvements in care goals, Black MSM would experience 0.3 to 0.8 YLG and White MSM 0.4 to 1.3 YLG compared with status quo.
Abbreviations: ART, antiretroviral therapy; CDC, US Centers for Disease Control and Prevention.aLife tables adjusted for tobacco smoking prevalence.and When attaining equity-centered goals with different status quo scenarios, Black MSM would gain 0.8 life-years, and White MSM would gain 0.7 life-years with attainment of the annual HIV testing goal in regions with status quo HIV testing every 6 years.When varying status quo receipt of care (from 90% to 75%), we projected that attaining 95% receiving HIV care would result in 0.5 to 1.3 YLG for Black MSM and 0.5 to 1.7 YLG for White MSM.When varying status quo virologic Figure 1.Model-Projected Years of Life Gained With Equal Improvements in Care Goals, Equity-Centered Goals, and an Equitable Care Continuum Among Non-Hispanic Black and White Men Who Have Sex With Men With HIV Compared With Status Quo

to
Figure 3. Model-Projected Years of Life Gained With an Equitable Care Continuum of HIV Care Compared With a Range of Status Quo Scenarios With More Frequent HIV Testing Than Current Status Quo This publication was made possible by funding from the US NIH (R01 AG069575 [to Dr Hyle], R01 AI042006 [to Dr Freedberg], R01 DA050482 [to Dr Reddy], T32 AI007433 [to Pinkney], R25MH119857 [to Dr Pinkney], K08 HD094638 [to Dr Neilan], and P30 AI110527 [to Dr Ahonkhai]), the Jerome and Celia Reich Endowed Scholar Award (to Dr Hyle), the Infectious Diseases Society of America/HIV Medicine Association Grants for Emerging Researchers/Clinicians Mentorship Program Award (to Dr Rich), the Steve and Deborah Gorlin Massachusetts General Hospital Research Scholar Awards (to Dr Freedberg), the Massachusetts General Hospital Scholar Award in Population and Health Care Research (to Dr Ciaranello), the Massachusetts General Hospital Executive Committee on Research Fund for Medical Discovery (to Dr Chiosi), and the Doris Duke Foundation Physicians Scientist Fellowship (to Dr Chiosi).The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.The contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH or other funders.53.Grulich AE, Jin F, Bavinton BR, et al; Expanded PrEP Implementation in Communities New South Wales (EPIC-NSW) research group.Long-term protection from HIV infection with oral HIV pre-exposure prophylaxis in gay and bisexual men: findings from the expanded and extended EPIC-NSW prospective implementation study.Lancet HIV.2021;8(8):e486-e494. doi:10.1016/S2352-3018(21)00074-6Comparison of Published Data and CEPAC Model Outcomes for Selected CEPAC Model Parameters of Status Quo HIV Care eTable 2. Selected CEPAC Model Input Parameters by HIV Care Scenario eTable 3. Comparison of Published Data and CEPAC Model Outcomes During First 5 Years From Initiation of ART for Receipt of Care and Virologic Suppression eTable 4. Relative Mortality Ratios by Smoking and Prevalence Among Black and White People With HIV eTable 5. Range of Smoking Prevalence Used in Sensitivity Analyses Derived From Mdodo et al eTable 6.Current Receipt of Care and Virologic Suppression Levels Reported Among Black MSM and White MSM in Georgia, California, and New York City eFigure 1.The HIV Care Continuum Among Non-Hispanic Black and White MSM With HIV in the US With Status Quo and Equal Improvements in Care Goals eFigure 2. The HIV Care Continuum Among Non-Hispanic Black and White MSM With HIV in the US With Equity-Centered Goals, and Equitable Care Continuum eFigure 3. Model Schematic Funding/Support: Disclaimer: