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Methods and Applications: Exploration for the Priority of HIV Intervention: Modelling Health Impact and Cost-Effectiveness — Six Cities, Eastern China, 2019–2028

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  • Abstract

    Introduction

    In order to enhance the effectiveness of resource allocation, regions must tailor their responses to their specific epidemiological and economic situations.

    Methods

    Utilizing Spectrum software, we projected the cost-effectiveness of 10 chosen HIV interventions in six cities in eastern China from 2019 to 2028. We assessed three scenarios — Base, Achievable, and Idealized — for each city. The analysis included the projected number of HIV infections and deaths averted, as well as the incremental cost-effectiveness ratios for each intervention in the six cities.

    Results

    In Shijiazhuang, Wuxi, Yantai, and Zhenjiang, cities with initially low antiretroviral therapy (ART) coverage, ART showed significant effectiveness, especially for males. Conversely, in Foshan and Ningbo, where ART coverage was notably high, oral pre-exposure prophylaxis (PrEP) for men who have sex with men (MSM) proved effective in the Idealized scenario. MSM outreach, ART for males, and ART for females demonstrated cost-effectiveness across all six cities in both Achievable and Idealized scenarios at the predefined thresholds for each city.

    Discussion

    Maintaining an appropriate coverage rate for outreach to MSM can lead to cost-effectiveness. In cities with low ART coverage, scaling up ART remains a crucial intervention. In regions with high ART coverage, consideration may be given to the utilization of oral PrEP for MSM individuals, requiring budget allocation.

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  • Funding: Supported by the National Science Foundation of China (Grant No. 71874169)
  • [1] Kripke K, Eakle R, Cheng A, Rana S, Torjesen K, Stover J. The case for prevention - Primary HIV prevention in the era of universal test and treat: a mathematical modeling study. EClinicalMedicine 2022;46:101347.CrossRef
    [2] Kapiriri L, Lee NM, Wallace LJ, Kwesiga B. Beyond cost-effectiveness, morbidity and mortality: a comprehensive evaluation of priority setting for HIV programming in Uganda. BMC Public Health 2019;19(1):359.CrossRef
    [3] Atun R, Chang AY, Ogbuoji O, Silva S, Resch S, Hontelez J, et al. Long-term financing needs for HIV control in sub-Saharan Africa in 2015-2050: a modelling study. BMJ Open 2016;6(3):e009656.CrossRef
    [4] Kasaie P, Weir B, Schnure M, Dun C, Pennington J, Teng Y, et al. Integrated screening and treatment services for HIV, hypertension and diabetes in Kenya: assessing the epidemiological impact and cost-effectiveness from a national and regional perspective. J Int AIDS Soc 2020;23 Suppl 1(Suppl 1):e25499. http://dx.doi.org/10.1002/jia2.25499.
    [5] Zhang YR, Wang LL, Jiang Z, Yan HJ, Liu XX, Gu J, et al. Estimating costs of the HIV comprehensive intervention using the spectrum model - China, 2015-2019. China CDC Wkly 2022;4(25):5549.CrossRef
    [6] The People’s Bank of China. Chart of CNY exchange rate midpoint. http://www.pbc.gov.cn/rmyh/108976/109428/index.html. [2022-6-26]. (in Chinese).
    [7] Sahu D, Kumar P, Chandra N, Rajan S, Shukla DK, Venkatesh S, et al. Findings from the 2017 HIV estimation round & trend analysis of key indicators 2010-2017: evidence for prioritising HIV/AIDS programme in India. Indian J Med Res 2020;151(6):56270.CrossRef
    [8] Sundararajan R, Ponticiello M, Nansera D, Jeremiah K, Muyindike W. Interventions to increase HIV testing uptake in global settings. Curr HIV/AIDS Rep 2022;19(3):18493.CrossRef
    [9] Colvin CJ. Strategies for engaging men in HIV services. Lancet HIV 2019;6(3):e191200.CrossRef
    [10] Yeh PT, Kennedy CE, Minamitani A, Baggaley R, Shah P, Verster A, et al. Web-based service provision of HIV, viral hepatitis, and sexually transmitted infection prevention, testing, linkage, and treatment for key populations: systematic review and meta-analysis. J Med Internet Res 2022;24(12):e40150.CrossRef
    [11] Reitsema M, van Hoek AJ, van der Loeff MS, Hoornenborg E, van Sighem A, Wallinga J, et al. Preexposure prophylaxis for men who have sex with men in the Netherlands: impact on HIV and Neisseria gonorrhoeae transmission and cost-effectiveness. AIDS 2020;34(4):62130.CrossRef
    [12] Celum C, Baeten JM. Lessons on PrEP from the SEARCH study in east Africa. Lancet HIV 2020;7(4):e21920.CrossRef
    [13] Leech AA, Burgess JF, Sullivan M, Kuohung W, Horný M, Drainoni ML, et al. Cost-effectiveness of preexposure prophylaxis for HIV prevention for conception in the United States. AIDS 2018;32(18):278798.CrossRef
    [14] Jijón S, Molina JM, Costagliola D, Supervie V, Breban R. Can HIV epidemics among MSM be eliminated through participation in preexposure prophylaxis rollouts? AIDS 2021;35(14):2347-54. http://dx.doi.org/10.1097/QAD.0000000000003012.
    [15] Stover J, Glaubius R, Kassanjee R, Dugdale CM. Updates to the spectrum/AIM model for the UNAIDS 2020 HIV estimates. J Int AIDS Soc 2021;24 Suppl 5(Suppl 5):e25778. http://dx.doi.org/10.1002/jia2.25778.
  • FIGURE 1.  Total HIV infections averted by 10 selected HIV interventions in Achievable and Idealized Scenarios in six cities from 2019 to 2028.

    Abbreviation: VCT=Voluntary counseling and testing for adult population; SSTT=Secondary students with teachers trained in AIDS; FSW=Female sex worker; MSM=Men who have sex with men; PrEP=Pre-exposure prophylaxis; HRH=High risk heterosexual; ART=Antiretroviral therapy; AS= Achievable Scenario; IS=Idealized Scenario.

    * indicates that the impact of MSM receiving lubricants was modeled as 0 in six cities.

    TABLE 1.  Coverage of 10 selected interventions in six cities in 2019.

    Selected interventions (% per year)FoshanNingboShijiazhuangWuxiYantaiZhenjiang
    VCT0.220.310.400.140.410.49
    Condoms for adult population025.4118.7539.0920.480
    SSTT99.9095.002.503.000.001.40
    FSW outreach99.9072.0028.3499.9092.0094.00
    MSM outreach79.3259.2070.0029.9492.704.80
    MSM receiving lubricants79.32011.219.987.203.90
    Oral PrEP for HRH000000
    Oral PrEP for MSM000000
    ART for males99.9099.9050.8686.1438.6179.48
    ART for females99.9099.9016.9342.5810.7549.90
    Abbreviation: VCT=voluntary counseling and testing for adult population; SSTT=secondary students with teachers trained in AIDS; FSW=female sex worker; MSM=men who have sex with men; PrEP=pre-exposure prophylaxis; HRH=high risk heterosexual; ART=antiretroviral therapy.
    Download: CSV

    TABLE 2.  Overall costs and cost-effectiveness in the Achievable Scenario and the Idealized Scenario among six cities from 2019 to 2028.

    Cost and health impact Foshan Ningbo Shijiazhuang Wuxi Yantai Zhenjiang
    Total cost of Base Scenario (Million CNY) 141.05 203.55 443.48 202.16 156.53 82.36
    Total cost of Achievable Scenario (Million CNY) 145.16 212.53 473.88 222.13 171.50 86.70
    Total cost of Idealized Scenario (Million CNY) 375.62 1,054.31 866.18 684.72 915.93 444.30
    Total number of infections averted AS 9 19 1,580 335 618 284
    IS 118 131 2,608 477 1,618 401
    Total number of deaths averted AS 0* 0* 550 132 469 61
    IS 1 1 796 156 775 61
    Incremental cost per infection averted (Million CNY) AS 0.47 0.47 0.02 0.06 0.02 0.02
    IS 1.98 6.51 0.16 1.01 0.47 0.90
    Incremental cost per death averted (Million CNY) AS 105.62 103.20 0.06 0.15 0.03 0.07
    IS 436.82 1,432.25 0.53 3.10 0.98 5.89
    Abbreviation: AS=Achievable Scenario; IS=Idealized Scenario; CNY=Chinese Yuan.
    * indicates that the numbers provided are rounded integers. The total deaths averted in Foshan and Ningbo were 0.039 and 0.087, respectively.
    Download: CSV

    TABLE 3.  Incremental cost per HIV infection averted for 10 selected HIV interventions in two scenarios across six cities from 2019 to 2028 (thousand CNY).

    Selected
    interventions
    Foshan Ningbo Shijiazhuang Wuxi Yantai Zhenjiang
    AS IS AS IS AS IS AS IS AS IS AS IS
    VCT 53,976.14 9,265.54 60,648.14 62,654.05 1,697.46 1,756.36 15,228.19 15,783.12 8,355.87 8,588.52 105,931.86 16,552.63
    Condoms for adult population 1,242.07 1,537.69 237.21 241.46 265.94 272.39 564.35 571.22 47.04* 48.05* 9.05* 28.91*
    SSTT 3,941.67 3,941.67 253.34 263.72 1,376.34 1,491.83 488.55 501.79 1,814.65 1,661.12
    FSW outreach 2,271.00 2,271.00 36.64* 37.49* 40.63* 40.63* 11.85* 11.85*
    MSM outreach 33.06* 33.06* 42.48* 42.48* 0.39* 0.39* 19.76* 19.99* 1.70* 1.70* 6.27* 6.49*
    MSM receiving lubricants
    Oral PrEP for HRH 68,969.20 67,956.75 115,145.91 114,166.19 9,481.25 9,505.91 35,247.30 35,593.72 18,679.28 18,630.42 27,134.91 27,549.97
    Oral PrEP for MSM 147.08* 159.14* 181.99 194.71 15.40* 17.94* 57.63* 64.17* 16.22* 18.59* 33.65* 37.78*
    ART for males 9.75* 9.75* 19.09* 19.09* 12.30* 12.13* 4.26* 4.26*
    ART for females 8.66* 12.53* 15.27* 17.89* 18.51* 22.34* 2.61* 2.62*
    Note: “−” indicates that the impact was 0 and cannot be divided.
    Abbreviation: VCT=Voluntary counseling and testing for adult population; SSTT=Secondary students with teachers trained in AIDS; FSW=Female sex worker; MSM=Men who have sex with men; PrEP=Pre-exposure prophylaxis; HRH=High risk heterosexual; ART=Antiretroviral therapy; AS= Achievable Scenario; IS=Idealized Scenario.
    * indicates that the intervention in this city was cost-effective at the threshold level of this city.
    Download: CSV

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Exploration for the Priority of HIV Intervention: Modelling Health Impact and Cost-Effectiveness — Six Cities, Eastern China, 2019–2028

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Abstract

Introduction

In order to enhance the effectiveness of resource allocation, regions must tailor their responses to their specific epidemiological and economic situations.

Methods

Utilizing Spectrum software, we projected the cost-effectiveness of 10 chosen HIV interventions in six cities in eastern China from 2019 to 2028. We assessed three scenarios — Base, Achievable, and Idealized — for each city. The analysis included the projected number of HIV infections and deaths averted, as well as the incremental cost-effectiveness ratios for each intervention in the six cities.

Results

In Shijiazhuang, Wuxi, Yantai, and Zhenjiang, cities with initially low antiretroviral therapy (ART) coverage, ART showed significant effectiveness, especially for males. Conversely, in Foshan and Ningbo, where ART coverage was notably high, oral pre-exposure prophylaxis (PrEP) for men who have sex with men (MSM) proved effective in the Idealized scenario. MSM outreach, ART for males, and ART for females demonstrated cost-effectiveness across all six cities in both Achievable and Idealized scenarios at the predefined thresholds for each city.

Discussion

Maintaining an appropriate coverage rate for outreach to MSM can lead to cost-effectiveness. In cities with low ART coverage, scaling up ART remains a crucial intervention. In regions with high ART coverage, consideration may be given to the utilization of oral PrEP for MSM individuals, requiring budget allocation.

  • 1. School of Health Service Management, Anhui Medical University, Hefei City, Anhui Province, China
  • 2. Division of Prevention and intervention, National Center for AIDS and STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
  • 3. Jiangsu Provincial Center for Disease Control and Prevention, Nanjing City, Jiangsu Province, China
  • 4. Zhenjiang Center for Disease Control and Prevention, Zhenjiang City, Jiangsu Province, China
  • 5. Wuxi Center for Disease Control and Prevention, Wuxi City, Jiangsu Province, China
  • 6. Shandong Provincial Center for Disease Control and Prevention, Jinan City, Shandong Province, China
  • 7. Yantai Center for Disease Control and Prevention, Yantai City, Shandong Province, China
  • 8. Guangdong Provincial Center for Disease Control and Prevention, Guangzhou City, Guangdong Province, China
  • 9. Foshan Center for Disease Control and Prevention, Foshan City, Guangdong Province, China
  • 10. Hebei Provincial Center for Disease Control and Prevention, Shijiazhuang City, Hebei Province, China
  • 11. Shijiazhuang Center for Disease Control and Prevention, Shijiazhuang City, China
  • 12. Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou City, Zhejiang Province, China
  • 13. Ningbo Center for Disease Control and Prevention, Ningbo City, Zhejiang Province, China
  • Corresponding author:

    Zhen Jiang, jiangzhen@chinaaids.cn

  • Funding: Supported by the National Science Foundation of China (Grant No. 71874169)
  • Online Date: May 17 2024
    Issue Date: May 17 2024
    doi: 10.46234/ccdcw2024.089
  • To effectively implement customized interventions, each region and country must address their unique epidemiological and economic situations and establish key actions to enhance local human immunodeficiency virus (HIV) responses. Creating tailored financial strategies for sustainability is crucial to guarantee universal access and better health results. Progress evaluation should encompass a comprehensive spectrum of HIV interventions to benefit all demographic groups.

    Studies using Spectrum modules have shown that HIV intervention programs are cost-effective in regions like sub-Saharan Africa, Asia, and the Caribbean (14). Nonetheless, due to the significant variability in HIV prevalence and intervention coverage in eastern China, it is challenging to extrapolate these results to that specific area.

    This study aims to forecast the health outcomes and cost-effectiveness of scaling up HIV interventions, and to prioritize life-saving HIV interventions in six cities in eastern China, utilizing the Spectrum modules.

    • Five cities in eastern China, namely Foshan, Ningbo, Shijiazhuang, Wuxi, and Yantai, were chosen based on the following criteria: each city had a total population exceeding three million and reported over 200 new cases of HIV infection annually. To simultaneously assess the cost-effectiveness discrepancies between two cities within the same province and provide insights for subsequent spatiotemporal distribution studies, Zhenjiang — an additional city in Jiangsu Province like Wuxi, boasting a population of three million and approximately 50 newly reported HIV cases each year — was included in the analysis (5).

      A standardized data collection tool was developed following the Spectrum framework to calculate costs and model healthcare payer perspectives. Data from public and service sectors in six cities between 2015 and 2019 were collected. This study investigates the cost-effectiveness of 10 key HIV interventions (Table 1) and presents the HIV intervention priorities across sampled cities for the period 2019–2028.

      Selected interventions (% per year)FoshanNingboShijiazhuangWuxiYantaiZhenjiang
      VCT0.220.310.400.140.410.49
      Condoms for adult population025.4118.7539.0920.480
      SSTT99.9095.002.503.000.001.40
      FSW outreach99.9072.0028.3499.9092.0094.00
      MSM outreach79.3259.2070.0029.9492.704.80
      MSM receiving lubricants79.32011.219.987.203.90
      Oral PrEP for HRH000000
      Oral PrEP for MSM000000
      ART for males99.9099.9050.8686.1438.6179.48
      ART for females99.9099.9016.9342.5810.7549.90
      Abbreviation: VCT=voluntary counseling and testing for adult population; SSTT=secondary students with teachers trained in AIDS; FSW=female sex worker; MSM=men who have sex with men; PrEP=pre-exposure prophylaxis; HRH=high risk heterosexual; ART=antiretroviral therapy.

      Table 1.  Coverage of 10 selected interventions in six cities in 2019.

      Three scenarios were simulated to project the outcomes of scaling up interventions in each city, under the assumption of an unlimited budget.

    • In the Base scenario, from 2020 to 2028, all interventions maintain the same coverage as in 2019.

    • Enhance the scope of specific interventions by double up to 99.90% by 2028, with the exception of oral pre-exposure prophylaxis (PrEP) for high-risk heterosexual (HRH) individuals and men who have sex with men (MSM) due to the absence of prior testing and coverage in the studied cities. Simultaneously, escalate the coverage of oral PrEP for HRH and MSM from 0% in the starting year to 5% by 2028. Linear interpolation was utilized to project the coverage rates between 2020 and 2027, while the coverage for other interventions remained constant from 2019.

    • In this case, it was assumed that the coverage rate of the 10 chosen interventions would reach 99.90%. Linear interpolation was used to simulate the coverage rates for the years 2020–2027. The coverage rates of the remaining interventions were held constant at 2019 levels.

      Definitions of the 10 selected intervention coverage and the remaining interventions’s coverage all displayed in the Supplementary Table S1. The Coverage assumptions for 10 selected HIV interventions in the target year 2028 were displayed in Supplementary Table S2. Unit costs for each intervention were based on local data from six cities in 2019 and kept constant in the model, as outlined in Supplementary Table S3.

      Initially, the model simultaneously expanded the coverage of ten selected interventions to determine the total infections and deaths prevented, as well as the costs for each scenario in each city. Subsequently, each intervention was individually scaled up per scenario in every city to analyze the outcomes of each intervention.

    • The number of infections and deaths prevented by scaling up interventions from the Base scenario to the Achievable or Idealized scenarios was directly derived from the model calculations. Costs for each scenario, presented in 2019 Chinese Yuan (CNY) with a 3% annual discount rate and an exchange rate of 1 USD=6.90 CNY (6), were calculated. Incremental cost was manually determined by comparing intervention costs under the Achievable or Idealized scenarios with those under the Base scenario. The incremental cost-effectiveness ratio (ICER) was calculated as the ratio of incremental costs to infections averted. To account for economic variations across cities, cost-effective interventions in each city were classified as those with an ICER below the 2019 per capita GDP (Supplementary Table S4) for that city per infection averted.

    • A one-way sensitivity analysis was performed by adjusting the unit cost of selected interventions by +/- 50% of the original values to assess the model's stability.

    • Table 2 illustrates the comprehensive costs and cost-effectiveness of two distinct scenarios across six cities from 2019 to 2028. During this period, under the Achievable scenario with Shijiazhuang reaching optimal impact, a total of 1,580 HIV infections and 550 deaths were prevented. In contrast, the Idealized scenario showed even greater impact, with 2,608 HIV infections and 796 deaths averted. The least impact was noted in Foshan and Ningbo. As anticipated, the costs per infection and death averted in the Idealized scenario were considerably higher compared to those in the Achievable scenario across all six cities. In municipalities with high initial antiretroviral therapy (ART) coverage, like Foshan and Ningbo, the ICERs were significant, yielding 0.47 million yuan per infection averted in the Achievable scenario and exceeding 100 million yuan in the Idealized scenario, indicating poor cost-effectiveness when scaling up interventions. Conversely, in the other four cities with lower initial ART coverage, such as Shijiazhuang and Yantai, escalating current intervention coverage proved to be highly cost-effective, adhering to the cost-effectiveness thresholds established for these cities within the Achievable scenario.

      Cost and health impact Foshan Ningbo Shijiazhuang Wuxi Yantai Zhenjiang
      Total cost of Base Scenario (Million CNY) 141.05 203.55 443.48 202.16 156.53 82.36
      Total cost of Achievable Scenario (Million CNY) 145.16 212.53 473.88 222.13 171.50 86.70
      Total cost of Idealized Scenario (Million CNY) 375.62 1,054.31 866.18 684.72 915.93 444.30
      Total number of infections averted AS 9 19 1,580 335 618 284
      IS 118 131 2,608 477 1,618 401
      Total number of deaths averted AS 0* 0* 550 132 469 61
      IS 1 1 796 156 775 61
      Incremental cost per infection averted (Million CNY) AS 0.47 0.47 0.02 0.06 0.02 0.02
      IS 1.98 6.51 0.16 1.01 0.47 0.90
      Incremental cost per death averted (Million CNY) AS 105.62 103.20 0.06 0.15 0.03 0.07
      IS 436.82 1,432.25 0.53 3.10 0.98 5.89
      Abbreviation: AS=Achievable Scenario; IS=Idealized Scenario; CNY=Chinese Yuan.
      * indicates that the numbers provided are rounded integers. The total deaths averted in Foshan and Ningbo were 0.039 and 0.087, respectively.

      Table 2.  Overall costs and cost-effectiveness in the Achievable Scenario and the Idealized Scenario among six cities from 2019 to 2028.

      Figure 1 and Table 3 display the cost-effectiveness of HIV interventions in six cities under Achievable and Idealized scenarios. In cities like Shijiazhuang, Wuxi, Yantai, and Zhenjiang, ART, especially for males, showed high effectiveness in averting infections. The most impactful strategy was ART for males in Shijiazhuang, projected to prevent 1,367 infections from 2019 to 2028. The majority of prevented deaths were attributed to ART based on the Spectrum framework (Supplementary Table S5). In Foshan and Ningbo, with high ART coverage, oral PrEP for MSM in the Idealized scenario demonstrated significant effectiveness.

      Figure 1. 

      Total HIV infections averted by 10 selected HIV interventions in Achievable and Idealized Scenarios in six cities from 2019 to 2028.

      Abbreviation: VCT=Voluntary counseling and testing for adult population; SSTT=Secondary students with teachers trained in AIDS; FSW=Female sex worker; MSM=Men who have sex with men; PrEP=Pre-exposure prophylaxis; HRH=High risk heterosexual; ART=Antiretroviral therapy; AS= Achievable Scenario; IS=Idealized Scenario.

      * indicates that the impact of MSM receiving lubricants was modeled as 0 in six cities.

      Selected
      interventions
      Foshan Ningbo Shijiazhuang Wuxi Yantai Zhenjiang
      AS IS AS IS AS IS AS IS AS IS AS IS
      VCT 53,976.14 9,265.54 60,648.14 62,654.05 1,697.46 1,756.36 15,228.19 15,783.12 8,355.87 8,588.52 105,931.86 16,552.63
      Condoms for adult population 1,242.07 1,537.69 237.21 241.46 265.94 272.39 564.35 571.22 47.04* 48.05* 9.05* 28.91*
      SSTT 3,941.67 3,941.67 253.34 263.72 1,376.34 1,491.83 488.55 501.79 1,814.65 1,661.12
      FSW outreach 2,271.00 2,271.00 36.64* 37.49* 40.63* 40.63* 11.85* 11.85*
      MSM outreach 33.06* 33.06* 42.48* 42.48* 0.39* 0.39* 19.76* 19.99* 1.70* 1.70* 6.27* 6.49*
      MSM receiving lubricants
      Oral PrEP for HRH 68,969.20 67,956.75 115,145.91 114,166.19 9,481.25 9,505.91 35,247.30 35,593.72 18,679.28 18,630.42 27,134.91 27,549.97
      Oral PrEP for MSM 147.08* 159.14* 181.99 194.71 15.40* 17.94* 57.63* 64.17* 16.22* 18.59* 33.65* 37.78*
      ART for males 9.75* 9.75* 19.09* 19.09* 12.30* 12.13* 4.26* 4.26*
      ART for females 8.66* 12.53* 15.27* 17.89* 18.51* 22.34* 2.61* 2.62*
      Note: “−” indicates that the impact was 0 and cannot be divided.
      Abbreviation: VCT=Voluntary counseling and testing for adult population; SSTT=Secondary students with teachers trained in AIDS; FSW=Female sex worker; MSM=Men who have sex with men; PrEP=Pre-exposure prophylaxis; HRH=High risk heterosexual; ART=Antiretroviral therapy; AS= Achievable Scenario; IS=Idealized Scenario.
      * indicates that the intervention in this city was cost-effective at the threshold level of this city.

      Table 3.  Incremental cost per HIV infection averted for 10 selected HIV interventions in two scenarios across six cities from 2019 to 2028 (thousand CNY).

      At the cost-effectiveness threshold of each city, interventions such as outreach to MSM, ART for males, and ART for females were found to be cost-effective across six cities in both scenarios. Among these, MSM outreach was identified as the most cost-effective, with a range between 0.39 to 42.48 thousand yuan per infection averted. However, the effectiveness of MSM outreach may plateau with expanded coverage, as depicted in Figure 1. For instance, in Zhenjiang and Wuxi, the number of HIV infections averted through MSM outreach increased significantly from Achievable to Idealized scenarios, while the impact in the other four cities did not show a further increase with scaled-up coverage.

      The results indicate that the epidemiological efficacy of the intervention is influenced by the coverage levels in different scenarios. Supplementary Table S6 presents the cost per HIV infection averted based on varying unit costs of interventions. A direct correlation was observed between unit cost and cost per HIV infection averted; a 50% decrease in unit cost resulted in a similar decrease in the cost per HIV infection averted, and vice versa (Supplementary Table S7).

    • Our research conducted using the Spectrum model offers valuable insights for guiding resource allocation. Between 2019 and 2028, Shijiazhuang demonstrated the highest potential impact with the lowest ICER compared to other cities analyzed. Situated in Hebei province, Shijiazhuang stands out due to its large population of 11 million, low ART coverage, and limited HIV resources per capita. In contrast, Foshan had the lowest estimated potential impact, while Ningbo had the highest ICER. These cities, located in prosperous provinces like Guangdong and Zhejiang, exhibit high ART coverage and ample HIV resources. Therefore, prioritizing funding towards regions with growing economies, low treatment rates, and substantial populations is crucial in shaping the future of HIV intervention strategies (7).

      The study showcased that transitioning from an Achievable to an Idealized scenario for a single intervention coverage results in a minor health impact change at a significantly higher cost. For instance, the ICER in the Idealized scenario is estimated to be approximately 4 times (in Foshan) to 45 times (in Zhenjiang) greater compared to the Achievable scenario. Thus, opting for an Achievable scenario is advisable for policymakers with constrained resources across the six cities.

      The results guide the development of a ten-year priority intervention plan for six cities, including MSM outreach, ART for males, and ART for females. Prior research has shown that MSM outreach significantly enhances HIV testing rates (8) and encourages prompt treatment (9). However, there is limited data on the cost-effectiveness of MSM outreach (10). Our study indicated that the impact of MSM outreach on health outcomes plateaued at a baseline coverage of around 59.2% (in Ningbo). Beyond this threshold, supplementary interventions are necessary to address remaining gaps due to the saturation of MSM outreach.

      ART has proven to be the most effective and economical approach for reducing HIV infections and mortalities in Shijiazhuang, Wuxi, Yantai, and Zhenjiang. In contrast, oral PrEP for MSM has emerged as the strategy of choice in Foshan and Ningbo, areas with high ART coverage, to meet the objectives of decreasing new HIV infections. These findings align with previous oral PrEP modeling studies (1112). Nonetheless, the adoption of this strategy in Ningbo, where the ICER soared to 181.99 and 194.71 thousand yuan per infection averted, was deemed not cost-effective according to the city’s threshold of 146.12 thousand yuan per infection averted. While extensive ART coverage may significantly curb HIV transmission, rendering PrEP redundant and uneconomical in such cases (13), the indirect benefits of enhanced HIV testing and linkage to subsequent treatment attributable to PrEP cannot be overlooked (14). Given the substantial public health challenge posed by the prevalence of HIV among MSM in China, it is imperative that economically developed areas with high ART coverage continuously evaluate and expand oral PrEP for MSM, ensuring sufficient budgetary provisions. To achieve the ambitious aim of halting the HIV epidemic, strategies must be meticulously tailored and implemented at the local level.

      Like all modeling studies, this study is subject to some limitations. First, due to insufficient regional data, we utilized some national-level indicators in the model, potentially impacting the accuracy of projections. Second, the lack of data on mobile populations could lead to underestimation of local epidemics. Third, our models did not consider the impacts of disruptions related to coronavirus disease 2019 (COVID-19) (15). While COVID-19 does not directly influence HIV transmission biologically, it does affect various factors such as awareness, behavior, and healthcare resource availability, as well as resource allocation in response to the sporadic nature of the epidemic.

      In conclusion, this study by Spectrum delineated key actions for regions sampled from 2019 to 2028 to improve HIV response and achieve optimal health outcomes in AIDS control. The utilization of Spectrum is crucial for guiding prioritization in cities based on their unique epidemiological, economic, and HIV response characteristics.

    • No conflicts of interest.

    • Thank the staff from Jiangsu Provincial CDC, Guangdong Provincial CDC, Zhejiang Provincial CDC, Shandong Provincial CDC, Hebei Provincial CDC, Shijiazhuang CDC, Yantai CDC, Ningbo CDC, Zhenjiang CDC, Foshan CDC, and Wuxi CDC for their assistance in data collection and verification.

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