This paper describes the development of a formula to determine which evidence-based behavioral interventions (EBIs) targeting HIV-negative persons would be cost-saving in comparison to the lifetime cost of HIV treatment and the process by which this formula was used to prioritize those with greatest potential impact for continued dissemination. We developed a prevention benefit index (PBI) to rank risk-reduction EBIs for HIV-negative persons based on their estimated cost for achieving the behavior change per one would-be incident infection of HIV. Inputs for calculating the PBI included the mean estimated cost-per-client served, EBI effect size for the behavior change, and the HIV incidence per 100,000 persons in the target population. EBIs for which the PBI was </= $402,000, the estimated lifetime cost of HIV care, were considered cost-saving. We were able to calculate a PBI for 35 EBI and target population combinations. Ten EBIs were cost-saving having a PBI below $402,000. One EBI did not move forward for dissemination due to high start-up dissemination costs. DHAP now supports the dissemination of 9 unique EBIs targeting 13 populations of HIV-negative persons. The application of a process, such as the PBI, may assist other health-field policymakers when making decisions about how to select and fund implementation of EBIs.

Despite advances in HIV prevention and treatment during the past decade, more than 39 000 HIV diagnoses were made in the United States in 2016.1 In addition, persistent disparities in HIV acquisition and care, particularly among men who have sex with men (MSM) and racial/ethnic minority groups, make it difficult to end HIV. To focus our nation’s efforts toward this goal, the first comprehensive National HIV/AIDS Strategy for the United States was released in July 2010 with 4 goals: (1) reduce new HIV infections, (2) increase access to care and improve health outcomes for people with HIV, (3) reduce HIV-related disparities and health inequities, and (4) achieve a more coordinated national response within the federal government and between the federal government and state, local, territorial, and tribal governments.2 In 2015, the National HIV/AIDS Strategy was updated and extended to 2020.3 During the past 8 years, the National HIV/AIDS Strategy has helped focus HIV prevention and care research, programs, and community advocacy. This supplemental issue of Public Health Reports focuses on demonstration projects led or co-led by the Centers for Disease Control and Prevention’s (CDC’s) Division of HIV/AIDS Prevention and funded by the US Department of Health and Human Services (HHS) Secretary’s Minority AIDS Initiative Fund (SMAIF). These projects targeted HIV prevention and improving health outcomes among racial/ethnic minority populations disproportionately affected by HIV.

INTRODUCTION: From 2012 through 2015, the Centers for Disease Control and Prevention (CDC) provided funding to 5 health departments for demonstration projects using HIV surveillance data to link people with newly diagnosed HIV to care. We assessed how well these health departments established linkage to care, how the demonstration projects helped them with this work, and if they sustained these activities after CDC funding ended. MATERIALS AND METHODS: We obtained quantitative and qualitative data on linkage-to-care activities from health department communications and progress reports submitted to CDC. We calculated and combined linkage-to-care results for the 5 health departments, and we compared these results with the combined linkage-to-care results for 61 health departments that received CDC funding for routine HIV prevention activities (eg, HIV testing, linkage to and reengagement in HIV care, HIV partner services) and for the same 5 health departments when they used only routine HIV prevention activities for linkage to care. RESULTS: Of 1269 people with a new HIV diagnosis at the 5 health departments, 1124 (89%) were linked to care, a result that exceeded the 2010-2015 National HIV/AIDS Strategy goal (85%), the CDC Funding Opportunity Announcement performance standard (80%), and combined results for the 61 health departments (63%) and the same 5 health departments (66%) using routine HIV prevention activities. Benefits of the projects were improved collaboration and coordination and more accurate, up-to-date surveillance data. All health departments continued linkage-to-care activities after funding ended. PRACTICE IMPLICATIONS: Using HIV surveillance data to link people with HIV to care resulted in substantial clinical and public health benefits. Our observations underscore the importance of collaboration among medical providers, public health staff members, community-based organizations, and people with HIV to ensure the best possible clinical and public health outcomes.

Recent advances in the use of antiretroviral drugs for the prevention of HIV infection present a historic opportunity to better control the spread of the disease. Despite an estimated 18% decline in the number of annual HIV infections between 2008 and 2014 (http://bit.ly/2ftovat), there were approximately 38 000 new infections in 2014, 70% of which were among men who have sex with men (MSM). As a consequence of improved survival with antiretroviral therapy (ART), the number of persons living with HIV has increased to 1.1 million. However, all of these persons are a potential source of new infections to their partners, particularly the 15% who do not know that they are infected, as well as those who know their HIV status but have not achieved a suppressed viral load (i.e., as a result of ART). Each infected person incurs $402 000 in discounted lifetime costs.1

Advances in HIV testing, treatment, and prevention produced a decline in the number of new HIV diagnoses in the United States over the past 10 years, with the largest declines seen in mother-to-child transmission and among women and people who inject drugs. However, diagnoses have only stabilized among gay, bisexual, and other men who have sex with men (MSM) in the past five years, and increases continue among Hispanic/Latino MSM.1 Furthermore, disparities persist; MSM, transgender persons, African Americans and Hispanics/Latinos, and persons residing in the Southern United States are the most disproportionately affected subpopulations.1 | The disparities in HIV diagnoses are associated with myriad social, contextual, and structural factors. The National HIV/AIDS Strategy for the United States (NHAS), originally released in 2010 and updated to 2020,2 describes principles, priorities, and actions federal agencies should use to guide a collective national response that will reduce new HIV infections, increase access to care, improve outcomes for persons living with HIV, and reduce disparities. To achieve the NHAS goals, the Centers for Disease Control and Prevention (CDC) adopted a high-impact prevention (HIP) approach3 that targets the best combinations of scientifically proven, cost-effective, and scalable interventions to the right populations in the right geographic areas. Following up Nunn et al.,4 we discuss CDC’s HIV research and programmatic efforts under the HIP approach.

BACKGROUND: Over a three-year period, CDC invested $102.3 million in a large-scale HIV testing program, the Expanded HIV Testing Initiative, for populations disproportionally affected by HIV. Policy makers, who must optimize public health given a set budget, are interested in the financial return on investment (ROI) of large-scale HIV testing. METHODS: We conducted an ROI analysis using expenditure and outcome data from the program. A health system perspective was used that included all program expenditures including medical costs of treating newly diagnosed patients. We incorporated benefits of HIV transmissions averted from persons diagnosed of their infection through the Initiative compared to when, on average, those persons would have been diagnosed without the Initiative (3 years later in the base case). HIV transmissions were derived from a published mathematical model of HIV transmission. In sensitivity analysis, we tested the effect of 1 -5 year alternate testing intervals and differences in the prevalence of undiagnosed HIV infection. RESULTS: Under the Initiative, 2.7 million persons were tested for HIV, there was a newly diagnosed HIV positivity rate of 0.7%, and an estimated 3,381 HIV infections were averted. It achieved a return of $1.95 for every dollar invested. ROI ranged from $1.46 - $2.01 for alternative testing intervals of one to five years and remained above $1 (positive return on investment) with a prevalence of undiagnosed HIV infection as low as 0.12%. CONCLUSION: The Expanded Testing Initiative yielded ROI values of >$1 under a broad range of sensitivity analyses and provides further support for large-scale HIV testing programs.

Among US racial/ethnic groups, Blacks are at the highest risk of acquiring HIV/AIDS. In response, the Centers for Disease Control and Prevention (CDC) has launched the Heightened National Response to Address the HIV/AIDS Crisis Among African Americans, which seeks to engage public and nonpublic partners in a synergistic effort to prevent HIV among Blacks. The CDC also recently launched Act Against AIDS, a campaign to refocus attention on the domestic HIV/AIDS crisis. Although the CDC's efforts to combat HIV/AIDS among Blacks have achieved some success, more must be done to address this crisis. New initiatives include President Obama's goal of developing a National HIV/AIDS Strategy to reduce HIV incidence, decrease HIV-related health disparities, and increase access to care, especially among Blacks and other disproportionately affected populations.