Toward a New Framework for Equity in Epidemic Allocations: Implications of HIV-Prevention-Allocation Misalignment

The important and timely article "Optimal Allocation of Societal HIV-Prevention Resources to Reduce HIV Incidence in the United States" by Sansom et al. (p. 150) models different federal and private HIV-prevention resource allocation strategies to prioritize HIV funding through 2027. Modeling exercises are useful starting points for decision making yet may not fully incorporate real-world complexities because of model assumptions and limited quantifiable inputs. Models provided exclude multilevel interventions, policy and structural-level initiatives, and within-group cost differentiation, all key considerations for affecting communities at highest risk for HIV infection. Sansom et al. punctuate the misalignment between epidemic burden and resource allocation. Current allocations for HIV screening among low-risk heterosexuals constitute 25.3% of the total prevention budget and are 22 times greater than funds earmarked for high-risk men who have sex with men (MSM). MSM accounted for 69% of incident HIV diagnoses in 2018, more than seven times the number of new HIV diagnoses of heterosexual sex.1 Within MSM, Black or Latinx MSM account for 67% and MSM younger than 35 years account for 65% of new diagnoses. New infections are concentrated in the South. The Ending the HIV Epidemic strategy is an important step forward in directing HIV-prevention resources to jurisdictions experiencing the highest HIV burdens.2 Although the most likely (limited reach) scenario modeled by Sansom et al. begins this process of resource realignment, we advocate more intentional rectification of these misalignments by redistributing HIV-prevention resources so they reach the populations most at risk: young Black and Latinx MSM and transgender women (transwomen).The Pareto principle applies to the current HIV epidemic in the United States: a small proportion of people- Black and Latinx MSM and transwomen younger than 35 years, accounting for less than 1% of the US population- experience a large proportion (> 30%) of new cases.