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Ç The Authoi 2u1S. Publisheu by 0xfoiu 0niveisity Piess on behalf of the Infectious Biseases Society of
Ameiica. All iights ieseiveu. Foi Peimissions, please e-mail: jouinals.peimissionsÇoup.com
TestandTreatinLosAngeles:Amathematicalmodeloftheeffectsof
testandtreatfortheMSMpopulationinLACounty

NeerajSood
1,+
,ZacharyWagner
1
,AmberJaycocks
2
,EmmanuelDrabo
3
,
RaffaeleVardavas
*,4
1
Schaeffei Centei foi Bealth Policy anu Economics, 0niveisity of Southein Califoinia, SSSS
S. Figueioa Stieet, 0nit A Los Angeles, CA, 9uu89-727S
2
PhB Canuiuate, Paiuee RANB uiauuate School, 1776 Nain Stieet, Santa Nonica, CA 9u4u1
S
PhB Canuiuate, Titus Family Bepaitment of Phaimaceutical Economics anu Policy,
0niveisity of Southein Califoinia, Los Angeles, CA, 9uu89-727S
4
RANB Coipoiation, 1776 Nain Stieet, Santa Nonica, CA 9u4u1
*
Coiiesponuing Authoi:

Raffaele vaiuavas 1776 Nain Stieet, Santa Nonica, CA 9u4u1
Tel: +1-S1u-S9S-u411 x6u79; email: Raffaele_vaiuavasÇianu.oig
+
Alteinative Coiiesponuing Authoi: Neeiaj Soou, SSSS S. Figueioa Stieet, 0nit A Los
Angeles, CA 9uu89-727S, 0SA; Tel: +1-21S-821-7949; email: nsoouÇhealthpolicy.usc.euu

Key Points:
We use a mathematical mouel to simulate the use of the test-anu-tieat policy foi
contiol of BIv¡AIBS in Los Angeles County
We finu that the significant epiuemiological benefits pieuicteu by the mouel aie
counteibalanceu by substantial incieases in multi-uiug iesistance


Abstiact
Background: Theie is eviuence to suggest that antiietioviial theiapy (ART) anu BIv
testing ieuuce the piobability of tiansmission of BIv. This has leu health officials acioss the
0S to take steps towaius a test-anu-tieat policy. Bowevei, the extent of the benefits
geneiateu by test-anu-tieat is uebatable, anu theie aie conceins, such as incieaseu multi-
uiug iesistance (NBR), that iemain unauuiesseu.

Methods:We uevelopeu a ueteiministic epiuemiological mouel to simulate the BIv¡AIBS
epiuemic foi men who have sex with men (NSN) in Los Angeles County (LAC). We
calibiateu the mouel to match the BIv suiveillance uata fiom LAC acioss a ten-yeai peiiou,
Clinical Infectious Diseases Advance Access published March 13, 2013

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staiting in 2uuu. We then mouifieu oui mouel to simulate the test-anu-tieat policy anu
compaieu epiuemiological outcomes unuei the test-anu-tieat scenaiio to the status quo
scenaiio ovei the yeais 2u12-2u2S. 0utcome measuies incluueu new infections, ueaths,
new AIBS cases, anu NBR.

Results:Relative to the status quo, the test-anu-tieat mouel iesulteu in a S4% ieuuction in
new infections, 19% ieuuction in ueaths, anu S9% ieuuction in new AIBS cases by 2u2S.
Bowevei, these iesults aie counteibalanceu by a neai uoubling of the pievalence of NBR
(9.u6% compaieu to 4.79%) in 2u2S. We also founu that the effects of incieasing testing
anu tieatment weie not complimentaiy.

Conclusions:Although test-anu-tieat geneiates substantial benefits it will not eliminate
the epiuemic foi NSNs in LAC. Noieovei, these benefits aie counteibalanceu by laige
incieases in NBR.

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S
Introduction
Recent eviuence suggests antiietioviial theiapy (ART) ieuuces BIv tiansmission
piobability, paiticulaily if initiateu at eaily stages of the uisease |1-Sj. Eviuence also
suggests testing BIv+ causes uiamatic ieuuctions in sexual activity levels, which also
ieuuces BIv tiansmission piobability |4, Sj. In light of this eviuence, health officials acioss
the 0niteu States (0.S.) aie taking steps towaius scaling up testing piogiams anu
iecommenuing immeuiate ART initiation to inuiviuuals testing positive, iegaiuless of CB4
cell count |6j. Some aigue a "test-anu-tieat" policy coulu leau to elimination of the BIv
epiuemic |7-9j.
Although ieasons exist foi optimism iegaiuing the iole of incieaseu testing anu tieating in
BIv pievention agenuas, some conceins iemain unauuiesseu. 0ne impoitant concein is
that incieaseu ART use cieates moie multi-uiug iesistant (NBR) stiains which might limit
the benefits of test-anu-tieat |1uj. Tieatment iesistance alieauy poses a majoi public
health pioblem in the 0S |11j. Theiefoie, ueteimining how to implement test-anu-tieat
policies wheie BIv pievention is maximizeu anu NBR pievalence is minimizeu is
impoitant.
Pievious mathematical mouels that simulate the impact of scaling up test-anu-tieat policies
show mixeu iesults. Some finu uiamatic benefits |7, 12j, while otheis finu only mouest
effects |1S-1Sj. Theie is also eviuence fiom a natuial expeiiment suggesting that some
mouel iesults may be exaggeiateu |16j. The uisciepancy in mouel finuings ieflect the
sensitivity of test-anu-tieat outcomes to uiffeiing unueilying assumptions about BIv

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pievalence, piopoition of unuiagnoseu cases, iisky sexual behavioi, anu othei population
oi location specific paiameteis |17, 18j. This highlights the ciitical neeu to calibiate
mathematical mouels to mimic ieal-woilu BIv pievalence anu inciuence tienus |19j.
Auuitionally, none of these papeis explicitly auuiess potential effects of test-anu-tieat
policies on the spieau of NBR. Bowevei, an eailiei stianu of liteiatuie examining expanueu
ART use auuiesses this issue anu iepoits mixeu finuings. Some finu that incieasing the
peicentage of people using ART woulu substantially ieuuce the BIv epiuemic's seveiity
even in the piesence of high ART iesistance levels |9, 2uj. Bowevei, the authois note that
emeigence of highly tiansmissible iesistant stiains of BIv can significantly ieuuce the
benefits of expanueu use of ART |9j. Baggaley et al. finu that contiolling Sub-Sahaian
Afiican BIv epiuemics thiough tieatment is ineffective as incieasing the piopoition on
tieatment incieases the emeigence anu spieau of uiug iesistance |21j. 0theis finu benefits
fiom expanueu ART use aie counteibalanceu by mouest incieases in iisky sexual behavioi
|21-2Sj.
0ui stuuy contiibutes to this liteiatuie by using a mathematical mouel to simulate
effects of incieaseu testing anu eaily initiation of tieatment foi men who have sex with
men (NSN) in Los Angeles County (LAC). No pievious stuuy has focuseu on test-anu-tieat
in LAC. In the 0.S., LAC has the laigest inciuence of BIv anu NSNs account foi 82% of all
people living with BIv¡AIBS (PLWBA) |24, 2Sj. We calibiate oui mouel using BIv
suiveillance uata fiom LAC foi the yeais 2uuu to 2uu9. Following calibiation, we
manipulate paiameteis ielating to test-anu-tieat to simulate alteinate test-anu-tieat policy
scenaiios. To assess the inuiviuual anu complementaiy effects of testing anu tieating on
epiuemiological outcomes, the intensity of both testing anu tieatment iates aie vaiieu.

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Finally, we also assess how the intensity of each mechanism affects the poition of the
population with NBR. The iesults coulu help infoim policy makeis on best appioaches foi
the test-anu-tieat policy anu wheie to focus futuie BIv pievention effoits.
Methods
StudyDesign
To mouel the LAC BIv¡AIBS epiuemic we calibiate a ueteiministic epiuemiological mouel
to match LAC's BIv suiveillance uata acioss a ten-yeai peiiou (2uuu-2uu9). We obtain the
set of mouel paiameteis that best iepiouuce the obseiveu BIv¡AIBS pievalence tienus foi
NSNs. We then mouify oui mouel to investigate effects of the test-anu-tieat policy wheieby
BIv testing iates aie incieaseu anu newly uiagnoseu BIv+ inuiviuuals aie immeuiately
tieatment eligible. We focus on the NSN population because they iepiesent ovei 82% of
PLWBA in LAC anu theii biological anu behavioial chaiacteiistics aie likely to uiffei fiom
heteiosexuals. (See Technical Appenuix foi moie uetail)
ModelStructure
We constiuct a compaitmental BIv tiansmission mouel. 0ui mouel stiuctuie follows the
geneial appioach useu in pievious BIv tiansmission mouels, anu in paiticulai that useu by
Smith et al. |11j. 0ui mouel consiueis the uynamics in the eia of tiiple theiapy anu
theiefoie consiueis uynamics of acquiieu anu tiansmitteu multi-uiug iesistance (NBR).
Figure1 uisplays oui compaitmental BIv mouel, wheieby inuiviuuals in oui population
piogiess ovei the uiffeient stages of the infection. 0nuei status quo, tieatment eligibility is

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baseu on stanuaiu CBC guiuelines: auvanceu uisease anu¡oi CB4 cell count less than SSu
cells¡micio-litei, which although lowei than cuiient tieatment guiuelines, was the
guiueline foi most of the calibiation yeais. The mouel is integiateu numeiically anu tiacks
the uynamics of the population in each compaitment as it changes ovei time.
KeyInputParametersandRanges
0ui mouel incluues S4 paiameteis, foi which we pioviue unceitainty ianges baseu upon
liteiatuie ieview, expeit opinion, anu oui subjective iange assessment (foi uetails see
technical appenuix, Tables 4-8). Key paiameteis foi this stuuy incluue the iate that
tieatment eligible inuiviuuals initiate anu auheie to tieatment (), the iate that unawaie
BIv+ inuiviuuals get testeu foi BIv (), the iate that NBR is acquiieu foi people on
tieatment (i), anu the piobability of BIv tiansmission pei sexual paitneiship (). To
account foi uiffeient infectiousness levels anu iisky sexual activity at uiffeient uisease
stages, the paiametei is unique foi each mouel compaitment. A key mouel assumption is
that BIv+ inuiviuuals, awaie of theii seiostatus, significantly ieuuce iisky behavioi; we
account foi this by ensuiing the sampling iange of foi stage } is S6%-76% lowei than the
sampling iange of foi stage I. |4j
SurveillanceData
The suiveillance uata we use, as a iefeience to calibiate oui mouel, was taken fiom LAC
Semi-Annual Suiveillance Repoits fiom 2uu8-2u1u. The suiveillance uata pioviues annual
numbeis of PLWBA by tiansmission gioup foi yeais 2uuu-2uu9. These iepoits

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uiffeientiate BIv+ inuiviuuals fiom those with AIBS anu we uistiibute these stages
accoiuingly in oui mouel (see Technical Appenuix, Section 4).
ModelCalibration
In this section, we biiefly summaiize how we calibiate the mouel; moie uetails on the
calibiation aie pioviueu in the technical appenuix, section S. To calibiate oui mouel we use
a Latin Bypeicube Sampling (LBS) methou anu match the mouel output to LAC suiveillance
uata fiom 2uuu-2uu9. We fiist iun Suu,uuu LBS simulations baseu on paiametei ianges
fiom the piioi liteiatuie. Next, we uiop simulations that uo not match piioi estimates of
the piopoition of PLBWA who aie unawaie of theii BIv status |26j, anu NBR pievalence
|11, 27j. Finally, we select the top 1uuu simulations that best match estimates of total
numbei of PLBWA in LAC suiveillance uata foi the yeais 2uuu to 2uu9. We use these
simulations to cieate naiiowei paiametei ianges anu iun an auuitional Suu,uuu LBS
simulations. As befoie, we uiop simulations that uo not match piioi estimates of the
piopoition of PLBWA who aie unawaie of theii BIv status anu NBR pievalence. In
auuition, we only ietain simulations wheie pieuicteu AIBS cases anu non-AIBS BIv awaie
cases aie both less than S% uiffeient fiom the 2uu9 suiveillance uata. Finally, of the
iemaining simulations, we choose the simulation that best matches the total numbei of
PLBWA in LAC suiveillance uata foi the yeais 2uuu to 2uu9. We label this as the "Best Run"
anu use the paiameteis piouuceu by this iun as the main mouel paiameteis. Figure2
compaies iesults fiom the "Best Run" simulation to the suiveillance uata.

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TestandTreatModel
To simulate the test-anu-tieat policy, we extenu the BIv mouel uesciibeu above by
incoipoiating two auuitional compaitments, TJ
s
anu TJ
r
, iepiesenting the non-uiug
iesistant anu uiug-iesistant infecteu inuiviuuals who initiate tieatment eaily piioi to CB4
counts falling below eligibility guiuelines (see Technical Appenuix, Figuie S). The J to TJ
path,
tj
, iepiesents the eaily tieatment initiation iate foi infecteu inuiviuuals with a CB4
cell count above SSu-cells¡millilitei. We assume compaitment T}'s iisk of tiansmission is
96% lowei than the iisk of compaitment }'s tiansmission |1j.
Testing iates anu iates at which people begin tieatment aie key foi test-anu-tieat policy
outcomes. We test a iange of paiametei combinations to assess how moie aggiessive
testing anu moie aggiessive tieatment inuiviuually anu jointly impact BIv ielateu
outcomes.
0ui baseline test-anu-tieat simulation assumes the following: 1) the expecteu time to
tieatment initiation foi those with CB4 cell counts above the thiesholu of SSu
cells¡millilitei is the same as foi those with CB4 count below this thiesholu; 2) the aveiage
uuiation foi unuiagnoseu PLWBA to get testeu changes fiom 4.4 yeais to 1 yeai. In
auuition to oui baseline scenaiios, we pioviue a iange of othei scenaiios that combine
uiffeient testing anu tieatment intensity levels.
In LAC, achievable incieases in testing anu tieatment levels aie uncleai. To estimate
feasibility, we calculate new uiagnoses anu new people initiating tieatment aftei the fiist
yeai, which seives as a pioxy foi effoit anu iesouices put towaius the policy. Table1

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piesents new BIv uiagnoses anu new people beginning tieatment uuiing the fiist yeai of
the test-anu-tieat policy with alteinative scenaiios of testing anu tieatment intensity. 0ui
baseline scenaiio (test eveiy one yeai anu tieatment initiation 2.S yeais aftei uiagnosis)
iesults in a 11S% inciease in new uiagnoses anu a S6% in new people initiating tieatment
uuiing the fiist yeai compaieu to the status quo. The most aggiessive stiategy we simulate,
assumes annual testing anu tieatment initiation six months aftei becoming eligible. This
iesults in incieases of 114% anu 1S6%, iespectively. The least aggiessive stiategy we
simulate, assumes testing eveiy 4.4 yeais anu tieatment initiation 2.S yeais aftei becoming
eligible (simply a change in the tieatment eligibility guiuelines), still iesults in an 18%
inciease in new people initiating tieatment in the fiist yeai compaieu to the status quo.
This is explaineu by the new tieatment guiuelines that allow people to become eligible
immeuiately aftei uiagnosis iathei than waiting until they have a CB4 cell count below SSu.
SensitivityAnalysis
We fiist conuuct a one-way sensitivity analysis to ueteimine how the mouel iesults aie
impacteu by each paiametei inuiviuually. In paiticulai, we ie-estimate the mouel by
vaiying each paiametei by 1u% above anu below the baseline values, while holuing all
othei paiameteis fixeu. We useu these new paiametei values to estimate effects of test-
anu-tieat on new infections anu NBR. This allows us to unueistanu which paiameteis most
influence oui iesults. We also conuuct a multivaiiate sensitivity analysis by iesampling
1uu,uuu paiametei sets fiom the paiametei iange above. We use estimates fiom this
analysis to iepoit the 9S% confiuence inteival foi oui baseline test-anu-tieat iesults. (see
Technical Appenuix, Section 7 foi moie uetail)

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Results
Figure3 uisplays iesults unuei the baseline test-anu-tieat scenaiio compaieu to the status
quo. The baseline test-anu-tieat scenaiio iepiesents a 11S% inciease in the numbei of
fiist-yeai uiagnoseu BIv cases anu a S6% inciease in the numbei of PLWBA tieateu in the
fiist yeai (see Table1). Figure3 shows the peicent of the population that is unawaie
ieuuces ovei a ten-yeai peiiou fiom 2u% in 2u1S to about S% in 2u2S anu the peicent of
PLWBA on ART incieases fiom 62% in 2u1S to about 76% in 2u2S. 0vei these ten-yeais,
the uiamatic changes in testing anu tieatment leau to laige ieuuctions in new infections
(S4%; 9S% C.I. Su-S7), ueaths (19%; 9S% C.I. 17-21), anu new AIBS cases (S9%; 9S% C.I.
S6-41). Bowevei, contiasting these benefits, the NBR pievalence neaily uoubles to 9% by
2u2S (9S% C.I. 7.8-1u.2).
Table2 piesents epiuemiological outcomes foi all simulateu scenaiios. 0ui baseline
scenaiio iesults in a substantial ieuuction in all epiuemiological measuies. The most
aggiessive stiategy, testing annually anu tieatment initiation aftei six months, incieases
new uiagnoses by 114% anu tieatment by 1S6% in the fiist yeai (see Table1). This
stiategy also cieates a 47% ieuuction in new infections, a 28% ieuuction in ueaths, anu a
64% ieuuction in new AIBS cases by 2u2S. Bowevei, unuei this scenaiio, the poition of
PLWBA with NBR neaily tiiples to 1S.7% in 2u2S. The least aggiessive stiategy we
simulateu, testing eveiy 4.4 yeais anu tieatment initiation aftei 2.S yeais÷essentially just
a change in tieatment eligibility guiuelines÷still yielus a 6% ieuuction in new infections, a
6% ieuuction in ueaths, anu an 11% ieuuction in new AIBS cases, with only a 1.S%
inciease in NBR.

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Table2 also shows the two mechanisms, testing anu tieating, aie not complementaiy. We
see ioughly equal benefits fiom incieasing testing iates iegaiuless of tieatment initiation
iates anu vice-veisa. Foi example, unuei the least aggiessive tieatment stiategy (aveiage
uuiation to tieatment of 2.S yeais) theie is an auuitional 28% ieuuction in new infections,
wheieas unuei the most aggiessive tieatment stiategy (aveiage uuiation to tieatment of 6
months) an auuitional 29% ieuuction. Similaily, a change fiom the least aggiessive
tieatment stiategy to the most aggiessive tieatment stiategy auus ioughly the same
benefit unuei all levels of testing intensity.
We also examineu scenaiios without eaily tieatment guiuelines implementeu (i.e., only
incieasing testing iates). This allows analysis of how much test-anu-tieat benefit is
ueiiveu fiom eaily tieatment anu how much comes fiom incieasing testing (see Technical
Appenuix, Table 17). We finu that without any change to tieatment guiuelines anu only
incieasing testing, we get about half the epiuemiological benefits, while NBR iemains
stable.
SensitivityAnalysis
0veiall, oui iesults aie iathei stable, with the laigest impact of any 1u% change in oui
baseline paiameteis iesulting in only a 1.82 peicentage point change in new infections. We
finu new infections aie most sensitive to the paiameteis that iepiesent sexual behavioi
(i.e., the tiansmissibility paiameteis anu numbei of paitneis).
Foi NBR, we finu that oui iesults most sensitive to the iate of iesistance. Similai to new
infections, the iesults foi NBR weie iathei stable; the laigest impact of any 1u% change in

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oui baseline paiameteis iesults in a .4S peicentage point change in NBR pievalence. A
complete uesciiption anu iesults of the multivaiiate sensitivity analysis useu foi
confiuence inteivals is founu in section 7 of the Technical Appenuix.
We also ian an auuitional simulation using oui best paiametei estimates fiom the clinical
liteiatuie without any calibiation. 0nuei this scenaiio, we finu peicent ieuuctions in
ueaths anu new AIBS cases uue to test-anu-tieat to be unueiestimateu by 6.4S peicentage
points anu 14.S2 peicentage points, iespectively, while peicent ieuuctions in new
infections iemain ielatively stable. Absolute ieuuctions in all outcomes aie significantly
unueiestimateu (See Technical Appenuix, Section 7.4).
Also, since theie aie no uata on the ielative ieuuction in infectiousness uue to ART foi
NSNs÷uata aie foi uiscoiuant couples÷we test the sensitivity of oui assumption of a
96% ieuuction in infectiousness fiom ART using the uppei anu lowei enus of the Cohen et
al. 9S% confiuence inteival, 99% anu 7S% ieuuctions, iespectively |1j. We also conuuct a
thiiu simulation assuming a Su% ieuuction foi auuitional contiast. We finu that
assumptions about this paiametei have only a mouest influence on oui iesults (See
Technical Appenuix, Section 7.S).
Discussion
We calibiateu oui mouel to accuiately pieuict tienus in BIv¡AIBS pievalence in LAC fiom
2uuu-2uu9. We useu this mouel to evaluate the effects of the test-anu-tieat policy in LAC.
The iesults show that the test-anu-tieat policy can geneiate substantial ieuuctions in new
infections, ueath, anu new AIBS cases. Bowevei, contiaiy to uianich et al., even the most

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aggiessive test-anu-test policy uoes not eliminate the BIv epiuemic |7j. These finuings aie
consistent with Walensky et al., Long et al., anu Soiensen et al who finu only mouest policy
effects when moueling the epiuemic in the 0.S |1S-1Sj.
We also finu that the epiuemiological benefits of test-anu-tieat aie counteibalanceu by
laige NBR incieases. It is uncleai to what extent incieases in NBR will affect the couise of
the BIv epiuemic. Consistent with velasco-Beinanuez et al. anu Lima et al. we show that
even when NBR incieases thieefolu, incieasing tieatment iates still biings epiuemiological
benefits in the shoit-iun |9, 2uj. Even when we simulate the mouel fai into the futuie anu
NBR pievalence appioaches 2S%, the policy is still beneficial (see Technical Appenuix,
section 9). Bowevei, in the long-iun it is possible new foims of NBR evolve with highei
iesistance intensity oi gieatei tiansmissibility, which coulu exaceibate NBR consequences.
Conveisely, it is also possible NBR coulu be mitigateu by the invention of new vaiiants of
uiugs that aie less susceptible to iesistance. With such unceitainty about the couise of
NBR, it is uncleai whethei benefits fiom incieasing test-anu-tieat outweigh costs of
incieasing NBR. If policy makeis aie iisk-aveise, a moie cautious appioach to BIv
pievention might involve moie focus on testing without changing tieatment guiuelines to
covei eaily stage BIv. We finu that by simply incieasing testing iates we ueiive ioughly
half the benefits of the full test-anu-tieat policy with no NBR inciease. Results also suggest
that benefits of incieasing testing iates anu tieatment iates occui inuepenuently,
suggesting that implementation neeu not occui in unison.
0ui mouel has its limitations. Fiist, mathematical mouels aie only as goou as the available
uata useu foi the paiameteis anu calibiation. We iigoiously calibiateu oui mouel to veiy

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accuiately match LAC suiveillance uata anu we show that if we hau not calibiateu anu
insteau simply chosen paiameteis baseu on clinical liteiatuie, we woulu have
unueiestimateu the benefits of test-anu-tieat. Bowevei, many of oui paiameteis aie
uifficult to measuie anu BIv suiveillance uata useu foi calibiation itself might have
measuiement eiioi. Seconu, oui mouel is not stiatifieu by iisk, ethnicity, oi age. Futuie
mouels shoulu attempt to achieve moie gianulaiity. Thiiu, oui mouel uoes not consiuei the
use of PiEP. Recent FBA appioval of Tiuvaua foi PiEP may play an impoitant iole in futuie
BIv inciuence anu uiug iesistance. Fouith, oui simulations uo not fully exploie the
implications of behavioi among people who initiate tieatment eaily. The possibility exists
that eaily tieatment will iesult in incieaseu iisky behavioi in BIv+ anu susceptible
populations because tiansmission is less likely. Anothei possibility is people who initiate
eaily-stage tieatment aie less likely to fully auheie to tieatment; this coulu inciease the
acquiieu NBR iate, though the piecise ielationship between auheience anu NBR is
unknown. In summaiy, behavioial changes may mitigate the benefits of test-anu-tieat anu
futuie ieseaich shoulu exploie implications of these behavioial changes. Fifth, we omit
costs fiom oui mouel, which piecluues us fiom iuentifying the optimal combination of
testing anu tieating. Futuie ieseaich shoulu incluue a cost effectiveness analysis of
alteinate test-anu-tieat policy options to iuentify the optimal policy. 0nueistanuing
buugetaiy anu scaling-up constiaints of alteinate pievention piogiams woulu pioviue
insight on wheie to focus futuie pievention effoits.

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Funding
This woik was suppoiteu by the Eunice Kenneuy Shiivei National Institute of Chilu Bealth
anu Buman Bevelopment |uRANT #: Ru1BBuS4877j. The funuing souice hau no iole in the
uesign oi conuuct of this stuuy.
AuthorContributions
All authois anu especially Rv anu EB contiibuteu to the uesign of the ueteiministic
epiuemiological mouel. NS, ZW, anu Rv contiibuteu to the wiiting of the manusciipt. ZW,
A}, anu EB contiibuteu to the liteiatuie ieview anu geneiation of paiametei ianges. A}
calculateu the initial conuitions anu the mouel baseline. ZW anu NS cieateu all manusciipt
tables. EB, ZW, anu A} cieateu all tables anu figuies in the technical appenuix. All authois
contiibuteu to the stuuy uesign, mouel calibiation, anu wiiting of the technical appenuix.
ConflictsofInterest
The authois ueclaie no conflicts of inteiest

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Table1. Fiist yeai effects of the test-anu-tieat policy on BIv uiagnoses anu tieatment
initiation with uiffeient levels of testing anu tieatment intensity compaieu to the status
quo.
Scenario
NewHIVDiagnosisInFirstYear
(%ChangefromStatusQuo)
NewPeopleInitiating
TreatmentInFirstYear
(%ChangefromStatusQuo)
StatusQuo 4,4S7 S,696
Treatment2.5Years*
Test Eveiy 1 Yeai** 9,SS7 (11S%) 7,724 (S6%)
Test Eveiy 2 Yeais 7,S76 (71%) 7,S17 (28%)
Test Eveiy S Yeais 6,689 (S1%) 7,1S4 (26%)
Test Eveiy 4.4 Yeais* 4,4SS (u%) 6,7S2 (18%)
Treatment1Year
Test Eveiy 1 Yeai 9,S14 (114%) 11,248 (97%)
Test Eveiy 2 Yeais 7,S62 (7u%) 1u,S4S (82%)
Test Eveiy S Yeais 6,678 (S1%) 9,97S (7S%)
Test Eveiy 4.4 Yeais* 4,427 (u%) 9,u71 (S9%)
Treatment6Months
Test Eveiy 1 Yeai 9,48S (114%) 14,S62 (1S6%)
Test Eveiy 2 Yeais 7,S44 (7u%) 1S,17S (1S1%)
Test Eveiy S Yeais 6,66S (Su%) 12,S96 (121%)
Test Eveiy 4.4 Yeais* 4,419 (u%) 11,198 (97%)
*Cuiient uuiation baseu off mouel calibiation
**Baseline Scenaiio








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Table2.Epiuemiological outcomes unuei uiffeient test-anu-tieat intensity levels compaieu to the
status quo
Cumulativefrom20132023
%ofTotalHIV/AIDS
Populationin2023
Scenario
New Infections
(%Reuuction)
Beaths
(%Reuuction)
New AIBS Cases
(%Reuuction)
%Nulti Biug
Resistant
%0nawaie
StatusQuo S4,u67 42,u8S 48,9u7 4.79% 2u.u%
Treatment2.5Years*
Test Eveiy 1 Yeais** SS,79S (S4%) S4,127 (19%) 29,824 (S9%) 9.u6% 4.Su%
Test Eveiy 2 Yeais S9,7u7 (27%) S6,u79 (14%) S4,1S1 (Su%) 8.19% 7.S7%
Test Eveiy S Yeais 42,249 (22%) S7,417 (11%) S7,19u (24%) 7.64% 9.4S%
Test Eveiy 4.4 Yeais* Su,676 (6%) S9,748 (6%) 4S,SSu (11%) 6.u7% 18.S1%
Treatment1Year
Test Eveiy 1 Yeais S1,2S1 (42%) Su,2S7 (28%) 22,1S2 (SS%) 11.9u% S.67%
Test Eveiy 2 Yeais SS,271 (SS%) S1,89u (24%) 2S,7u9 (47%) 1u.77% 6.14%
Test Eveiy S Yeais S7,9SS (Su%) SS,u1S (22%) 28,246 (42%) 1u.uS% 7.97%
Test Eveiy 4.4 Yeais* 47,226 (1S%) SS,61u (1S%) S4,76S (29%) 7.8S% 16.S7%
Treatment6Months
Test Eveiy 1 Yeais 28,489 (47%) 27,8u7 (S4%) 17,642 (64%) 1S.7u% S.2u%
Test Eveiy 2 Yeais S2,S7S (4u%) 29,172 (S1%) 2u,S17 (S8%) 12.S1% S.S9%
Test Eveiy S Yeais S4,9S7 (SS%) Su,u84 (29%) 22,SS6 (S4%) 11.7S% 7.u2%
Test Eveiy 4.4 Yeais* 44,S89 (18%) S2,6SS(22%) 28,7S7 (41%) 9.22% 1S.18%
*Cuiient uuiation baseu off mouel calibiation
**Baseline Scenaiio









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Figure1. BIv Tiansmission Nouel: inuiviuuals in oui mouel aie uiviueu into eight key BIv
infection statuses: susceptible oi BIv negative (S), infecteu in the piimaiy stage of infection (P),
infecteu anu unawaie of being infecteu (I), uiagnoseu infecteu but not tieatment-eligible (}),
infecteu anu tieatment-eligible (E), tieateu but no piogiession to AIBS (T), piogiession to AIBS but
not tieateu (A), anu piogiession to AIBS anu tieateu (TA). We uistinguish between infecteu
inuiviuuals with uiug sensitive BIv stiain (subsciipt s) fiom those infecteu with the multi-uiug-
iesistant (NBR) BIv stiain (subsciipt r).
-


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Figure2.CalibrationResults. As shown, oui
calibiateu mouel can accuiately pieuict tienus in
numbei of AIBS anu non-AIBS BIv awaie cases in
LAC foi the yeais 2uuu to 2uu9.

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Figure3. Baseline Test anu Tieat Scenaiio Compaieu to the Status Quo

a t U n i v o f S o u t h e r n C a l i f o r n i a o n M a r c h 1 4 , 2 0 1 3 h t t p : / / c i d . o x f o r d j o u r n a l s . o r g / D o w n l o a d e d f r o m

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