Keywords
Health financing
Health policy
Viral suppression
PrEP coverage
How to Cite
Abstract
Background Ending the HIV epidemic requires identifying the most effective system-level policy levers for reducing transmission. This study quantifies the association between key health system indicators and estimated HIV incidence across U.S. states from 2013 to 2022. Methods A fixed-effects panel data model was applied to data from all 50 states and the District of Columbia, controlling for time-invariant state heterogeneity. Data sources included the AHEAD Dashboard (HIV incidence, viral suppression, PrEP coverage), the National Health Expenditure Accounts (CHE/GDP, OOP/CHE), and HRSA Ryan White HIV/AIDS Program reports (service utilization). Missing outcome data (4.2%) were handled via listwise deletion, with multiple imputation confirming robustness. Sensitivity analyses, including exclusion of the District of Columbia, alternative clustering structures, and varied lag specifications, confirmed result stability. Results Higher viral suppression rates were associated with concurrent reductions in HIV incidence (β = −0.0041, p < 0.001). PrEP coverage showed a significant negative association (β = −0.0018, p < 0.01). Out-of-pocket expenditure as a share of CHE was negatively associated with incidence (β = −0.0023, p < 0.05); however, this association likely reflects selection among stably retained, insured patients rather than a causal protective effect. Aggregate CHE/GDP was not statistically significant, highlighting the primacy of targeted interventions over broad spending increases. Conclusions Targeted biomedical interventions, specifically viral suppression and PrEP scale-up, emerge as the dominant drivers of HIV incidence reduction in the United States. Policymakers should prioritize service-specific investments and financial protections for key populations over undifferentiated health spending increases. Recent national data reinforce these findings, with Ryan White Program viral suppression reaching a record 91.4% in 2024.
References
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