We optimized societal spending on HIV prevention (increased by given fixed amounts of federal funds) to assess whether it is possible to decrease annual HIV incidence in the United States to less than 10,000 cases in 5 years and less than 3,000 cases in 10 years, and thus achieve the HHS Ending the Epidemic (EHE) incidence targets. We applied the HIV Optimization and Prevention Economics (HOPE) model, a dynamic, compartmental model that simulates that portion of the U.S. population aged ? 13 that is sexually active or injects drugs. Our analytic time horizon was 2020 through 2029. The model applied current estimated public and private HIV prevention spending ($2.803 billion for 2020) each year to the following intervention categories: HIV screening (MSM and heterosexuals at high and at low risk, and PWID), HIV care continuum (linkage to care at and after diagnosis, prescription of ART, retention in care, viral suppression), PrEP, and SSPs. To model the effect of additional prevention funding, we divided the 10-year time frame into three time periods and added $500M/year for 2020-2021, $1.5B/year for 2022-2024, and $2.5B/year for 2025-2029. Using three scenarios, we estimated the impact of additional prevention and treatment spending with and without optimizing allocation of funds to the most impactful interventions: Scenario 1a with no optimization; Scenario 1b where the optimization started in year 6 of EHE period (2025, phase 2 of EHE); and Scenario 1c where the optimization started in year 3 of EHE period (2022). The additional prevention and treatment spending was approximately $15B higher over the 10 year time period in all scenarios compared to the current allocation, and total infections decreased by around 190,000 to 240,000 in the three scenarios compared to the current allocation (Table: Scenario Comparisons). Only in Scenario 1c did the allocation of funds allow the 2024 and 2029 incidence targets to be met. All three scenarios resulted in dramatic decreases in HIV incidence. However, optimization of prevention funding early in the time period was needed to reach EHE targets. An optimal allocation of resources is difficult to achieve in the real world, as it assumes flexibility of funding between various governmental and private agencies and programs to maximize efficacy of available funding. The EHE initiative has the potential for reaching ambitious goals with the dedication of significant funding increases across all 10 years of the initiative.
