The potential effect of COVID-19-related disruptions on HIV incidence and HIV-related mortality among men who have sex with men in the USA: a modelling study

Background During the COVID-19 pandemic, men who have sex with men (MSM) in the USA have reported similar or fewer sexual partners and reduced HIV testing and care access compared with before the pandemic. Pre-exposure prophylaxis (PrEP) use has also declined. We aimed to quantify the potential effect of COVID-19 on HIV incidence and HIV-related mortality among US MSM. Methods We used a calibrated, deterministic, compartmental HIV transmission model for MSM in Baltimore (MD, USA) and available data on COVID-19-related disruptions to HIV services to predict effects of reductions in sexual partners (0%, 25%, 50%), condom use (5%), HIV testing (20%), viral suppression (10%), PrEP initiations (72%), PrEP adherence (9%), and antiretroviral therapy (ART) initiations (50%). In our main analysis, we modelled disruptions due to COVID-19 starting Jan 1, 2020, and lasting 6 months. We estimated the median change in cumulative new HIV infections and HIV-related deaths among MSM over 1 and 5 years, compared with a base case scenario without COVID-19-related disruptions. Findings A 25% reduction in sexual partners for 6 months among MSM in Baltimore, without HIV service changes, could reduce new HIV infections by median 12 & middot;2% (95% credible interval 11 & middot;7 to 12 & middot;8) over 1 year and median 3 & middot;0% (2 & middot;6 to 3 & middot;4) over 5 years. In the absence of changes in sexual behaviour, the 6-month estimated reductions in condom use, HIV testing, viral suppression, PrEP initiations, PrEP adherence, and ART initiations combined are predicted to increase new HIV infections by median 10 & middot;5% (5 & middot;8 to 16 & middot;5) over 1 year, and by median 3 & middot;5% (2 & middot;1 to 5 & middot;4) over 5 years. Disruptions to ART initiations and viral suppression are estimated to substantially increase HIV-related deaths (ART initiations by median 1 & middot;7% [0 & middot;8 to 3 & middot;2], viral suppression by median 9 & middot;5% [5 & middot;2 to 15 & middot;9]) over 1 year, with smaller proportional increases over 5 years. The other individual disruptions (to HIV testing, PrEP and condom use, PrEP initiation, and partner numbers) were estimated to have little effect on HIV-related deaths (<1% change over 1 or 5 years). A 25% reduction in sexual partnerships is estimated to offset the effect of the combined service disruptions on new HIV infections (change over 1 year: median -3 & middot;9% [-7 & middot;4 to 1 & middot;0]; over 5 years: median 0 & middot;0% [-0 & middot;9 to 1 & middot;4]), but not on HIV deaths (change over 1 year: 11 & middot;0% [6 & middot;2 to 17 & middot;7]; over 5 years: 2 & middot;6% [1 & middot;5 to 4 & middot;3]). Interpretation Maintaining access to ART and adherence support is of the utmost importance to maintain viral suppression and minimise excess HIV-related mortality due to COVID-19 restrictions in the USA, even if disruptions to services are accompanied by reductions in sexual partnerships. Findings A 25% reduction in sexual partners for 6 months among MSM in Baltimore, without HIV service changes, could reduce new HIV infections by median 12?2% (95% credible interval 11?7 to 12?8) over 1 year and median 3?0% (2?6 to 3?4) over 5 years. In the absence of changes in sexual behaviour, the 6-month estimated reductions in condom use, HIV testing, viral suppression, PrEP initiations, PrEP adherence, and ART initiations combined are predicted to increase new HIV infections by median 10?5% (5?8 to 16?5) over 1 year, and by median 3?5% (2?1 to 5?4) over 5 years. Disruptions to ART initiations and viral suppression are estimated to substantially increase HIV-related deaths (ART initiations by median 1?7% [0?8 to 3?2], viral suppression by median 9?5% [5?2 to 15?9]) over 1 year, with smaller proportional increases over 5 years. The other individual disruptions (to HIV testing, PrEP and condom use, PrEP initiation, and partner numbers) were estimated to have little effect on HIV-related deaths (<1% change over 1 or 5 years). A 25% reduction in sexual partnerships is estimated to offset the effect of the combined service disruptions on new HIV infections (change over 1 year: median ?3?9% [?7?4 to 1?0]; over 5 years: median 0?0% [?0?9 to 1?4]), but not on HIV deaths (change over 1 year: 11?0% [6?2 to 17?7]; over 5 years: 2?6% [1?5 to 4?3]).