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

ABSTRACT

Social stigma inhibits provision and uptake of HIV prevention and care;experiences and anticipation of stigma in health care settings are associated with lower rates of HIV testing, preexposure prophylaxis uptake, retention in care, and antiretroviral therapy adherence. [...]relying solely on biomedical HIV prevention for young Black and Latinx gay and bisexual men and transwomen will not constitute a sufficient response to their needs. In response, local researchers collaborated with local sexual and gender minority youths of color to develop, implement, and evaluate a multilevel HIV-prevention and care intervention.3 The Pennsylvania Department of Health and the state's HIV Planning Group, whose composition has robustly included most-at-risk populations empowered to identify priority populations and recommend resource allocations, supported and promoted the project for statewide scale-up. Emerging research incorporating wraparound clinical harm reduction4 and intersectional stigma reduction5 into biomedical HIV prevention shows promise. Because of their complexity, such interventions are difficult to operationalize, field, and consolidate into cost-per-person metrics;for these reasons, multilevel, social determinants-based interventions are excluded from allocation models provided. The proposed EqEA framework may help achieve Ending the HIV Epidemic endpoints and offers insights for other infectious diseases, such as directing COVID-19 prevention resources to minority communities wherein SARSCoV-2 is exacting a disproportionately lethal toll and federal aid formulas for hospitals have large-scale racial biases.7 Adopting equitable allocation strategies will ensure that resources do not remain woefully misaligned and our systems do not exacerbate the welldefined shortcomings of decades of efforts. >4jPH CORRESPONDENCE Correspondence should be sent to M. Reuel Friedman, PhD, PO Box 7319, Pittsburgh, PA 15213 (e-mail mrf9@pitt.edu).