What Tools Do We Have to End the US HIV Epidemic? A Review of Structural, Biomedical and Implementation Interventions and Their Potential Population Impact.

INTRODUCTION

The United States Ending the HIV Epidemic (EHE) initiative was always challenged by structural and implementation barriers to HIV care. On top of that, since 2025, there are additional political and policy barriers that make this goal seem increasingly difficult to achieve. This review identified evidence-based structural, implementation and biomedical interventions available to support each of the EHE pillars and estimated their potential population-level impact, accounting for potential barriers.

METHODS

We conducted a targeted literature review of US studies presenting data on efficacy or effectiveness of interventions pertaining to the EHE pillars-prevention, diagnosis, treatment and response-published as of September 2025. We searched interventions included in the US Centers for Disease Control and Prevention HIV Compendium and Response Evidence Brief, all publicly available EHE jurisdictional plans, and the peer-reviewed literature. Potential population impact of an intervention was determined as the product of its effectiveness and scale of delivery. Scale was the product of population reach, provider adoption and structural barriers.

RESULTS

Of 570 studies identified, 57 met the inclusion criteria. We estimated that pre-exposure prophylaxis (PrEP) uptake could increase as much as nearly two-fold (risk ratio [RR]: 1.93, 95% CI: 1.30, 1.96) through pharmacies integrated in primary care clinics. Online HIV self-testing kits were among the most promising interventions to increase testing uptake by two-fold (RR: 1.99, 95% CI: 1.56, 2.57) Finally, a clinic-based education app offering tailored health education could result in a 45% absolute increase (RR: 1.45, 95% CI: 1.29, 1.70) in viral suppression among people living with HIV.

CONCLUSIONS

Interventions that address barriers to PrEP, HIV testing and adherence to treatment have substantial population-level impact on HIV care outcomes across EHE pillars through changing the context of how care is offered, understood and delivered.