Reducing HIV incidence in the Southern United States through routine opt-out HIV screening

To evaluate the potential contributions of routine opt-out testing (ROOT) in clinical settings and preexposure prophylaxis (PrEP) on achieving 'Ending the HIV Epidemic in the US' (EHE) incidence reduction goals in the South.

Simulation study.

An agent-based epidemic projection model simulated adherence to the CDC's ROOT guidelines. Simulations were informed by literature reviews, the National Survey of Family Growth and ARTnet. Interventions included ROOT in Community Health Center (CHC) and emergency departments alone and in combination. PrEP was modeled as either persistent at 2019 levels or expanding consistent with historical trends.

ROOT in CHCs and emergency departments averted 13.9% (95% simulation interval: -15.5 to 42.4) of infections and increased the proportion of persons with HIV (PWH) who were aware of their status from 84.8 to 94.4% (95% simulation interval: 92.8-95.4). In conjunction with the ongoing expansion of PrEP, the proportion diagnosed increased from 84.8% at baseline to 95.1% (95% simulation interval: 93.9-96.4) and 23.3% (95% simulation interval: -7.9 to 50.6) of infections were averted, reducing the annual incidence rate by 42.4% compared to the baseline scenario.

In our analysis, ROOT coupled with the ongoing expansion of PrEP averted almost a quarter of new infections over the 8 years from 2022 to 2030. While short of the overall EHE goal of 90%, it represents substantial potential progress for a low-cost and low-barrier intervention. ROOT also provides a method for identifying PWH who are undiagnosed both in and out of priority populations, those out of care, and individuals reluctant to seek screening.