Ending Ryan White services may increase human immunodeficiency virus incidence

1. In this simulation study involving persons with human immunodeficiency virus living in the United States, ending Ryan White services in cities with high disease burden was projected to lead to a one-quarter decrease in viral suppression within a year.

2. As a result, new human immunodeficiency virus infections would increase by twenty to fifty percent, depending on the timing of recovery of viral suppression.

Evidence Rating Level: 2 (Good)

Study Rundown: The Ryan White human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) Program provides HIV medical care, treatment, and support for over half of the 1.2 million people living with HIV in the United States, especially those who would not otherwise be able to access care. This study aimed to assess the impact that interruption of Ryan White services may have on HIV infection rates using a city-level model of disease transmission. The model showed that if Ryan White services were to end in July 2025, average viral suppression across all cities would decrease by approximately one-quarter within one year. In the worst-case scenario where viral suppression did not recover, infections would increase by nearly fifty percent nationwide, with adults younger than 25 years being the most heavily affected. Were viral suppression to recover in 2027, a nearly twenty percent increase in infections would still be seen; no recovery until 2029 would mean a nearly forty percent increase in infections. The major variables affecting between-city variation in infection rates were the proportion of people with HIV receiving Ryan White services in 2025 and the average transmission rate in 2025. The study was limited by a dependence on survey data and a lack of analysis of downstream consequences such as quality of life, spillover effects, and financial costs. Nevertheless, this study suggests that stopping Ryan White services may drastically reduce viral suppression and increase HIV infection rates in the United States.

Click to read this study in AIM

Relevant Reading: AIDS Drug Assistance Program disenrollment is associated with loss of viral suppression beyond differences in homelessness, mental health, and substance use disorders: An evaluation in Washington state 2017–2019

In-Depth [prospective cohort]: This simulation study aimed to evaluate the impact of the interruption or cessation of Ryan White services on HIV infection rates. The Johns Hopkins Epidemiologic and Economic Model was used to study transmission, and included 31 cities across the United States with high HIV burden. The study modeled 4 scenarios: a “continuation” scenario where Ryan White services were not discontinued, a “cessation” scenario where Ryan White services were discontinued in July 2025 and viral suppression did not recover, a “brief interruption” scenario where viral suppression recovered in 2027, and a “prolonged interruption” scenario where viral suppression recovered in 2029. The proportion of Ryan White clients who would lose viral suppression was estimated from a survey of clinic directors, administrators, and health officials who were familiar with Ryan White programs. The primary outcome was the relative projected excess incident HIV infections from 2025 to 2030 due to Ryan White program cessation or interruption, while the secondary outcome was the absolute number of excess infections from 2025 to 2030. If Ryan White programs were not discontinued, 154,429 incident HIV infections would occur between 2025 and 2030. Discontinuation of Ryan White services in July 2025 would cause viral suppression to decrease from 74% in 2025 to 49% in 2026. In the “cessation” scenario, the number of additional infections would be 75,436 (95% CrI, 19,251 to 134,175) across all 31 cities, corresponding to an excess of 49%. In this scenario, infections increased by 65% (95% CrI, 17% to 113%) among adults aged 25 years or younger versus 45% (95% CrI, 12% to 79%) among those older than 25 years. The “brief interruption” scenario would see 28,999 additional infections (95% CrI, 7507 to 51,820; excess, 19%), while the “prolonged interruption” scenario would see 57,933 additional infections (95% CrI, 14,995 to 102,827; excess, 38%). In a “conservative” secondary analysis incorporating data from 2 observational studies of Ryan White clients, viral suppression decreased from 76% in 2025 to 63% (95% CrI, 59% to 67%) in 2026. In this scenario, permanent discontinuation of Ryan White services would lead to 34,051 additional infections (95% CrI, 23,902 to 45,147; excess, 22%), “brief interruption” would lead to 13,166 additional infections (95% CrI, 9290 to 17,439; excess, 9%), and the “prolonged interruption” scenario would lead to 26,336 additional infections (95% CrI, 18,477 to 34,908; excess, 17%). Overall, this study suggested that interruption of Ryan White services would decrease viral suppression and increase infection rates across the United States.

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