Universal test and treat strategy could dramatically cut new HIV infections, model predicts
Annual, universal voluntary HIV testing followed by immediate antiretroviral therapy (ART) for those with a positive diagnosis (irrespective of clinical stage or CD4 count) would reduce new cases of HIV infection in a severe epidemic from 20 in 1,000 people to one in 1,000 within 10 years, a mathematical model developed by specialists from the World Health Organization predicts (26 November, www.thelancet.com).
Such a strategy could have additional public health benefits, suggest the authors of the study, including a reduction in the incidence of tuberculosis and the transmission of HIV from mother to child. The model also suggests that there could be a significant reduction of HIV-related morbidity and mortality in resource limited countries with generalised HIV epidemics.
The Lancet paper points out that roughly three million people worldwide had received ART by the end of 2007, but an estimated 6.7 million were still in need of treatment and a further 2.7 million became infected in 2007.
The authors say: “Instead of dealing with the constant pressure of newly infected people, mortality could decrease rapidly and the epidemic could begin to resemble a concentrated epidemic with particular populations remaining at risk. The focus of control would switch from making ART available to people with greatest need to providing support and services for those who are receiving ART. Transmission could be reduced to low levels and the epidemic could go into a steady decrease towards elimination as those receiving ART grew older and died.
“Although other prevention interventions, alone or in combination, could substantially reduce HIV incidence, our model suggests that only universal voluntary HIV testing and immediate initiation of ART could reduce transmission to the point at which elimination might be feasible by 2020 for a generalised epidemic, such as that in South Africa.”
In an accompanying comment piece, WHO researchers point out that the paper does not signal a change in WHO guidance on HIV treatment. However, they call for further research and discussion.
They say: “Advantages of immediate treatment on diagnosis could include: simplified clinical management, reduction in the high mortality rates from late diagnosis, control of HIV-associated tuberculosis and effective prevention of mother-to-child transmission of HIV, including through breastfeeding.”
However, they note: “Feasibility is challenged by: weak health systems and inadequate health personnel, choice of appropriate drug regimens, treatment adherence, drug toxicity, drug resistance and need for durable second- and third-line regimens, the logistics, reliability and acceptability of regularly testing a whole population for HIV infection and behavioural risk compensation.”
In a second comment piece, Geoffrey Garnett and Rebecca Baggaley, of Imperial College London, say: “The suggested strategy would reflect public health at its best and its worst. At its best, the strategy would prevent morbidity and mortality for the population, both through better treatment of the individual and reduced spread of HIV. At its worst, the strategy will involve over-testing, over-treatment, side-effects, resistance and, potentially, reduced autonomy of the individual in their choices of care.
"The individual might gain no personal benefit from testing and early treatment, but they would benefit from protecting partners — and who could object to that, unless they were recklessly exposing others to infection? It is easy to see how enforced testing and treatment for the good of society would follow from such an argument. Partial success would lead to infection becoming concentrated in those with a high risk, with an increased danger of stigma and coercion.”
Citation: The Pharmaceutical Journal URI: 10040930
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