Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission

[Guest guest]

Editors' note: As traditional methods struggle to control the HIV, bold new

approaches are called for. In this modelling study, Reuben Granich and

colleagues from WHO propose annual universal testing of all people over the age

of 15 years for HIV, and starting antiretroviral treatment immediately,

regardless of CD4+ level, for those found to be HIV positive. Although initially

more expensive than present practice, the authors argue that such a scaled up

approach might actually lead to elimination of HIV and would

save money by 2050.

The Lancet, Volume 373, Issue

9657<http://www.thelancet.com/journals/lancet/issue/vol373no9657/PIIS0140-6736(0\

8)X6055-6>,

Pages 48 - 57, 3 January 2009

doi:10.1016/S0140-6736(08)61697-9<http://www.thelancet.com/popup?fileName=cite-u\

sing-doi>

Universal voluntary HIV testing with immediate antiretroviral therapy as a

strategy for elimination of HIV transmission: a mathematical model

Summary Background Roughly 3 million people worldwide were receiving

antiretroviral therapy (ART) at the end of 2007, but an estimated 6·7

million were still in need of treatment and a further 2·7 million became

infected with HIV in 2007. Prevention efforts might reduce HIV incidence but are

unlikely to eliminate this disease.

We investigated a theoretical strategy of universal voluntary HIV testing and

immediate treatment with ART, and examined the conditions under which the HIV

epidemic could be driven towards elimination.

Methods We used mathematical models to explore the effect on the case

reproduction number (stochastic model) and long-term dynamics of the HIV

epidemic (deterministic transmission model) of testing all people in our

test-case community (aged 15 years and older) for HIV every year and starting

people on ART immediately after they are diagnosed HIV positive.

We used data from South Africa as the test case for a generalised epidemic, and

assumed that all HIV transmission was heterosexual.

Findings The studied strategy could greatly accelerate the transition from the

present endemic phase, in which most adults living with HIV are not receiving

ART, to an elimination phase, in which most are on ART, within 5 years. It could

reduce HIV incidence and mortality to less than one case per 1000 people per

year by 2016, or within 10 years of full implementation of the strategy, and

reduce the prevalence of HIV to less than 1% within 50 years.

We estimate that in 2032, the yearly cost of the present strategy and

the theoretical strategy would both be US$1·7 billion; however, after this time,

the cost of the present strategy would continue to increase whereas that of the

theoretical strategy would decrease.

Interpretation Universal voluntary HIV testing and immediate ART, combined with

present prevention approaches, could have a major effect on severe generalised

HIV/AIDS epidemics. This approach merits further mathematical modelling,

research, and broad consultation.

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Dr RK Sood

drrksood@...

+91 9418064077, +91 9445157327