Universal Testing, Prompt Treatment Could Slash HIV
WEDNESDAY Nov. 26, 2008 -- A combination of universal voluntary HIV testing and immediate antiretroviral treatment (ART) following diagnosis of HIV infection could reduce HIV cases in a severe generalized epidemic by 95 percent within 10 years, a World Health Organization study finds.
The researchers used computer modeling to examine the impact of testing all people aged 15 years and older for HIV every year and starting ART immediately after a person is found to be infected with HIV, the virus that causes AIDS. Data from South Africa was used as a test case for a generalized epidemic, and the model assumed all HIV transmission was heterosexual.
"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," wrote Dr. Reuben Granich, of the WHO's department of HIV/AIDS, and colleagues.
"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 generalized epidemic, such as that in South Africa. This analysis lends support to, and extends, earlier analyses suggesting that rapid scale-up of conventional ART approaches could greatly reduce mortality and have a substantial effect on HIV incidence."
They said this approach "merits further mathematical modeling, research, and broad consultation."
The study was published online and in an upcoming print issue of The Lancet.
In an accompanying comment on the study, Professor Geoffrey P. Garnett of Imperial College London, U.K., wrote that this type of HIV control 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," Garnett wrote. "At its worst, the strategy would 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," Garnett wrote.
Posted: November 2008