Case Study 18: Test & Treat

[HIV Ethics&Policy]

 

An exciting new discussion.  Please send your responses to 

<policy...@googlegroups.com>,

Test & Treat debate

Granich et al

In a recent modelling study, WHO researchers suggested that 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. Elimination of HIV in generalised epidemics may be feasible by 2020. (See Lancet Editor's summary)

 Critiques

• ·    Dieffenbach & Fauci: The model should include variable such as increased behavioural disinhibition, drug resistance, and the higher frequency of transmission during acute HIV infection.
• ·         Wagner & Blower: Elimination would take 70 years.  However our modeling results show treatment could act as an effective prevention tool and significantly reduce transmission, even if only symptomatic individuals receive ARVs. Treatment should first, and foremost, be used for therapeutic purposes. Hence, we recommend – when resources are limited – targeting those in need of treatment.

 

Questions for discussion:

1. 1.    In view of the fact that SA has the largest number of PWAs in the world, is the Test & Treat (T&T) strategy one that the Dept/Health should be considering now? Why, or why not?
2. 2.    What impact, do you think, would T&T have on the individual-level (sexual behaviour, risk perception, stigma)?
3. 3.    On societal-level (perceptions of HIV/AIDS, discrimination, public health care systems, other chronic illnesses)?
4. 4.    Where should the money for T&T come from?  Should SA siphon off money from other prevention strategies (male circumcision, vaccine research, condoms) and education campaigns (Komanani, World AIDS Day events)?
5. 5.    What would T&T mean for the health system?  Task-shifting? TB?
6. 6.    How will we get all people to test for HIV? 
7. 7 Additional Comments?

 

 

 Sources:

Granich RM, Gilks CF, Dye C, De Cock KM, Williams BG. Universal voluntary

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

HIV transmission: a mathematical model. Lancet. 2009;373(9657):48-57.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)61697-9/fulltext?_eventId=login

 

Universal Voluntary Testing and Treatment for Prevention of HIV Transmission

Carl W. Dieffenbach, PhD; Anthony S. Fauci, MD

JAMA. 2009;301(22):2380-2382.

http://www.who.int/hiv/events/artprevention/dieffenbach.pdf

 

 

Voluntary universal testing and treatment is unlikely to lead to HIV elimination: a modeling analysis

Bradley G. Wagner1 and Sally Blower

Natureprecedings

http://precedings.nature.com/documents/3917/version/1