Can Universal Testing and Treatment Reduce HIV Infection Rates?

Health Official Weigh the Benefits and Challenges

Credit: Mario Tama/Getty Images

Despite advances in the treatment and management of HIV, the annual rate of new infections in the U.S. remains steady at around 50,000 cases per year. Moreover, the U.S. Centers for Disease Control and Prevention (CDC) reports that of the estimated 1.1 million Americans living with HIV, nearly one in five has never been tested, while nearly 56% of those diagnosed with HIV are not receiving medical care.

In response to these statistics, the U.S. Prevention Services Task Force (USPSTF) issued recommendations in April 2013 that all Americans ages 15 to 65 be tested for HIV.

Furthermore, the panel recommended periodic screenings for individuals at high-risk of infection, including men who have sex with men (MSM), active injection drug users (IDUs), and persons who have acquired or are requesting testing for a sexually transmitted disease (STD).

Meanwhile, the U.S. Department of Health and Human Services (DHHS) also updated their guidelines in 2013, recommending antiretroviral therapy (ART) for all HIV-infected people—with "strong" recommendations for therapy CD4 counts under 500 cells/µL and "moderate" recommendations for CD4 counts over 500 cells/µL.

This places the U.S. in discordance with other international guidelines, including those of the World Health Organization (WHO), which endorses ART at CD4s under 500.

In doing so, it edges the U.S. even closer to a Universal Voluntary Testing and Treatment (UTT) policy, a strategy whereby ART is initiated at the time of diagnosis.

What Is Universal Testing and Treatment (UTT)?

While UTT has been theorized for some years now, the concept really only came to the fore in 2006 when Julio Montaner of the British Columbia Centre for Excellence in HIV/AIDS presented mathematical evidences showing that universal ART of those infected with HIV could shrink the global HIV population from 40 million to one million by 2050.

Much of the research that ensued focused on the implication of UTT in hyper-prevalent regions such as sub-Saharan Africa, where the infection rates can run in excess of 20%.

One 2009 study conducted by the WHO looked specifically at South Africa—a country with the largest HIV population in the world—and concluded that by identifying and placing every HIV-infected South African on treatment, UTT could

  • reduce HIV incidence and mortality to less than one case per 1,000 (or 0.1%) per year within 10 years, while;
  • reducing the prevalence of HIV to less than 1% within 50 years.

However, a number of studies have since contradicted the WHO findings. One such study conducted by the UCLA Center for Biomedical Modelling estimated that it would take 40 years, not 10, to reduce HIV incidence and mortality to 0.1%, and suggested that an underestimation of costs by the WHO—both real and logistical—could make the program wholly unsustainable.

Furthermore, the study criticized the WHO for ignoring the potential risk and implications of population-based HIV resistance.

Evidence in Support of UTT

Despite divergent opinions, supporters of UTT point to several key studies which show that, in certain populations, the strategy can significantly reduce the so-called "community viral load" (CVL). Mounting evidence supports the theory that by reducing a population's CVL through ART, the relative potential for HIV transmission is reduced. In short, lower CVL correlates to lower transmission rates.

In 2010, San Francisco became the first city to implement a "test and treat" policy, a decision largely considered controversial at the time. In a study presented at the 2012 Conference on Retroviruses and Opportunistic Infections (CROI), researchers from the University of California San Francisco reported that, as a result of the new policy, the proportion of people starting ART with a CD4 of over 350 increased from 48% in 2004 to 92% in 2010.

Moreover, of those who entered the program with a CD4 count of over 500, 50% were able to rapidly suppress their viral load to undetectable levels. Previous to this, only one in ten were able to achieve this.

Mathematical modelling from San Francisco General Hospital has since predicted that the policy will result in a 76% decrease in new infections among MSM by the year 2015. MSM comprise nearly 90% of the city's HIV population.

Challenges of UTT Implementation

Despite evidence of success in San Francisco, it's clear that the dynamics of the disease vary greatly from community to community. In short, what may well work in San Francisco—where 82% of those living with HIV are linked to care and are predominantly white (63%)—may not work as well in Chicago, where only half are linked to care and are predominantly African-African (60%).

The challenges to implementation, therefore, go well beyond the simple provision for UTT. It demands a coordinated and targeted multidisciplinary response in order to achieve a number of key goals, namely:

  • Increasing HIV testing, particularly in communities with high seroprevalence. This includes offering routine, opt-out screenings not only at emergency rooms, sexual health clinics and drug treatment centers, but in primary care settings and during hospital admissions.
  • Linking and retaining those who have tested positive to appropriate medical care. Many U.S. cities are now enacting integrated "TLC" (Test-Link-to-Care) programs to better ensure that patients access care at the time of diagnosis.
  • Increasing outreach to at-risk communities. This is not only to identify new HIV infections, but to locate and re-engage patients "lost to follow up" to the appropriate medical care.
  • Enlisting newly diagnosed individuals to voluntarily refer others from their social, sexual, or drug-using networks for HIV testing. A number of these programs have demonstrated new positivity rates of between 3.4% and 7.1%, compared to just 1.1% identified in traditional urgent care settings.
  • Improving treatment adherence and viral suppression of those on ART. According to the CDC, only 28% of Americans on ART have fully suppressed viral loads. At this level, one can expect to have an additional 1.2 million new infections by 2033. Increased monitoring, centralized data collection, and viral load "mapping" (to identify spatial distribution of CVL by community) are seen as viable means by which to reverse this trend.

So IS UTT a Done Deal?

A number of U.S. cities have begun taking steps to integrate these and other programs into their public health services. Whether this means that "test-and-treat" will actively be adopted as a standard-of-practice remains to be seen.

There are still a number of contentious issues surrounding UTT, not least of which are the potential long-term drugs toxicities that some believe have not yet been fully assessed. Others are not convinced that early ART initiation will return a so-called "survival benefit," while others still query the ethical and functional challenges of UTT implementation.

The Strategic Timing of Antiretroviral Treatment (START) trial will likely provide more definitive answers to some of these questions. The study, which enrolled 4,000 people in 34 countries, will compare immediate versus deferred ART in individuals with CD4 counts over 500. Data from the trial is expected to be released in 2015.


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