Universal HIV testing and immediate treatment could reduce but not eliminate HIV/AIDS epidemic
Study examines real-world impact of strategy in Washington, D.C.
9-Jul-2010 - Implementing a program of universal HIV testing and immediate antiretroviral treatment (ART) for infected individuals could have
a major impact on the HIV/AIDS epidemic in Washington, DC, but a new study finds that it would not halt the epidemic, something that a previous report had projected.
In a paper that will appear in the August 15 issue of Clinical Infectious Diseases and has been released online, researchers find that the so-called "test-and-treat"
strategy could reduce new HIV infections by 15 percent over the next five years while conferring large survival benefits to HIV-infected patients.
"Test-and-treat will save lives, but it won't stop the HIV epidemic in its tracks all by itself," says Rochelle P. Walensky, MD, MPH, of the Massachusetts
General Hospital (MGH) Division of Infectious Disease, who led the study." It is only a single new and important page in the HIV-prevention playbook."
Test-and-treat has been the subject of widespread interest and controversy in the scientific community. In January 2009, WHO scientists published a report in The Lancet suggesting
that a voluntary system of annual HIV testing of all adults, followed by immediate provision of ART for those testing positive, "could nearly stop transmission and drive HIV into an
elimination phase." Inspired by these findings, researchers and public health officials have rushed to design and implement test-and-treat studies and interventions. The National
Institute for Allergy and Infectious Diseases (NIAID) recently announced a two-year, $26.4 million partnership with the Washington, DC, Department of Health that includes a pilot
study of the test-and-treat strategy. However, some experts have expressed concern that the assumptions underlying the WHO findings painted too optimistic a picture of the likely outcomes.
The current study used epidemiologic data and results from HIV screening programs conducted in the U.S. capital to give a realistic picture of the likely impact of a test-and-treat
effort in that city, which has one of the nation's largest rates of HIV infection. This contrasts with the WHO study which employed data from sub-Saharan Africa and assumed truly universal screening and
treatment with optimal clinical outcomes. "The reality of HIV screening programs, even the best ones, is that many people are never reached for screening, some refuse screening or do not link to care,
and many of those who are treated do not maintain viral suppression," notes Kenneth A. Freedberg, MD, MSc, of the MGH Department of Medicine, the report's senior author.
"The benefits of expanded testing to persons with undiagnosed HIV infection are unquestioned," Walensky says. "Earlier detection and linkage to care saves lives; this alone is a reason for
test-and-treat. But pinning all our hopes on the latest 'magic bullet,' underestimating the logistical obstacles, and forgetting that prevention requires an integrated package of strategies puts us at
risk of falling into a trap we've seen before. Our analysis suggests that test-and-treat will likely be a very important addition to the treatment and prevention armamentarium, but the
expectations for its impact should be realistic."
Walensky and Freedberg are both associate professors of Medicine at Harvard
Medical School. Additional co-authors of the Clinical Infectious Diseases
report are Bethany Morris, Callie Scott, MSc, and Erin Rhode, MS, MGH Department
of Medicine; A. David Paltiel, PhD, Yale School of Medicine; Elena Losina, PhD,
Brigham and Women's Hospital; and George Seage, ScD, Harvard School of
Public Health. The study was supported by grants from the NIAID, the National Institute
of Mental Health and the Doris Duke Charitable Foundation.
Massachusetts General Hospital, established in 1811, is the original
and largest teaching hospital of Harvard Medical School. The MGH conducts
the largest hospital-based research program in the United States, with an annual
research budget of more than $600 million and major research centers in AIDS, cardiovascular
research, cancer, computational and integrative biology, cutaneous biology, human genetics, medical
imaging, neurodegenerative disorders, regenerative medicine, systems biology, transplantation biology and photomedicine.
Contact: Sue McGreevey
Massachusetts General Hospital