The role of testing and counselling for HIV prevention and care in the era of scaling-up antiretroviral therapy.
ABSTRACT HIV Testing and Counselling (TC) programmes are being scaled-up as part of efforts to provide universal access to antiretroviral treatment (ART).
Mathematical modelling of TC in Zimbabwe shows that if universal access is to be sustained, TC must include prevention counselling that enables behaviour change among infected and uninfected individuals. The predicted impact TC is modest, but improved programmes could generate substantial reductions in incidence, reducing need for ART in the long-term.
TC programmes that focus only on identifying those in need of treatment will not be sufficient to bring the epidemic under control.
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ABSTRACT: The current moves to provide access to antiretroviral therapy (ART) to all in need has led to a push to HIV test. In particular, there have been policy moves endorsed by the World Heath Organization and UNAIDS to introduce routine 'opt out' HIV testing in countries with high prevalence. A number of claims have been made with regard to the benefits of increasing the numbers of people on antiretroviral therapy. Two of these claims are disputed here. Treatment roll-out and the associated push for routine testing raise questions of concern to public health and human rights. While it is claimed that treatment roll-out will reduce stigma and discrimination, there is little evidence to support the claim. It is also claimed that treatment uptake will reduce the likelihood of HIV transmission and that thus treatments themselves have a preventive effect. This direct effect of treatment uptake on prevention is augmented, it is claimed, if use is made of the voluntary counselling and testing (VCT) encounter and people counselled to act safely. Again there is little evidence to support the claims made. In addressing the evidence for these two claims, the paper cautions against the large scale adoption of routine 'opt out' or, as it is sometimes called, 'provider-initiated' testing.AIDS Care 05/2006; 18(3):230-5. · 1.60 Impact Factor
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ABSTRACT: To investigate HIV incidence during a trial of two voluntary counselling and testing (VCT) strategies. Counselling may promote beneficial behavioural change, although knowledge of negative status does not appear to contribute further benefit. The parent cluster-randomized trial demonstrated much greater uptake of VCT when counselling and rapid testing were available on-site (intensive VCT) than through pre-paid vouchers to an external provider (standard VCT). Anonymous HIV tests had been requested from all employees at enrolment and after 2 years intervention. The study setting was 22 businesses in Harare, Zimbabwe. Participants were 3146 HIV-negative individuals remaining in employment at the end of intervention, of whom 2966 (94.3%) consented to repeat testing. VCT linked to basic HIV care was provided and the main outcome measures were HIV incidence under each study arm, as a retrospective secondary analysis. Mean VCT uptake in this cohort was 70.7 and 5.2%, respectively, in the intensive and standard arms. Crude HIV incidence was 1.21 per 100 person-years, with non-significantly higher rates in the intensive VCT arm [mean site incidence 1.37 and 0.95 per 100 person-years, respectively; adjusted rate ratio 1.49 (95% confidence interval 0.79-2.80). Highly acceptable VCT did not reduce HIV incidence in this predominantly male cohort. HIV incidence was highest in the high uptake VCT arm, lending support to a US trial in which rapid testing appeared to have adverse behavioural consequences in some HIV-negative clients. Careful comparison of outcomes under different counselling and testing strategies is needed to maximize HIV prevention from global scale-up of VCT.AIDS 03/2007; 21(4):483-9. · 6.41 Impact Factor
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ABSTRACT: Through major efforts to reduce costs and expand access to antiretroviral therapy worldwide, widespread delivery of effective treatment to people living with HIV/AIDS is now conceivable even in severely resource-constrained settings. However, the potential epidemiologic impact of treatment in the context of a broader strategy for HIV/AIDS control has not yet been examined. In this paper, we quantify the opportunities and potential risks of large-scale treatment roll-out. We used an epidemiologic model of HIV/AIDS, calibrated to sub-Saharan Africa, to investigate a range of possible positive and negative health outcomes under alternative scenarios that reflect varying implementation of prevention and treatment. In baseline projections, reflecting "business as usual," the numbers of new infections and AIDS deaths are expected to continue rising. In two scenarios representing treatment-centered strategies, with different assumptions about the impact of treatment on transmissibility and behavior, the change in the total number of new infections through 2020 ranges from a 10% increase to a 6% reduction, while the number of AIDS deaths through 2020 declines by 9% to 13%. A prevention-centered strategy provides greater reductions in incidence (36%) and mortality reductions similar to those of the treatment-centered scenarios by 2020, but more modest mortality benefits over the next 5 to 10 years. If treatment enhances prevention in a combined response, the expected benefits are substantial-29 million averted infections (55%) and 10 million averted deaths (27%) through the year 2020. However, if a narrow focus on treatment scale-up leads to reduced effectiveness of prevention efforts, the benefits of a combined response are considerably smaller-9 million averted infections (17%) and 6 million averted deaths (16%). Combining treatment with effective prevention efforts could reduce the resource needs for treatment dramatically in the long term. In the various scenarios the numbers of people being treated in 2020 ranges from 9.2 million in a treatment-only scenario with mixed effects, to 4.2 million in a combined response scenario with positive treatment-prevention synergies. These analyses demonstrate the importance of integrating expanded care activities with prevention activities if there are to be long-term reductions in the number of new HIV infections and significant declines in AIDS mortality. Treatment can enable more effective prevention, and prevention makes treatment affordable. Sustained progress in the global fight against HIV/AIDS will be attained only through a comprehensive response.PLoS Medicine 02/2005; 2(1):e16. · 15.25 Impact Factor