Universal Voluntary HIV Testing with Immediate Antiretroviral Therapy as a Strategy for Elimination of HIV Transmission: A Mathematical Model

Department of HIV/AIDS, WHO, Geneva, Switzerland.
The Lancet (Impact Factor: 45.22). 12/2008; 373(9657):48-57. DOI: 10.1016/S0140-6736(08)61697-9
Source: PubMed


Roughly 3 million people worldwide were receiving antiretroviral therapy (ART) at the end of 2007, but an estimated 6.7 million were still in need of treatment and a further 2.7 million became infected with HIV in 2007. Prevention efforts might reduce HIV incidence but are unlikely to eliminate this disease. We investigated a theoretical strategy of universal voluntary HIV testing and immediate treatment with ART, and examined the conditions under which the HIV epidemic could be driven towards elimination.
We used mathematical models to explore the effect on the case reproduction number (stochastic model) and long-term dynamics of the HIV epidemic (deterministic transmission model) of testing all people in our test-case community (aged 15 years and older) for HIV every year and starting people on ART immediately after they are diagnosed HIV positive. We used data from South Africa as the test case for a generalised epidemic, and assumed that all HIV transmission was heterosexual.
The studied strategy could greatly accelerate the transition from the present endemic phase, in which most adults living with HIV are not receiving ART, to an elimination phase, in which most are on ART, within 5 years. It could reduce HIV incidence and mortality to less than one case per 1000 people per year by 2016, or within 10 years of full implementation of the strategy, and reduce the prevalence of HIV to less than 1% within 50 years. We estimate that in 2032, the yearly cost of the present strategy and the theoretical strategy would both be US$1.7 billion; however, after this time, the cost of the present strategy would continue to increase whereas that of the theoretical strategy would decrease.
Universal voluntary HIV testing and immediate ART, combined with present prevention approaches, could have a major effect on severe generalised HIV/AIDS epidemics. This approach merits further mathematical modelling, research, and broad consultation.

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Available from: Reuben Granich, Sep 05, 2014
    • "Kwange and Budambula also demonstrated that there was no significant difference in sputum conversion rates at 2-and 5-months between HIV-negative TB patients and HIV-positive TB patients on ART[26]. Current research suggests that ART should be started early and preferably as soon as a person is tested positively for HIV[14,232425, and opposed to current recommendations to use CD4 count of 350–500 cells/mm 3 or less, or clinical staging of disease to determine who was eligible for ART[20]. However, as more and more HIV-positive patients are put on ART, there will be additional burden on already overburdened staff and more patients will be at risk of immune reconstitution inflammatory syndrome. "
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    ABSTRACT: Sub-Saharan Africa (SSA) has borne the greatest burden of the tuberculosis (TB) and HIV pandemics. In attempt to halt and reverse the situation, World Health Organization-inspired policies have been adopted by many countries. However, implementing these policies have seen limited success. And few studies have been conducted to ascertain the factors influencing interventions and their implementation. This review therefore sought to use comparative analysis to determine the activities implemented, service delivery models as well as the barriers and facilitators of TB/HIV integration in SSA. Many literatures were identified and selected based on a criteria. Narrative approach was then used to review the literature. Eight articles were identified based on different TB/HIV integration programmes across SSA. TB/HIV implemented interventions were HIV screening for TB patients, co-trimoxazole preventive therapy and antiretroviral therapy for eligible HIV positive patients. Three main service delivery models with varying levels of integration were identified: referral, partial integration and full integration model. Staff shortages, poor documentation, lack of resources, irregular supply of drugs, inadequate infrastructure were barriers whereas direct supervision, standardization and mutual adjustment were identified as facilitators of integration. TB/HIV integration in SSA is feasible but the uptake of interventions has been low due to barriers arising from the local policies and other contexts. Identified facilitators can therefore be used to promote TB/HIV integration.
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    • "Adherence to recommended HIV screening and laboratory monitoring in this high-risk population are crucial steps in the HIV continuum and will likely require the development of genderspecific services to more effectively engage WWUDs in HIV prevention and treatment to prevent HIV infection and transmission. HIV testing and monitoring is central to HIV treatment-as-prevention strategies (Granich et al., 2009; Montaner, 2013). Important in these findings are factors that may facilitate and impede treatment-asprevention efforts. "
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    ABSTRACT: Background: Substance use and HIV are syndemic public health problems in Malaysia. Harm reduction efforts to reduce HIV transmission have primarily focused on men with substance use disorders. Objectives: To explore HIV risk behaviors, substance use, and social factors associated with poor health outcomes among women who use drugs in Malaysia. Methods: A cross-sectional survey of 103 drug-using women in Kuala Lumpur, Malaysia were recruited to assess their medical, psychiatric and social comorbidity as well as their engagement in nationally recommended HIV testing and monitoring activities. Results: One-third reported having ever injected drugs, with most (68.2%) having recently shared injection paraphernalia. Sex work (44.7%) and infrequent condom use (42.4%) were common as was underlying psychiatric illness and physical and sexual violence during childhood and adulthood. Most women (62.1%) had unstable living situations and suffered from an unmet need for social support and health services. HIV prevalence was high (20%) with only two thirds of women eligible for antiretroviral therapy having received it. Suboptimal HIV testing and/or monitoring was positively associated with interpersonal violence (AOR 2.73; 95% CI 1.04-7.14) and negatively associated with drug injection (AOR 0.28; 95% CI 0.10-0.77). Conclusions/importance: Women who use drugs in Malaysia demonstrate considerable medical, psychiatric and social co-morbidity, which negatively contributes to optimal and crucial engagement in HIV treatment-as-prevention strategies. Mental health and social support may be key targets for future public health interventions aimed at drug-using women in Malaysia.
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    • "However, on the other hand, timely HIV testing provides the benefits of reduction of the spread of the virus and continued health of infected individuals through access to HIV health care services. Several studies have shown that patients who initiate early ART are less likely to spread the virus [6] [7] [8] . "
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    ABSTRACT: Objective: To assess the prevalence of HIV infection, to highlight HIV-testing refusal rates among participants in a population-based tuberculosis survey and to assess the implication for programme implementation. Methods: This cross-sectional study on the characteristics of participants who refused HIV testing was conducted in a national survey in Zambia. All eligible participants were aged above 15 years and included in the analysis. Results: Out of the 44 791 tuberculosis survey participants, 14 164 (31.6%) refused to participate in HIV testing. The unemployed, rural dwellers, married, and those aged 15- 24 years were associated with higher refusal rates. Conclusions: Strategies to improve HIV testing acceptance are necessary. Qualitative research is recommended to understand the reasons for testing refusals so that remedial interventions can be implemented.
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