Abstract
Background 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. Methods and Findings 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. Conclusions 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.
Highlights
In June 2001, heads of state and government convened a United Nations Special Session on HIV/AIDS and adopted unanimously the ‘‘Declaration of Commitment on HIV/AIDS’’ [1]
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
Will the extension of antiretroviral therapy (ART) to millions who suffer from AIDS in developing countries be the long-awaited breakthrough in the response to HIV, or will the emphasis on treatment detract from prevention efforts, and hamper AIDS control in the medium and long term? The experience in high-income countries underscores the potential perils of failing to adapt prevention strategies to an environment in which life-saving treatment becomes available on a large scale; more favorable outcomes in some settings [12,13] indicate that rising risk behavior is not an inevitable outcome of increased treatment access
Summary
Infections from HIV continue to increase, especially in subSaharan Africa. The World Health Organization has a plan to get more than 3 million people on treatment by 2005 (the ‘‘3 by 5’’ initiative); the overall effect of this plan on the population’s health is uncertain, and will depend on the balance between treatment and prevention efforts. They tried to predict the number of new infections and deaths each year in sub-Saharan Africa until 2020 depending on whether control efforts focused on prevention, treatment, or both. What they found was that by far the most effective way of decreasing new infections and deaths was to combine the two approaches, and that by doing so more than 29 million new infections and 10 million deaths might be prevented compared with continuing at current levels of prevention and care. Policy makers around the world could use information like this to decide where best to direct attention and funding to combat HIV/AIDS. Where Can I Find More Information? Joint United Nations Programme on HIV/AIDS, AIDS epidemic update, December 2004: http://www.unaids.org/wad2004/report.html World Heath Organization, 3 by 5 Initiative: http://www.who.int/3by5/ Global HIV Prevention Working Group: http://www.kff.org/hivaids/ hivghpwgpackage.cfm
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