Universal Access to HIV Treatment versus Universal ‘Test and Treat’: Transmission, Drug Resistance &amp; Treatment Costs

Bradley G Wagner,Sally Blower,D William Cameron

doi:10.1371/journal.pone.0041212

Universal Access to HIV Treatment versus Universal ‘Test and Treat’: Transmission, Drug Resistance & Treatment Costs

Bradley G Wagner, Sally Blower + Show 1 more

Open Access

https://doi.org/10.1371/journal.pone.0041212

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Journal: PloS one	Publication Date: Sep 5, 2012
Citations: 71	License type: CC BY 4.0

Affiliation: University of California, Los Angeles

Abstract

In South Africa (SA) universal access to treatment for HIV-infected individuals in need has yet to be achieved. Currently ∼1 million receive treatment, but an additional 1.6 million are in need. It is being debated whether to use a universal ‘test and treat’ (T&T) strategy to try to eliminate HIV in SA; treatment reduces infectivity and hence transmission. Under a T&T strategy all HIV-infected individuals would receive treatment whether in need or not. This would require treating 5 million individuals almost immediately and providing treatment for several decades. We use a validated mathematical model to predict impact and costs of: (i) a universal T&T strategy and (ii) achieving universal access to treatment. Using modeling the WHO has predicted a universal T&T strategy in SA would eliminate HIV within a decade, and (after 40 years) cost ∼$10 billion less than achieving universal access. In contrast, we predict a universal T&T strategy in SA could eliminate HIV, but take 40 years and cost ∼$12 billion more than achieving universal access. We determine the difference in predictions is because the WHO has under-estimated survival time on treatment and ignored the risk of resistance. We predict, after 20 years, ∼2 million individuals would need second-line regimens if a universal T&T strategy is implemented versus ∼1.5 million if universal access is achieved. Costs need to be realistically estimated and multiple evaluation criteria used to compare ‘treatment as prevention’ with other prevention strategies. Before implementing a universal T&T strategy, which may not be sustainable, we recommend striving to achieve universal access to treatment as quickly as possible. We predict achieving universal access to treatment would be a very effective ‘treatment as prevention’ approach and bring the HIV epidemic in SA close to elimination, preventing ∼4 million infections after 20 years and ∼11 million after 40 years.

Highlights

Treating HIV-infected individuals has both a therapeutic and a preventive effect, because treatment reduces viral load
Our analysis of Rc shows if the treatment-induced reduction in infectivity is $85%, the HIV epidemic in South Africa could be eliminated by using a universal ‘test and treat’ strategy
These results are in agreement with those of the World Health Organization (WHO) [5,10]

Summary

Introduction

Treating HIV-infected individuals has both a therapeutic and a preventive effect, because treatment reduces viral load. Granich and colleagues at the World Health Organization (WHO) have claimed, based on mathematical modeling, that a universal T&T strategy would lead (within a decade) to HIV elimination in South Africa and cost less (over 40 years) than achieving universal access to treatment in that country [5,10]. We use a modified version of this model, which incorporates greater realism, to predict the impact on the HIV epidemic in South Africa of (i) a universal T&T strategy and (ii) achieving universal access to treatment. The universal T&T strategy is based on annual HIV testing for the entire population of South Africa (,30 million adults aged between 15 and 49 years) and providing immediate treatment for all HIV-infected adults regardless of their CD4 cell count (i.e., their need for treatment). We compare our predictions with the WHO’s predictions [5,10]

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