Comparative effectiveness of HIV testing and treatment in highly endemic regions.
BACKGROUND
Universal testing and treatment holds promise for reducing the burden of human immunodeficiency virus (HIV) in sub-Saharan Africa, but linkage from testing to treatment sites and retention in care are inadequate.


METHODS
We developed a simulation of the HIV epidemic and HIV disease progression in South Africa to compare the outcomes of the present HIV treatment campaign (status quo) with 4 HIV testing and treating strategies that increase access to antiretroviral therapy: (1) universal testing and treatment without changes in linkage to care and loss to follow-up; (2) universal testing and treatment with improved linkage to care; (3) universal testing and treatment with reduced loss to follow-up; and (4) comprehensive HIV care with universal testing and treatment, improved linkage to care, and reduced loss to follow-up. The main outcome measures were survival benefits, new HIV infections, and HIV prevalence.


RESULTS
Compared with the status quo strategy, universal testing and treatment (1) was associated with a mean (95% uncertainty bounds) life expectancy gain of 12.0 months (11.3-12.2 months), and 35.3% (32.7%-37.5%) fewer HIV infections over a 10-year time horizon. Improved linkage to care (2), prevention of loss to follow-up (3), and comprehensive HIV care (4) provided substantial additional benefits: life expectancy gains compared with the status quo strategy were 16.1, 18.6, and 22.2 months, and new infections were 55.5%, 51.4%, and 73.2% lower, respectively. In sensitivity analysis, comprehensive HIV care reduced new infections by 69.7% to 76.7% under a broad set of assumptions.


CONCLUSIONS
Universal testing and treatment with current levels of linkage to care and loss to follow-up could substantially reduce the HIV death toll and new HIV infections. However, increasing linkage to care and preventing loss to follow-up provides nearly twice the benefits of universal testing and treatment alone.
Bendavid
Eran
E
Division of General Internal Medicine, Center for Health Policy, Department of Management Science and Engineering, Stanford University, 117 Encina Commons, Stanford, CA 94305-8526, USA. ebd@stanford.edu
Brandeau
Margaret L
ML
Wood
Robin
R
Owens
Douglas K
DK
D000293:Adolescent; D000328:Adult; D019353:Endemic Diseases; D005260:Female; D015658:HIV Infections / Q000175:diagnosis* / Q000188:drug therapy* / Q000401:mortality; D006801:Humans; D008297:Male; D008403:Mass Screening; D008498:Medical Record Linkage; D015995:Prevalence; D013019:South Africa / Q000453:epidemiology; D055815:Young Adult