title: Universal access to HIV treatment versus universal 'test and treat': transmission, drug resistance & treatment costs.
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.
authors.affiliation: David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, United States of America.
authors.forename: Bradley G
authors.initials: BG
authors.lastname: Wagner
authors.forename: Sally
authors.initials: S
authors.lastname: Blower
mesh_terms: D015496:CD4-Positive T-Lymphocytes / Q000166:cytology; D003140:Communicable Disease Control; D024882:Drug Resistance, Viral; D015658:HIV Infections / Q000175:diagnosis / Q000191:economics / Q000453:epidemiology / Q000628:therapy*; D017048:Health Care Costs; D006297:Health Services Accessibility; D006301:Health Services Needs and Demand / Q000191:economics; D006801:Humans; D008962:Models, Theoretical; D015995:Prevalence; D013019:South Africa; D014944:World Health Organization