We know that potential pitfalls exist that could
make the test-and-treat strategy difficult to accomplish. Larger-scale
proof-of-concept trials will help determine whether those pitfalls
can be avoided.
many parts of the world, people are afraid of being tested and finding
out that they are infected with HIV. Educating, engaging and working
closely with people living in affected communities are essential
Taking drugs regularly and on schedule for the rest of a person’s
life (or until a cure is found) is not easy. ART also carries side
effects that reduce compliance. Fortunately, studies have consistently
shown that compliance in places like Africa is generally better
than in the developed world.
Viral load suppression
and drug resistance. We must be able to reduce and
keep the viral loads of HIV-positive people at undetectable levels.
New drug regimens make this achievable and there is evidence that
as drug treatment has improved over the last 15 years, there has
been a corresponding decline in the levels of both acquired and
transmitted drug resistance.
The most effective way to ensure that there is little or no residual
transmission is to monitor transmission among discordant couples
(couples in which only one person is infected). When such events
occur, it may be necessary to genotype the infections to determine
if the person was infected from inside or outside the relationship.
While this raises ethical questions that must be dealt with, genotyping
will be the most direct measure of effectiveness.
Costs and cost-effectiveness.
A published work by the World
Health Organization estimates that if test-and-treat were used throughout
South Africa, it would prevent 3.8 million new cases of HIV and
3.9 million deaths, and save $11 billion during the next 40 years.
The test-and-treat strategy would also cut the costs of disabilities
associated with HIV/AIDS, bringing the total saved during the next
40 years to $17.4 billion in South Africa alone. Additional cost/benefit studies will need to be conducted as part of the test-and-treat proof of concepts to determine how the strategy impacts long-term costs, employment, tax revenues and several other socioeconomic factors.