Our proposal to end AIDS

Variables

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.

Acceptability. In 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 steps.

Compliance. 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.

Residual transmission. 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.