Test All, Treat All for HIV: Just Another Shot in the Dark

The authors of an article entitled ‘HIV drugs for treatment, and for prevention’ write as if to ask why we would delay using antiretroviral (ARV) drugs for preventing, in addition to for treating HIV, when so much evidence points to the effectiveness of such a strategy. But their rhetoric could be interpreted another way. They and others in the HIV industry seem to be saying, in a tone of mounting desperation, “Look, nothing else has worked so far, let’s try it until something else comes along”. In a list of failed possibilities including condoms, behaviour change of various kinds, circumcision, vaccines, microbicides and treating other sexually transmitted infections (STI), something else probably will come along. Whether that something will also fail remains to be seen.

The authors may object that some of those possibilities have not failed, for example, circumcision. Well, results of circumcision trials and even large scale circumcision rollout are shrouded in controversy but in Kenya, the only place where substantial numbers have been circumcised, the issue is far from resolved. And the biggest worry for some people is that Kenya does not have adequate health facilities to rollout any widespread programme safely. Aside from that, some worry that the program is being rolled out before its effectiveness has been adequately demonstrated. Maybe circumcision can help in areas where levels are currently low but this is by no means clear.

The effectiveness of condoms, also, is not as clear as one might expect. The latest results from the Kenya Demographic and Health Survey, 2008-09, suggests that people using condoms are often more likely to be HIV positive. It’s not certain why this is so and people would be unwise to give up using condoms, but a major problem with condoms and contraception in general in some countries, Uganda, for example, is availability and accessibility. The Kenyan DHS report, along with many other DHS reports, also cast doubt on the value of various behaviour change campaigns. Behaviour often doesn’t change, for various reasons. But even where it does, this doesn’t seem to have much impact on HIV transmission.

Testing everyone for HIV and treating everyone found to be HIV positive, the strategy advocated by the authors in question, may well have its virtues. If it’s possible to test everyone in every country that has high HIV prevalence regularly, perhaps every year, that would be a good start. Then, being able to treat all of them, for the rest of their lives, would also be required. Mathematical models have shown, apparently, that if such massive numbers of people could be tested regularly and then treated for the rest of their lives this would, under optimal conditions, quickly eradicate HIV (although not all models are in agreement). All we have to do is ensure optimal conditions.

Uganda doesn’t currently have optimal conditions for such a strategy, nor does any other high prevalence country. Testing is slow, many have never been tested, others return for testing more than once but most don’t. There is even an unmet demand for testing which may take some time to meet, given the country’s poor infrastructure and health network. Condom distribution is failed by a stop-start supply and contraception more generally suffers from similar problems, despite family planning being pursued in the country for several decades before HIV was recognised.

In fact, the country’s reasonably modest aim, to treat all HIV positive people who have reached a specific stage of disease progression, is not being met either. Drugs often don’t reach their destination or arive too late. Some remain in storage, even until they have expired, because of lack of infrastructure and health systems. Funding for ARV treatment comes exclusively from external donors. And these donors are talking about reducing funding substantially, some have already done so. An important question is not just about whether these conditions will be changed but would it really be possible to successfully implement a strategy like ‘test and treat’? Does the country’s performance over the past 25 years suggest that it would be possible?

The results of trials that show that HIV transmission is very low when people are on ARV treatment seem impressive. But a universal ‘test and treat’ programme would be, presumably, rolled out under the same conditions as previous HIV prevention programmes. Or maybe the latest one will be rolled out under optimal conditions? Maybe health institutions, infrastructures, education and other social services will be improved to the extent that this test and treat programme will work. It seems likely that HIV transmission would reduce somewhat without a test and treat programme under these conditions. At least it would be a possibility, however surplus to requirements it may become.

But there is still the same worry about this and all the failed or failing programmes that went before: shouldn’t we be frank about what we know and don’t know about HIV transmission, especially the extent to which HIV is sexually transmitted? We know HIV is not always transmitted sexually, but the HIV industry is very coy about admitting the extent of non-sexual transmission. And all the programmes listed above presuppose sexual transmission of HIV, whether they involve vaccines, microbicides, condoms, behaviour change, circumcision, STI treatment or a selection of these combined. Maybe test and treat is different, perhaps it will also reduce non-sexual HIV transmission. But it won’t, on its own, alter the circumstances that result in non-sexual transmission. Rolling out a disease prevention programme that is indifferent as to how that disease is spread seems foolhardy.