Would the 'test and treat' strategy work?

Would the 'test and treat' strategy work?

When a person becomes infected with HIV it can take up to three months before the virus is detected by standard antibody tests. If a person is tested during this time they may receive a ‘false negative’ result, which means that even though the test is negative, they are in fact infected with HIV. It is also during this period of time when they are most infectious.

Therefore even by treating everyone who tested positive for HIV to stop onward transmission of the virus, there would still be a group of people who had received a false negative result and who could still pass on the virus (at the point when they would be more infectious).

What would be the effects on the individual?

Once a person starts taking antiretroviral treatment, they have to take it exactly as prescribed, and for the rest of their life. If not, they significantly increase the risk of drug resistance. In addition, antiretroviral drugs often have unpleasant side effects and the long-term effects of taking the drugs are still unknown. It is for these reasons that treatment is currently only recommended when HIV has attacked the immune system to an extent where, without treatment, the person's health will start to deteriorate.¹² For many people living with HIV this means not starting treatment for years. Starting treatment at an earlier stage could therefore potentially be detrimental to the individual's health. It could also be viewed as unethical in countries where medical codes of practice make the care of the individual patient the doctor's first concern.

Is it feasible?

Other doubts raised are whether it would be possible to achieve the desired high HIV detection levels even in well-resourced countries, especially when stigma, criminalisation and human rights abuses act as strong deterrents to accessing testing services. Although substantial effort has already been invested into increasing the number of people tested for HIV, targets are far from being met. In America, for example, around 20 percent of those infected with HIV are unaware of their status, and many people are still only tested once they have been diagnosed with an opportunistic infection. Barriers that prevent people from getting tested would therefore need to be addressed.

The same is true for providing treatment: some countries are struggling to provide treatment for those who really need it. By the end of 2008 in developing and transitional countries, only 42 percent of those in need of antiretroviral treatment were receiving it. This falls short of the goal of providing antiretroviral treatment to 80 percent of those in need by 2010. If targets cannot be met now, it is highly unlikely there would be enough funding to treat those whose HIV infection has not yet significantly damaged their immune system.

In addition to providing more antiretroviral drugs, there would be administrative and human resources obstacles. These include finding additional doctors and nurses to prescribe the drugs, extra counsellors for pre and post-test counselling, and staff to support and encourage adherence among those taking treatment. It would be extremely difficult for countries to find the money for these costs in addition to finding the money to provide universal treatment. Indeed, the 'test and treat' strategy proposed by Granich and colleagues has been criticised for substantially underestimating the actual costs that it would entail.¹³ However, it has been argued that although in the short term it would be very costly, it has the potential to be cost-effective in the long term.