Why the new HIV Test and Treat policy is a good timing

By Joseph Wasswa

Ministry of Health released new HIV/AIDS guidelines, announcing the new HIV prevention strategy of "Test & Treat". This means that any person who tests HIV-positive is supposed to be enrolled on ART immediately without any other considerations and this is in line with World Health Organisation's global target of eliminating HIV/AIDS by 2030 and the ambitious 90-90-90.

As said by former Harvard retrovirology professor, William Haseltine (one of the pioneers of AIDS research), "universal test & treat (UTT) strategy now offers the best hope of controlling the HIV epidemic"

Given the narrow range of acceptable HIV prevention tools worldwide, UTT is currently fronted as the prospective new prevention strategy which possibly will be vastly effective in high HIV prevalence settings like Uganda. UTT encompasses giving voluntary counseling and testing to the whole population as well as immediately offering ART to all those who test HIV-positive regardless of their clinical stage or CD4 count.

This strategy has the potential of making a sharp decline in HIV new infections and as well can conceivably exterminate HIV as a public health misfortune in a time frame of 15-20 years to come resulting in plummeting the morbidities and mortalities associated with it according to WHO'S Mathematical Model, although these forecasts are centered on assumptions that may be questioned with some people contending that the probable effects of this intervention may be much more limited.  

As we strive to cause a positive impact in the fight against HIV/AIDS while implementing this seemingly unfeasible policy, we should not forget that it is by now apparent that most persons who test positive do not link with medical care or take months to start on ARVs due to a number of factors.

Furthermore, in pushing for test & treat as an HIV prevention strategy, we should not overlook the element of programmes performing very poorly when it comes to retaining patients in care after diagnosis or initiating individuals on ART before them falling utterly ill. It won't be enough for availing treatment as patients tend to not want to start treatment until they are clinically sick.

Besides, execution of this policy on a wide scale is going to prove logistically and economically perplexing and may overwhelm the prevailing health services. So promoting HIV testing should be the leading step in accessing care since it is being strongly advocated not only as a likely HIV prevention tool but also as one way of normalising and destigmatising HIV.

So to make the policy achievable, a better understanding of the obstacles to testing, knowledge of test result and the subsequent linkage to care should be attained to create vital operational modifications to service delivery.  Also extreme care should be taken since partial success may lead to the infection becoming concentrated in Most at Risk People (MARPs)  leading to augmented risk of stigma and coercion. Equally the other challenges are; solving the problem of how well the different modes of testing can help in linking the HIV-positive individuals to treatment and care, what are the consequences in respect to confidentiality, stigma and or pressure to accept test and sustaining of some testing models in the long term given the abundant competing priorities and pressures on resources.

A variety of models will need to be examined including; door-to-door campaigns and home-based testing; work-place VCT services, mobile test units that visit communities periodically, stand-alone VCT centers in conveniently placed communal locations (e.g. market-places, bus-stands, religious venues) and or on-site VCT within health units, provided either as a stand-alone service or integrated within healthcare provision in an "opt-out" model.

It is important to examine multiple options as there will be population sub-groups to whom some models will not be available or acceptable and alternatives should exist if high uptake is to be achieved. Community health workers, lay counselors and even "expert patients" may provide the most feasible option for roll-out of the test & treat policy. When assessing these questions, the quantity and quality of service provided by a given model of testing needs to be examined.

However, studies have shown that this strategy is more effective in terms of improving HIV testing accessibility to persons who need it as well having an extremely effective treatment outcome (Viral Suppression) in those who enroll during its implementation but has little impact on the number of HIV positive people started on ARVs explaining the lack of impact on new HIV infections observed in some places already implementing it, so the reasons for the unfortunate linkage to care will necessity to be unpacked.

Incidentally, in a presentation of his findings from the first major research study of ‘test and treat' as a public health intervention for eliminating HIV/AIDS,  a cluster-randomized controlled trial which began in 2012 titled "The impact of universal test and treat on HIV incidence in a rural South African population: ANRS 12249 TasP trial, 2012-2016 to the 21st International AIDS Conference, Durban (2016) by Dabis F et al. of the University of Bordeaux,  it was discovered that the policy unsuccessfully failed to decrease the HIV new infections in the populations where it was provided.

Nevertheless with this strategy, in the long term government and other stake holders will save money as it will drastically reduce the chance of an HIV-positive person transmitting the virus to others if he/she is on treatment and his/her viral load is undetectable.   

Additionally, this strategy is going to reveal our public health at its best and its worst, where at its best it is to prevent morbidity and mortality for the people through improved treatment of the person and reduced spread of the HIV disease. Whereas at worst, it may include over-testing, over-treatment, side effects, drug resistance and possibly reducing independence of the people in their choices of care.

The writer is medical practitioner