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Mauro Schechter, JournalWatch: “Test and Treat” Requires Attention to Early Infection


“Test and Treat” Requires Attention to Early Infection
by Mauro Schechter, MD, PhD, September 19, 2011

A mathematical model suggests that nearly 40% of new HIV infections are attributable to sexual contact with individuals who are in the early stages of infection. [my bolding —rk]

Mathematical models have suggested that testing all adolescents and adults annually for HIV infection and immediately treating those found to be infected (the “test-and-treat” approach) could significantly reduce, and even prevent, HIV transmission in the setting of a generalized HIV epidemic (JW AIDS Clin Care Dec 15 2008). However, some experts have questioned whether these models adequately account for the increased likelihood of viral transmission during early versus chronic infection. [my bolding —rk]

Now, researchers have developed a new mathematical model based on detailed behavioral and viral-load data collected in Lilongwe, Malawi, where heterosexual contact is the predominant mode of HIV transmission. The model included parameters for both casual and steady sexual partnerships and also allowed for changes in transmissibility during the course of infection. Early infection was defined as the first 6 months.

The findings:

  • Thirty-eight percent of all new infections are attributable to sexual contact with individuals who are in the early stages of infection.
  • Interventions aimed solely at decreasing transmission during early infection would significantly reduce the prevalence of HIV infection but would not, even with 100% coverage, eliminate HIV entirely.
  • Elimination of the epidemic is possible only with 95% to 99% coverage of interventions targeted at chronic infection. If that level of coverage is not attainable, substantial reductions in prevalence can be achieved by adding interventions that reach 25% to 75% of people with early infection.

Comment: The main advantage of this model is that it is based on empirical behavioral and viral-load data, whereas most others are based on assumptions. The results suggest that interventions aimed at reducing the prevalence and incidence of HIV infection must target early infection, [my bolding —rk] unless near-complete coverage of those with chronic infection is achieved. Implementing the test-and-treat approach would entail complex logistics, including frequent testing (at least every 6 months, if early infections are to be detected) and acceptance of long-term treatment on the part of all infected individuals. Given that financial resources are always limited, information is urgently needed on how best to use this and other interventions to get the biggest bang for the buck.

— Mauro Schechter, MD, PhD

Dr. Schechter is a Professor of Infectious Diseases at Universidade Federal do Rio de Janeiro, Head of the AIDS Research Laboratory at Hospital Universitario Clementino Fraga Filho, and Principal Investigator of Projeto Praça Onze at Hospital Escola São Francisco de Assis in Brazil. He reports no conflicts of interest.

Published in Journal Watch HIV/AIDS Clinical Care September 19, 2011

CITATION(S):

Powers KA et al. The role of acute and early HIV infection in the spread of HIV and implications for transmission prevention strategies in Lilongwe, Malawi: A modelling study. Lancet 2011 Jul 16; 378:256.

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