Adherence & Retention
Comparative Effectiveness of HIV Testing and Treatment in Highly Endemic Regions
Context
Universal testing and treatment holds promise for reducing the burden of HIV in sub-Saharan Africa, but linkage from testing to treatment sites and retention in care are inadequate.
Objective
To compare the mortality and epidemiologic implications of linkage to care and loss to follow-up when considering universal HIV testing and treatment.
Design, Settings, and Patients
We developed a simulation of the HIV epidemic and HIV disease progression in South Africa to compare the outcomes of the present scale up (Status Quo) with four strategies to increase access to antiretroviral therapy: (1) universal testing and treatment without changes in linkage to care and loss to follow-up; (2) universal testing and treatment with improved linkage to care; (3) universal testing and treatment with reduced loss to follow-up; and (4) comprehensive HIV care with universal testing and treatment, improved linkage to care, and reduced loss to follow-up.
Main Outcome Measures
Survival benefits, new HIV infections, and HIV prevalence.
Results
Compared to the Status Quo, universal testing and treatment (1) was associated with a life expectancy gain of 12.0 (11.3–12.2) months of life, and 35.3% (32.7%–37.5%) fewer infections over a 10-year time horizon. Improved linkage to care (2), prevention of loss to follow-up (3), and comprehensive HIV care (4) provided substantial additional benefits: life expectancy gains compared to the Status Quo were 16.1, 18.6, and 22.2 months, and new infections were 55.5%, 51.4%, and 73.2% lower, respectively. In sensitivity analysis, comprehensive HIV care reduced new infections by 69.7%–76.7% under a broad set of assumptions.
Conclusions
Universal testing and treatment with current levels of linkage to care and loss to follow-up could substantially reduce the HIV death toll and new HIV infections. However, scaling up linkage to care and preventing loss to follow-up provides nearly twice the benefits of universal testing and treatment alone.
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