Clinical Uncertainties, Health Service Challenges, and Ethical Complexities of HIV "Test-and-Treat"

A Systematic Review

In 2011 some 2.5 million people worldwide were newly infected with HIV. One promising strategy to control the spread is called test-and-treat. This strategy calls for routinely testing individuals for HIV and immediately starting those infected on anti-retroviral therapy (ART), regardless of the stage of their disease. This would reduce infected individuals’ plasma viral load and the likelihood of them transmitting the infection.

These researchers conducted a systematic review of the scientific literature to identify clinical, health service, and ethical issues surrounding the test-and-treat strategy.

"Despite the test-and-treat strategy's promise, unanswered questions about its clinical rationale, operational feasiblity, and ethical appropriateness have led to vigorous debate in the global HIV community."

Key Findings

  • Published models showing test-and-treat as eliminating HIV were derived from “uncertain or unreal assumptions.”

  • Concerns were raised that test-and-treat would lead to more risk-taking among HIV-infected individuals and have less effect on preventing HIV transmission.

  • Test-and-treat depends on timely detection of infection and that is not feasible in high-prevalence settings that also are low on health resources.

  • Early treatment and life-long ART treatment may lead to drug toxicity and drug resistance.

  • Poverty, incarceration, substance abuse, and stigma present barriers to ART adherence.