The debate about universal coverage gained momentum after a series of recently-published papers demostrated the evident benefits in starting ART earlier than when it is currently recommended. At the same time, some scholars have developed a mathematical model demonstrating that if a very large section of the sexually active population is being tested at least every 2-3 years, and those found HIV+ are enrolled into ART treatment, it can dramatically reduce transmission and incidence of new HIV cases in the following few years. Though this has not been tried or piloted so far, it has sparked a lively discussion on its feasibility, its effectiveness in the “real world,” and its possible constraints.
The postulated approach of “test and treat,” as it has been named, presents a number of obvious problems when implementation is examined: Where is the necessary workforce to expand these services beyond its actual capacity, when even now there is an acute shortage of qualified staff? For how long shall we rely on standardized first-line regimens, when soon we may need to invest resources in the more expensive and complex second-line regimens? How could universal coverage of HIV counseling be reached if most countries are still struggling to increase their own stagnating coverage? Beyond the enthusiasm and sometimes the rhetoric of its supporters, this strategy needs to be carefully and cautiously planned before any decision is taken.
It will be very exciting to finally see a steep expansion of ART services that combines the individual benefits for the patient with the public health benefits of a drastic reduction of HIV transmission. It may even happen some day sooner rather than later, despite raising some skeptical reactions.
While following the future scientific and policy developments, organizations like JSI should be prepared to tackle the anticipated disadvantages of such an approach, particularly transforming the HIV control programs again into a “vertical” intervention, disjointed from their context. How can a test-and-treat approach for HIV work in those countries with a generalized HIV epidemic where it is still a challenge to secure an adequate test-and-treat for pneumonia in children (one of the most common causes of under-5 mortality), for epilepsy (whose treatment is a life long one similarly to ART), or for diabetes (whose incidence is on the increase in the whole of sub.Saharan Africa)?
The so-called system strengthening, whose “mantra” is so dear to policy makers and donors these days, will never be reached in the presence of intra-system inequities between diseases that receive most of the financial support and policy consideration and those others that seem to be falling into the category of non-infectious neglected diseases.