Clinical Uncertainties, Health Service Challenges, and Ethical Complexities of HIV “Test-and-Treat”: A Systematic Review

On the basis of our review, we have summarized uncertainties, challenges, and complexities we identified in the literature, and we have made research and implementation recommendations that should be considered to improve the likelihood of the test-and-treat strategy’s success

Sonali P. Kulkarni

2013

Scholarcy highlights

  • WE HAVE SEEN significant progress in expanding HIV prevention and care services worldwide, an estimated 2.5 million individuals were newly infected in 2011.1 Universal testing and treatment to prevent transmission of HIV has gained considerable interest from funders and international agencies as a potential public health approach to controlling the spread of the epidemic. In a “test-and-treat” strategy, individuals would be routinely tested for HIV, and those who are identified as being HIV infected would be started on antiretroviral therapy immediately, irrespective of their stage of disease, to reduce their plasma viral load and thereby reduce their likelihood of transmitting the infection
  • On the basis of our search strategy, we identified 207 articles
  • Of the 114 full-length articles we reviewed, we excluded 16 on the basis of full-length article review criteria
  • A great deal of work related to numerous clinical uncertainties, health service challenges, and ethical complexities remains to be done
  • Until this work is done, implementation efforts should be focused on achieving universal testing and treatment according to current World Health Organization guidelines for the initiation of ART
  • Sonali Prakash Kulkarni is with the Division of HIV and STD Programs, Los Angeles County Department of Public Health, Los Angeles, CA, and the Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles
  • The Population Effect of antiretroviral therapy to Reduce HIV Transmission study, which uses mixed methods to assess community engagement and acceptability and human rights concerns to inform the design of a test-and-treat trial in 2 communities in Zambia and Uganda, will help address these 3 ethical issues.23,120 The study will include qualitative research on trust, barriers, and experiences in service delivery; an assessment of 5 components related to human rights and ethics; and engagement with African partners to identify study sites, all while highlighting local issues that are key to implementing the test-and-treat strategy.23,120

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