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"Treatment as Prevention" Proposed as Element of the National HIV/AIDS Strategy

February 2010

A significant question that has perplexed and even divided HIV experts in recent years is whether and how "Test & Treat" programs to assure that a greater percentage of HIV-positive people learn their serostatus and take antiretroviral medications might serve to reduce new cases of HIV infection. Several studies have concluded that viral suppression resulting from effective HIV therapy makes it less likely that an HIV-positive person can transmit HIV to an HIV-negative partner, even in the absence of condom use during sex. Statistical models have come to different conclusions about the extent to which programs to increase the diagnosis and treatment of HIV-positive people might reduce HIV transmission on a population-wide basis, but various models have concluded that they would have impact.

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In December 2009, Project Inform and Community HIV/AIDS Mobilization Project (CHAMP) convened a multi-disciplinary group of HIV experts to consider whether implementing a strategy to significantly increase participation in HIV testing, care and treatment could help the US accomplish three important goals: 1) to increase the percent of HIV-positive Americans who know their status, 2) to improve the health outcomes of individuals who are HIV-positive, and 3) to reduce HIV incidence.

Based upon a review of currently available data and existing programs from multiple jurisdictions, the Think Tank resulted in a recommendation that a new effort called Testing & Linkage to Care Plus, or TLC+ (the Plus referring to Treatment), has significant potential to help the US meet the three goals described above. (A review of this scientific literature is available online The participants also concluded that TLC+ should become a key element of the National HIV/AIDS Strategy, currently under development by the Obama Administration, because of its additional potential to support the three stated objectives of the Summary. (Read the article National HIV/AIDS Strategy.)

TLC+ proposes a standard of care in which all public and private testing providers work intensively with HIV-positive people as soon after diagnosis as possible to link them voluntarily to primary medical care, prevention with positives counseling, as well as social services that can support them to engage in and maintain participation in HIV treatment. Its components are designed to benefit people newly diagnosed with HIV, those who have not previously been ready or able to engage in care and treatment owing largely to a lack of needed social services to support their readiness, and those who have been lost to systems of care and treatment.

A thorough description of TLC+. Briefly, its elements include:

  • Assuring that HIV-positive individuals know their HIV status as soon after infection as possible;
  • Effective and timely linkage of newly diagnosed HIV-positive people to primary medical care and social services that will prepare them to consider initiation of treatment, as well as efforts to re-engage individuals who have been lost to systems of care;
  • Prompt evaluation of eligibility and readiness for HIV therapy, and support for its initiation;
  • Effective efforts to support retention in care and adherence to HIV therapy to maintain viral suppression;
  • HIV prevention counseling and support; and
  • STI screening and treatment.

TLC+ would promote much-needed integration of existing testing, care and treatment, support services and prevention programs at all levels of government and create specific and measurable outcomes for those efforts. While some medical providers and local jurisdictions are already taking steps to implement it, the Think Tank concluded that TLC+ should become a national program, delivered through intensive collaborations of state and local health departments, medical providers, social services agencies, and AIDS service organizations -- including prevention-focused agencies. Its further design and implementation necessitate an unprecedented level of coordination among the National Institutes of Health (NIH), Centers for Disease Control & Prevention, Department of Health & Human Services and other federal agencies responding to HIV/AIDS, as well as intensive efforts to assure that these agencies' funding streams are combined to enable such a strategy at the local level.

The NIH is currently conducting a study of the feasibility of implementing Test & Treat as a potential tool in prevention. We nevertheless believe that TLC+ can and should become a part of the National HIV/AIDS Strategy and be implemented nationally in the near future. It would not be ethical to delay improved efforts to increase the percentage of HIV-positive Americans who know their serostatus and are engaged in care and treatment that may protect their health, in addition to the possible benefits for prevention accruing from this strategy.

The Think Tank also highlighted a set of issues that serve as significant barriers to strengthening the health outcomes of HIV-positive people, and that will reduce the potential effects of TLC+ if they are not addressed. It was therefore recommended that the National HIV/AIDS Strategy establish policies and programs to address these conditions:

  • Stigma and discrimination continue to act as powerful barriers to an individual's willingness to be tested for HIV and engage in care and treatment if they are HIV-positive. Major national efforts, including visible Presidential leadership, are needed to address these barriers.
  • It is clear that many primary medical providers are failing to encourage patients to be tested for HIV and to follow up in sensitive and helpful ways because they are uneasy about sex, sexual identity, race, drug use and other social and behavioral factors associated with HIV and AIDS. A significant national effort that includes national medical associations and medical schools must be launched to establish standards of care regarding the offering of HIV testing, care and treatment, and to encourage providers to follow them. Presidential leadership is also necessary on this point.
  • Similarly, there is evidence that many people at risk for HIV are failing to be tested or to enter care and treatment based on a serious misunderstanding of their benefits, the effectiveness of HIV treatment, and the availability of low or no cost care and treatment. A significant national campaign is needed to help people at risk for HIV infection better understand the benefits of knowing their serostatus and addressing HIV disease, and even to promote testing, care and treatment.
  • California has passed a law requiring that all insurers and payer sources reimburse for HIV testing whenever ordered by a medical provider. Additional state and/or Federal legislation to this effect may be needed to ensure universal access to testing. President Obama has commissioned a study of this issue, and related issues, by a panel of the Institute of Medicine.
  • Adequate resources do not currently exist to assure that all HIV-positive Americans are able to receive affordable or no-cost care and treatment. Without such a guarantee, the US will never be able to fully control this epidemic. National healthcare reform, establishing HIV care and treatment as an entitlement program, or significant increases in Ryan White funding will be essential to the success of this strategy.

Project Inform believes that TLC+ has enormous potential to support many thousands of Americans to preserve their health and well-being, and to help the US gain much greater control of the AIDS epidemic. Along with members of a national TLC+ Work Group that was formed to continue the work started at the Think Tank, we will continue to work with the newly appointed President's Advisory Council on HIV/AIDS, the Office of National AIDS Policy, and all relevant federal agencies to further develop the policies and programs that will be necessary to implementing TLC+ on a national basis. Regular updates on the status of this effort will appear at www.projectinform.org.



  
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This article was provided by Project Inform. Visit Project Inform's website to find out more about their activities, publications and services.
 
See Also
National HIV/AIDS Strategy for the United States: Executive Summary
U.S. Announces First National HIV/AIDS Strategy
More on U.S. HIV/AIDS Policy

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