Universal Access to HIV Treatment versus Universal 'Test and Treat': Transmission, Drug Resistance & Treatment Costs

In South Africa (SA) universal access to treatment for HIV-infected individuals in need has yet to be achieved. Currently similar to 1 million receive treatment, but an additional 1.6 million are in need. It is being debated whether to use a universal 'test and treat' (T&T) strategy to try to eliminate HIV in SA; treatment reduces infectivity and hence transmission. Under a T&T strategy all HIV-infected individuals would receive treatment whether in need or not. This would require treating 5 million individuals almost immediately and providing treatment for several decades. We use a validated mathematical model to predict impact and costs of: (i) a universal T&T strategy and (ii) achieving universal access to treatment. Using modeling the WHO has predicted a universal T&T strategy in SA would eliminate HIV within a decade, and (after 40 years) cost similar to$10 billion less than achieving universal access. In contrast, we predict a universal T&T strategy in SA could eliminate HIV, but take 40 years and cost similar to$12 billion more than achieving universal access. We determine the difference in predictions is because the WHO has under-estimated survival time on treatment and ignored the risk of resistance. We predict, after 20 years, similar to 2 million individuals would need second-line regimens if a universal T&T strategy is implemented versus similar to 1.5 million if universal access is achieved. Costs need to be realistically estimated and multiple evaluation criteria used to compare 'treatment as prevention' with other prevention strategies. Before implementing a universal T&T strategy, which may not be sustainable, we recommend striving to achieve universal access to treatment as quickly as possible. We predict achieving universal access to treatment would be a very effective 'treatment as prevention' approach and bring the HIV epidemic in SA close to elimination, preventing similar to 4 million infections after 20 years and similar to 11 million after 40 years.