'Test-and-treat': the end of the HIV epidemic?

Purpose of review The aim is to review recent literature on 'test-and-treat', a prevention strategy that promotes high levels of HIV testing and initiating antiretroviral therapy upon diagnosis, regardless of CD4 cell count. Antiretroviral therapy (ART) has been shown to dramatically reduce viral load which is strongly associated with the risk of transmission, therefore there is the potential to reduce HIV transmissions with ART. Recent findings Recent papers from observational studies on heterosexual sero-discordant couples found an overall rate of transmission of HIV-1 from ART-treated patients of 0.46 per 100 person-years, confirming the possibility of using ART as a prevention strategy. Several models have been used to predict the effect of this strategy and the potential risks of it. Randomized controlled trials are currently ongoing investigating the effect of ART on reducing infectiousness and the feasibility of this policy. Summary More precise estimations of the transmission risk under virally suppressive ART (especially in MSM) and of change in sex risk behaviour at diagnosis and at start of ART are needed. Further, the benefit to individual health of very early ART initiation and the feasibility of this policy need to be evaluated. Achieving very high levels of testing should be a high priority due to the benefits of initiating ART in all those who are in need (CD4 cell count < 350 cells/mu l) and potential benefits on incidence due to reductions in risk behaviour in those diagnosed. Use of ART immediately at diagnosis in those with high CD4 cell counts should await results from further studies.