The aim of this review is to examine the emerging results from the HIV universal test and treat (UTT) cluster-randomized trials in sub-Saharan Africa, discuss how expanding access to HIV clinical services is likely to reshape the arc of HIV epidemics, and consider implications for HIV prevention and control strategies in the coming decade.
The effect of universal HIV testing followed by immediate antiretroviral treatment (ART) on community-level HIV incidence remains unclear upon completion of five randomized trials. Only two of the four trials that measured HIV incidence found significant reductions in community-level incidence. Even in these trials, HIV incidence remained above levels required for epidemic control (≤1 case per 1000 person-years) despite high levels of ART coverage and viral suppression. These findings may indicate that community-delivered HIV services are not reaching the high-frequency transmitters who sustain HIV epidemics and are likely members of marginalized or hard to engage core groups.
With expanded access to HIV services in sub-Saharan Africa, HIV epidemics are transitioning from hyperendemic to declining/endemic epidemic phases, characterized increasingly by the reconcentration of HIV in marginalized or hard to engage core groups. To move toward epidemic control, novel HIV service delivery models and technologies are needed to engage those who continue to drive HIV incidence in this new epidemic phase.
aDepartment of Global Health
bDepartment of Medicine
cDepartment of Epidemiology, University of Washington, Seattle, Washington, USA
dKenya Ministry of Health, Nairobi, Kenya
eFred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington, USA
Correspondence to Katrina F. Ortblad, Sc.D., MPH, International Clinical Research Center, University of Washington, 325 Ninth Avenue, Seattle, WA 98104, USA. Tel: +1 206 520 3800; e-mail: email@example.com