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PROJECTING THE BENEFITS OF ANTIRETROVIRAL THERAPY FOR HIV PREVENTION

Sunday, 29th of July 2012

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  PROJECTING THE BENEFITS OF ANTIRETROVIRAL THERAPY FOR HIV PREVENTION:  THE IMPACT OF POPULATION MOBILITY AND LINKAGE TO CARE

1.   Jason R. Andrews1, Robin Wood4, Linda-Gail Bekker4, Keren Middelkoop4 and

  Rochelle P. Walensky1,2,3

+ Author Affiliations

1.    ¹Division of Infectious Diseases, Massachusetts General Hospital 

2.    ²Division of General Medicine, Department of Medicine, Massachusetts General HospitalBoston 

3.    ³Harvard University Center for AIDS Research, Harvard Institute for Global Health CambridgeMassachusetts 

4.    ⁴Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Republic of South Africa

1.    Correspondence: Jason R. Andrews, MD, Division of Infectious Diseases, Massachusetts General Hospital, 50 Staniford St, 9th Fl, Boston, MA 02114 (jandrews6@partners.org).

Abstract below; full text available to JID subscribers

Background. Recent mathematical models suggested that frequent human immunodeficiency virus (HIV) testing with immediate initiation of antiretroviral therapy (ART) to individuals with a positive test result could profoundly curb transmission. The debate about ART as prevention has focused largely on parameter values. We aimed to evaluate structural assumptions regarding linkage to care and population mobility, which have received less attention.

Methods. We modified the linkage structure of published models of ART as prevention, such that individuals who decline initial testing or treatment do not link to care until late-stage HIV infection. We then added population mobility to the models. We populated the models with demographic, clinical, immigration, emigration, and linkage data from a South African township.

Results. In the refined linkage model, elimination of HIV transmission (defined as an incidence of <0.1%) did not occur by 30 years, even with optimistic assumptions about the linkage rate. Across a wide range of estimates, models were more sensitive to structural assumptions about linkage than to parameter values. Incorporating population mobility further attenuated the reduction in incidence conferred by ART as prevention.

Conclusions. Linkage to care and population mobility are critical features of ART-as-prevention models. Clinical trials should incorporate relevant data on linkage to care and migration to evaluate the impact of this strategy.