Andrews J.R., Wood R., Bekker L.-G., Middelkoop K., Walensky R.P.
Division of Infectious Diseases, Massachusetts General Hospital, 50 Staniford St, Boston, MA 02114, United States; Division of General Medicine, Department of Medicine, Massachusetts General Hospital, Boston, United States; Harvard University Center for AIDS Research, Harvard Institute for Global Health, Cambridge, MA, United States; Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
Andrews, J.R., Division of Infectious Diseases, Massachusetts General Hospital, 50 Staniford St, Boston, MA 02114, United States; Wood, R., Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa; Bekker, L.-G., Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa; Middelkoop, K., Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa; Walensky, R.P., Division of Infectious Diseases, Massachusetts General Hospital, 50 Staniford St, Boston, MA 02114, United States, Division of General Medicine, Department of Medicine, Massachusetts General Hospital, Boston, United States, Harvard University Center for AIDS Research, Harvard Institute for Global Health, Cambridge, MA, United States
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. © The Author 2012.
antiretrovirus agent; anti human immunodeficiency virus agent; article; demography; health care; human; Human immunodeficiency virus infection; immigration; morbidity; population migration; priority journal; sensitivity analysis; virus transmission; adolescent; disease transmission; health care delivery; highly active antiretroviral therapy; Human immunodeficiency virus infection; methodology; migration; patient attitude; South Africa; theoretical model; Adolescent; Anti-HIV Agents; Antiretroviral Therapy, Highly Active; Disease Transmission, Infectious; Emigration and Immigration; Health Services Accessibility; HIV Infections; Humans; Models, Theoretical; Patient Acceptance of Health Care; South Africa
