January 3, 2009
Universal voluntary HIV testing with immediate
antiretroviral therapy as a strategy for elimination of HIV
transmission: a mathematical model
Reuben M Granich, Charles F Gilks, Christopher Dye, Kevin M De Cock, Brian G Williams
Roughly 3 million people worldwide were receiving antiretroviral therapy (ART) at the end of 2007, but
an estimated 6·7 million were still in need of treatment and a further 2·7 million became infected with HIV in 2007.
orts might reduce HIV incidence but are unlikely to eliminate this disease. We investigated a theoretical
strategy of universal voluntary HIV testing and immediate treatment with ART, and examined the conditions under
which the HIV epidemic could be driven towards elimination.
We used mathematical models to explore the eﬀ
ect on the case reproduction number (stochastic model) and
long-term dynamics of the HIV epidemic (deterministic transmission model) of testing all people in our test-case
community (aged 15 years and older) for HIV every year and starting people on ART immediately after they are
diagnosed HIV positive. We used data from South Africa as the test case for a generalised epidemic, and assumed
that all HIV transmission was heterosexual.
The studied strategy could greatly accelerate the transition from the present endemic phase, in which most
adults living with HIV are not receiving ART, to an elimination phase, in which most are on ART, within 5 years. It
could reduce HIV incidence and mortality to less than one case per 1000 people per year by 2016, or within 10 years
of full implementation of the strategy, and reduce the prevalence of HIV to less than 1% within 50 years. We estimate
that in 2032, the yearly cost of the present strategy and the theoretical strategy would both be US$1·7 billion; however,
after this time, the cost of the present strategy would continue to increase whereas that of the theoretical strategy
Universal voluntary HIV testing and immediate ART, combined with present prevention approaches,
could have a major eﬀ
ect on severe generalised HIV/AIDS epidemics. This approach merits further mathematical
modelling, research, and broad consultation.
25 years after the discovery of HIV,
control of the HIV
epidemic remains elusive and some have called for a
re-examination of the approach to control this virus.
Development of an eﬀ
ective HIV-1 vaccine remains a
remote possibility, and trials of vaginal microbicides have
not shown any protective beneﬁ
transmission is mainly heterosexual, male circumcision
can reduce adult heterosexual HIV transmission, but
only by about 40% at the overall population level.