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Early treatment requires regular testing. Photograph: Yannick Tylle/ /Corbis
Early treatment requires regular testing. Photograph: Yannick Tylle/ /Corbis

We can eliminate HIV by 2030. Regular testing is a crucial part of the solution

This article is more than 8 years old

By 2020, 90% of all HIV-positive people must get tested, 90% of those who test positive must get treated and 90% of those treated must have effective response

The big announcement out of the Aids conference in Vancouver last month was that early treatment of HIV is better than delayed treatment, with half the rate of death and complications. When I was discussing it with a patient shortly after, he was surprised that this counted as news.

“Didn’t we already know this?” he asked. My patient’s surprise was understandable. Current guidelines recommend early treatment, even though we didn’t have the proof. Now we have it, and this long-awaited evidence tells us more than how to treat individual patients, like the ones I work with as an HIV specialist. It tells us it’s time to talk about eliminating the virus altogether. We can do this by making annual HIV testing a standard practice.

The endgame for HIV will require several strategies. The first one is early testing. It’s the only way to identify and diagnose those who are HIV-infected, and early testing opens the door to early treatment. But globally, an estimated 19 million people, or more than half of those living with HIV, have not been tested and so don’t realize they have it. While the situation is better in the United States, with only about a sixth of those with HIV undiagnosed, this fraction doubles to a third for HIV-positive 18-34 year-olds. Not enough people are getting tested, and the people who most need repeat testing are not getting tested often enough.

We have simple, cheap and rapid HIV tests that give pretty reliable results. But we still need to make HIV testing part of our everyday conversation, since very few people anywhere are comfortable asking for an HIV test or talking openly about their status. We need a simple and clear message about the need for early testing accompanied by the message that it isn’t shameful to ask for an HIV test. While there may be debate in the medical and public health communities about exactly how often and for whom to recommend testing, we should all be able to agree that the simplicity of a clear message on routine, annual HIV testing makes sense.

We have made so much progress in a short time with HIV, especially in the last five years, that we now can imagine eliminating it. If 90% of all HIV-positive people in the world get tested by the year 2020, and 90% of those who test positive go on treatment, and 90% of those on treatment have effective suppression of their HIV infection, then research predicts that new HIV infections will finally be eliminated by 2030. At the Vancouver meeting, researchers were excited about this “90-90-90” endgame. It sounds fantastic until we remember where we are at now: less than 50% for the first of the three 90s.

The endgame in public health can take a long time. It requires patience, resources and a culture of commitment to public health. It took almost two centuries to go from Edward Jenner’s discovery of the smallpox vaccine in 1796 to the last case of smallpox in 1977. In 2000, the elimination of syphilis in the US was within reach and then slipped away just over 10 years later. Consider our short attention span for Ebola. Last year, the Ebola outbreak in West Africa commandeered front pages for weeks while now, the current closure efforts are rarely in the news. The endgame is less exciting – almost boring – but it’s essential.

I have seen far too many patients die with advanced Aids because they were afraid to get tested, or they didn’t know where to go for a test. Even now, in the United States, people still die of Aids because they did not get an early diagnosis. We finally have the tests and the treatments to put such tragedies behind us. Now that we have the proof about early treatment, we need to change the conversation around early testing by making annual testing the norm. When we get to the point where enough people are tested early and treated early, we will have the opportunity to eradicate it.

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