Putting TLC+ to the Test

By Carl W. Dieffenbach, Ph.D., Director of NIAID Division of AIDS

Dr. Carl Dieffenbach, PhD

If we routinely test everyone for HIV and treat those who are infected, could we bring an end to the HIV/AIDS epidemic? The test and treat concept, modeled on data from South Africa by scientists at the World Health Organization, is a provocative HIV prevention strategy. According to mathematical modeling, a successfully implemented test and treat program could significantly reduce the number of HIV infections in South Africa within 10 years. While a growing number of experts within the HIV/AIDS community are intrigued at the possibility, no one knows whether this strategy would work in the real world.

The National Institutes of Health (NIH), the premier research institution of the U.S. government, is taking steps to find out. NIH is planning a 3-year study in 6 major U.S. cities. Called TLC+ (for Enhanced Test, Link to Care Plus Treat Strategy), this study will explore the feasibility of expanding HIV testing, better linking those who test HIV positive to medical care and treatment, and improving adherence to HIV treatment. The components of TLC+ will be evaluated against the current standard of HIV testing and treatment.

Its effectiveness will depend on a number of key factors. For starters, TLC+ requires a high level of acceptance and commitment to routine HIV testing. Changing public perception is never easy, so we’ll need various forms of social marketing to help lay the groundwork for a more supportive environment. The success of TLC+ also hinges on the ability to reach at-risk individuals. Outreach will be critical, so expanding HIV testing services at strategic sites such as emergency rooms and hospital admission desks is a good place to start.

The next critical component of TLC+ is successfully linking newly diagnosed individuals into care and treatment. Unfortunately, many people don’t make it to their follow-up medical visits for a variety of reasons. Yet these individuals can continue to spread the virus in their communities until we entice them to step through the door, whether it’s giving them a pat on the back or offering financial incentives.

Finally, all HIV-infected individuals, regardless of disease stage, need to start antiretroviral therapy (ART) when they and their health care provider decide it’s the right time. Equally as important as starting, they need to faithfully adhere to their drug regimens to ensure good health, low risk of HIV-related complications and reduce the risk of developing drug resistance. We know that ART can dramatically lower the level of the virus in the blood to undetectable levels, which may reduce the risk of HIV transmission. This is a crucial step in the TLC+ strategy that will hopefully pay future dividends in reducing the spread of HIV in communities.

Comments

[Shelby]

TLC is a step in the right direction in decreasing the global impact of HIV/AIDS. It seems like the hardest aspect of the experiment is getting those who test positive to report for treatment.

[Georgette King]

We are very excited about our roll in organizing the TLC-Plus study. More FAQs about TLC-Plus can be found on the HIV Prevention Trials (HPTN) website http://www.hptn.org/web%20documents/HPTN065/065_TLCPlusCmtyFAQv1_25Feb10.pdf . Additional updates will be posted on our Facebook page http://www.facebook.com/USHIVPrev . We welcome your posting of questions and comments on our FB Wall.

[Matt Williams]

"If we routinely test everyone for HIV and treat those who are infected, could we bring an end to the HIV/AIDS epidemic?"

The answer is no.

Treatment is by consent. If you reframed this statement to replace having HIV with eating saturated fat would people think you are barmy? Probaly yes, and recommend a softer approach perhaps. Despite cardiovascular disease and type 2 diabetes being an more general health burden, there is not the same moral imperative to treat. It looks like the nicest possible witch hunt.

Furthermore, especially in relation to South Africa, but also the developed world, the model ignores many very real social constraints and valuations around getting an HIV+ diagnosis.

I know personally in South Africa people who tested postitive then died without treatment or commited suicide because the social alternatives were impossible to negotiate. This is hard to get onto modellers' graphs.

However, if the aim of test and treat+ is to increase access to lifesaving medicine, this is a very good idea. I am interested to see what is proposed regarding overcoming the difficult social valuations which constrain people accessing treatment. And of course, you need to be able to pay for treatment, or get it paid for, which is some countries, including America, is not always possible.

- matt

[Daniel Reeders]

I've just posted a response to this article, with the title "Tender, Loving Financial Incentives", and I hope you won't mind if I post the link here: http://badblood.wordpress.com/2010/04/02/tender-loving-incentives/

I think your program rationale makes sense within the logic of the models you've likely considered, and I talk about different models (behavioural economics, cultures of care) that suggest different directions.

[Bill Jesdale]

"giving them a pat on the back or offering financial incentives"

Is it just me or does that sound incredibly paternalistic?

The NYT recently had an article about how offering people financial incentives for "good" lifestyle choices didn't work at all.

[Richard Jefferys]

"Is it just me or does that sound incredibly paternalistic?"

No, it's not just you, it's a poor choice of words at best and at worst it reflects a very limited conception of what the alternatives to financial incentives are. It also only characterizes the downside of delaying treatment from a prevention perspective, when an individual's health can also suffer profoundly if they lack ongoing access to care. I would argue that educating people about HIV pathogenesis and particularly the potential long term health consequences of persistent immune activation and inflammation should be a critical component of adherence initiatives, on the basis that education could have a more lasting impact than financial incentives (which, as far as I can tell from the literature, typically only have an impact for as long as they are given).

[PubH]

Routine testing and specifically access to treatment, are key to curbing the HIV/AIDS epidemic, however this idea assumes that once a patient knows that he or she is HIV+ that he/she will take measures to prevent transmitting it to others. In a perfect world this would be the case. Unfortunately there are many individuals who know their status and continue to engage in unsafe sex (or even "safe" sex) without disclosing their status to sexual partners. I feel this is an aspect of the epidemic that is often overlooked and until this is commonly integrated into prevention campaigns we will continue to see spikes in preventable transmission.