When we look at the spread of the HIV infection and at the changing face of the HIV epidemic in our country, it is time to reevaluate our efforts in HIV education and get back to the basics.  Is the ABC (Abstinence, Be faithful, Condom use) working?  Is this preventive message effective? Or even reaching the people that are at highest risk?

In an attempt to better deliver this message and take a proactive roll in prevention and early treatment, the concept of Test-and-Treat was born.  Test-and-Treat  embodies two theories: First, that early diagnosis and treatment will limit the risk of both AIDS and non AIDS related health problems in people living with the virus.  Secondly, that reducing viral load to undetectable levels in as many people within a community as possible will greatly reduce the rate of ongoing transmission of HIV.

The idea is very attractive: if we identify and treat everybody that is HIV positive in a community, we could eventually reduce and eliminate the” HIV community viral load”, and therefore eliminate HIV transmission.  By testing and treating we could also diagnose people in earlier stages, preventing HIV / AIDS complications, reducing cost of treatment and significantly reduce the taboo linked to HIV testing.

Unfortunately, this Test-and-Treat initiative is somewhat controversial.  In order to be effective, wide spread HIV testing needs to be implemented in our communities, at all levels: from the primary care doctors conducting a routine medical examination, to patients seen at the emergency room for unrelated problems.  Many medical establishments do not have the staff and training necessary to perform this task, nor the training needed to deliver the appropriate counseling.

Another real challenge comes when we have to figure out a way to link all the newly diagnosed cases with the already limited resources for care and medications.  As impossible as it may seem, there are several examples in diverse communities in San Francisco , Washington DC , Canada and even Africa, where the results of this approach  demonstrated cost effectiveness,  even in poor communities.

Two presentations at this year’s CROI—one from San Francisco, where the epidemic remains largely centered among men who have sex with men (MSM), and one from Baltimore that was focused on injection drug users (IDUs)—added further evidence that lowering HIV levels within a community might reduce new HIV cases. However, defining how to measure, evaluate or use community viral load data remains controversial.

It is estimated that about 20 percent of HIV positive people in the US remain undiagnosed, either because they have no access to medical care or they have not been tested for HIV. We also know that the majority of new infections occur from exposure to this undiagnosed population.  This is why it is so important to identify and test this particular group.

The challenge of increasing HIV testing, keeping people in care and suppressing viral loads in these communities will likely be no easier than it is to treat most other types of chronic diseases in the same communities like diabetes or heart disease.   But any initiative needs to start first with “testing” and the motivation for getting a voluntary HIV test varies from person to person.  By now we know that just voluntary HIV testing definitely does not lead to enough people getting tested to produce changes in HIV spread in the community.

Even if testing becomes universal in a community, the next hurdle is treatment.  Test-and-Treat means when a person that gets tested is found to be positive, the person is brought to care immediately and treatment, if necessary, is initiated without much delay. This may represent a big problem for most communities, in which reduction in HIV/AIDS funding barely covers the expense today of treating the uninsured population.

We should not wait for the results of further models or studies before we start implementing changes in our communities.  We have witnessed major efforts by our local health department and local Institutions like The Center (headed by Randy Stephens) to make testing more accessible. Significant efforts in testing will definitely impact transmission of the virus, even in people that are not able to start treatment immediately after diagnosis.

To move an entire community in one direction, every person needs to start by moving themselves; so the next time you go to your doctor for a routine evaluation, don’t forget to ask for an HIV test.