HIV treatment as prevention: The key to an AIDS-free generation

The presence of elevated human immunodeficiency virus (HIV) viral load within blood and genital secretions is a critical driver of transmission events. Long-term suppression of the viral load to undetectable levels through the use of antiretroviral therapy is standard practice for the clinical management of HIV. Antiretroviral therapy therefore can play a key role in curbing HIV transmission. The results of a randomized clinical trial and several observational studies have now confirmed that antiretroviral therapy markedly decreases the risk of HIV transmission. Mathematical models and population-based ecologic studies suggest that further expansion of antiretroviral coverage within current guidelines can play a major role in controlling the spread of HIV. The expansion of so-called “treatment as prevention” initiatives relies on maximal uptake of the HIV continuum-of-care cascade to allow for the successful identification of people who are not yet known to be HIV-infected, for engaging patients in appropriate care, and for subsequently achieving sustained virologic suppression in patients with the use of antiretroviral therapy. Since 2010, the joint United Nations AIDS (UNAIDS) program has called for the inclusion of antiretroviral treatment as a key pillar in the global strategy to control the spread of HIV infection. This has now been invigorated by the release of the World Health Organization's 2013 Consolidated Antiretroviral Therapy Guidelines, which recommends offering treatment to all HIV-infected individuals with CD4 cell counts below 500/mm3, to serodiscordant couples, to individuals coinfected with tuberculosis and hepatitis B virus, to pregnant women, and to children below the age of 5 years (regardless of CD4 cell count in this groups).