The 2011 results of the HIV Prevention Trials Network 052 randomized clinical trial (RCT)1 evaluating antiretroviral treatment as prevention (TasP) of HIV transmission heralded a new era of HIV/AIDS control as the debate about prioritizing treatment or prevention comes to an end.2 For many years, the best hope for ending the HIV epidemic was thought to lie in the development of an effective vaccine. But for now, the most effective preventive interventions will come from tools we already have, including antiretroviral therapy (ART), pre-exposure prophylaxis (PrEP) with ART, male circumcision, and condoms.
There is broad consensus that prevention strategies need to involve a combination of proven prevention interventions.3 There is also strong advocacy that TasP should be the backbone of population-based prevention.3-4 With considerable enthusiasm, the international research community has produced mathematical models of TasP to postulate the end of AIDS, an AIDS-free generation, and a cost-effective strategy that saves billions of investments in the future.5-6 Yet such widespread enthusiasm needs to be tempered with programmatic realities. In the era of global economic uncertainty, we need to overcome a number of specific challenges to realize any population-wide benefits of TasP.
EVIDENCE FOR TASP
Mathematical models may be useful for raising policy implications, but they are highly susceptible to the assumptions that inform them. The heterogeneity of estimates of TasP benefits weakens their inferences severely. …