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(See the HIV/AIDS Major Article by Sood et al on pages 1789–96.)

A substantial body of evidence has emerged highlighting that early initiation of antiretroviral therapy (ART) for patients with human immunodeficiency virus (HIV) infection has both private and public health benefits. In various studies, early initiation of ART has been associated with greater survival among those infected; fewer combined clinical endpoints such as pulmonary tuberculosis, severe bacterial infection, and death; and, more recently, earlier restoration of CD4+ T cells [1–5]. This growing evidence on the private health benefits of early ART for HIV has led to a trend in recommendations to commence ART earlier and earlier, now to the point that guidelines suggest that ART be offered to all patients with HIV regardless of CD4 cell count [6]. In addition to the private benefits of early initiation of ART, a number of studies demonstrate an important public health benefit as well, namely, markedly reduced transmission rates of HIV due to reductions in viral load associated with ART [1, 7, 8]. The public health benefit of early ART in reducing disease transmission has formed the basis for widely proposed “test-and-treat” strategies that argue for universal testing for HIV and treatment of individuals who are seropositive, with the hope being near-eradication of HIV. Complex mathematical models of HIV disease dynamics have been used to simulate the impact of test-and-treat policies on the future incidence and prevalence of HIV. Not surprisingly, these studies have found mixed results, with some demonstrating dramatic reductions in HIV prevalence and others suggesting more modest reductions [9–14]. Nearly all studies are unanimous, however, in demonstrating reductions in HIV incidence and death associated with test-and-treat policies.

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