Treatment as prevention: toward an AIDS-free generation

In British Columbia, Canada, intensive efforts have been made to implement and maintain a treatment-as-prevention strategy among the HIV-infected population. Acceleration of antiretroviral therapy coverage has resulted in a substantial increase in the median CD4+ cell count at which treatment is initiated and a dramatic decline in community plasma HIV RNA levels. This has resulted in a reduction in diagnoses of new cases of HIV infection, including among injection drug users. Proportions of individuals with viral suppression have steadily increased and the expansion of antiretroviral therapy coverage has not been associated with increased levels of HIV resistance. Further, adoption of routine HIV testing in acute care settings has been very well accepted and has captured new cases at a rate of 5 per 1000 tests outside of high-risk populations, offering an additional strategy for identifying and linking at least some individuals with undiagnosed HIV infection to care. Deriving optimal individual and social health outcomes in HIV infection requires improvement in every element of the cascade of care. This article summarizes a presentation by Julio S. G. Montaner, MD, at the IAS-USA continuing education program held in San Francisco, California, in March 2013.