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The Economics; Financing and Implementation of HIV Treatment as Prevention: What will it Take to Get there?

"The 2013 Lancet Commission Report; Global Health 2035; rightly pointed out that we are at a unique place in history where a ""grand convergence"" of health initiatives to reduce both infectious diseases; and child and maternal mortality - diseases that still plague low income countries - would yield good returns in terms of development and health outcomes. This would also be a good economic investment. Such investments would support achieving health goals of reducing under-five (U5) mortality to 16 per 1 000 live births; reducing deaths due to HIV/AIDS to 8 per 100 000 population; and reducing annual TB deaths to 4 per 100 000 population. Treatment as prevention (TasP) holds enormous potential in reducing HIV transmission; and morbidity and mortality associated with HIV/AIDS - and therefore contributing to Global Health 2035 goals. However; TasP requires large financial investments and poses significant implementation challenges. In this review; we discuss the potential effectiveness; financing and implementation of TasP. Overall; we conclude that TasP shows great promise as a cost-effective intervention to address the dual aims of reducing new HIV infections and reducing the global burden of HIV-related disease. Successful implementation will be no easy feat; though. The dramatic increases in the numbers of persons who need antiretroviral therapy (ART) under a TasP approach will pose enormous challenges at all stages of the HIV treatment cascade: HIV diagnosis; antiretroviral (ARV) initiation; ARV adherence and retention; and increased drug resistance with long-term enrolment on ART. Overcoming these implementation challenges will require targeted implementation; not focusing exclusively on TasP; most-at-risk population (MARP)-friendly services for key populations; integrating services; task shifting; more efficient programme management; balancing supply and demand; integration into universal health coverage efforts; demand creation; improved ART retention and adherence strategies; the use of incentives to improve HIV treatment outcomes and reduce unit costs; continued operational research and tapping into technological innovations."