Background: Early case identification and ART initiation at diagnosis in HIV-infected individuals (Test and Treat [TnT]) is being considered as an HIV prevention strategy. We sought to estimate the impact of a TnT strategy on the lifetime secondary HIV cases attributable to a recently-infected individual in sub-Saharan Africa.

Methods: We used a state-transition simulation model of HIV disease, screening, and treatment to project outcomes of a TnT strategy in a cohort of recently-infected individuals in Cote d Ivoire. We examined combinations of screening frequency (current practice [client-initiated testing or testing in patients with symptoms], current practice + routine screening every 3 yrs, current practice + annual routine screening) and ART initiation (CD4 ≤350/μl or at diagnosis). Input data included: mean age 32 yrs; mean CD4 553/μl; mean HIV RNA level 4.7 log copies/mL. HIV transmission rates ranged from 0.2-9.0/100 PY depending on HIV RNA; the combined probability of test offer, acceptance, and linkage to care was 31%; the probability of HIV RNA suppression on ART was 80% at 24 wks for each of 2 sequential regimens; loss to follow-up (LTFU) on ART was 16% at 12 mo.

Results: Compared to a standard of care (SOC) with screening according to current practice and ART initiation at CD4 ≤350/μl, a TnT strategy with annual screening and ART at diagnosis increased mean per person life expectancy (LE) by 37.5 mo, decreased secondary HIV cases 5 yrs after infection by 16.6%, but increased lifetime secondary cases by 11.1%.

Survival, LE, and secondary HIV cases were sensitive to changes in the combined probability of test offer, acceptance, and linkage to care, LTFU, and the ART failure rate in the TnT strategy. Decreases in the ART failure rate, such as through increases in treatment adherence, and decreases in transmission risk, such as through use of other preventive interventions, led to larger decreases in secondary HIV cases at 5 yrs as well as decreases in lifetime secondary cases.

Conclusions: A TnT strategy will increase survival in newly HIV-infected individuals in sub-Saharan Africa. Increases in survival, if associated with increased survival time off ART or on non-suppressive ART, will be accompanied by decreases in secondary HIV cases at 5 yrs but increases in lifetime secondary cases. Increases in treatment adherence and use of other preventive interventions, in conjunction with TnT, will be necessary to decrease lifetime secondary HIV cases.