A new study and an accompanying editorial published in the August 14 issue of The Lancet highlight the potential to reduce ongoing HIV transmission in a community simply through aggressive testing and treatment of HIV-positive people with antiretroviral (ARV) drugs.

“Why 27 years after the discovery of HIV, does the epidemic remain uncontrolled?”

This is the question posited by Franco Maggiolo, MD and Sebastiano Leone, MD, from the Ospedali Riuniti in Bergamo, Italy, in their editorial. They answer it, in part, by pointing to the “unsatisfactory” nature of the available prevention methods in reducing transmission.

They also point, however, to a study published in the same issue of The Lancet—by Julio Montaner, MD, and his colleagues from the British Columbia Centre for Excellence in HIV/AIDS in Vancouver—which provides strong evidence that rapid scaled up provision of ARV therapy in HIV-positive people in British Columbia, substantially reduces new infections.

Montaner and his colleagues found that during the first big roll-out of HIV drugs in British Columbia—between 1996 and 1999—the number of new HIV diagnoses dropped by about 40 percent, and that during a second big roll-out—between 2004 and 2009—new diagnoses dropped by 23 percent. Comparatively, during a period where new use of ARVs was relatively flat, the rate of new diagnoses remained stable

Maggiolo and Leone note that, “The results of [Montaner’s] analysis were mainly driven by the reduction of new infections in patients with a history of drug use.” They hypothesize, however, that ARV therapy, “might prove effective within other risk populations, provided that the source individuals are thoroughly identified and correctly treated.”

A new feasibility study is doing just that in Washington, DC. People with HIV are being identified through wide-scale HIV testing programs, and rapidly entered into HIV care and treatment. Maggiolo and Leone state their anticipation that this study, “would tell us whether [ARV treatment] can succeed as an epidemic control measure.”

‘While waiting for an effective vaccine, experiences such as [the study in British Columbia] should be strongly considered by clinicians, national and international agencies, policy makers, and all parties involved in the development of treatment guidelines,” conclude the authors, “because the population-based dimension of [ARV therapy] might play an important part in the future control of the HIV epidemic.”

Health officials in San Francisco appear to be listening, as the Department of Health there recently instituted a policy of intensive HIV testing and treatment of all people found to be HIV positive, regardless of their current CD4 count.

While this policy remains controversial among key opinion leaders—arguing that immediate treatment may heighten the risk of side effects, adherence problems and drug resistance and that studies must first prove that immediate therapy is beneficial to those living with HIV before it be considered for public health goals—the trend in some United States cities appears to be headed in that direction. Additionally, some groups in southern Africa—where HIV continues to rage out of control—are begging donors to consider this strategy in the developing world.