Why a universal antiretroviral regimen?

In 2015, with its "Treat all" recommendation, World Health Organization (WHO) removed all restrictions on eligibility for antiretroviral treatment (ART) among HIV positive people. WHO estimates that by the end of 2018, 20 million people worldwide will be receiving combination ART. An additional 15–17 million will be in need of ART but unable to access or afford it [1]. Most of the existing supply of antiretrovirals (ARVs) is provided through international agencies, such as PEPFAR and the Global Fund, or governments of low- and middle-income countries (LMICs), all of which face stable or shrinking health care budgets.

The economic challenges facing global provision of ARVs alone represent an overwhelming barrier to full treatment access. When combined with the logistical and implementation barriers, civil unrest, increasing ARV drug resistance worldwide, and continued issues with stigma in many parts of the world, it is hard to imagine how the treatment needs of all people with HIV can be met with existing programs and resources.

It is now quite clear that effective ART not only benefits the individual through immune reconstitution and elimination of the risk of opportunistic diseases, but also protects individuals at risk of acquiring HIV through sexual contact or intravenous drug use [2]. In theory, a strategy that places everyone with HIV on suppressive ART for a generation would substantially – and perhaps permanently – reduce the risk of HIV infection worldwide. The challenge then is to develop a strategy with the highest likelihood of meeting this goal.