Strong influence of behavioral dynamics on the ability of testing and treating HIV to stop transmission

Choosing between strategies to control HIV transmission with antivirals requires understanding both the dynamics affecting those strategies' effectiveness and what causes those dynamics. Alternating episodes of high and low contact rates (episodic risk) interact with increased transmission probabilities during early infection to strongly influence HIV transmission dynamics. To elucidate the mechanics of this interaction and how these alter the effectiveness of universal test and treat (UT8T) strategies, we formulated a model of UT8T effects. Analysis of this model shows how and why changing the dynamics of episodic risk changes the fraction of early transmissions (FET) and the basic reproduction number (R(0)) and consequently causes UT8T to vary from easily eliminating transmission to having little effect. As the length of risk episodes varies from days to lifetimes, FET first increases, then falls. Endemic prevalence varies similarly. R(0), in contrast, increases monotonically and is the major determinant of UT8T effects. At some levels of episodic risk, FET can be high, but eradication is easy because R(0) is low. At others FET is lower, but a high R(0) makes eradication impossible and control ineffective. Thus changes in individual risk over time must be measured and analyzed to plan effective control strategies with antivirals.