The Universal HIV Test and Treat (UTT) strategy represents a challenge for science, but is also a challenge for individuals and societies.
Are repeated offers of provider-initiated HIV testing and immediate antiretroviral therapy (ART) socially-acceptable and can these become normalized over time?
There is limited research addressing how communities respond to participating in a research programme that involves substantial normative social change in community cultures and perceptions.
South Africans have been exposed to rapidly changing discourses from public authorities with regard to the cause of HIV/AIDS, the ways to prevent HIV infection and to care for people with HIV.
Clinicaltrials.gov: NCT01509508; South African Trial Register: DOH-27-0512-3974.
Four large-scale cluster randomized trials are ongoing in Eastern and Southern Africa to measure the efficacy of a Universal Test and Treat (UTT) approach in ‘real life’ : ANRS 12249 Tas P (Treatment–as-Prevention) in South Africa [2,3]; HPTN 071 Pop ART in South Africa and Zambia [4,5]; SEARCH in Kenya and Uganda  and the Botswana Combination Prevention project .A recent meta-analysis of home-based voluntary HIV testing in sub-Saharan Africa showed that the proportion of people who accept home-based HIV testing ranged from 58.1% to 99.8% overall (pooled percentage 83.3%), and from 58.1 to 91.8% in South Africa specifically .This review did not present data on repeat HIV testing, however the few available reports on uptake of consecutive HIV testing campaigns show a 75-80% uptake of a second test among those tested the first time [12,13].In summary, the main hypothesis of the Tas P trial is that HIV testing of all adult members of a community, followed by immediate ART initiation of all, or nearly all, HIV-infected participants regardless of immunological or clinical staging, will prevent onward transmission and reduce HIV incidence in this population.The Tas P trial is a cluster-randomised trial implemented in the Hlabisa sub-district, in rural northern Kwa Zulu-Natal in South Africa, an area with approximately 228 000 Zulu-speaking inhabitants.We constructed a multi-disciplinary research programme implemented as part of the ANRS 12249 Treatment-as-Prevention (Tas P) trial in South Africa.In this paper, we first briefly present the overall trial design.Finally we discuss some of the emerging issues raised by UTT strategies that are unlikely to be answered in the short-term by any of the ongoing trials.The protocol of the Tas P trial, registered on (NCT01509508), has been described elsewhere .The HIV prevalence in the sub-district is one of the highest in the world, with around 29% of adults infected with HIV .The UTT strategy being tested in the cluster-randomised Tas P trial has two main components (the trial intervention package): universal and repeat home-based HIV testing of all resident adults and immediate ART initiation.