摘要：We describe a number of pitfalls that may occur with the push to rapidly expand access to antiretroviral therapy in sub-Saharan Africa. These include undesirable opportunity costs, the fragmentation of health systems, worsening health care inequities, and poor and unsustained treatment outcomes. On the other hand, AIDS “treatment activism” provides an opportunity to catalyze comprehensive health systems development and reduce health care inequities. However, these positive benefits will only happen if we explicitly set out to achieve them. We call for a greater commitment toward health activism that tackles the broader political and economic constraints to human and health systems development in Africa, as well as toward the resuscitation of inclusive and equitable public health systems. THE GLOBAL MOVEMENT TO reduce the price of medicines and expand access to antiretroviral therapy (ART) continues to gather momentum. In sub-Saharan Africa (SSA), the region with the highest number of people living with AIDS, millions of dollars are being directed at this cause through governments as well as through the Global Fund to Fight AIDS, Tuberculosis and Malaria, the World Bank, and bilateral overseas development aid. Private foundations such as the Gates and Clinton Foundations, and nongovernmental organizations such as Médecins Sans Frontières, are providing additional funds and technical support. The World Health Organization (WHO) has further catalyzed efforts by announcing its aim to help put 3 million people in developing countries on ART by the end of 2005. It currently estimates that only 100000 people out of 4.1 million who need it in Africa are receiving ART. 1 The plans to expand access to ART are therefore bold and ambitious and are a testament to a campaign that has challenged the indifference of governments and societies to people living with AIDS and the “profiteering” of pharmaceutical companies. Just as important, the campaign around treatment access has helped motivate health workers and mobilize civil society in Africa around a struggle for health. However, there are a number of inadequately acknowledged pitfalls associated with the push to rapidly expand access to ART in SSA. Unless the push to expand access to ART is placed within the context of a response to comprehensive health systems development, it will fail to avoid the pitfalls and undermine the desired aim of reducing AIDS-related mortality.
