Free Antiretrovirals Must Not Be Restricted Only to Treatment-Naive Patients

D espite the " 3 by 5 " initiative [1], which aims to treat 3 million people with antiretrovirals (ARVs) by the end of 2005, access to ARVs in resource-poor settings remains limited. Moreover, in some ARV-access programmes, free ARVs are provided only, or preferentially, to patients who are ARV naive. Treatment restricted to patients who are ARV naive was initially the case in Uganda, with the free ARVs provided by the Multi-Country AIDS Programme and the Presidential Emergency Plan for AIDS Relief. While in the policy documents of both projects it was not stated that free ARVs should be given preferentially to ARV-naive patients, many physicians involved in the roll-out of ARVs in Uganda felt that this was what these projects were recommending. Indeed, the Ministry of Health's " Antiretroviral Treatment Policy for Uganda " stated that " those who are clinically eligible and can afford to pay for ART will be encouraged to do so. Those already in privately provided and privately paid ART should be encouraged to remain in this situation. Others who become clinically eligible over time and have the ability to pay or have a third party able to pay in their place or cost share with them, should pay full cost for ART, whether they avail themselves of treatment provided in the public or private sector " [2]. These policy statements were interpreted by many clinicians to mean that patients who are already paying for their drugs can afford to do so and are not a priority for free drugs. In this essay, we explain the rationale for restricting free access to treatment-naive patients, and then we outline the reasons why such restriction is highly problematic. There are four principal reasons why free ARVs are being restricted to treatment-naive patients. Firstly, ARV treatment regimens are more predictable in ARV-naive patients [3]. Programmes limited to this population will provide what donors most desire: good outcomes. Secondly, ARV-naive patients will usually respond readily to less expensive fi rst-line ARV regimens, and only a few will require more complex and costly second-line ARVs. Thirdly, results of programmes are easier to compare, because similar ARV regimens are started in more homogeneous, comparable populations. And fi nally, it is often believed that patients who in the past have been able to buy ARVs should continue to do so. There are, however, serious problems with this strategy of restricted access. …