Editorial: Scale-up of antiretroviral therapy in sub-Saharan Africa – priorities for public health research Shabbar Jaffar 1 , Edward Mbidde 2 , Alistair Robb 3 , Alex Coutinho 4 , Moses Muwanga 5 , Carla Makhlouf Obermeyer 6 , Ian Weller 7 , Graham Hart 7 , Peter G. Smith 1 , Andy Haines 1 and Heiner Grosskurth 2 1 London School of Hygiene and Tropical Medicine, London, UK 2 Uganda Virus Research Institute, Entebbe, Uganda 3 Department for International Development, Kampala, Uganda 4 The AIDS Support Organisation, Kampala, Uganda 5 Wakiso District Council, Entebbe, Uganda 6 HIV Division, World Health Organisation, Geneva, Switzerland 7 Centre for Sexual Health & HIV Research, University College London, London, UK keywords antiretroviral therapy, ART, HAART, HIV prevention, Africa, public health, research priorities The scale-up of antiretroviral therapy (ART) in Africa is the largest health delivery programme ever contemplated on the continent. About 1.3 million people are now on ART and a further 3.5 million are estimated to be in current need of ART. Research is required urgently to identify strategies of scaling-up ART delivery to ensure that it has high coverage, is effective and is available equitably. Furthermore, the number of new infections occurring daily far outstrips the number of patients being placed on ART (World Health Organization, 2007), and to halt the expanding number eligible for treatment, a pressing priority for research is to determine ways of effectively integrating human immunodeficiency virus (HIV) preven- tion with ART delivery strategies. At present, most government-led ART programmes are based in district or tertiary-level hospitals. This limits the number who can be treated; as hospital services are overburdened, there is a severe shortage of clinical staff, especially physicians, and most hospitals are in urban settings and difficult to access by the majority of people who live in rural areas (Jaffar et al. 2005; Gilks et al. 2006). Home-based care may not be acceptable in many settings because of stigma issues, but it is being evaluated in at least one cluster randomized trial (Jaffar et al., unpublished data). Peripheral health facilities, run by nursing staff or clinical assistants, provide basic primary care in rural communities across Africa. Research is required to determine if ART could be initiated and maintained from such centres. Could the centres monitor patients for side effects from therapy? Could they make referrals to hospitals as and when appropriate? What kind of adherence support and behaviour counselling should the centres provide? How often should patients be followed up and by whom? What should be the minimum cadre of staff involved in the different components of ART delivery and how should they be trained and supported? What are the costs of ART both to the health services and to the patients? Rigorous studies are needed to address these questions, ideally randomized trials. The focus should be on identifying cost-effective packages of monitoring and support needed for ART delivery, with comparisons made with a standard hospital delivery model. There is an urgency to find answers, and biological endpoints such as virological failure can be used as the primary end- points if these are considered to be good surrogate measures of treatment failure and survival in ART-naı¨ve populations. In settings with high HIV prevalence, 10% of the adult population could be on ART within a few years (Van Damme et al. 2006). The scale-up of ART services provides a unique opportunity for intensifying HIV pre- vention efforts as more resources are directed towards HIV programmes and more people come forward for HIV- testing. Integrating HIV prevention with ART roll-out is crucial and might ensure that prevention remains the key priority. Existing HIV prevention efforts such as condom pro- motion and voluntary counselling and testing (VCT) should be strengthened and more widespread use of circumcision to decrease susceptibility to HIV infection needs to be promoted and implemented. Research is needed to identify strategies that maximize the uptake of these and to determine how the availability of ART might be used to strengthen prevention efforts. Reinforcing prevention activities to household members of those on ART may be an effective strategy, though issues of stigma remain a major impediment in many societies. Tropical Medicine and International Health doi: 10.1111/j.1365-3156.2007.01896.x volume 12 no 9 pp 1009–1010 september 2007 ª 2007 Blackwell Publishing Ltd 1009