Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Optimizing HIV treatment programs Sergio Bautista-Arredondo a , Tyler E. Martz a , Veronika J. Wirtz b and Stefano M. Bertozzi a,c Introduction Although access to antiretroviral therapy (ART) expanded exponentially in low-income and middle- income countries over the past decade, only four of the nine million people in low-income and middle- income countries in need of treatment were on ART at the end of 2008 [1]. What this figure fails to capture is that, although roughly one of the three people in need of treatment receive treatment each year, about two of the three people in need die without ever having been treated. With global HIV prevalence remaining at 33 million and with 2.7 million new infections in 2007 [2], access to and effectiveness of treatment will remain of critical concern for years to come. Treatment for HIV relies on ART as the only current treatment option shown to be effective. However, in order to maximize the number of quality life years extended with ART, HIV treatment programs have to be optimized. There- fore, the objective of the present article is to outline a few key issues based on available evidence that project managers need to focus on in order to get the most benefit for available resources. Although this outline may seem straightforward, the fact remains that most HIV/AIDS treatment programs in low-income and middle-income countries are implemented subopti- mally. We do not intend to provide the answers, but rather to directly outline the key questions that project managers should be asking themselves. Effective coverage of optimized treatment including adherence must be increased. In order to do so, one must determine the key actors making decisions that affect access to treatment, quality of care, adherence, and the incentives and constraints they face. Aligning incentives, relaxing constraints, and regulation are the main tools that program managers can use to optimize their treatment program and that should be explored in more contexts and at different program scales, while evaluating and documenting successes and failures. Coverage encompasses the questions of who gets access, when to initiate ART and with what combinations, when to switch ART combinations, and even the more con- troversial question of when to possibly stop treatment. Healthcare providers, and to some degree program managers, implicitly answer most of these questions through the decisions they make everyday. Improving adherence involves decisions made by the patients, but also decisions made by physicians and program managers that involve counseling, support, and optimization of treatment. a Center for Evaluation Research and Surveys, b Center for Health Systems Research, National Institute of Public Health, Cuernavaca, Morelos, Mexico and c Bill & Melinda Gates Foundation, Seattle, Washington, USA Correspondence to Sergio Bautista-Arredondo, Director a.i. of the Health Economics Division, Center for Evaluation Research and Surveys, Mexican National Institute of Public Health, Av. Universidad 655, Cuernavaca, Morelos 62100, Mexico E-mail: sbautista@correo.insp.mx. Current Opinion in HIV and AIDS 2010, 5:232–236 Purpose of review Increasing demand for HIV treatment and limited resource availability will require the optimization of treatment programming to not only improve individual treatment outcomes, but also to maximize overall benefit for available resources. Recent findings Available research, although recognizing the importance of ensuring or improving treatment adherence, largely focuses on patient barriers or incentives. More research is necessary to examine how decisions made at all levels of treatment programming affect treatment outcomes. Summary Explicit decisions regarding treatment access, initiation, drug combinations, and potential termination of treatment along with addressing incentives and barriers to treatment adherence are necessary to maximize the overall benefit for available resources. This factor will depend on the involvement of the three main treatment actors, program managers, health practitioners, and patients. Keywords cost, HIV/AIDS treatment, optimization Curr Opin HIV AIDS 5:232–236 ß 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins 1746-630X 1746-630X ß 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins DOI:10.1097/COH.0b013e32833860d3