Montague et al. BMC Public Health 2011, 11:701 http://www.biomedcentral.com/1471-2458/11/701 demonstrates that it is possible to achieve high levels of immunological reconstitution and virological suppression among FSW, and that treatment with ART of FSW can give results that are nearly comparable to those obtained amongst women in the general population. However, as Huet et al themselves point out, their results were obtained within the framework of a research study which used frequent visits combined with intensive counseling and case management services to maintain patients in care. There are several programs in sub- Saharan Africa that offer prevention and care services to FSW with the aim to reduce the transmission of HIV from FSW to their male clients and partners. Some of these programs have started providing ART to their clients or have set up referral systems. So far, no data have been published on the levels of adherence and virological sup- pression achieved amongst FSW in these programs, but the results will likely be less successful than those pre- sented by Huet et al. Moreover, these results from Burkina Faso cannot be readily extrapolated to other settings in Africa. For instance, alcohol abuse may be more common in FSW in other parts of Africa, especially Eastern and Southern Africa, and interfere with adherence [3,4]. The challenge will be the development of affordable and scal- able programs to optimize adherence. Not offering ART to FSW is not an option. The recent release of results from the HPTN 052 trial confirming the efficacy of antire- troviral therapy in the prevention of HIV transmission highlights the potential importance of ART programs as part of comprehensive efforts to reduce HIV transmission, including transmission from FSW to their male clients and partners [5]. The sustainability of HIV prevention programs targeting FSW has been a challenge ever since the late 1980’s when these programs were first piloted. This challenge will become even greater when care with ART is integrated into the programs. To be sustained, the interventions of necessity must be transferred to the national HIV care program. National HIV program managers, particularly in the era of declining funding through programs such as PEPFAR, are put in the position of balancing high cost case management interventions against expanded access to antiretroviral medications for the broader population. In this context, what appears to be a sustainable interven- tion when subsidized by outside grant funding becomes difficult to maintain over the long-term. The Seek, Test, Treat and Retain strategy offers an attractive model over the long run for controlling the HIV epidemic. This article, while providing confirmation that even the hardest to reach populations can be reached with enough resources, highlights the challenges that will be faced in realizing the potential benefits of this strategy. Though expanded access to treatment for the 75% of the population may be feasible within the structures of Page 2 of 2 national HIV care programs, reaching the hard to reach populations and sustaining the adherence to ARV treat- ment that will be necessary to truly curb the epidemic will require substantial resources over and above the cost of provision and monitoring of antiretroviral therapy. To achieve these goals and curtail the epidemic of HIV, advocacy from both medicine and public health providers will be critical to generate the support and political will necessary to sustain and enhance HIV care programs worldwide. Author details 1Warren Alpert School of Medicine at Brown University, Miriam Hospital, 164 Summit Ave, Providence, RI 02906, USA. 2Department of Public Health and ITM HIV/AIDS Center, Institute of Tropical Medicine, Nationalestraat 155, B- 2000 Antwerp, Belgium. Competing interests The authors declare that they have no competing interests. Received: 22 August 2011 Accepted: 14 September 2011 Published: 14 September 2011 References 1. Floyd S, Molesworth A, Dube A, Banda E, Jahn A, Mwafulirwa C, Ngwira B, Branson K, Crampin AC, Zaba B, Glynn JR, French N: Population-level reduction in adult mortality after extension of free anti-retroviral therapy provision into rural areas in northern Malawi. PLoS One 2010, 5(10):e13499. 2. WHO: Towards universal access: Scaling up priority HIV/AIDS interventions in the health sector. Geneva: WHO; 2010. 3. Chersich MF, Luchters SM, Malonza IM, Mwarogo P, King’Ola N, Temmerman M: Heavy episodic drinking among Kenyan female sex workers is associated with unsafe sex, sexual violence and sexually transmitted infections. Int J STD AIDS 2007, 18(11):764-769. 4. Hendershot CS, Stoner SA, Pantalone DW, Simoni JM: Alcohol use and antiretroviral adherence: review and meta-analysis. J Acquir Immune Defic Syndr 2009, 52(2):180-202. 5. HIV treatment as prevention–it works. The Lancet 2011, 377:1719. Pre-publication history The pre-publication history for this paper can be accessed here: http://www.biomedcentral.com/1471-2458/11/701/prepub doi:10.1186/1471-2458-11-701 Cite this article as: Montague et al.: Sustainability of programs to reach high risk and marginalized populations living with HIV in resource limited settings: implications for HIV treatment and prevention. BMC Public Health 2011 11:701. 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