Montague et al. BMC Public Health 2011, 11:701 http://www.biomedcentral.com/1471-2458/11/701 C O M M E N T A R Y Open Access Sustainability of programs to reach high risk and marginalized populations living with HIV in resource limited settings: implications for HIV treatment and prevention Brian T Montague1*, Bea Vuylsteke2 and Anne Buvé2 Abstract The experiences of the past 10 years have shown that it is feasible to treat HIV infected patients with ART even in severely resource constrained settings. Achieving the levels of antiretroviral coverage necessary to impact the course of the HIV epidemic remains a challenge and antiretroviral therapy coverage in most nations remains short of even current recommendations. Though treatment as prevention and seek, test, treat and retain strategies are attractive, realization of the benefits of these strategies will require the ability to successfully engage key hard to reach populations such as sex workers. The successes engaging these populations in research settings as seen in the article by Huet et al are encouraging, however key questions remain regarding the sustainability of these efforts as patients are transitioned back to national HIV control programs, many of which are struggling even to maintain the current panels in care in the face declining external funding for HIV care. To achieve the critical goals of increasing treatment uptake and retention and thereby 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 the necessary HIV care programs worldwide. When the first programs providing access to antiretroviral treatment were launched in Africa in the early years of the 21st century, they were met with a lot of skepticism. There were concerns about the costs and the feasibility, and about adherence. The experiences of the past 10 years have shown that it is feasible to treat HIV infected patients with ART even in severely resource constrained settings, and that immunological reconstitution and virological suppression can be achieved for large numbers of patients resulting in declines in mortality [1]. Nonetheless there are still huge challenges ahead. In surveillance data from the World Health Organization in 2009, antiretroviral cover- age according to 2006 guidelines with a CD4 cell count threshold of < = 200 was 52% worldwide. Coverage based on the higher 2010 threshold of CD4 count < = 350 was only 36%. Only 8 low or middle income countries have * Correspondence: brianmontaguedo@gmail.com 1Warren Alpert School of Medicine at Brown University, Miriam Hospital, 164 Summit Ave, Providence, RI 02906, USA Full list of author information is available at the end of the article been able to achieve ART coverage rates of greater than or equal to 80% [2]. A substantial portion of HIV care has been subsidized through contributions from programs such as the US President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund and it is unclear whether the present level of funding will be maintained, let alone increased. In the context of limited and at times declining funding for antiretroviral therapy (ART), ART programs targeting marginalized and difficult to reach populations such as female sex workers (FSW), may not be considered a priority. Concerns about feasibility and adherence in ART programs for FSW resonate with the skepticism that was voiced 10 years ago about ART programs in low resource settings. ART programs for FSW indeed do face a number of challenges. FSW are hard to reach and tend to be mobile; and adhering to a strict treatment regimen may be difficult for them because of the nature of their work and their lifestyles. The question is whether these barriers can be overcome. The study by Huet et al. © 2011 Montague et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.