Sir- Elliot Marseille and colleaguesMarseille E, Hofmann P, Kahn J. HIV prevention before HAART in sub - Saharan Africa. Lancet 2002; 359: 1851 - 56 [Text]  believe that activism for access to AIDS treatment prevents informed debate about resource allocation. In Thailand, activism has a more positive outcome. The yearly budget of the Thai government for antiretrovirals has been constant since 1995.

Attempts in 1998 to reduce the price of these drugs by producing them locally met with aggressive pressure by the US government and the pharmaceutical industryWilson D, Cawthorne P, Ford N, Aongsonwang S. Global trade and access to medicines: AIDS treatments in Thailand. Lancet 1999; 354: 1893 - 95 [Text].

Activist support drew attention to the right of Thailand to produce generic antiretroviralsvon Schoen Angerer T, Wilson D, Ford N, Kasper T. Access and activism: the ethics of providing antiretroviral therapy in developing countries. AIDS 2001; 15 :(suppl) S81 - S90. Six generic antretrovirals are now available, with one triple regimen costing US$27 per month per patient. A demonstration on World AIDS Day, 2001, by more than 1,000 Thai people with HIV/AIDS in front of government house, demanded that the government increase access further by including antiretroviral treatment in a new universal health insurance scheme.

A joint Ministry of Public Health/Non-governmental organisations committee was then established to scale up implementation of AIDS treatment. Informed debate is necessary during implementation of treatment programmes and during the process of resource allocation.

Médecins sans Frontières (MSF) supports three district hospitals setting up antiretroviral treatment programmes in Thailand. Preliminary training sessions gave us the chance to assess the motivation and concerns of the hospital staff. Most staff commit themselves to working in these difficult programmes mainly to prevent new infections. They share Marseille and colleagues' scepticism that HAART makes prevention more effective and they worry that making treatment widely available could encourage high-risk behaviour. Such concerns need to be discussed openly and all opinions respected. Nevertheless, staff in all three hospitals also want to work for the good of the whole community and feel they cannot do a complete job without providing treatment.

Not providing treatment leads to a sense of hopelessness in both staff and patients, which reduces the effectiveness of prevention interventions. Provision antiretroviral therapy in resource-poor settings needs concerted dialogue with health workers and patient groups. Activism needs to respond to legitimate concerns.

However, a debate confined to issues of cost-effectiveness is too narrow, and polarisation of the debate into a prevention versus HAART argument will not help either cause.

Most importantly, a massive increase in funding assistance from western governments is needed. The Global Fund for AIDS, tuberculosis and malaria, standing at a tenth of what is required to fight AIDS alone, is a tragic indictment of the inadequate worldwide commitment to the world's greatest pandemic.