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David McCoy, DrPH, BMed, Mickey Chopra, MSc, BMed, Rene Loewenson, PhD, Jean-Marion Aitken, MA, Thabale Ngulube, PhD, MBChB, Adamson Muula, MPH, MBBS, Sunanda Ray, MPH, MBBS, Tendayi Kureyi, MPhil, Petrida Ijumba, MPH and Mike Rowson, MSc

Petrida Ijumba is with the Health Systems Trust, Durban, South Africa. Mickey Chopra is with the University of Western Cape School of Public Health, Cape Town, South Africa. Rene Loewenson is with the Training and Research Support Centre, Harare, Zimbabwe. Thabale Ngulube is with the Centre for Health, Science & Social Research, Lusaka, Zambia. Adamson Muula is with the University of Malawi, Lilongwe. Sunanda Ray and Tendayi Kureyi are with the Southern Africa AIDS Network in Harare, Zimbabwe. Mike Rowson is with Medact, London, United Kingdom. At the time of writing, David McCoy was with the Health Systems Trust, Durban South Africa; Sunanda Ray was with the Southern Africa AIDS network, Harare, Zimbabwe, and Jean-Marion Aitken was an independent consultant in Lilongwe, Malawi.

Correspondence: Requests for reprints should be sent to Petrida Ijumba, Health Systems Trust, PO Box 808, Durban 4000, South Africa (e-mail: petrida{at}hst.org.za).

We describe a number of pitfalls that may occur with the push to rapidly expand access to antiretroviral therapy in sub-Saharan Africa. These include undesirable opportunity costs, the fragmentation of health systems, worsening health care inequities, and poor and unsustained treatment outcomes. On the other hand, AIDS "treatment activism" provides an opportunity to catalyze comprehensive health systems development and reduce health care inequities.

However, these positive benefits will only happen if we explicitly set out to achieve them. We call for a greater commitment toward health activism that tackles the broader political and economic constraints to human and health systems development in Africa, as well as toward the resuscitation of inclusive and equitable public health systems.

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