We would like to compliment Gill et al.  on their article ‘No room for complacency about adherence to antiretroviral therapy in sub-Saharan Africa’. We agree with their concern that adherence to antiretroviral therapy in resource-limited countries will probably decline as treatment access expands. We suggest, however, that future declines in adherence will be less related to publication bias, as suggested by the authors, than to the end of a ‘honeymoon perioD' defined by two phenomena.
First, the initial individuals who gained access to antiretroviral therapy in resource-limited settings may possess greater resources, heightened motivation, and are probably not representative of the larger HIV epidemic. As treatment access expands beyond this select group, population adherence levels will probably fall (although not to the levels of 60–70% reported in north America) .
Second, early reports on adherence in resource-limited settings were largely based on individuals who had recently initiated treatment [3–6]. Adherence often declines over time as the benefits of treatment plateau and the long-term side-effects of treatment, such as neuropathy and lipodystrophy, accumulate [7–9]. Gill et al.  cited two observations in sub-Saharan Africa suggesting that adherence may decline over time, but these studies may have overestimated the decline. In the intent-to-treat, missing-equals-failure analysis of Laurent el al. , individuals who stopped therapy because of toxicity or interruptions in access were counted as non-adherent with detectable virus. In the abstract by Akam , also cited by Gill et al. , the estimate of 68% adherence among patients receiving self-pay therapy is largely attributable to the 53% who discontinued treatment as a result of financial constraints.
Adherence, commonly defined as ‘taking medication as prescribeD', presumes access to therapy. Lack of access to therapy and failure to adhere to therapy are different problems requiring different solutions. The former calls for stable drug supply and distribution, whereas the latter calls for interventions to sustain individual behavior. We agree with Gill et al.  that there is no room for complacency about adherence to therapy, but neither is there room for complacency about access to therapy.
1. Gill CJ, Hamer DH, Simon JL, Thea DM, Sabin LL. No room for complacency about adherence to antiretroviral therapy in sub-Saharan Africa. AIDS 2005; 19:1243–1249.
2. Bangsberg DR, Deeks SG. Is average adherence to HIV antiretroviral therapy enough? J Gen Intern Med 2002; 17:812–813.
3. Orrell C, Bangsberg D, Badri M, Wood R. Adherence is not a barrier to delivery of HIV antiretroviral therapy in resource-poor countries. AIDS 2003; 17:1369–1375.
4. Laurent C, Diakhate N, Gueye NF, Toure MA, Sow PS, Faye MA, et al
. The Senegalese government's highly active antiretroviral therapy initiative: an 18-month follow-up study. AIDS 2002; 16:1363–1370.
5. Oyugi JH, Byakika-Tusiime J, Charlebois ED, Kityo C, Mugerwa R, Mugyenyi P, Bangsberg DR. Multiple validated measures of adherence indicate high levels of adherence to generic HIV antiretroviral therapy in a resource-limited setting. J Acquir Immune Defic Syndr 2004; 36:1100–1102.
6. Byakika-Tusiime J, Oyugi JH, Tumwikirize WA, Katabira ET, Mugyenyi PN, Bangsberg DR. Adherence to HIV antiretroviral therapy in HIV+ Ugandan patients purchasing therapy. Int J STD AIDS 2005; 16:38–41.
7. Ickovics JR, Cameron A, Zackin R, Bassett R, Chesney M, Johnson VA, Kuritzkes DR, for the ACTG 370 Protocol Team. Consequences and determinants of adherence to antiretroviral medication: results from Adult AIDS Clinical Trials Group protocol 370. Antivir Ther 2002; 7:185–193.
8. Howard AA, Arnsten JH, Lo Y, Vlahov D, Rich JD, Schuman P, et al
. A prospective study of adherence and viral load in a large multi-center cohort of HIV-infected women. AIDS 2002; 16:2175–2182.
9. Ammassari A, Antinori A, Cozzi-Lepri A, Trotta MP, Nasti G, Ridolfo AL, et al
. Relationship between HAART adherence and adipose tissue alterations. J Acquir Immune Defic Syndr 2002; 31(Suppl. 3):S140–S144.
10. Akam A. Anti-retroviral adherence in a resource poor setting. In: XVth International AIDS Conference. Bangkok, 30 March–2 April 2004 [Abstract B12311].