Summary points

The ever-growing HIV treatment programs in sub-Saharan Africa (SSA) present local policy makers with complex decision dilemmas, as international guidelines emphasize the need for expanded access to antiretroviral therapy (ART), yet funding has flatlined.
We argue that the current evidence base for prioritizing ART scale-up strategies results in recommendations that are theoretically optimal but practically infeasible to implement.
Cost-effectiveness analyses (CEAs) of scaling up ART in SSA should be made more responsive to the needs of policy makers by taking into account the local health system.
We provide suggestions for a better integration of health system constraints into CEA by integrating supply- and demand-side constraints in mathematical models and improving the dialogue between researchers and policy makers.