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Tough choices: tenofovir, tenders and treatmentScaling up antiretroviral therapy (ART) in developing countries would not have been possible without market competition, which has driven down the price of standard first-line ARV drugs from more than US$12,000 per person per year in 2000 to US$99 today. However, access to new, second-line ARVs remains largely restricted to originator (patented) drugs. This causes significant challenges in countries where access to newer drugs is becoming inceasingly important as programmes mature and face challenges related to drug toxicity and resistance. Toxicity, in particular, has emerged as a major reason for individual drug switches and regimen changes, and is strongly implicated in decreasing adherence.