In May Cameroon’s government announced that anti-retroviral (ARV) treatment would be free for all HIV-positive people in the country who needed it. For the more than 500,000 people living with HIV in the African country, this seemed miraculous: “All the evidence [says] you need to offer ARVs for free in order to let many people take advantage of them, and there are a growing number of countries that do,” says Chris Collins of the International Treatment Preparedness Coalition (ITPC).

Countries around the world—from Thailand to Botswana—have worked hard in recent years to provide free antiretroviral treatment to people living with HIV. But what exactly does “free” mean? In a world of asterisks and fine print, researchers are finding that supposedly free meds often come with a cost—and it’s a price tag that could be worth millions of lives.

“In many cases, what’s called free treatment is not really free [because] there are a variety of necessary health care costs [associated with it] that are not covered,” says Collins, a project coordinator for the ITPC’s fourth “Missing the Target” report, an examination and analysis of global treatment access. “There are so many other costs, such as those for transportation, or charges for viral load and CD4 tests.”

For every person who is well positioned to access free antiretrovirals, there are many others who can’t take advantage of the free treatment, says Collins. Take Cameroon: Many of its poor HIV-positive people cannot afford the registration fees required of patients who seek treatment. Pregnant women and children under the age of 5 are exempt from individual test fees, but others must pay for CD4 tests, viral load analysis and other lab tests that indicate whether treatment is working. These tests also identify potential drug-resistance issues and provide positive incentive—by showing clinical improvement in a patient’s health—that can encourage their compliance to treatment.

Another widespread problem is transportation: Positive people who don’t live close to local health centers often don’t have the money to pay for transportation to and from the clinics—let alone the energy to make the hours-long trips on foot. In short, if you have limited funds, you may have to go without “free” care.

The “Missing the Target” report found similar problems in a number of countries including Cambodia, Uganda and China. It recommends that “supplementary services, in addition to treatment, must be free if poor people are to initiate and sustain care.” Past studies have also suggested increased funding for clean drinking water and nutritious food, both essential for oral medications to be most effective.

The Cameroonian government recently pledged that an additional 12,000 people who cannot afford the associated fees will have access to medications by the end of this year. “We have got to start thinking about treatment differently and more holistically,” says Collins. “A more comprehensive-based [outlook] could save millions of lives.” Could we truly be free at last?