To date, a minority of persons living with HIV worldwide has benefited from the advances in HIV therapeutics fueled by the scientific community, policy-makers, advocates, and the pharmaceutical industry in the global North. A growing body of evidence demonstrates that access to highly active antiretroviral therapy can be successfully scaled-up in less wealthy nations in the South. High rates of adherence correspond with clinical, immunologic, and virologic outcomes similar to those seen in wealthier nations. Recent reports of successful programs highlight the provision of free care, reliance on the international funding sources, and proactive adherence counseling. As access to antiretroviral therapy has improved, there is an urgent need to develop better strategies for initiating and monitoring therapy, including the scale-up of viral load testing.