The barriers to providing highly active antiretroviral therapy (HAART) in poor countries have until recently seemed insurmountable. The cited problems have ranged from weak health systems and poor infrastructure to inadequate numbers of health professionals. In reality, the main barrier has been the very high cost of antiretroviral drugs. Current increase in access to HAART has resulted from cuts in the price of antiretroviral drugs and increased funding by international bodies, notably the Global AIDS Fund, the World Bank, and the President Bush Emergency Program for AIDS Relief.

Africa's grim AIDS data include 25 million people living with HIV and 2.2 million dead in 2003 alone.1 The challenge now is to move quickly from small town or community specific projects to provide nationwide high quality, equitable, and sustainable programmes. Valuable lessons have been learned from pilot programmes in poor countries, including the Malawi experience described in this issue, but individually these do not provide a blueprint for universally applicable scale-up models (p 1163).2 However, if the cumulative knowledge from these programmes is applied with tactical adjustment tailored …