Over one million people in sub-Saharan Africa now access HIV treatment, and as the prognosis of life expectancy on antiretroviral therapy (ART) improves, the central question that arises for governments, civil society and the private sector must be: how will we pay for the healthcare costs?This paper critically evaluates the need to provide effective treatment, prevention and care for HIV over the long term. Compelling evidence and moral argument suggest that the right combination of treatment and prevention policies, bolstered by grassroots mobilization and effective treatment literacy campaigns, can prevent new infections, save lives and mitigate the impact of HIV/AIDS. South Africa's HIV epidemic and its antiretroviral roll-out provide instructive global templates. The scale of the epidemic, the political responses, the epidemiological evidence and the outcomes data are lessons for countries where there is only a low-level epidemic at present. The investment needed to provide universal ART in South Africa will be substantial, but the economic rationale to act now is compelling. Brazil and to a lesser extent Thailand have responded with increased urgency and foresight. When compared with South Africa, their successes lend further credence to the importance of augmenting HIV prevention efforts with widespread access to treatment and care. Despite the obstacles, important gains have been made in South Africa, with community level health facilities documenting noteworthy treatment and adherence results. Our example suggests that even after tragic mistakes have been made, collective action, evidence-informed programmes, and sustained investment can still save lives and mitigate the epidemic.