Despite the clear benefits of antiretroviral therapy (ART), only three countries in sub-Saharan Africa have achieved the "3 by 5" goal of treating at least half of the persons living with HIV/AIDS who need it. A major obstacle faced by many lower income countries is the establishment of treatment programs in rural areas where there is a scarcity of trained health care providers and infrastructure. This paper reviews published data on rural ART programs in lower income countries to identify necessary components of such a program. No clearly superior model for rural ART delivery has emerged. All programs document the need for expanded physical infrastructure, laboratory development, recruitment/training of additional health care providers, and/or the introduction of new technologies in order to effectively support the needs of ART roll-out.