To limit the public health consequences of HIV/AIDS, the South African government implemented a comprehensive treatment programme in April 2004.1 While antiretroviral therapy (ART) dramatically increases life expectancy for infected individuals,2,3 there is often significant morbidity and mortality among patients with advanced HIV infection who start ART, and care is required after treatment has failed.4 Expanding the ART programme requires increased health care system capacity, including that of secondary hospitals, to provide treatment at the appropriate scale and without crowding out other essential health services. The introduction of ART has resulted in interventions increasingly aimed at aggressively treating opportunistic infections and resuscitating patients with advanced HIV so that they may benefit from longer-term ART. The increased survival time of patients on ART will probably result in higher levels of demand for secondary hospital treatment and increased need for management of antiretroviral (ARV)-related toxicity and immune reconstitution inflammatory syndromes (IRIS). These treatment requirements can be expected to increase in proportion to the level and scale of the national ART roll-out. To ensure that South African secondary level health services are not overburdened in caring for these patients, specific operational and financial provisions need to be made.