By focusing on access to free antiretroviral treatments in Botswana, this article offers a privileged vantage point over transformations in international health policies in the South. The partnership between the government of Botswana, the pharmaceutical company Merck & Co., and the Bill and Melinda Gates Foundation was made possible through preexisting biomedical collaboration between the government of Botswana and the Harvard School of Public Health. This configuration of actors and interests offers a broad view of contemporary global health partnerships in which philanthropy, science, and public health overlap. In being determined by their convenience, accessibility, and chance of success, global health interventions tend to reproduce inequalities within health systems and on a global level.