Background: Access to pediatric antiretroviral therapy (ART) in rural areas remains limited due to the unique challenges faced by providers and patients. Few rural ART programs have been evaluated to determine whether these challenges affect care and treatment response. Methods: Routinely collected data from 3 pediatric ART programs in rural and urban Zambia were obtained from medical records. Participants included human imm3unodeficiency virus-infected children <15 years of age presenting for care between August 2004 and July 2008. Characteristics at presentation, time to ART initiation, and treatment response were compared between urban and rural children. Results: A total of 863 children were enrolled (562 urban and 301 rural). At presentation, children in rural clinics were significantly younger (3.4 vs. 6.5 years), had higher CD4 T-cell percentages (18.0% vs. 12.8%), less advanced disease (47.5% vs. 62.3% in World Health Organization stage 3/4), lower weight-for-age Z-scores (-2.8 vs.-2.3), and traveled greater distances (29 vs. 2 km). Rural children eligible for ART at presentation took longer to initiate treatment (3.6 vs. 0.9 months); no differences were found in time to ART initiation among children ineligible at presentation (15.4 vs. 12.1 months). For the 607 children initiating ART, clinical and immunologic status improved in both urban and rural clinics. Mortality was highest in the first 90 days of treatment and was higher at all times in rural clinics. Conclusions: The findings support expansion of ART programs into rural areas to increase access to treatment services and reduce inequities. © 2010 by Lippincott Williams & Wilkins.