The practice of fine-needle aspiration (FNA) became popular in Scandinavian countries in the middle of the 20th century and, in the United States, several decades later.1 Its relative ease of performance makes FNA highly attractive for adoption in low-resource countries, where higher rates of infections and infection-related malignancies are encountered.2 Late presentation of disease is more frequent in these areas, in addition globalization, with its inherent lifestyle change, has led to an increase in cancers that traditionally were more prevalent in developed nations.3, 4 However, it is these poorly resourced countries that may lack the health infrastructure to manage a high burden of both infectious and malignant disease. There are severe shortages of laboratories and personnel in many areas of Africa, which may negatively impact diagnosis, resulting in inappropriate treatment. Limited patient access to adequate laboratory facilities reduces clinicians' confidence in their ability to manage patients, whereas lack of accurate diagnoses compromises national and international statistics that impact negatively on the provision of rational health interventions that may improve the general health of a population.4 FNA as a diagnostic technique in under-resourced communities requires equipment that may already be available in many health facilities. It may be performed as a low-complication outpatient or bedside procedure, without the use of anesthesia, curtailing costs. Sophisticated laboratory equipment is not required to process samples. Simple stains, such as acid fast stains, performed on existing FNA slides can improve diagnostic accuracy. Medical personnel, including pathologists, are not necessarily required to perform FNA.5 For almost 2 decades, our cytopathology unit has successfully trained nurses to perform FNAs, because there was (and continues to be) a critical shortage of medical doctors. In our clinical setting, FNA is often one of the first diagnostic procedures to be performed. Many patients undergo definitive treatment based on cytodiagnosis alone, enabling an early entry point to the health care system, which considerably reduces referrals for more invasive procedures.5 Although FNA may be an indispensable tool in under-resourced settings, limitations do exist. Poor socioeconomic conditions may result in limited or delayed access to health services. Cytotechnologists and pathologists require both training and experience to achieve reliable diagnostic accuracy.6 Rapid results can be obtained after an FNA has been performed; however, logistical constraints, such as staff shortages, may lead to delays in reporting. Resources in terms of both money and skilled personnel to perform ancillary tests may not be available. Unfortunately, if a poorly resourced clinical service is limited or unavailable to treat malignancies, then it is possible that precious health resources may be better used elsewhere. Our cytopathology unit based in Johannesburg, South Africa is a large public-sector laboratory that reports approximately 13,000 FNAs per year. The majority of patients undergoing FNA may not require further management (eg, for diagnoses such as reactive lymphoid hyperplasia, lymphoepithelial lesion of the salivary gland, fibroadenoma of the breast, and benign thyroid nodules), or they can be managed at a primary health level (eg, for mycobacterial infection). Patients who are referred to a secondary or tertiary health center with an established FNA diagnosis are eligible for expedited management. This cytopathology unit organizes, manages, and staffs FNA clinics in 7 secondary and tertiary hospitals in the vicinity of Johannesburg, which ensures that most of FNAs are of good quality. The cytopathology unit also provides an image-guided FNA service. Every day, personnel from our cytology unit are to be found in the radiology suites of several nearby hospitals, where they make a preliminary diagnosis on site and triage material for appropriate ancillary investigations. Image-guided FNA obviates the need for open biopsy in many instances, enabling considerable saving in terms of operating room time and the services of anesthesiologists and surgeons. In this country, FNA has come to the forefront in the management of human immunodeficiency virus (HIV)-positive patients. South Africa is currently in the throes of the dual and deadly epidemics of HIV and tuberculosis (TB). It is estimated that approximately 10% of the South African population is infected with HIV (ie, 5.26 million individuals). The highest rates are observed in women ages 15 to 49 years, 17.4% of whom are infected with HIV.7 According to the World Health Organization,8 the prevalence and incidence of tuberculosis in South Africa in 2012 were 857 per 100,000 and 530 per 100,000, respectively, with greater than 190,000 patients coinfected with both HIV and TB. HIV-infected patients have much higher rates of extrapulmonary TB compared with their HIV-negative counterparts. FNA is extremely valuable in the diagnosis of extrapulmonary mycobacterial infection in its many guises, including granulomatous inflammation, suppurative necrotic inflammation, mycobacterial spindle pseudotumor, and aspirates comprising entirely necrosis. The HIV epidemic, although devastating for patients, families, and communities, results in fascinating cytopathology. In our unit, we regularly encounter both acquired immunodeficiency syndrome (AIDS)-defining and non-AIDS–defining malignancies, such as Hodgkin and non-Hodgkin lymphoma (including unusual types like plasmablastic lymphoma), Kaposi sarcoma, hepatocellular carcinoma, and lung carcinoma. Infections regularly encountered on FNA include cryptococcal and histoplasmosis lymphadenitis. Another area in HIV management that lends itself to FNA is the diagnosis of the side effects of antiretroviral therapy. We perform many FNAs on males with gynecomastia resulting from antiretroviral therapy, especially those receiving protease inhibitors. In addition, FNA is helpful to distinguish immune reconstitution inflammatory syndrome (IRIS) from other causes of deterioration in an HIV-infected individual, the management of which varies considerably. FNA is highly advantageous in pediatric population, in which clinical examination and radiologic studies alone may not be able to determine the etiology of a mass lesion. Lymphadenopathy is an extremely common finding in children. In the vast majority of patients, this is caused by benign reactive lymphoid hyperplasia. In a child with persistent lymphadenopathy, a benign FNA diagnosis is reassuring. In this cytopathology unit, FNA in children yields various other benign lesions, such as mycobacterial infection, Echinococcal (hydatid) cyst, lymphoepithelial lesion, and malignancy. This cytology unit serves 2 large, academic pediatric oncology units in the Johannesburg area, namely, Chris Hani Baragwanath and Charlotte Maxeke Johannesburg Hospitals, both of which function as referral units for children with cancer from a very large population in South and Southern Africa. FNA is one of the first diagnostic modalities in these wards, and we regularly aspirate and diagnose an astounding array of childhood tumors, such as nephroblastoma, neuroblastoma, rhabdomyosarcoma, lymphoma, Ewing sarcoma/primitive neuroectodermal tumor, desmoplastic small round cell tumor, germ cell tumor, nasopharyngeal carcinoma, and hepatocellular carcinoma.9, 10 Therefore, FNA is a very useful procedure for the diagnosis of superficial and deep mass lesions in under-resourced health care settings. Minimal basic equipment but appropriately trained staff is required to perform, process, and assess FNAs, and many valuable diagnoses are made based on cytomorphology alone. Despite some of the limitations inherent to this type of health care setting, we believe FNA really has made, and continues to make, a positive impact on the management of most patients. We wish to acknowledge two cytopathology initiatives with which we have been personally involved: Dr. David Kaminsky and the Africa Calls team, and the Sub-Saharan FNB Tutorials organized by Drs. Field, Geddie, and Zarka. Pamela Michelow, MBBCh, MSc, MIAC, is Principle Medical Officer in the Cytology Unit, National Health Laboratory Service, with a joint appointment as Senior Researcher, Department of Anatomical Pathology, University of the Witwatersrand, Johannesburg, South Africa. One of her interests is the use of cytopathology in HIV-infected patients, in low resource settings. Luvo Fatman, MBChB, MSc, is a Medical Officer in the Cytology Unit, National Health Laboratory Service, Johannesburg, South Africa. Dr. Fatman manages the Cytology Unit's fine-needle aspiration clinics, which are situated in several nearby hospitals; coordinates the image-guided fine-needle aspiration service; and instructs nurses, residents, and clinicians on how to perform fine-needle aspirations.