After 20 years and millions of agonizing deaths from AIDS in Africa, the logjam over the high prices of drugs for treating the disease has been broken. In recent months, under mounting public pressure and through the "quiet diplomacy" of the UN, the pharmaceutical industry has reduced prices for many drugs by. 80-90 per cent. In early June, Botswana became the first African country to take advantage of these lower prices, announcing that in the new year it will seek to provide the full range of HIV and AIDS therapies to as many as 100 000 infected citizens.

Until very recently, Dr. Peter Piot, executive director of the Joint UN Program on HIV/AIDS (UNAIDS), said in late May, the idea of providing costly life-saving drugs and complex medical care to sufferers in developing countries w;as considered controversial, even radical, by many donor governments, private-sector actors, humanitarian organizations and health care professionals.

Since the introduction of the first life-prolonging treatments for AIDS in 1987, many sufferers in the industrialized North, even among the poor, gained access to the drugs and often lived longer than they would have otherwise. But the afflicted in the impoverished South, aside from the very rich or the very lucky, could not get the medicines and soon died. Critics bitterly termed this disparity "medical apartheid." UN Secretary-General Kofi Annan has spoken of an "ethical imperative" to treat the sick regardless of means.

Since its launch in 1996, UNAIDS has advocated a two-pronged attack on the disease: combining education and prevention for those not yet infected, with care and treatment for the tens of millions of people around the world who are.

However, many donor officials and health professionals regarded proposals to treat carriers of the Human Immunodeficiency Virus (HIV) that triggers Acquired Immune Deficiency Syndrome (AIDS) as unrealistic, saying that such a course would divert painfully scarce resources away from more cost-effective education and prevention programmes. The extremely high cost of the drugs put them beyond the reach of all but the wealthiest individuals in developing countries, they noted. Nor were public health systems in poor countries able to cope with the complexity of the treatments, some analysts asserted, or the need for ongoing testing and follow-through. When UNAIDS called last year for an international multi-billion dollar programme of prevention and treatment for Africa, which now accounts for 70 per cent of all infections worldwide and nearly 80 per cent of fatalities, Dr. Piot noted, "the word 'irresponsible' was not far away."

But no more. In recent months a combination of market forces and mounting political pressures on the pharmaceutical industry have seen prices for many drugs drop drastically. Some now are even provided free to developing countries. Although the discounts still price many of the medicines beyond Africa's means, the reductions have transformed the debate about costs—which the World Health Organization (WHO) has identified as the principal obstacle to the wider availability of AIDS medicines.

Concerns about delivery in poorer countries have also been challenged. On 4 April, more than 100 medical and development experts at Harvard University in the US declared that "objections to HIV treatment in low-income countries are not persuasive," and issued a detailed blueprint for a widespread treatment program. "Poor infrastructure," they asserted, "can be overcome through well-designed and well financed international efforts."

The final element—external financing—received a boost in Abuja, Nigeria, in late April with Mr. Annan's announcement of a Global AIDS and Health Fund to increase funding for AIDS, malaria and tuberculosis programs in developing countries from its current level of under $2 bn annually to the $7-10 bn needed.

Although the world has yet to commit the resources and political will needed to win the battle against AIDS in Africa and other developing regions, the "paradigm" as Dr. Piot noted, has now shifted from whether to treat the infected in developing countries to how.