The fight against AIDS in Africa is entering a phase of great promise and peril: the drug-treatment era.
After years of debating how and if Africans diagnosed with HIV/AIDS should be treated, there's now significant global agreement that the 25 million people in sub-Saharan Africa estimated to have the disease will eventually get anti-AIDS drugs.
Yet, there's also a growing realization that dependence on these drugs will require new spending, including billions of dollars for new tests and treatments. The reason: A patient's first set of AIDS drugs usually loses its effectiveness after four to five years and must be replaced by "second-line" drugs, which are roughly eight times more expensive.
"The era of implementation has started," said Peter Piot, executive director of the UN AIDS agency, at this week's International Conference on AIDS and Sexually Transmitted Infections in Africa, here in Abuja, Nigeria's capital. "The world is now committed to universal treatment."
As recently as two years ago, a debate raged over whether Africans could carry out the complicated treatment process. US aid-agency chief Andrew Natsios famously stated in 2001 that Africans "don't know what Western time is," and wouldn't take pills at appointed hours.
In addition to that concern - heavily criticized and disproven - there was skepticism that AIDS drugs could be widely distributed because of often-inadequate infrastructure and the difficulties of administration in conflict areas. The cost factor was daunting for donors, because the drugs are too costly for most patients.
Meanwhile, the idea of AIDS treatment as a universal right has gained ground. At the Africa-focused G-8 summit in July, leaders of the world's richest nations committed to HIV/AIDS prevention, treatment, and care for as close to everyone as possible by 2010.
Currently, only about 500,000 people with HIV or AIDS across Africa are getting drugs. Two years ago, it was just 75,000. Countries around the continent are boosting efforts to provide free or low-cost treatment.
Nigeria just announced it will provide drugs to 250,000 people by next year, up from an official 30,000 now - out of at least 3.3 million thought to have the disease here.
Meanwhile, since 2003, funds available for AIDS have nearly tripled, according to the UN. A major source: a $15 billion, five-year US commitment called the President's Emergency Plan for HIV/AIDS Relief or PEPFAR.
Yet, there are new cautionary notes.
A big-smiling Nigerian named Ibrahim Umoru is emblematic of coming trouble.
"I've been living with this funny, stupid virus for five years," he says.
At first, he bought drugs for $161 a month, though he only made $123 a month as a fish trader. Burning through savings, he had to sell the family's "beautiful white Golf" car and the prized plot of land that he planned to give his children. Soon, he had to forgo drugs for three months. Since they must be taken consistently, this accelerated his need for second-line treatment. He became desperate.
It's not clear yet how quickly first-line drugs become ineffective in Africa, with its high rates of malnutrition and poverty. But at one South Africa clinic run by Medecins Sans Frontières, or Doctors Without Borders (MSF), 17 percent of patients needed second-line drugs by year 4. MSF pays $194 per patient per year for first-line drugs - and $1,661 for second-line treatment.
"If we don't get access to these newer drugs at reasonable prices, the result could be catastrophic for Africa," says Eric Goermaere, head of MSF's South Africa mission.
Drug firms say prices will come down. "The higher the volume, the lower the price will be," says Donald de Korte of the US-based pharmaceutical company Merck.
But there are added costs: The test to assess when a patient should switch to second-line treatmentcosts at least $20.
As for Mr. Umoru, he ended up connecting with an MSF clinic in his hometown, Lagos. It donated his second-line drugs.
"The only thing left to sell was my electronics," he says, adding with a laugh, "I mean, I could hardly sell my children!"