World Aids Day today
Challenging a global scourge
At the end of 2008, Dr Peter Piot, the founding Executive Director of
UNAIDS, will leave his post after leading the organisation since his
appointment in 1994. He reflected on past milestones and future
challenges in an interview with John Donnelly on the eve of Word Aids
Day, December 1,
When you look back on your time at
UNAIDS, what do you consider the three biggest breakthroughs?
Peter Piot: The first one came in 1996, when treatment was discovered
and became available, and equally important to that was the major
reduction in the price of antiretrovirals later. They are both very
important milestones.
The second one was the UN General Assembly Special Session on
HIV/AIDS in 2001. That was a turning point. After that, the Global Fund
(to Fight AIDS, Tuberculosis and Malaria) was created; presidents and
prime ministers took charge of the response in many countries; AIDS made
it to the top of the agenda in the world. It was no longer just an issue
for ministers of health.
It was discussed in places where you discuss the really big issues.
And the third thing, I guess, is that the fact that the money we
spent last year on AIDS reached US$ 10 billion. It’s a formidable
resource mobilisation. A really important part of that is the major role
of people living with HIV. Money is the result of the combination of
this activism and the political work symbolised in the General Assembly
session.
Can you describe a moment when you
received epidemiological data that scared you?
PP: Many of them. My most recent experience was when I saw the data
recently on the rise in HIV in the gay populations in Asia. It was
exactly what we saw in the West in the early 1980s. I saw the same thing
with injecting drug users in Eastern Europe about 10 years ago. And when
I was working in central Africa, in then Zaire, in the mid-1980s, South
Africa had less than 2 per cent prevalence. Then, a few years later, you
saw it skyrocketing, and say, ‘Wow. That’s unbelievable.’ There have
been many moments like this.
It’s something that I think we should bear in mind when we think of
the future of this epidemic. The virus will continue to surprise us.
That’s why I’m very sceptical when people say about Asia, ‘Oh, it
will be limited to concentrated populations.’ Maybe, maybe not. We don’t
know.
Has the fight against AIDS
strengthened or weakened health systems?
PP: There’s absolutely no evidence that I’ve seen that it undermines
health services. If anything, it certainly strengthened certain
services, such as laboratories. Determined governments will make sure
that disease specific funding is used to strengthen local capacity.
The AIDS epidemic itself has overburdened health systems. It also for
the first time has brought money to strengthen the health workforce in,
say, Malawi where they even built health clinics with AIDS funds.
Ethiopia is another example. They have a strong government and a strong
minister of health.
He has been using AIDS funds to build rural health clinics. But let’s
also not forget that if we had waited until the health services were
fixed before introducing antiretroviral therapy, as so many suggested,
we would still be nowhere on ART and millions would have died.
What concerns you most about the
response to the epidemic today?
PP: What really concerns me is that while we’ve made measurable
progress on access to treatment, we don’t have the same impact when it
comes to HIV prevention. Is it because we need more time, or are we not
on the right track? I personally think more and more that we need to be
working with the professionals who do the marketing for branding
businesses, who know how to influence people’s beh-aviours. HIV
prevention is what will require the extra shot in the arm.
You’ve identified a US$ 10 billion
annual shortfall in the fight against AIDS. What’s your best argument to
increase funding?
PP: The number one argument is that funding for AIDS works, is saving
lives, and has shown high return on investments. The needs are there.
Just take treatment-close to 4 million are now on antiretrovirals today,
but still about 8 million need it. Also, we are so far better equipped
to spend the money before. Initially, systems had to be developed, labs
established, people trained. Delivering the goods is now cheaper because
we have made the initial investments.
How could the global financial crisis
affect programmes?
PP: If there’s a decline in funding, the return on the investment
will be much less. Postponing action just increases the bill later on. I
worry now that governments will cut the social sector first. That is
often the experience in economic downturns. In Japan, after their
financial crisis in 1990, they cut development assistance by 60%. And
without ODA, without The Global Fund, the heavily AIDS-affected and
poorest countries won’t be able to run their AIDS programmes.
In developing countries, governments may have less income. They may
have fewer remittances, less private direct investments. That means more
people will be vulnerable, and could lead to an increase in sex work. We
don’t know this will happen. But it’s something I’m very concerned
about.
You often describe yourself as an
activist. What is your grade for activists over the past several years?
Where have they succeeded? Failed?
PP: I think activists have been hugely successful in terms of
treatment, advocacy, and mobilizing funds, particularly for The Global
Fund. That’s a top grade. But as for activists working for prevention,
well, Treatment Action Campaign in South Africa is doing it, but they
are an exception.
How do you take politics out of the
prevention debates?
PP: It’s not possible-and there’s nothing wrong with that. It’s about
fundamental choices in society and life. Thinking that we could have a
society that is completely rational about these 12 things is an illusion
and may not be good. You need to have a set of values and principles
guiding policies, and then you automatically get into politics with
AIDS. The key is to make sure it is good politics, the politics where as
much as possible that if there is scientific evidence, that evidence is
used to save lives.
There are still countries where harm reduction in working with drug
users is against the law. That’s bad politics.
What’s going to be especially hard in
prevention work ahead?
PP: In Asia and Eastern Europe, we have to start looking beyond sex
workers and drug users, and how it could make inroads in the general
population. And secondly, in an increasing number of eastern and
southern African countries, up to half of all infections are occurring
in stable couples. How do we deal with that? That calls for a revision
in our approaches. In addition we need help from business to
professionalize HIV prevention.
What will be the role of the modes of
transmission studies that show where the new infections are likely to
occur?
PP: They should be very helpful because we don’t always know what is
going on. We may be basing our prevention work on where the epidemic was
five years ago. It may have changed, or may not have changed.
My concern is not only that we have good studies, but the studies are
used. In Lesotho, similar studies led to changes. In Thailand, they are
trying to change the prevention approach based on new information, and
in China, the studies are drawing attention to homosexual men. Most
difficult will be in countries with generalised epidemics-how to
interpret the information. If HIV is in married or stable couples, boy,
that’s quite a lot of people, and how do you do that? |