Photo:UNAIDS/ GirardinAt the end of 2008, Dr Peter Piot, the founding Executive Director of UNAIDS, will leave his post after leading the organization since his appointment in 1994. He reflected on past milestones and future challenges in an interview with John Donnelly:
How are you feeling on the eve of your departure?
Peter Piot: I thought my last couple of months would be pretty quiet. (Laughs) I underestimated that a bit. But my main objective has been to secure our funding for next year. That is always a challenge.
When you look back on your time at UNAIDS, what do you consider the three biggest breakthroughs?
PP: 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 mobilization. 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 symbolized 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% 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 behaviors. 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?
Photo:UNAIDS/ GirardinPP: 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 generalized 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?
In your speech at the International AIDS Conference in Mexico City, you quoted Bob Marley’s lyrics,“Get up, stand up, don’t give up the fight”. Then you said, “That’s what I will do. What will you do?”
PP: I don’t know yet. I’ll be in an academic position at Imperial College in London, United Kingdom, and will continue some work in AIDS, but as a citizen and member of the community.
I need some time now to work on my next life. But I definitely want to work across disciplines. Like Bob Marley said, ‘We’ve got a mind of our own’”.