by Piot, Peter
Of course it was Mahler, who was the host, who made the opening remarks, and what he said was basically, “Even though we’re here to raise money for AIDS, and thanks for coming, don’t forget there are so many more important health problems in the world.” Talk about a fund-raising strategy; you could see Jonathan’s face going green. So then I stood up and stoutly pledged Belgium to do something extremely vigorous but suitably vague. Basically: “We welcome this program, which is badly needed, and we will fully support it.” And then the United States jumped in: “We fully agree with the representative of Belgium.”
It was fine: the donor country governments carried it through, and they raised over $50 million. But among some people at WHO—who in the past decade had abandoned “vertical” health programs aimed at single diseases, plugging away instead at primary health care across the board—all this probably reinforced the feeling that AIDS was a competitor for their limited funds.
Part of the problem with WHO was and still is systemic: it was an inborn error of structure. The regional directors of WHO (there are six) are elected by the Ministries of Health of their regions. Thus they have political legitimacy that in a sense is as large as that of the director-general of WHO in Geneva, who is elected by the same member states. Although the director-general is nominally their boss, the regional directors lead their regions in a very sovereign way. Many were fundamentally hostile to new ideas. These men refused to give up control over their regions to a new centralized AIDS program in headquarters in Geneva. They would be Mann’s nemesis.
DR. ROBIN RYDER, a curly haired, infectious disease specialist who worked for the CDC, replaced Jonathan as the director of Projet SIDA. Robin thrived in Kinshasa, laughing all the time, joking with everyone: he was a convivial man, as well as being very good at his job. He expanded the project enormously, until there were over 300 people working there, and he organized huge cohorts to study various aspects of HIV infection. He was also meticulous. Running such a large office in Kinshasa must not have been an easy thing, and he was lucky to have Frieda Behets to do the job. Logistics alone were a major headache, in a city where the phone almost never functioned. It was Robin who really fueled the whole project to create a proper blood bank. By this time, our estimate of HIV prevalence in Kinshasa was 3 to 4 cases per 100 adults. And we were still seeing plenty of transfusion-related HIV infection at Mama Yemo Hospital: about 1000 cases a year; more, in that one hospital, than in the whole of the United States at the time. This was not a research issue but it was an ethical one, and it was Robin who got the German international aid agency, GTZ, to set up a real blood bank and staff it.
Typically, an hour after someone gave blood it was being used in surgery. So the blood bank needed to use rapid tests rather than the then-more-accurate but slower ELISA. However, the rapid tests were now coming onto the market in a situation of pure anarchy: not all were reliable, and developing countries had no ability to certify or approve them. My lab in Antwerp began doing quality control tests on the rapid tests, funded by the AIDS program at WHO. We put together a serum bank, with sera from people well-documented as infected with HIV, and others with “problem” sera—patients who had autoimmune diseases such as lupus, which may give false positive to HIV tests, or from countries with endemic malaria, another key infection that we knew sometimes led to false results with the early HIV antibody tests.
However, some people in Kinshasa continued to be infected with HIV via blood donations, because technicians weren’t available to do the testing at night and on weekends. We could see that almost all of them rapidly became infected with HIV. A blood transfusion was clearly much more likely than sex to transmit HIV, and the resulting immune loss also seemed to be much more rapid and devastating.
However, the majority of people with HIV in Kinshasa were infected through sexual contact, and it was important to design interventions to prevent heterosexual transmission. Based on the principle to start where the problem is greatest and where you can easily reach people at risk, we decided to try to prevent HIV infection among sex workers and their clients. The Matonge district in Kinshasa was the obvious place to work. So Marie Laga and Nzila set up a clinic for prostitutes in Matonge, based on our experience in Kenya. Matonge wasn’t exactly a red-light district—there was a lot else going on there too—but there were plenty of bars and dancings, and all day long you could hear music in the streets, the hypnotic whine of the Congolese guitar. Nobody could sit still; the nurses would all be swaying to the music, there was laughing and chatter: it was a great atmosphere for a medical center.
We educated sex workers about AIDS—especially condom use and how to negotiate it with their clients and partners. We offered medical care, not only for sexually transmitted diseases, but also in general for the women and their children. We tried to comfort the women with HIV infection—at the beginning of the project a staggering 26 percent were positive—and in those days there was no treatment for HIV infection. We lost many women, who left behind too many orphans to be taken care of by their extended families. Many of these children ended up on the street. It was heartbreaking, but we were powerless in the absence of any treatment. Our center soon became a popular place with the whole neighborhood. After a few years, there was a significant decline in new infections.
Ryder was a pediatrician, and he was also instrumental in pioneering studies of mother-to-child transmission of HIV, at a time in the 1980s when it was not clear how HIV was transmitted to neonates and infants, and what the risk factors were. In Kinshasa, HIV-infected pregnant women were transmitting HIV to their babies with a frequency of 40 percent, compared to 5 to 10 percent in the United States. We also did a significant amount of work on cofactors for sexual transmission of AIDS. It was becoming clear from our work in Nairobi that genital ulcers from chancroid and chlamydia can favor the transmission of HIV. The high prevalence of poorly treated sexually transmitted infection in many urban populations of Central Africa was creating a highway for heterosexual transmission, multiplying its efficiency. This was of crucial importance for future programs to prevent the transmission of HIV, because it meant that by treating other sexually transmitted infections, we could hope to reduce the incidence of HIV.
Bob Colebunders’s team and his successor Jos Perriens were among the first to unravel the connection between tuberculosis and HIV infection. They found that over 20 percent of patients with tuberculosis in Kinshasa also had HIV, much higher than in the general population. The connection was immune deficiency, which makes people vulnerable to tuberculosis disease, just as to other infections. Because infection with Mycobacterium tuberculosis is so prevalent already in developing countries, the AIDS epidemic generated in its shadow an epidemic of tuberculosis that became the leading cause of death in AIDS patients in Africa. Among other things we also showed that the then used treatment for tuberculosis in Zaire did not work for patients with dual TB and HIV infection, and developed a more effective treatment. Colebunders also discovered that a particular type of urticaria-like skin rash was diagnostic for HIV in Central Africa, as is shingles in adults. Projet SIDA was an apparently unending source of new discoveries: we did more groundbreaking work in a year than most research projects in Europe could hope to uncover in five years. Every year Jim Curran from the CDC and I met in Kinshasa with Tom Quinn, representing the NIH, to review the scientific highlights, a moment of pure joy for the brain. We got along extremely well: there were great celebrations with all staff in Matonge, with live music, and Jim Curran cracking memorable jokes. It felt like one large family. But there was also some institutional positioning, and as the poor cousin, I had to use pretexts of “human capital” to attempt to demonstrate that we Belgians were contributing equally to the Projet SIDA budget, whereas the US government was actually paying the lion’s share.
MEANWHILE, WE KNEW that there was also AIDS in Nairobi. We had seen cases among the prostitutes we treated at our clinic. But until the HIV antibody test was commercially available, we
couldn’t do proper testing on a wide scale; we were receiving batches of prototypes, but we were sending all those tests to the Kenyan blood banks. So we banked sera. Working with Joel Breman and Karl Johnson on Ebola had taught me not just to properly preserve all the blood samples we gathered but also to be very careful to have meticulous administration, so we would know who was behind the sera: gender, age, circumstances. That is the type of bureaucracy that I favor. I now had an incredibly valuable library dating back to the early 1980s.
When the ELISA test for HIV antibodies appeared on the market in 1985, we were astonished that 9 percent of all the patients coming to us in Nairobi with sexually transmitted infections had HIV virus in their blood. (This being a rather specific sample of people, it didn’t necessarily have great bearing on the prevalence in the whole population.) Among prostitutes who came in, the figure was over 60 percent: a stunning figure, at the time unparalleled anywhere in the world. Most of these women came from the Kagera region in Tanzania: this was some of the first evidence that the epidemic radiated out from the Lake Victoria region. What had been a smart survival strategy for these women had become a death strategy when the HIV epidemic emerged.
Using the banked sera, we could actually trace when the epidemic in Nairobi started. In 1980, none of the men we saw with sexually transmitted diseases had the HIV antibody. In 1981 it was already 3 percent of men, and 6 percent of women—a little higher among prostitutes, specifically, but not much: 7.1 percent. You could see it was spreading like bush fire. AIDS was a new thing in Nairobi, and it had hit the ground running. Compelled by these results, we decided to add AIDS research to our project in Nairobi, with a major focus on HIV infection in prostitutes. We set up a clinic in the Pumwani district, which was basically a slum that concentrated a large number of sex workers. We used a couple of rooms in the municipal health office; there were goats and sheep and a permanent market of all kinds of second-hand clothes and shoes just outside. You could buy only a left shoe, or only a right one.
Elizabeth Ngugi, the former head nurse, became a key figure, something between a community leader and a mother for these women who were despised, rejected, and badly treated by everyone, men and women. It was thanks to her that the project later achieved its life-changing work with some of these women, and it was in Pumwani that I perceived the incredibly powerful way that they could organize themselves, despite their lowly status. Even before AIDS, groups of women had banded together to contribute to health care or other emergency needs for their peers, and now Elizabeth helped them to set up more consistent groups for support and care.
I USED TO drive around Kinshasa myself; negotiating the chaos of the streets was actually kind of fun, and in any case I had no spare funds to pay a driver. But once, driving to the prostitute clinic in Matonge, I was followed by three men from Mobutu’s fearsome secret police, the AND. Then they overtook my car, blocking me; they pulled me out of the car and searched it. When they found the slide projector that I had intended to use for a training session for the nurses, they mistook it for a video camera and accused me of being a Pakistani journalist.
A Pakistani journalist? I might have laughed, but with my hands against the car I was too preoccupied with other emotions. I told them I was a scientist, a member of Mobutu’s Order of the Leopard, but they just laughed at me and said they were taking me to AND headquarters—which would mean serious trouble, possibly for days. I pleaded with them to take out my wallet—they could have the cash I was carrying—and check for my Leopard ID. When they found it, they muttered about the photograph, but then the atmosphere switched in the second: they slapped me on the back, and laughed, and wanted to know all about my work in Matonge.
“Why a Pakistani journalist?” I asked them, and they said it was my beard, and my tan: I didn’t look completely white. The whole episode was surreal, just another weird pothole in a normal day’s work in Zaire.
I HAD BEEN helping Jonathan Mann set up his program at WHO in Geneva: I helped him identify people who could work in his new Control Program on AIDS, and set up advisory committees with the few scientists working on AIDS in those days. His right hand was Dr. Daniel Tarantola, a French veteran of many public health programs, including smallpox eradication, and unsurpassed for his organizational capacity (and humor). We had met in Nairobi and hit it off immediately. Daniel’s brainchild was the short-term national AIDS plan that Jonathan wanted every country to adopt. The main idea was that by establishing a plan, AIDS would be discussed in the Ministries of Health, a budget would be allocated, money raised from donors, and as many countries as possible would finally start HIV prevention programs (treatment was not yet an option in the 1980s). They would take a clear look at the epidemiological situation and develop a program for “social marketing” of condoms, which meant that rather than go for boring public health–type messages, they would use the techniques of consumer marketing to promote a social good. Additionally, it involved developing distribution networks that meant you didn’t have to go into a pharmacy to buy a condom, but could buy one in small kiosks and at ambulant vendors together with soap and matches and lightbulbs.
With few exceptions, such as Uganda, the majority of African governments still either denied the reality of the epidemic or showed a cynical skepticism, accepting international aid without making much of an effort to fight the virus. In rich countries AIDS was associated with homosexual behavior, prostitution, or intravenous drug use and it was difficult for them to acknowledge these realities in their own countries. When confronted with studies showing very high levels of infection they denounced them as biased samples or said that their country was struggling with far more important health issues, which for most African countries at the time was absolutely true. However they did not see the epidemic that was spreading silently: in most countries outside Central Africa, people had been infected with HIV too recently to be ill or die; it takes on the average eight years after infection before one develops AIDS.
Zaire was, I believe, the first country to adopt a national AIDS plan; Ngali left Projet SIDA to become director of the plan. He began distributing condoms to the women who sold drinks and cigarettes and cola nuts at stands set up outside bars and nightclubs, or those just walking around with trays on their head. They were called the marchés ambulantes, “the walking markets.” They made a little profit on their condom sales and it was a much more effective way to reach people. Mobutu’s party had developed a very effective way of reaching people through traditional groups—theater, dance, and other entertainment—and Ngali worked the AIDS message into that process. With Population Services International (PSI) we developed a cool brand of condoms, “Prudence,” “pour l’homme sur de lui-meme” (for the self-assured man), with the slogan “Confiance d’accord, mais prudence d’abord” (Trust is fine, but prudence comes first). It worked. Prudence condoms became very popular in Kinshasa. HIV prevalence in the city in 2010 is hardly higher than 25 years before, and it may be that these early prevention programs had a real impact and saved many lives.
Music was key. Franco Luambo, from the TP-OK—Tout Puissant Orchestre Kinshasa—Jazz Band, was one of the most popular singers in Kinshasa. He wrote a song, “Attention Na Sida,” and people danced to it in every nightclub. “Use radio, TV, newspapers / To tell the people about AIDS / We have to tell them how to protect themselves / We must all fight AIDS . . . ” Then he died of AIDS, in 1989, and a copper plaque with his name on it was fixed to the tall stone pyramid, “Le Monument aux Artistes,” on the Place de la Victoire. By the early 1990s almost every name on that pyramid belonged to a young and talented musician, and almost every one of them had died of AIDS. All the plaques have been stolen now, but the bare, stubby pyramid remains: a slightly surreal reminder of yet another terrible loss suffered by Central Africa.
Ngali confided in us the kind of pressure he was under to kick back part of his budget to officials from the Ministry of Health and other cronies of the regime. He was a principled man, and he w
orried a great deal. It is a high-risk project, to be an honest man in Zaire; a few years later, he died in a mysterious car accident.
When Mann laid out his scheme for every country to issue a short-term plan for fighting AIDS, his idea was to short-circuit the resistance he was encountering from the WHO regional directors by sending consultants to each country who were directly responsible to WHO headquarters. Each consultant would take a look at the current AIDS situation and how it was being dealt with, and specifically epidemiology, clinical management, lab services, blood banks, and condom availability and promotion.
Jonathan asked me a couple of times to join his team at WHO Headquarters, but I was not ready yet to make the leap from fieldwork, research, and seeing patients, to the more distant policy level—as much as I had become convinced that policy was key to stopping this unfolding epidemic. I did, however, go to Ghana for WHO as a consultant, to help set up the Ghanaian AIDS Plan, in a team led by Lev Kodhakievich, a Russian who had worked in smallpox eradication. The Ghanaian government initially was suspicious and we had to wait for a week to receive permission to work, which we received thanks to the intervention of Ghana-born Peter Lamptey, who established the AIDS program of Family Health International, to which I became an adviser. In the meantime we visited some of the old castles along the coast, where dozens or hundreds of slaves were once crammed like produce into the basement, sometimes directly under the chapel or the airy dining room of the dwellings of their English, Dutch, or Danish masters.
Ghana didn’t have a huge AIDS problem, except in one northeastern region. Just like the Tanzanian women in Nairobi, women there traditionally went to the capital or to a neighboring country, Côte d’Ivoire, for two or three years, where they would work in commercial sex and then come home with enough money to start a business.