by Piot, Peter
Because of our good collaboration with Nathan Clumeck’s group in Brussels, we also started to connect patients seen in the two centers, which at this point saw the majority of people with HIV in Belgium. This is how we put together a cluster of women with HIV, who were mostly connected with each other through sex with the same man, who had kept a diary of his very active sex life. We interviewed and tested most of his partners, and as much as possible their partners. This was not only a very delicate undertaking, but sometimes also a drama. We found that 11, or 56 percent, of his 19 female partners had become infected with HIV, and that one in eight regular male partners of these women had subsequently become infected with HIV. Two women had slept only once with this HIV-positive engineer from Burundi, who died before we had unravelled this deadly cluster of sexual encounters. None of the women considered themselves at risk for HIV. It took a few years to contact all the individuals and put the puzzle in order. In the late eighties there were still skeptics about heterosexual transmission of HIV, particularly from women to men and outside sub-Saharan Africa. In 1989 we published what is still the largest documented cluster of heterosexuals with HIV in the New England Journal of Medicine with Nathan as the first author.
In nearly all ways the situation for AIDS patients was even more hopeless in Africa than in Belgium, because even palliative care, never mind pain management and intensive care, were rarely available to AIDS patients.
Then came a glimmer of hope. At the end of 1986 a clinical study showed that azido-thymidine (AZT)—developed in the 1960s as an anticancer medication but never licensed—slowed the progress of AIDS. Six months into the clinical trial 19 patients receiving a placebo had died, but only 1 person in the group receiving AZT had done so. In March 1987 AZT received approval from the US Food and Drug Administration, becoming the first-ever medication to provide proven treatment for AIDS.
An electroshock went through the still-small world of AIDS doctors. While ramping up production, Burroughs Wellcome began to distribute small quantities of the drug. I had worked with the Burroughs Wellcome team in Belgium doing tests of acyclovir, for herpes, so I knew exactly whom to contact. Thus simple networking ensured that our Belgian patients began receiving treatment at the same time as patients in New York and San Francisco, before the drug even came on the market.
The cost of treatment was $7000 to $10,000 per patient per year. In Belgium this never became the heated political issue that it did in the United States, because patients didn’t actually have to pay such sums: they were picked up by the social insurance system. But I was very aware of it, and of the implication that our patients in Africa would simply never be able to afford to be treated.
Still, in the beginning we celebrated. We were relieved and optimistic. And our patients improved; they put on weight, got up and walked, and some even ran and went back to work. But after a while it became clear that this improvement was only temporary. AZT had serious hematological side effects, and worse, the virus mutated so fast that viral strains became resistant to the drug. We were back to square one for saving lives.
IN GENEVA, MEANWHILE, Mann was fighting bureaucracies maybe more even than AIDS. He put AIDS on the public health agenda, and he put the public health agenda on the stage. He had fantastic political skills and a real gift for explaining. He mobilized money and made sure that basically every developing country had a national AIDS program, had some funding, and had started awareness-raising about AIDS and how to avoid it. There was enormous resistance from governments on all continents due to a combination of denial of risky sexual activities in their societies, the perception that this was a Western disease, and the concern that too much attention for AIDS would undermine their struggle with a plethora of other serious health problems. And then there are those whose priority is not their people’s well-being, but accumulating personal power and wealth.
I became the chair of the Steering Committee on Epidemiology and Surveillance of WHO’s Global Programme on AIDS, where I was glad to rejoin several epidemiologists for whom I had great affection as well as respect, such as Jean-Baptiste Brunet from France, John Kaldor from Australia, and Roy Anderson from Great Britain, besides the other capable members of the group. We met regularly in Geneva, and advised on the epidemiological work of the AIDS program. We were uncertain of WHO’s methodology to estimate numbers of people with HIV and with AIDS in the world—a difficult task under any circumstance, but even more so in the early days of the epidemic when few individual countries had reliable data. They were initially using what is called a Delphi survey—when you have no data but ask experts to give their best guess, basically, and then you take an average—and later mathematical models that predicted peaks of the epidemic that some populations already had surpassed.
Later it turned out that the numbers from WHO were, in fact, grossly underestimated for Africa and Eastern Europe, and overestimated for Western Europe and Asia. But my point was not so much that they were inaccurate—few of us could have claimed to do better with the data at hand—but that we should not have claimed to be able to provide solid estimates at all. (This changed enormously in the following decade, and by the way, UNAIDS’ data are, in my humble opinion, the best and most solid data on any health problem in the world.)
I persuaded the Belgian Development Ministry to start another project in Burundi: a small version of Projet SIDA that did some baseline research, epidemiological surveys and training, and started prevention and care programs. And Kevin De Cock, my Belgian friend in CDC, began a research program in Côte d’Ivoire: Projet RetroCI. We agreed to work together, and Peter Ghys from my group in Antwerp worked there with Kevin full time.
The Ivoirian capital Abidjan was particularly interesting in that it showed evidence of HIV-1 (the same type of the virus that was in the United States, Kinshasa, and Nairobi), but also of HIV-2, a second type that had been discovered in Senegal by Max Essex, from Harvard, and Souleymane Mboup, a Senegalese professor of microbiology and one of Africa’s leading scientists. It became clear that HIV-2 could cause the same AIDS symptoms that HIV-1 did, but it appeared to be less virulent and was spreading less rapidly. Nonetheless, by 1990 AIDS became the leading cause of death in Abidjan, and HIV-1 the predominant HIV type. (Projet RetroCI later played a major role in the introduction of antiretroviral therapy in Africa, besides delivering excellent science, training, and HIV prevention.) By this time, you could actually watch the epidemic spreading: countries falling ill, hospitals overcrowded with AIDS patients, companies losing highly trained staff. In some parts of Uganda and Tanzania, there were already so many AIDS orphans that their grandmothers simply couldn’t cope.
THE THIRD INTERNATIONAL AIDS Conference was held in Washington in 1987, and I was asked to speak at the opening. This was a very big deal for me, and I was planning to announce to the world unequivocally that there is heterosexual transmission of HIV, indeed a lot of it. Robert Gallo was speaking, and Vice-President George H. W. Bush was going to speak next. I was waiting my turn, sitting in the front row of the conference room at the Washington Hilton when—just like in one of those nightmares—I realized that I had left my speech in my hotel room upstairs. I raced out. When I got back Bush’s security people didn’t want to let me in. Finally I made it, just in time to watch as people hissed at Bush and turned their backs on him, in protest against President Reagan’s plans for more extensive HIV testing programs. I never thought of myself as someone with undue respect for authority but I believe we should always let people speak, even if we disagree. We can protest before or after. I did agree to a large extent with the protesters’ points, though: the US government could do much better on AIDS, from funding research and prevention programs, to countering AIDS-related discrimination. This was the year that ActUp was founded in New York by gay AIDS activists. Together with other activist groups they would become a very vocal and effective force to accelerate research and access to AIDS treatment, and were soon an integral part of the growing AIDS “movement.”
Washington was the first of a long series of protests at AIDS conferences, and I myself sometimes became the object of them. AIDS activism in the eighties and nineties could be loud and out of control. Nowadays we’ve sanitized these protests: conferences arrange a short window so the activists can go ahead and make their points. In Washington in 1987, police with long yellow rubber gloves arrested AIDS activists outside the Hilton on Connecticut Avenue. We have come a long way.
By this time, the European Union had set up a Task Force on AIDS, and was beginning to send money to fund AIDS-related projects, as a form of emergency development aid. Lieve Fransen, the Flemish doctor who had worked in our research project in Kenya and then moved to Antwerp to earn her PhD, was running this task force. One day she called me and asked whether I was interested in developing an AIDS control program in Lubumbashi, the capital of Shaba province in southeastern Zaire.
This project wasn’t about doing research. It was about doing what needed to be done: provide a safe blood supply, try to improve the public health service in general by training people, and rehabilitate the medical lab so they could properly diagnose. It was the work of a nongovernmental organization, and I was an academic. Nonetheless, when I thought it over I found that I wanted to do it. I wanted to do something practical about AIDS, with direct impact on public health. Instead of studying reality, I wanted to actually change it.
The first thing we did once the project actually got started, in 1988, was to refurbish the public health laboratory, which meant new equipment and an architect—even the roof had to be rebuilt. I became like a manager of a big operation, though Drs. Kambali Magazani from Zaire and Geert Laleman from Antwerp ran the project on-site. All kinds of things went wrong, from using rapid tests for blood that were sensitive to fluctuations in temperature and had a short shelf-life to incorrect readings. Things broke and shifted and rotted. I quickly learned that funding was not the only hurdle to an organized project, and not just in Africa but everywhere.
I remember a midwife at the hospital. She had AIDS: fungal and herpetic infections in the mouth, intractable diarrhea. There was a Tanzanian pathologist and he told me that in 15 years he had never seen anything like the swollen lymph nodes he was now seeing daily. There clearly was AIDS in Lubumbashi, and I felt I was watching the epidemic move in, but it was doing so in slow motion. HIV prevalence was low—something like 3 percent, compared to the 6 percent we estimated in Kinshasa—and the incidence, the measure of new infections, didn’t seem to be explosive. The big question was, Would it stay this way?
We were 1000 miles away from Kinshasa, deep in southern Africa. The Shaba province (and Lubumbashi) is a kind of panhandle that sticks way down south into Zambia in an awkward, artificial-looking shape. And yet, in the Zambian copper belt, just across the border, the prevalence of HIV was far higher—over 15 percent—and it was spreading much more quickly.
Since colonial times the miners were permitted to live in Lubumbashi alongside their families. The Belgian mining companies built family housing and schools, they hired the sons of miners. It was a different setup from the system that mining companies created in Zambia, with tens of thousands of single men away from their families, living in hostels, doing a terrifying dangerous job, with recourse to prostitution often their sole sexual expression. Was this the explanation for the difference in HIV levels? We still do not know. Again I realized that there was not going to be one AIDS epidemic in the world but many different ones, depending on behavior and culture, and that any kind of solutions that could be put together were going to have to be tailor-made.
IN 1988 MANN organized a major ministerial conference in London that was attended by 115 ministers of health, more than had ever gathered on a specific disease. Before that meeting, Minister Ruhakana Rogunda from Uganda was the lone voice who in a dramatic speech at the World Health Assembly in 1987 had called his peers to face the reality of AIDS on their continent. Even though many attending the London meeting were still in denial about the scale of the problem in their own countries—and several came from governments that had pledged to shut out foreigners with HIV—all of the ministers signed off on a declaration backing the human rights and dignity of people living with HIV. This had not been a foregone conclusion by any means. Since Mann’s arrival in 1986, WHO had been giving governments a range of services, from technical help with drawing up three- to five-year AIDS plans, to funds for new laboratories and training programs for medical professionals; it was even fund-raising from Western governments to support AIDS programs in poor countries.
The budget for the Global Programme on AIDS had grown bigger than any other single program at WHO, but it was raised directly from donor countries: it didn’t come from WHO’s general budget. The name itself, Global Programme on AIDS (GPA), emphasized that this was not a temporary or short-term emergency. Jonathan Mann also established a Global Commission on AIDS with highly respected political and scientific figures, to protect him, I think, from the political pressures.
Halfdan Mahler’s term of office as director-general of WHO came to an end. He had received multiple complaints about Jonathan from irate ministers of health who felt pressured to address AIDS but the two of them had developed a good working relationship, with a lot of mutual respect. Hiroshi Nakajima, formerly the WHO regional director for Asia, was appointed as the new director-general. This was a whole different story.
Mann had done something very unusual for WHO since the eradication of smallpox. He directed his short-term plans straight out of headquarters: he completely bypassed the regional offices and sent his staff and temporary consultants to each country. This really was the only solution, otherwise in many countries there would have been virtually no movement to ward off the epidemic. But in doing this he created powerful resistance against him from the regional directors who control around three-quarters of the WHO budget.
Jonathan had the guts and political acumen to convene a meeting of the Global Commission on AIDS in Brazzaville—the city that hosted WHO’s regional office for Africa—in essence forcing the regional director to confront the reality of AIDS in Africa under the impatient eyes of eminent persons from across the world. This is when I met one of Asia’s marketing geniuses, Senator Khun Meechai Viraidya from Thailand, who was a member of the commission. We got to know each other when I was looking for someone of my height to ask to lend me fresh clothes, as my suitcase had not arrived (and neither had Jim Curran’s). Meechai immediately gave me a suitcase full of all I needed, and we became friends for life. Meechai was a businessman, politician, and community leader—an entrepreneur in many respects, and above all a superb communicator. He became the architect of Thailand’s successful AIDS program, imposing 100 percent condom use in commercial sex, which was flourishing in Thailand. This ultimately led to a decline of HIV in the country—one of the very early achievements in HIV prevention in the world.
In the meantime HIV continued its spread over the world, discriminating nowhere. The Soviet Union reported its first case in 1987, and in November 1988 I went to Moscow with a team of Belgian AIDS experts to share our experience with our Russian colleagues, who were very concerned about further spread of HIV in their vast country. Until then all AIDS patients from the USSR had been hospitalized, often for months, in the Institute for Infectious Diseases in Moscow. While Dr. Vadim Pokrovsky, the top soviet AIDS epidemiologist, was showing us around in his institute I suddenly saw three Africans at the end of the corridor. I tried my luck and shouted, “Bonjour!” The three men rushed to me, happy to be able to tell their sad story in a language they mastered far better than Russian. They were students at Lumumba University from Burkina Fasso and Burundi, had tested positive for HIV on arrival in Russia, and had spent several months in what was basically quarantine, even if they were in good health. I promised I would bring up their case with the authorities to see if they could help these students. Just like small Belgium, the Soviet Union was confronted with multiple entry points for HIV. Little did we
know at the time that Russia and the former Soviet republics would experience a still-growing HIV epidemic driven by injection drug use.
It was my first visit to Moscow, and I don’t pretend I fully understood what was going on, particularly in the quite secretive days of the Soviet Union. But there was clearly change in the air among health colleagues, who were eager to connect with us. It was already bitter cold, but the people were warm once we socialized.
IN ANTWERP, OUR lab started using simple techniques to look at pieces of the genome of all kinds of isolates of HIV-1. At some point these strains had been grouped into A, B, C, D, and so on, based on the sequences of the envelope gene, and there was a great deal of discussion of their relative pathogenicity and how you could develop a vaccine to protect against them all—a still-unresolved challenge. When in 1989 members of my team, Bob De Leys and Martine Peeters, isolated two very unusual HIV-1 strains from a couple from Cameroon, the genetic variation of HIV appeared to be even wider than we thought. The woman was nineteen and both she and her husband had persistent generalized lymphadenopathy, but their serum gave only faint bands in the confirmatory Western blot test. The virus that we found in it was very aberrant. (We called it ANT70, though it is now known as Group O: Group “Oh” not Group “Zero.”) It had major differences with all the known strains of both HIV-2 and HIV-1, and was particularly divergent in the envelope glycoprotein. Sampling indicated that 5 to 8 percent of HIV-1 infected individuals in Cameroon harbored the Group O variant, but five additional strains of HIV-1 subtypes (A, B, E, F, and H) were also found. It seemed that in Cameroon and surrounding countries such as Gabon, the greatest diversity of HIV strains were circulating, suggesting that the virus had had more time to diversify there than elsewhere.