by Piot, Peter
We also encountered political denial about HIV estimates, but it’s hard to argue with vetted data and dead bodies. Countries like Russia, China, India, and South Africa at some point all accused UNAIDS of inflating figures. Russia, and in fact most former USSR countries (with the notable exception of Ukraine), simply did not want to deal with AIDS: at the time, the tidal wave of HIV that would swamp heroin users across the former USSR was still invisible and unreported, and they wanted to keep it that way. Even when Russia began to face an explosive HIV epidemic, in the late 1990s, it downplayed the problem.
China too wanted initially to control all information; and Chinese officials were reluctant to change their statistical systems to indulge our concept of scientifically established random sampling. The population is also so vast that any estimate is a huge challenge, with provinces of over 100 million people. Later, however, China became very open about its AIDS problem.
India has a long history of disputing the statistics of international organizations, and its politicians in the early 1990s were not yet open to discussing risks associated with prostitution, homosexuality, and other taboo subjects. As it turned out, our estimates were not solid enough, and in 2007, when better local data became available, we announced a major decrease in our estimated number of people with HIV in India. We also had big problems with South Africa’s reports, especially after 2000, due to President Mbeki’s denialist policies. Some European countries were sloppy about their contributions, too—surprisingly even more so than a few of the African countries. For example, as late as 2004, we received forms filled in with pencil from Austria.
Still, we checked and re-checked the data, to obtain some of the best global estimates on a single disease. I felt it was vital to be transparent and guided by the science, not by the imperatives of advocacy or communication, so when we had got the numbers wrong, we said so.
But numbers weren’t enough. For UNAIDS to get its message across, we needed success stories, because to mobilize money and convince policy makers, it’s not enough to demonstrate that something is a really bad problem. If you can’t do something about it, and it’s a hopeless case, then what’s the point? As my old professor of social medicine in Ghent used to say, “a problem without a solution is not a problem.” I started scouting for success stories back when I was at the Global Programme on AIDS. Then, Uganda and Thailand reported—basically, anecdotal evidence—that programs to shift people’s sexual behavior were working. We saw this among gay men in some North American and European cities in the 1980s, but never in the developing world. So now I jumped on it.
Our data confirmed that the incidence of new HIV infections was declining slightly in both Uganda and Thailand—very different countries. In both countries, the key to this success was swift and early political action. In Uganda, President Yoweri Museveni had learned of the AIDS epidemic in 1986 from Cuban leader Fidel Castro, who helped him overthrow the previous Ugandan dictatorship. Museveni was a frank man—a former farmer and pastor, whose speeches were full of rural images and a very down-to-earth grasp of the world. He told me how shocked he had been the day Castro informed him that roughly one-third of the Ugandan soldiers sent to Cuba for training were positive for HIV. (At the time Cuba was testing everyone in the country and confining all HIV-positive individuals to camps.) To his credit, Museveni grasped the implications: he knew this might destroy both his army and his country. Unlike most African governments his administration acted quickly, with massive education campaigns through radio and traditional channels. The president’s slogan was “zero grazing”—another cattle image: monogamy. This evolved into the “ABC” campaign: Abstain, Be Faithful, or use a Condom.
WHO’s GPA and USAID provided strong logistic and financial support but the Ugandan response was inspired and led locally by AIDS pioneers such as Sam Okware, Elly Katabira, David Serwadda, Nelson Sewankambo, and David Opulo, as well as Noerine Kaleeba’s TASO. It was the first country where AIDS became a subject that one could openly discuss in society at large. One evening I was having dinner with Ugandan friends when one of the attendees stood up before the end of the meal, saying, “Sorry to leave early, but I need my rest because of HIV.” Nobody fell off their chair; we wished him good night, and the conversation continued where it had stopped. I thought, that’s how it should become all over the world.
Nationwide, the prevalence of AIDS in Uganda peaked in 1992, by which time 31 percent of pregnant women tested positive. By 1996 it had fallen to less than 20 percent. (It is now just over 6 percent, though slowly rising again.)
In Thailand, Mechai Viravaidya, a former deputy minister of industry with a vivid personality and a contagious love for people, spearheaded a humorous and effective anti-AIDS campaign out of the office of Prime Minister Khun Anand Panyarachun, together with Werasit Sittitrai, who had joined our staff. Their program consisted of three major campaigns: 100 percent condom use during sexual encounters with prostitutes, a “respect for women” campaign, and a barrage of anti-AIDS messages that were aired every hour on TV and radio. Every school was required to teach AIDS education classes. Mechai also taught schoolchildren to blow up condoms like balloons, to reduce embarrassment; he even ran a chain of restaurants called Cabbages and Condoms. It got to the point where in Thailand a condom is known as a Mechai—surely the supreme tribute to good branding. In 2004 during the Bangkok AIDS Conference Mechai and I distributed condoms at a highway tollbooth. Every single driver, male and female, recognized Mechai, and nobody seemed offended.
Less spectacularly, but just as significantly, Thai Prime Minister Anand had moved responsibility for AIDS programs from the Ministry of Health to his own office. The Thai approach was about as pragmatic as possible, with its chief aim to keep sex (including the lucrative sex industry) safe. And the results were just as unequivocal: with nationwide tests on army recruits, their data were extremely precise, and they could trace a decline in HIV prevalence in specific parts of the country.
These two countries became our beacons of hope in a grim landscape. A little later we added Senegal, where low HIV prevalence was maintained, probably thanks to a powerful synergy of the political leadership of President Abdou Diouf, technical leadership by bright young Senegalese experts such as Ibrahim Ndoye and Souleymane Mboup, a solid fabric of society, and Muslim and Catholic leaders, who used their pulpits to spread HIV prevention messages.
So AIDS was a very bad problem, sure, but it now had the beginnings of a solution: committed leadership, well-funded programs for HIV prevention (there was no effective treatment when UNAIDS started), and grassroots activism and support. Uganda became a core part of our political and communications strategy, because (a) if Uganda could do this there was no reason why Zambia, or Cambodia or Guatemala couldn’t achieve similar results; and (b) it was clearly worthwhile for Sweden, or Canada, to invest in such a strategy, because it promised to have real impact. We fondly imagined that Thailand, Uganda, and Senegal would soon be joined by other examples. But it was ten years before we could indicate over a dozen countries whose prevalence of HIV was falling.
I made Uganda the cornerstone of my speech at the first major international event for UNAIDS. The 11th International AIDS Conference, which took place in Vancouver in July 1996, was an important test of our influence in the broader (and highly critical) AIDS community, as well as with the world’s media. By then this annual AIDS-research conference had morphed into a huge event, with 15,000 delegates and 2000 reporters. So it was a significant opportunity for me to publicize UNAIDS, and even though I had to overcome a high degree of shyness and fear when talking to big crowds—my natural tendency as a child was to sit in a corner with a book—I lobbied hard to obtain a slot for our unknown agency at the opening plenary. It was difficult. As past president of the International AIDS Society I thought it would be easy, but as it turned out some people felt I had switched sides when I went to work for the UN.
We presented our first attempts at standardized statistics. Ove
r 33 million adults and children worldwide had been infected with HIV cumulatively. Over 90 percent of them lived in the developing world. In the past year alone, 3 million adults became infected: 8000 new infections per day. Every day over 6,500 adults were being newly infected in Africa; 800 in Southeast Asia; and 270 in the industrialized world. Partly because of these figures, Vancouver was the first international AIDS conference where the developing world was firmly on the agenda.
Most significantly, the Vancouver conference brought the AIDS community an extremely welcome shot of good news—a game changer that would completely change the life of people with HIV, as well as how the epidemic is perceived. A combination of three or more antiretroviral drugs, taken simultaneously, could significantly prolong life and delay the onset of AIDS symptoms in HIV-positive people. Known as highly active anti-retroviral therapy, HAART gave hope that seropositive people could live normal lives, with a near-normal life-span. I called Marie Laga, my successor in Antwerp, to share the news about this Copernican revolution for AIDS because she could not attend the conference; she was about to deliver and was more enthusiastic about the birth of her healthy boy Jef.
This treatment was incredibly expensive: up to US $20,000 per person per year. So although I was enthusiastic about the breakthrough, I was immediately concerned that the majority of people who needed it were in poor countries and simply could not afford the bill. Unacceptable. We needed to give patients in the developing world access to HAART. Human rights—just simple justice—demanded it. Thus in my speech I called for “bold action on many fronts” to ensure access to antiretroviral treatment for people with HIV in developing countries. Many years passed before this dream became reality, however.
A next challenge was to unify the world’s AIDS strategies, and in the first place those of UNAIDS’ partner agencies in the UN. On some policy issues it was extremely hard to reach agreement. The prevention of mother-to-child transmission of HIV was a first and very difficult test case. In February 1998, the Thai Ministry of Public Health and the US Centers for Disease Control announced that a trial had shown that a short course of AZT could dramatically reduce the risk that pregnant women would pass on HIV to their newborns. Soon after, another trial indicated that single-dose nevirapin was also effective. This was, to me, absolutely terrific news, and I fondly imagined that a prevention regimen would be swiftly and universally adopted, since we finally had a classic medical intervention to save babies, free from all the controversies around prevention of sexual transmission of HIV. How wrong I was! I kept pushing UNICEF, as the UN agency responsible for the protection of children, to put the subject at the top of its agenda. But even today, nearly 15 years after the first scientific evidence came in, coverage for mother-to-child transmission prevention is still only 60 percent.
Slow action on mother-to-child transmission of HIV reflected partly the poor state of maternal and neonatal health services in many African countries. These clinics, I knew, were and are swamped with hundreds of women a day; typically, they can take your blood pressure and that’s about it. But policy paralysis was also partly driven by a lack of leadership in international organizations, mainly due to the highly emotional controversy around HIV transmission through breast-feeding. There was no doubt that HIV can be transmitted by breast milk, but the research findings were sometimes conflicting; for example, some studies found that exclusive breast-feeding actually protected from HIV transmission. Above all, we knew that breast-feeding by HIV-negative mothers (the overwhelming majority of women) saved babies lives. UNICEF and others wanted to protect the progress made in promoting breast-feeding, which was always under threat from commercial pressures to sell baby formula. It is indeed true that in many areas, where clean water is not available, using baby formula can threaten children’s health. But so can AIDS: very much so. The question was how to ensure that women with HIV have the option to use affordable and safe breast-milk alternatives, to protect their babies from both HIV and diarrhea, while at the same time making sure that all other women breast-feed. This created a terrible dilemma. It was clearly urgent to run studies comparing which policy would save more lives—breast-feeding (with the risk of HIV transmission) or bottle-feeding (with the risk of diarrhea). But unfortunately emotions took over the debate. I convened several meetings, but none of them reached agreement. For years UNICEF and WHO avoided dealing with the challenges, and even in 1998 WHO published a nutrition manual stating there is no good alternative to breast-feeding. Retrospectively, I think I should have reached out more to the breast-feeding lobby to bring them together with AIDS interest groups. The world is full of single-issue groups—just as we were a single-issue group around AIDS—and the psycho-politics of all this can lead to tunnel vision. Whatever the reasons, a lot of time and lives were wasted by indecision on a tragically important issue.
Controversy surrounding the means by which to prevent sexual transmission of HIV also continued to rage. The question moved from theoretical to empirical when we certified that new HIV infections were declining in Uganda. Knowing which prevention intervention had made a difference was important for other countries, and for concentrating our efforts. But even today, there are heated debates about what exactly caused this decline, with a few claiming that it simply reflects the natural history of HIV, which was bound to decline anyway when those at risk were all infected. (This position is not supported by the data, by the way.) Others claimed it was all because of condom use, but there were also arguments that attributed the success to sexual abstinence, or monogamy. Actually it was probably a combination of the three “ABC” interventions, plus the urgency of countrywide mobilization and openness in discussion; in HIV prevention, the how is as important as the what. However, some scientists and journalists continue to fuel the debate in a fairly obsessive search for the magic bullet in HIV prevention—the single thing that made all the difference.
I regularly got letters or e-mails along the lines of “Dear Dr. Piot, if only UNAIDS would _______________ (fill in the latest fashion in HIV prevention), the epidemic would be brought under control.” Some went further, accusing me of suppressing vital information. And on occasion researchers insisted that I was deliberately ignoring their own groundbreaking work. It takes a thick skin to be director of UNAIDS! But nuts and obsessives aside, I learned early on that anything with the word only does not work in AIDS: it is a combination of actions that has impact population-wide.
Stopping the spread of HIV in injecting drug users was no less controversial. HIV was spreading like a flash flood via shared needles in much of Eastern Europe and some parts of Asia. I had experience with it, having helped to set up the first needle exchange program in Belgium in the early nineties, before I moved to Geneva. It may seem counterintuitive to provide needles and syringes to drug users, but at UNAIDS we promoted needle exchange and methadone substitution programs, because there is very strong scientific evidence that both reduce transmission of HIV.
In the early years of UNAIDS, only a few European countries, plus Australia, Canada, and some US cities, were using this approach, but most countries opposed it, sometimes vehemently, as in Russia. For example, in 1998, US Secretary of Health and Human Services Donna Shalala tried—and failed—to fund “harm reduction programs” for injecting drug users; but they remained banned from federal aid until President Obama repealed them in 2010. (Meanwhile, a large number of states had supported such programs through independent funding.)
Addiction is a very complex and tragic issue. I admit that I have never been completely at ease with either purely repressive or totally liberal policies regarding addictive drugs. I had many confrontations with both sides. The AIDS community tends to be very liberal, and I had to disagree with some colleagues for whom using drugs was not a problem so long as the needles were clean. I always supported harm reduction techniques—which are scientifically proven to be effective—and the human rights of drug users, but to me, the loss of autonomy involved in addiction is a terrible t
hing.
Back in 1992, American researcher Don Francis and I were asked by the Swiss federal authorities to evaluate a needle exchange program in Zurich. (The Swiss still have no generalized paid maternity leave, but they have needle exchange and heroin distribution.) So we went to their “needle park”—a large garden near the Central Station—at around 4 P.M. It was full of people injecting drugs, and purchasing drugs, in plain view. I saw one woman shooting up in a jugular vein in front of her child, and men in expensive suits coming straight from the office to buy a dose. At a kiosk where I guess they used to sell ice cream, the city health department was giving out clean needles. Don and I were baffled. Epidemiologically, sure, the program worked: all kinds of infections, not just HIV, were on the decrease. But, my God, it was scary to see the collective insanity of addiction up close.
Later I regularly met with drug users, to try to de-emotionalize the issue and convince policy makers to adopt a rational approach—with very mixed success. When the UN Office on Drugs and Crime joined UNAIDS we had access to a political mechanism to promote harm reduction, but it was hard work to move them from a police approach to one of public health. I think that what matters is to continue the dialogue, search for solutions, speak up for the users and for policy change, and I keep hoping that one day science discovers an effective treatment for the various addictions. So I guess even I sometimes dream of a magic bullet.