June 5, 2021, marks 40 years since the first reports of what was later known to be AIDS. Udani Samarasekera spoke with Peter Piot about the past, present, and future of the HIV/AIDS response.
Peter Piot, director of the London School of Hygiene & Tropical Medicine (London, UK), starts our interview with an apology. He had to move the time of our videocall slightly. The personable, statesman-like Piot explains that the COVID-19 situation in India has been keeping him busy, and he has another call straight after ours on the Lancet Citizens’ Commission on the COVID-19 response in India. But, he says, he was keen to speak to The Lancet about HIV because the issue is close to his heart. The Belgian microbiologist was instrumental in establishing Projet SIDA, the first research project on AIDS in Africa, in 1984. He was the founding executive director of UNAIDS (1995–2008). When I ask him whether he received my questions, he says that he did but that he generally prefers to be spontaneous. I start by asking him about the early days of the epidemic.
US: Could you tell me about your work on Projet SIDA and when you realised a health crisis was unfolding?
PP: I was working in Antwerp at the Institute of Tropical Medicine and, in 1980 and then later on, we increasingly got patients from central Africa who were hospitalised with this new mysterious disease. They all died, and we didn’t know what it was. Then, when we read on June 5 [1981], what came out of the US, this so-called gay disease, we said, ‘it looks like it, immune deficiency, opportunistic infections, and so on’. But there was one big difference: about one-third of our patients were women and it clearly looked like a viral illness. I could not understand why a virus would care about the sexual orientation of a human host. In any case, we saw more and more cases and I was in touch with colleagues in Kinshasa, with Dr Kapita, who was the head of internal medicine at Mama Yemo hospital. He said, ‘yes, we are also seeing more and more’. So, I went there with colleagues from the US Centers for Disease Control and Prevention [CDC] and National Institutes for Health [NIH], working with colleagues from the Ministry of Health in Zaire, the hospital, and the university. This was in 1983. I’d been in that hospital before, so I knew the place. But it had completely changed. When I walked through the internal medicine wards for men and for women, they were full of young adults and they were totally emaciated, had cryptococcal meningitis, and were dying. The last time I’d been there was 1980 and that was not the case. It was so overwhelming that I took a deep breath, and I knew this is bad and clearly heterosexual. I said, ‘this is going to be a disaster for Africa’. I also said, ‘this is what I want to work on’; I wanted to stop this epidemic. And that led to Projet SIDA, led by Jonathan Mann, with the Zaire Ministry of Health, CDC, NIH, and Institute of Tropical Medicine in Antwerp. So, for example, we were the first ones to find that people with HIV had a much higher risk of tuberculosis and of dying from tuberculosis. It was an exciting time; I don’t know how many papers we published in The Lancet.
US: What were your early challenges and successes in setting up UNAIDS?
PP: In the early days, I had too much of an academic approach. I thought, ‘OK, if we present the evidence, how bad the problem is, what we can do about it, then the rest would follow’. That was completely naive. After a few years, I brought together some friends but also people who are very critical and said ‘OK, what do we need to do?’ They gave me a hard time, but the conclusion was that we needed to go the political way. That’s where I said, ‘what matters in the big picture is the economy and security; let’s go get this on the UN Security Council agenda’. And we did. The first meeting ever of the new millennium of the UN Security Council was on AIDS.
The denial was so enormous everywhere. A turning point in Africa was the special summit of the Organisation of African Unity, as it was called then. One president after the other, with one exception, said, ‘yes, we have a problem’. You have to say what the problem is, otherwise, you can’t deal with the problem. That, for me, was a wonderful moment. The one exception was President Mbeki from South Africa, who said, ‘no, no, this is poverty, this doesn’t exist’. That was a big headache for me. That was the most powerful president in Africa then.
We had a UN General Assembly special session. One of the things I’m really disappointed by with the COVID-19 response is that there still hasn’t been a special session of the UN General Assembly. The biggest issue of our time! That’s a massive failure of leadership in the UN, in WHO, everywhere. And so, anyway, then came treatment. Here we had, not the solution, but at least part of the solution and we could save lives; it was no longer a death sentence. The problem was the price: US$14 000 per person per year. I became totally obsessed with bringing that price down. So that was a huge battle.
One of the things I’m most proud of at UNAIDS is that I brought people living with HIV to the table; in the board of UNAIDS, for the first time ever in the UN, but also in the UN General Assembly. I said, ‘we can’t solve this problem without involving all the people who are affected by it’.
US: What are the global priority actions to ‘turn the tap off’ on new HIV infections?
PP: What is happening now is real complacency. HIV has been very silent in the media and people’s minds. Mortality is still very high. But it’s the new infections—I think that’s a result of the fact that the strategy was entirely focused on treatment and not on prevention. I can see why. It’s easier to measure and organise and it’s less controversial. You don’t have to deal with all the tricky issues: sex, drugs, discrimination. That will be a never-ending battle, I think. There has been progress, but I think an all-out effort on prevention is what is needed. You have to put your efforts where the problem is and that is different from one country to another and even within a particular country. In Kenya, they have a very sophisticated plan of action and investments by the counties. In some counties, it’s more like young women, in others its more sex workers, on the coast there’s some drug use. They have a basic package for prevention, then what you add and where you put most of your resources are a function of that. That’s what we should all do.
A big hope is that we will have a vaccine in the future. I think we can still make progress though. But I’m very worried that, of course, with COVID-19, with all the attention going there, many other health and social issues are suffering from it, not just HIV. Even child immunisation has gone down. So strong leadership around AIDS is important. It’s important that UNAIDS speaks about AIDS and not just about the people’s vaccine and COVID-19 because WHO is there. I mean, there’s no point competing with WHO for that.
US: Have major global HIV/AIDS organisations ended their siloed and vertical responses to AIDS as called for in the 2018 International AIDS Society–Lancet Commission and broadened their mandates?
PP: I think what has happened is that a lot of the AIDS work has vanished. That was not the idea. I think there’s a bit of a paradox because HIV programmes were probably the least vertical in the sense that they were not just health, they were multisectoral and involving education. On the other hand, they were separate from health interventions. I always thought, for example, the most obvious one to work with is tuberculosis programmes because they’re so overlapping. They come together in The Global Fund [to Fight AIDS, Tuberculosis and Malaria], and I had hoped that The Global Fund could force this kind of collaboration because who holds the purse can say, ‘you don’t get the money if you don’t do it together’. But I don’t think that’s happened. I don’t see it yet. It’s more that the silo is disappearing. It’s not that the silo is joining with others because that’s what we want. Disappearing is bad because that’s also going to cost lives.
US: What lessons does 40 years of responding to the HIV/AIDS epidemic have for the COVID-19 response?
PP: The all-importance of leadership and of being science based. I think the AIDS response is prompt in adapting scientific progress but is then getting stuck with politics. The human rights dimension has not been there in the COVID-19 response. How many more reports do we need to have in this country that ethnic minorities are more affected? What has been the policy impact of that? Not much, as far as I can see. We need to be inspired, but we don’t have the luxury of 5–10 years.
US: What is your response to the UK’s 83% funding cut to UNAIDS?
PP: I just find it really shocking. It’s not just UNAIDS; UNFPA [UN Population Fund], which is very important for reproductive and sexual health; even UNICEF, which is usually spared because it’s about innocent children, not people who have sex. Also, the cuts in ODA [Official Development Assistance]-funded research in the UK—this is what I have to deal with. I think we’ll have to pay a price later on in terms of human lives.
US: Are you optimistic about the future of the HIV/AIDS response?
PP: I’m an optimist in general. I think it will be very patchy; some countries will do better than others. What could make a big difference is a vaccine, of course, and long-acting treatment. A lot will depend on leadership in countries, but also globally, I think.
Source : The Lancet
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