PHA-Exch> Leaving Platform That Elevated AIDS Fight [Peter Piot]

[Claudio Schuftan]

From: Vern Weitzel <vern.weitzel at gmail.com>
crossposted from: "[health-vn discussion group]" health-vn at cairo.anu.edu.au
http://www.nytimes.com/2008/12/30/health/30docs.html?_r=1&ref=science&pagewanted=all

Leaving Platform That Elevated AIDS Fight

Fred Merz for the New York Times
RAISING THE ALARM Dr. Peter Piot, the director of the United Nations AIDS
program for all of its 13 years, is retiring.
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By LAWRENCE K. ALTMAN, M.D
Published: December 29, 2008
Dr. Peter Piot, the only head of the United Nations AIDS program in its
13-year history, is retiring on Wednesday. He is credited as the person most
responsible for making heads of state understand the political, economic and
social ramifications of a pandemic that rivals the worst in history.


Dr. Peter Piot at a hospital in Kigali, Rwanda.
Although the toll of infected people and deaths grew during his tenure, Dr.
Piot, 59, said in an interview that he had achieved a number of successes.
He attributed them to basing policy recommendations on scientific evidence.

He said his program had raised global public concern about AIDS; vastly
increased the money spent to try to blunt the pandemic; lowered the price of
life-extending antiretroviral drugs for millions of infected people in poor
countries; and gave a voice to socially marginalized groups like gay men and
injecting drug users, who are at great risk for AIDS yet had virtually no
say in poor countries.

Dr. Piot (pronounced PEA-ott) recalled that when he became executive
director in 1996, about $250 million was spent that year in developing
countries on the disease.

"Trying to fix a global epidemic with that kind of money is impossible, but
that is what we were expected to do," he said.

The current figure is about $10 billion, and Dr. Piot said that "if we had
the kind of money that we have today 10 years ago, we would have never had
an epidemic so out of control."

Dr. Piot's program was born in part out of widespread frustration with a
lack of coordination among United Nations agencies concerned with AIDS —
particularly the World Health Organization, which was responsible for
monitoring the disease's global reach. In the early to mid-1990s, the health
organization's leadership was widely criticized for a seeming inability to
cope with a pandemic of the dimensions and social complexities of AIDS.

So member governments created a program to coordinate the United Nations'
role in defeating AIDS. The program now has 10 co-sponsors, all of them part
of the United Nations system.

Dr. Piot, who helped discover the Ebola virus and was one of the first
scientists to study AIDS, was named executive director by Boutros
Boutros-Ghali, then the United Nations secretary general.

"When we started, AIDS was definitely not on the world's political agenda,
and now it is," said Dr. Piot, speaking by telephone while participating in
AIDS meetings in Africa, where the disease has taken its greatest toll.

Dr. Piot helped the United Nations characterize AIDS as a global security
issue and make the disease the focus of the General Assembly's first session
ever devoted to any health issue. And he helped add AIDS to the agendas of
world economic forums.

As executive director, he said, he soon came to realize that scientists
alone could not defeat AIDS. Success would also require strong political
support from government leaders and civic groups.

The United Nations offered him a rare platform and access to the world's top
leaders. He traveled the world — 23 countries in 2008 alone, and countless
more over his tenure. Through moral suasion, his scientific expertise and
his experience as a student political activist in his native Belgium, he was
able to sway the views of many heads of state.

His position requires a palette of skills, he said. The director needs sound
scientific knowledge of the viral disease and its sociological
ramifications; appreciation of the economic and political realities of rich
and poor countries; and the diplomatic skills to talk to a pope,
pharmaceutical industry executives and AIDS activists, among many others.

Dr. Piot said he was confident that his deputy and successor, Michel Sidibé
of Mali, had the skills to keep AIDS a top global health issue.

Critics contend that the United Nations should not have created a separate
program devoted to a single disease, even a pandemic, because a narrow focus
can diminish the attention to other health problems.

Dr. Piot replies that without his program's efforts, millions more people
would have died. While a separate agency may not seem the most rational
approach, he said, "it works, and that is what matters." He added that
"well-focused organizations have much greater impact than those with broader
mandates."

AIDS has highlighted the difficulty of delivering antiretroviral drugs to
patients in poor countries, thereby focusing world attention on the
underlying cause: a lack of effective health care infrastructures.

That understanding has had an unexpected benefit, Dr. Piot said: "attracting
more money to strengthen these health systems." Indeed, in many cases AIDS
financing has been the only investment those systems have received.

A turning point in the direction of the United Nations AIDS program took
place in Dr. Piot's first year as executive director: the marketing of
powerful drug combinations that can allow many people with H.I.V. to live
near-normal lives.

The drugs, too expensive even for many patients in rich countries, were far
beyond the reach of the tens of millions of infected people in the
developing world.

At first, Dr. Piot said, "the development agencies and the traditional
public health communities were dead set against making access to treatment
available in poor countries."

Although he was skeptical at first about negotiating with industry to lower
the drugs' cost in poor countries, he encouraged more optimistic staff
members to try it anyway, "because no one else was doing it."

Negotiating lower prices was "largely Unaids's work until the Clinton
Foundation came in and shaved off the last bits to further lower the costs,"
Dr. Piot said.

Dr. Piot has endured criticism, including for having published inflated
estimates of the number of people infected with H.I.V. in the early years.

"We were wrong; we overestimated the potential of the epidemic in Asia,
particularly in India," he replied. "But we underestimated in several
African countries, and we definitely underestimated in Eastern Europe, where
we had not seen that epidemics were building up in Russia and Ukraine."

But he denied as "absurd" the accusation from some critics who contended
that he deliberately inflated the figures to raise the profile of AIDS. "We
have review panels, which include top epidemiologists from the world's top
academic and research and public health institutions," he said. "Every
estimate involves hundreds of people, and any of them would have denounced
efforts to distort the figures."

Current estimates are that 33 million people are living with H.I.V. and 20
million have died since the disease was first recognized in the United
States in 1981.

Working with political leaders was a constant challenge, Dr. Piot said.
Because member states run the United Nations, criticizing any of them can be
ticklish, if not impossible.

As H.I.V. ravaged South Africa, Thabo Mbeki, its president for much of Dr.
Piot's tenure, virtually denied that the virus caused AIDS. Dr. Piot could
not convince him otherwise.

Similarly, Dr. Piot said he wished he could have persuaded Russia to permit
methadone substitution therapy for injecting drug users, who are fueling a
growing AIDS epidemic. "Are these mistakes?" he said. "Well, they certainly
are failures, let us put it that way, in the sense that I have not been able
to convince the leadership there to go for a scientific approach."

On the other hand, he went on, in China "the top leadership did change
completely their policy on injecting drug use, and that was in 2005."

In an ideal world, Dr. Piot said, he would have leaders create large
nationwide and worldwide campaigns to prevent AIDS. That effort would
require sustaining AIDS awareness; using marketing efforts to promote condom
use; creating incentives for people to be tested for H.I.V.; organizing
circumcision clinics for males in some countries; and encouraging scientists
to work more closely and share data in the effort to develop an H.I.V.
vaccine.

"It is not the 'what' that is lacking in preventing AIDS," he said. "It is
the 'how to organize it' that is key."

In May, Dr. Piot will move to Imperial College London to create an institute
of global health. An aim is to nurture a younger generation of students to
apply the lessons of the AIDS battle to other diseases, including chronic
and noninfectious ones like heart disease, which are not well studied in the
developing countries.

Despite the financial difficulties of starting a new program at this time,
he said, "there is so much interest in global health that I am quite
optimistic."
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