No Time to Lose: A Life in Pursuit of Deadly Viruses (42 page)

I was thrilled when the G8 Summit in Gleneagles, Scotland, in June 2005 committed to “as close as possible to universal access to HIV treatment and prevention,” but my cynical half told me it would be difficult to promise more at a next summit—in any case it was the last time AIDS got such prominence at a G8 Summit, and the G20 did not seem to be interested in health or social issues.

It was in everybody’s interest that the US President’s Emergency Plan for AIDS Relief also be fully funded, so each year I urged members of Congress to continue to increase PEPFAR’s appropriation, as well as to fund UNAIDS and the Global Fund, since we each had unique and complementary contributions to the global AIDS response. Global AIDS Coordinator Mark Dybul and I often appeared together at congressional hearings and at think tank events, even speaking in 2007 at Reverend Rick Warren’s Saddleback Church in Orange County, California, as the support of Evangelical churches was crucial for the renewal of PEPFAR. Although I had given speeches in churches like the Cathedral of St. John the Divine in New York City and in the Church of San Francisco in Lima, Peru, they were always part of an AIDS event. This time, I was preaching for a real evangelical congregation, and I was quite nervous about it, especially having to talk about sensitive issues such as homosexuality. Before entering the stage in the vast hall, I took a deep breath, thought about Father Damien from my village, and spoke as I would have spoken in my home village of Keerbergen. After 30 minutes Rick Warren hugged me and said, “Home run!” (Maybe after all I would have made a good preacher.) The vote by US Congress of a $48 billion renewal of PEPFAR in 2008 was great news, and a rare moment of bipartisan consensus in an election year in Washington. I attended the signing ceremony in the White House with President George W. Bush, and the program continued under President Obama.

We had several severe setbacks, though. Perhaps not surprisingly, they appeared first in the countries that had shown the earliest achievements: Uganda saw a rise in new HIV infections after 2005, and in Thailand HIV was rising among homosexual men and injecting drug users, probably as a result of a refusal to introduce harm reduction programs and of the so-called War on Drugs, which was more a War on Drug Users under Prime Minister Thaksin Shinawatra. When, in 2007, UNAIDS gave Thailand a poor score card based on evidence coming from the Thai Ministry of Health, which had excellent epidemiologic data, the Thai delegate in the UNAIDS Program Coordination Board in Chiang Mai in northern Thailand objected strongly to our rating. He was in general a fierce defender of accountability and of independent evaluation, but obviously not when it concerned his own country. I was not willing to change Thailand’s ranking as the facts were not disputed. It was just an illustration that as an “intergovernmental” organization, UN entities were always at the mercy of their member states when publishing honest reports about countries, particularly when comparing performance among them.

AIDS remained a global issue, with infections occurring every day throughout the world. In absolute and relative terms the HIV problem in high-income countries was clearly much lower than on a continent like Africa, but after the introduction of antiretroviral therapy, budgets for HIV prevention declined, and in most European countries there was a gradual increase of new infections, particularly among gay men. In England, despite its very high rate of HIV testing and free treatment through the National Health Service, the number of new infections doubled over a period of 10 years, nearly exclusively in gay men and migrants from HIV endemic areas. Parts of the United States remained confronted with a bad HIV epidemic. I was a frequent visitor to Washington DC, but was basically confined to a triangle between Capitol Hill, Georgetown, and Dupont Circle, with an occasional dinner at a friend’s place outside this area. At one point in 2005 Michael Iskowitz, our man in DC, reminded me that with a 5 percent HIV prevalence, the District of Columbia had a worse HIV problem than most West African countries, and told me it was about time that I meet some people other than members of Congress, officials, academics, and white activists. He took me to The Women’s Collective in an African American part of Washington not far from Howard University. It was as if I had traveled to another country. This was a group of poor, mostly black women living with HIV, founded by Patricia Nalls, a courageous woman who had turned her personal experience with HIV into positive action—a bit like what Noerine Kaleeba had done in Uganda. One woman after the other told her story of parental abuse, nearly daily violence, rape, drug use, broken relationships, hunger, and poverty. One tiny woman of forty, who looked like she was over sixty years old, showed me what was left of her toes—eaten by rats—and told me that she was now sleeping in a tent in her apartment to protect her from rat bites. Another woman showed a small plastic bag like what you use to put any small containers with fluids through airport security: it contained three small bullets—the harvest of a night of violence on her street. I was speechless, and wondered how much a human being can endure. From meeting Holocaust survivors and HIV-positive widows of the Rwandan genocide, I learned that our human capacity to survive and find meaning in life is beyond imagination, though not without limits. These stories from several continents suggested that we needed to sustain prevention and treatment efforts, and not cry victory too soon.

While the response to AIDS became more vigorous across the world, HIV had become
hyperendemic
in southern Africa, meaning a very high HIV prevalence with continuing new infections. I continued to fail to understand what made southern Africa so different in terms of AIDS from the rest of Africa, and the rest of the world, but in any case I was convinced that the region required a truly exceptional response to bring the epidemic under control. Besides numerous visits to South Africa, I also went to the surrounding smaller countries that had HIV epidemics that were at least as bad. In the tiny landlocked mountain kingdom of Lesotho 31 percent of adults were HIV positive in 2005, in some areas even over 60 percent! Life expectancy at birth had fallen to thirty-five years, down from sixty-five without HIV, but the international community completely ignored this country which had become a major sweatshop for mostly Chinese factories. The country was confronting an unprecedented triple humanitarian crisis combining poverty, malnutrition, and AIDS. So I joined forces with Jim Morris, the Indiana native head of the World Food Programme, and Carol Bellamy from UNICEF to gather international support and also to see how a pioneering nationwide door-to-door HIV testing campaign worked in practice. The uptake was surprisingly high, and you could feel the impact of AIDS everywhere. In community after community people, mostly women, were organizing themselves to cope with AIDS in the family, and there was a lot of openness about the problem, though less so about condoms. In contrast, the government had a fairly bureaucratic approach to the AIDS crisis, something I raised with King Letsie III, who was concerned about the very survival of his people and had declared AIDS a national disaster. Similarly landlocked, but somewhat wealthier, Swaziland—remember my mission from WHO in 1977 to “eliminate sexually transmitted diseases”—had the highest HIV prevalence in the world by 2004, with a staggering 42 percent of pregnant women being infected with HIV. The Swazi epidemic had “feminized,” with over 55 percent of all people with HIV being women. Life expectancy at birth had collapsed to thirty-two years as a result of AIDS. In an alarming report, the UN Development Programme concluded that the “longer term existence of Swaziland as a country will be seriously threatened,” reminiscent of the plague in the Middle Ages. It is hard to imagine that in modern times a virus can have such an impact but already in 2005 Swaziland had about 70,000 orphans out of a total (and shrinking) population of 1.2 million, with child-headed households common. In Mambatfweni village I saw how communities tried to protect these children from all kinds of exploitation, including sexual abuse, and support them while leaving them in their original family homes rather than putting them in an orphanage. It was impressive how, with very limited resources, the community joined forces without waiting for help from outside, though the drugs to keep them alive came from international aid. Several times I met King Mswati III, the last absolute monarch in Africa, who had banned women under age eighteen from having sex inspired by an ancient chastity rule, but then promptly married a seventeen-year-old girl as his 13th wife. There was a huge credibility gap between his policies and his own behavior. Given the continuing high rate of new HIV infections, and the lack of circumcision among Swazi men, the country was an obvious candidate for a large-scale male circumcision campaign.

Even if it was confronted with an equally daunting HIV epidemic, Botswana on the other hand seemed on the path to recovery thanks to the exemplary leadership of President Festus Mogae and his entire cabinet, the considerable and well-managed resources from diamond mining, and international support, particularly from PEPFAR, the Gates Foundation, Merck, and several US universities.

However, the country was less successful in terms of preventing new infections, and sexuality and gender relations were still very sensitive issues.

SINCE THE DISCOVERY
of HIV in the 1980s we had all implicitly hoped that AIDS would go away one fine day and that technology—a vaccine, perhaps a cure—would eliminate HIV. No such luck. HIV is firmly embedded in both human cells and societies. I was very concerned about sustainability of our efforts: Who would pay for decades of treatment? Would we have new drugs when HIV became resistant to the current ones? How would second line antiretrovirals become affordable (Brazil’s HIV budget for medicines was already doubling because of the increased need for second line drugs)? How would political and community leadership be sustained? Prevention efforts? Lifelong adherence to treatment and safer sex? Etc. As President Festus Mogae had rightly asked when we discussed male circumcision—why were we not emphasizing more circumcision of newborn boys, instead of only adolescent and adult men as this would protect the new generations? I liked his long-term view, but stressed that we need to deal with the acute and the long-term—unfortunately international policy remained limited to the short-term, which I felt was a mistake and missed opportunity.

So in 2003 I initiated several projects to think through what the long-term trajectory of AIDS could be, and in particular what we needed to do
now
to ensure the best possible long-term outcome. We started with AIDS in sub-Saharan Africa, as the obvious priority, teamed up with Shell’s forecasting division in London, involving hundreds of concerned people in Africa. Under Julia Cleves’s leadership this resulted in a 2005 report “Three Scenarios for AIDS in Africa by 2025,” which made it clear that the worst was still to come in terms of impact of AIDS in southern and eastern Africa. It also made a strong case that it would not be enough to devote more resources to HIV treatment and prevention, but that supportive policies and good management would be equally key for achieving impact—nothing revolutionary, but important to state at a time when all attention went to raising money. Two years later I launched an initiative called “aids2031” (as the year 2031 will mark half a century since the first reports on AIDS in 1981). This was again an effort involving hundreds of AIDS experts and others, and was led by Heidi Larson, who had done work on the future of AIDS in the Asia region, and Stef Bertozzi. It turned out to be far more difficult than I anticipated to think so far ahead, perhaps because we were all struggling with daily crises of delivering HIV care and prevention. The highly politicized environment on AIDS might also have prevented people from daring to think outside the box, and some in the AIDS community feared that long-term foresight would deter from much needed action today. Not surprisingly it was young people who came up with the most innovative ideas, particularly during an aids2031 event at the Googleplex (Google’s headquarters in Mountainview, California), which led to the creation of the Global Health Corps by Jenna and Barbara Bush and Johnny Dorset, then in their twenties—an initiative that twinned young people from the United States and a developing country to work together in a health project.

The aids2031 recommendations called for a redesigned AIDS response, far more tailormade to the specifics of the multiple and diverse HIV epidemics across the world, and proposing various ways to optimize HIV programs. By the time the report came out in 2010, most of its recommendations had already been taken up by several funders and AIDS programs, all concerned now about sustainability, optimal use of resources, and long-term impact. Thanks to enlightened leadership from people such as ministers Tedros Adhanom Ghebreyesus and Agnes Binagwaho, countries such as Ethiopia and Rwanda made smart use of dedicated AIDS funding to strengthen their health systems overall, but most countries strictly followed the rules of the donors, thereby missing an opportunity for a more sustainable response. In times of financial crisis all these issues became key, and will be so for years to come.

When near the end of my term in July 2008 I launched the traditional biannual UNAIDS report, just before the International Conference on AIDS in Mexico City that Ban Ki-moon attended, I could for the first time announce a significant decrease in both deaths from AIDS as well as in new HIV infections (except in the former Soviet states). Finally, I was the bearer of good news.

SUNDAY NOON, NOVEMBER
30, 2008, Ndjili Airport, Kinshasa. I had just come from an informal breakfast at the private residence of the young Congolese President Joseph Kabila with whom I discussed how to address widespread sexual violence and rising HIV infections in eastern Congo, which was still in full-armed conflict. We were waiting in the very loud and chaotic VIP lounge for a South African Airways flight to Johannesburg where I would give my last World AIDS Day address as head of UNAIDS, and the first one in South Africa since the resignation of President Mbeki in September. Then my BlackBerry vibrated: “Dr. Piot? The secretary-general would like to talk to you. Please hold the line.” Ban Ki-moon thanked me for my input in the selection process for my successor (my mandate was coming to an end, beyond the maximum 10 years at this level in the UN), and he told me how impressed he was by Michel Sidibé during his interview. The telephone connection was very bad, and the noise and music in the airport lounge were as loud as in a bar in Matonge, but through it all I heard Ban saying solemnly in his soft voice: “I have decided to appoint Mr. Sidibé as executive director of UNAIDS with effect of the first of January 2009. Can you please call him, and ensure there is a smooth transition between you and Mr. Sidibé” I felt great relief; UNAIDS would be in good hands. I immediately called Michel in Geneva, nearly shouting through the Congolese crowd speaking loudly in their cell phones: “
Mon frère, toutes mes felicitations!
Ban Ki-moon has just appointed you. We’ll celebrate later this week in Bamako.” (We had planned a while ago to visit Michel’s native Mali together.) The connection broke off abruptly. The circle was completed in Congo, where my professional life had first taken off.