The Age of Aids [home page]

interview: peter piot

[photo of Peter Piot]

The executive director of UNAIDS since its creation in 1995, Dr. Peter Piot saw some of the first known AIDS cases in Zaire in the late 1970s. He returned to Central Africa in 1983 to conduct some of the early studies of prevalence there. Under his leadership, UNAIDS has become the chief organizing force for worldwide action against AIDS. "When you think of it that in, let's say, 25 years roughly, about 70 million people have become infected with this virus, probably coming from one [person] at some point, its mind-blowing," he says. "... All these people are connected with each other by definition, because they had sex with each other; they shared needles; they got a blood transfusion from someone who got it, or their mother had it. That's it. There are no other ways of transmission." Here, Piot talks about why AIDS needs to be at the top of leaders' political agendas; why prevention programs have to involve both abstinence approaches and condoms; and the future of the epidemic in the so-called "next wave" countries -- especially Russia and Eastern Europe. This is an edited transcript of an interview conducted Feb. 25, 2005, in Geneva.

Do you remember your first encounter with HIV, with the virus?

There are two different kinds. One I knew, and the other one I didn't know. What I didn't know was that in the late '70s, when I was working at Institute of Tropical Medicine in Antwerp, [Belgium,] we started seeing patients with something we had never seen before, and in every case people died.

The one I remembered -- because I participated in a [necropsy] of a person [who] was a Greek sailor, who came from what was then called Zaire [now Democratic Republic of Congo] and who had been a fisherman in Lake Tanganyika -- he had died with something very unusual, with the disseminated cryptococcal meningitis; in other words, an infection with a fungus that is very rare, and certainly if it's disseminated. And that was the first time. We knew afterwards because we had kept all the specimens, including blood, and he was HIV positive, and then it was a classic case of opportunistic infections and just name it.

Then I read, of course, the Morbidity and Mortality Weekly Report [MMWR] of CDC [Centers for Disease Control and Prevention] -- six cases [in] L.A., and so on. Then we started thinking, well, that sounds really like the Central Africans that we're seeing in our hospital, but we have women, so it can't be only gay men. It's different, but what is this?

And then in '83, AIDS really took over my life in a sense. I went to Kinshasa [the capital of Democratic Republic of Congo] with some colleagues from Centers for Disease Control in Atlanta, from the National Institutes of Health, and we did the first investigation on AIDS in Africa and found far more cases than we thought. The hypothesis was that if we see, say, 100 people with a syndrome that didn't have a name yet in these days and there was no cause yet identified, then there must be thousands of them in Central Africa where they come from, because who can afford to go to Europe for medical care? It's the wealthy; it's the powerful.

The two only issues that are really going to interest politicians are the economy and security. Š I believe that's the league [AIDS] should be in, not as yet another disease like malaria or TB.

And yes, when we came there, we saw men and women of what was then my age actually, young adults completely emaciated in the wards of [Kinshasa's Mama Yemo] Hospital, which I had known 10 years before when I was working on Ebola virus hemorrhagic fever. I hadn't seen that before. And then I knew what it was. I said, "Aha, this is bad news. It must be heterosexual," because there were more women than men. If something is heterosexual in terms of transmission of a disease, then that's also bad news, because that means that there is an enormous potential. I knew that it would change my life then, and since then I've been working on AIDS nearly full time.

Why did you know it would change your life?

I had this feeling that it was going to be so important, that there were so many questions unanswered, and that I had a lot of the experience and the kind of contact and experience in Africa, being a microbiologist, a physician, but also someone working on community aspects and development. I said, "That's it." And it's kind of these rare moments in life that you know something is going to happen, and most of the time that of course may turn out to be wrong. In this case, it was really right.

You're saying that it was a heterosexual virus disease in Africa from the beginning, unlike the way it was perceived in the West, particularly in the States.

Yeah. We actually wrote that also in the report on -- it's called, I think, "Acquired [immuno]deficiency syndrome in a heterosexual population in Zaire," which caused a lot of, shall we say, resistance. We had problems in publishing it because people said: "Heterosexual? AIDS? No, no, no. This is a gay disease." It even had at some point [the name] GRID [gay-related immunodeficiency].

I never understood why a virus would care about the sexual preference/orientation of its human host, because from the perspective of a virus, what is sex between human beings but contact between mucosal surfaces? It doesn't sound very romantic or exciting, but that's it -- so that the virus can jump from one cell to another. That's it. And some types of intercourse may be more efficient than others, like anal intercourse, but at the end of the day it's the same. So I was always puzzled by this kind of dogma, [that] this must be a homosexual disease.

And also because of all the women we saw. If you see mostly men, you could say OK, culturally this is not acceptable, so most of the men were lying. But when you saw so many women, and when you look at the epidemiology, it's people with lots of sex partners and so on. When you look at that article afterwards -- I read it again a few years ago, and I said, well, we hit the nail on the head with a lot of this, saying heterosexual [behavior] linked with multiple partners, poverty and so on and so on.

What kind of insights did [the Kinshasa trip] and others give you into the nature of the virus itself? …

... In terms of the human nature of the infection, it was clear it was young people; it was people who were let's say on the entrepreneurial side sexually -- a lot of sex workers were in there. Also what was striking to me was just in the population in Kinshasa, there was already the popular myth: There is this disease which kills young people, and they had made a relationship with sex somewhere or another, but certainly with prostitution. ...

And then the loneliness of the people who had it. They were just left alone to die. This element of stigma, of rejection, exclusion was certainly already there, and it's something that I felt very moved by, in addition to the enormous curiosity and excitement that you see -- well, what is going on here?

Lastly, I would say the fact that this had been going on for several years despite the presence of lots of local doctors, foreign researchers, doctors on other issues, and nobody had reported on it, that also told me a story. How could this go unreported, undealt with for two, three, four years? I mean, this was in '83, and it had been going on for several years.

Why?

I think it's on the one hand because maybe there are so many problems in terms of health. People are dying of so many causes that for a physician, for a nurse, it's running from one emergency to the other to say so, and trying to see as many patients as possible with very little means. That I would say is a very valid excuse for certainly the local medical profession. For the foreign doctors -- there was a Belgian and a French research institute and so on -- I find it hard to understand.

And it motivated you.

Yes, it motivated me. I was very young. I had worked in Zaire 10 years before, '76, when there was the first outbreak of Ebola virus. I worked in Kinshasa and in the Equatorial Province, and I'd been many times. I love the country to start with, but I also saw the potential for the havoc that an epidemic could make.

And then there was of course the scientific curiosity. Science is driven a lot by curiosity, wanting to know, and I was pretty young and wanted to know.

How do you imagine the virus in your own mind? ...

I see it as an extremely smart creature. It's diabolic certainly, but in a way that it makes use of all the opportunities -- I mean globalization. People travel, and there's the networks. When you think of it that in, let's say, 25 years roughly that about 70 million people have become infected with this virus, probably coming from one at some point, it's mind-blowing. It tells you also about the networks that exist, tells you another story about globalization. All these people are connected with each other by definition, because they had sex with each other; they shared needles; they got a blood transfusion from someone who got it, or their mother had it. That's it. There are no other ways of transmission. That virus has made optimal use of let's say communication networks and contact among people.

I see it as a very smart and a very diabolical virus at the same time, and an extremely sophisticated adversary. It adapts to any treatment; it develops resistance. It fools us all the time, all the time. And it has chosen not the most efficient road of transmission in terms of one-on-one contact, which is sexual intercourse. I mean, breathing air would be more efficient, or the food chain or water. But it's the most difficult to control because it's private behaviors, and [therefore] this is associated with stigma, with shame in many societies, if not in all, which, again, makes it harder to control.

It has this latent period where people don't get sick, so they're healthy. Nobody knows it. Transmission continues. Since I've worked with Ebola virus, I often make the comparison. Both are one of the most lethal viruses; there's nearly 100 percent mortality from it. But in one case you die about a week after you get sick, two weeks after infection. In the other case it's 10 years, 15 years, 20 years. The first one causes epidemics that up to now have nearly always died out spontaneously, because you close the hospital, and if you isolate people, it's finished. It's not well adapted to the human being. In the second case, we see a continuing expansion of the epidemic which I think will go on for some time.

So it's incredibly well adapted to us. It's a very, let's say, human virus, a very human epidemic. It touches right to the heart of our existence, and that's sexuality. You go back to Freud and you say Eros and [Thanatos], it's there, where you have sexuality and life linked directly to death, which of course life always is, but in this case this virus links it in a direct way. Fascinating also from that perspective.

Who was Jonathan Mann?

Jonathan Mann was a friend who started really the global awareness campaign around AIDS. I think that's really his place in history. He was a visionary. He had the ability of bringing in new blood, I would say, in[to] public health, which was a bit sclerosized, certainly, and had been unable to respond to AIDS in a big way.

He was a man with no patience, and retrospectively, that is something that you need also when you deal with AIDS. You need a combination of no tolerance for all the nonsense and for inaction, but on the other hand, it's a long-term vision. We worked together in Kinshasa from '84 on. I could see that he was a control freak on the one hand as much as he was generous in his collaboration.

It was a very complex personality as an individual, but an incredible mind in terms of linking things that were not linked before, like human rights, a political analysis and then, let's say, the public health aspects of AIDS and trying to move the field in that way. Very, very unique. I've never met anybody like him since then.

People often describe him as charismatic.

Yes, charismatic. Certainly he could tell a story much better than anybody else, convince people.

So talk more about what his impact has been.

First of all, after we had documented that there was a big AIDS problem in Kinshasa, he really organized the first AIDS research program in Africa [Project SIDA], and organized it in a big way. [He] documented all the basic aspects of AIDS in Africa, and not much has changed since then, I must say. It's in the first couple of years that all the basics were established.

But his biggest merit is that he established [the] Global Program on AIDS [GPA] in the World Health Organization, WHO, fighting bureaucracies maybe more than the virus, something I also know something about. He put AIDS on the public health agenda, organized a big ministerial conference of all ministers of health in London. That was quite the first. Mobilized money and made [sure] that basically every developing country had a national AIDS program, had some money and started awareness-raising. It all started with him.

What was his vision?

His vision was that AIDS is a threat to human development, that this epidemic is rooted in violations of human rights, that that's the reason why we have such an AIDS epidemic. And that became stronger and stronger over the years. That was not the case when we started working in Kinshasa. That vision, in terms of the human rights aspect, was not there, or at least he didn't communicate it. Yet we had hours and hours of discussions about this epidemic. But I think his conceptual framework was that one of human rights violations are the foundation of this epidemic.

I think that is a very important aspect of it, but I don't think it's everything. Today we would put more emphasis on poverty as a driver, poverty that disrupts families. Men go to the mines to look for work and are separate from their families, women in prostitution. But you can say poverty's a violation of human rights.

And also I think the gender aspect -- in other words, the inequality between men and women -- is also an extremely important driver that we didn't recognize in the beginning.

Can you explain why [Mann] was forced to resign? Or what happened?

My reading is that he didn't get what he wanted from the organization. It was not really a core priority. All the funding for the Global Program on AIDS was so-called voluntary funding. The organization itself, WHO, hardly put any of its own funds in it.

It was also about control. In WHO he was forced to go through the normal or let's say regular bureaucracy, which he felt was too slow.

And then I think a third aspect was the fact that he may have been getting too much visibility. He actually had become the public face of world health in general, and that may not have been appreciated by his bosses.

So at the time then, the World Health Organization, how concerned was the organization with HIV/AIDS?

Well, the Global Program on AIDS was of course the leader on AIDS in the world, but the organization as such was really not so committed when you look at the budget. I always say when you look at commitments, don't look at speeches but look at the budget, and that budget was extremely limited as far as the organization's own resources are concerned. It was all donor money that was specifically given for the Global Program on AIDS, which made it also very vulnerable, because near the end of Jonathan Mann's term, donors were also increasingly unhappy with the performance of the Global Program and started getting engaged themselves in programs on AIDS in the developing countries.

And how was the GPA different from UNAIDS [Joint United Nations Programme on AIDS]?

Very different in the sense that GPA was limited to working with ministries of health, first of all. Secondly, [it] was directly implementing programs. In other words, outsiders, foreigners, were executing programs in developing countries. We are working, first of all, through now 10 organizations through the U.N. system; that includes also the World Bank. [That's] a lot of money. And we're using an approach that goes beyond the ministries of health.

When I got into this job, I had three objectives. The first one was to put AIDS on the political agenda, not the agenda of the ministries of health, where it was getting on. That's obviously essential, but it's not enough. …

The second goal was in order to do that, we have to reposition AIDS as a problem for social economic development of security. The two only issues that are really going to interest politicians are the economy and security. The rest, OK, if we've got time left and money left, we'll deal with the rest. So that's what I tried to do and position AIDS there, because I believe that's the league it should be in, not as yet another disease like malaria or TB. I mean, they're very important, and I've spent a lot of my own life on them, on tropical disease and so on. But AIDS is different. It's very, very special and exceptional, and so that's what we did also in the beginning, repositioning it.

And thirdly, mobilizing money. When we started with UNAIDS, about $200 million was spent on AIDS in developing countries, in the poor countries. There's no way that you can stop such a complex epidemic worldwide with that kind of peanuts. WHO's budget on AIDS was much less than the GPA's, and it was all foreign money.

Now we are at about $6 billion, and it's still not enough -- still like halfway only at best. But a big difference is that of these $6 billion, $3 billion are coming from the governments and citizens of the developing countries themselves. ...

How do you respond to people who criticize UNAIDS as being sort of asleep at the wheel and not raising the alarm enough during [the '90s, when AIDS was exploding in sub-Saharan Africa]?

We were established in '95. That's when we started actually, so that's about five years after Jonathan Mann resigned. [Editor's Note: Mann died in a SwissAir plane crash in 1998.] In the meantime not much had happened, and there was a lot of dissatisfaction with the global response, which had completely changed [since] the beginning. So when we started with UNAIDS, I felt that the top priority was exactly to put AIDS on the political agenda. … It has to be on the agenda of presidents, of prime ministers, if it's a national emergency, a matter of national survival….

I'd seen also that with WHO's support to developing countries going down, that AIDS programs collapsed completely. There was no ownership except for a Uganda or a Thailand, or a Brazil later on. …

We had this enormous problem of getting over that denial of the top leadership. Not looking for excuses, but that was really the major obstacle. When you go back to it in Africa, that's what it was. What happened in the '90s and what I think is the great contribution of UNAIDS was to put AIDS on the political agenda exactly in Africa, also of donor countries.

But, for example, in Eastern Europe, we have not succeeded yet. It's not there yet. In Asia it's just happening now, slowly. China and India it's happening. But take Russia. It's not on the top agenda. Ukraine it was getting there, but in the countries of the former Soviet Union it's not. In Africa, we had the excuse we didn't know; in Eastern Europe, in Asia, there is not that excuse.

So that was our first job in UNAIDS, getting that in order. Plus, there was a collapse also of international funding, which was going more and more to so-called bilateral programs rather than to multilateral -- in other words, every donor doing their own thing.

What's your take on South Africa and the political leadership on HIV/AIDS there during the '90s, and [President Thabo] Mbeki's stand in particular?

Well, South Africa, just as in many other African countries, we've wasted enormous amounts of time and at the expense of many lives because the top leadership did not recognize that AIDS is such an exceptional threat basically to survival, to the survival of the nation.

On the one hand I understand that. There is really no precedent in history of an epidemic like AIDS. And African countries are struggling with extreme poverty, civil wars, stability, coming out of colonialism -- just name it. There are enough excuses, and retrospectively it's easier to say, "We should have done that," and so on. But who in the Western world had foreseen that this would take on such dimensions?

But the fact is that we've wasted so much time, and I think a country like South Africa has more resources -- money and skilled people -- than any other country in Africa and could have really taken on this epidemic, say, five years ago at least, and made a difference, including in terms of treatment.

I think they're doing quite a good job in terms of HIV prevention. The results are not there yet. But AIDS is very visible; there are lots of campaigns. But offering treatment to the 5 million people who are infected, that should have started much earlier.

Why was it decided to hold [the 2000 International AIDS Conference] in Durban, and what was the impact of that conference?

It was a decision that was made when I was the president of the International AIDS Society for several years and so involved in the planning of the conferences. Up to then, no AIDS conference had happened in the developing world, and we really wanted to have it in Africa because of the emergence of the epidemic in Africa. Two, South Africa had just been freed of apartheid. It has an infrastructure there, etc.

It was a very difficult conference, but also I think a historic conference because of the difficulties. The opening ceremony of the conference, which was in a cricket stadium, was pretty traumatic in a sense, and dramatic, [in] that President Mbeki gave a speech which was very disappointing for many of us, and I had to speak right after him. It was not my best moment, because hiding my disappointment was not so easy.

But the fact [was] that for the first time, the epidemic in Africa got really worldwide coverage in the media. It had built up, and we had been working with a lot of media, and there had been a series in The New York Times and so on right before, so it was already building up.

Secondly, the debate on access to treatment in developing counties really got into the open. I remember very well when there was a conference in Vancouver in '96 when it became clear that there was effective treatment available -- not a cure, but treatment. I gave a speech there also in the opening, and I immediately said, "Let's make sure that we do not exclude the majority of people living with HIV from that treatment." But nobody paid attention to that, because the agenda was "Let's get as many people as possible on treatment in the developed world." AIDS activists hadn't shown the slightest interest in AIDS in Africa, in the developing world. That was coming later, when treatment was accessible.

So the conference in Durban really was a breakthrough in terms of putting AIDS treatment on the agenda. At that time there were only three instances that were fighting for treatment. Besides UNAIDS, it was France and Brazil. WHO was not at all engaged in treatments; it [was] prevention, prevention. All the donors -- prevention, prevention. The government of South Africa, the government of India all said prevention, prevention only. And of course prevention is essential. But that was a very lonely time, and the conference in Durban was really for me a turning point, which was then followed by the special session of the U.N. General Assembly, where for the first time we succeeded in having access to treatment endorsed as an integral part of the response to AIDS.

That was the politically defining moment. Let's say Durban was the hype and putting it on the agenda, and then in the General Assembly we could gel that in a political way. And there also it was very fragile. We had all-night sessions just on making sure that treatment was included in it.

... How did the Global Fund [To Fight AIDS, Tuberculosis and Malaria] come about? What was the idea behind it?

I think what we've seen as of 2000 is more or less a building up of a momentum. For example, January 2000 was a debate in the U.N. Security Council, with Ambassador [Richard] Holbrooke chaired by Vice President Gore, then vice president. [That] was the first time that the Security Council debated on something that was not war and peace. That was a breakthrough because it opened so many doors, and presidents, prime ministers say, "Ooh, it was debated in the Security Council; this must be a serious problem," which was ridiculous, but I literally got that kind of reaction.

[U.N. Secretary-General] Kofi Annan got involved, and there was a summit in Abuja, [Nigeria], in April 2001 hosted by President [Olusegun] Obasanjo from Nigeria, where [there were], like, 20 heads of state from Africa -- again, first time [there was such a] top-level meeting on AIDS -- and Kofi Annan gave his historic speech where he called for a war chest. We had then estimated that we needed roughly $10 billion to stop this epidemic. We'd done some homework -- we had in UNAIDS -- but the messenger, of course, is as important as the message. In this case it was the secretary-general of the United Nations, and that triggered off a lot of interest, because here we had political growth, awareness. AIDS activists in developed countries became interested in the issue in developing countries. It's very recent.

The ministers of finance got interested because we had been able to demonstrate the economic loss to AIDS. Big business became interested, like the Chamber of Mines, the big mining companies in South Africa.

So pieces were kind of coming together, or the stars were in the right alignment. There was a General Assembly special session on AIDS which called for a global fund. ... So things like that happen when lots of forces are coming together. And that's how the Global Fund was created. ...

Later with the Bush administration's policy, I've talked to people within the administration, and it seems there was a sort of clear decision to of course contribute to the Global Fund, but also to do something with a U.S. stamp, for political reasons. But also there was a certain resistance to giving so much money to the U.N. Were you disappointed that America struck out on a unilateral program?

First of all, I believe that President Bush's State of the Union speech in 2003 really was a historic moment in the fight against AIDS. It put the debate on AIDS funding into another league, moved from the "m" word to the "b" word, from millions to billions. It's what I called for in Durban. I said, "We've got to move from 'm' to 'b,' with billions." Then what I got as a reaction, including from U.S. officials, is that "This is a very irresponsible statement for someone in your position. You know that that money is not available." And here comes the president of the United States saying, "Fifteen billion dollars is what I put on the table." ...

I think it really changed the dynamics internationally, because other countries started then also increasing their contribution, because on many things, America leads the way; it sets the trends.

But I was disappointed indeed that not more of the money went multilaterally to the Global Fund. I never expected, though, that all the money would go to the Global Fund. I mean, let's be realistic. I think that in order to maximize fund-raising, you need multiple channels. That's a reality in U.S., Congress; that's a reality in any country. It's a reality for citizens, for businesses.

But in order to optimize spending the money, you need to make sure that in countries, everybody comes together and that not everybody's running [in] a different direction. So the Global Fund is extremely important, because it works with all countries, and not only with the countries that are the primary partners of bilateral donors, because whether it's the U.S. or France or Germany, they have their favorite countries. But there are some that are left behind by everybody -- sometimes for good reasons, like Burma, [now called] Myanmar. Nobody wants to deal with the government there, but on the other hand, they have a bad AIDS epidemic. So that's where we established a fund so that we can collect the money and make sure, through local organizations, we can do it. That's the advantage of a Global Fund, that it can be specifically dealing with it.

But both are necessary, bilateral programs and multilateral programs. I think since the collapse of the Soviet Union, we've learned that total monopolies are rarely efficient or effective, so some diversity, some pluralism is necessary. But it's important that at the country level in the developing countries that donors work for the objectives of that country, not for their own agenda. And that is often the problem with donors, be it the U.S., be it others.

What about the critique I've heard from people in Washington that the Global Fund suffers from the problem that's sort of part of the whole U.N. structure in that it works through nation-states, and that often these nation-states might be corrupt and are really not that serious; that it's much better to work through NGOs [non-governmental organizations] and faith-based organizations? How do you respond to that?

Firstly, I should specify that the Global Fund is not a U.N. structure. The choice was deliberately to create something outside where we in the U.N. support how the money is spent and make the money work.

But I agree that you cannot deal with an epidemic like AIDS by just working with a government. But you can also not do it by ignoring the government. You need leadership in the government, but then you find who are the best people, the best organizations. That's how we also work in UNAIDS. We are not only working with the ministries of health or of finance or so on, because in some countries we would be nowhere.

But if you only deal with faith-based organizations, with the community groups, and you ignored the need for leadership by the government, by the administration, you're also going nowhere. So again you need this, what we call in our jargon, multisectoral -- I mean, you need at both levels.

And what about the emphasis on faith-based organizations and sort of the abstinence-focused grants that are being given out?

Well, these are two different issues, I think. The good thing is that faith-based organizations and churches and so on were not really enough involved in the fight against AIDS and were actually considered by people dealing with AIDS as a nuisance, to say the least. And they have so much to offer, both in terms of the services they provide -- in some countries over half of all medical care, of all education, is organized by faith-based organizations, the church, Islamic groups, whatever. So that's the opportunity.

Where we have reservations is if the approaches to prevention would be only dealing with abstinence, sexual abstinence, or only condoms. I find myself in the ironic situation that earlier on I would go into heated debates with colleagues saying: "Condoms only are not the solution. You need to think of others." It's reduction in partners and postponement of first sexual intercourse for kids. It's not healthy to start at 13 or so. We've always said it's a package deal. You need the whole picture. Otherwise we won't be able to be successful.

So you've made this case to USAID [United States Agency for International Development] people under previous administrations.

Yes.

And now it's different.

Now it's different. Now I make the case you need a full ABC [approach -- abstain, be faithful, use condoms], the whole package. But I should say also that I don't expect a church -- I'm speaking about a church, not about a faith-based organization -- that it would promote condoms. The church promotes whatever is according to the teachings of their church: chastity, abstinence, [being] faithful. But it does not oppose promotion of condoms, because we know that saves lives.

I was two weeks ago in Cameroon. Feb. 11 is the Day of the Sick in the Catholic Church, and I was there with about 60 bishops, cardinals, both from Africa and the Vatican. We had a very good debate and dialogue, where the door was open for condom use in specific circumstances, because the highest moral imperative is not only saving lives but "[Thou] shall not kill." There is an incredible debate, I know, in the Catholic Church. On the ground, when you talk to clergy and faith-based organizations on the ground who are confronted, particularly in Africa, with orphans, women infected by their husbands, etc., there is a far more pragmatic approach than in the top hierarchy. ...

On some of the so-called next-wave countries, what makes you lose sleep at night now? What do you worry about?

My biggest worry in terms of countries affected by AIDS is Russia and the countries of the former Soviet Union, because it's driven by a heroin epidemic in the first place, although there's more and more sexual transmission. There seems to be real denial about the potential for a huge crisis affecting the country, even an economic crisis, in the countries of the former Soviet Union. So I don't see the action that's necessary, and I see we're nearly at 1 million people infected.

How to get that on the political agenda I don't know. The fact that it's associated with drug use makes it even harder, because in most countries, drug users are not considered as full citizens. And which politician wants to be associated with a problem that has [increased through] drug use?

So that is my biggest headache. Knowing also that there is already a demographic crisis in Russia -- in other words, the population is declining for other reasons than AIDS -- so a few percentages of the population infected with HIV is going to have much more serious consequences for the Russian economy, for the health of the nation, the future security than there may be 10 percent or 15 percent in Africa with a population that is still growing, growing.

China?

China is going through very interesting times in general, the economy and so on, and society, but also as far as AIDS is concerned. We see a spread of HIV in [injection] drug use populations in certain provinces, but also more and more through sexual transmission in the most entrepreneurial provinces, the ones that are the engine of the Chinese economy and maybe of the world economy.

The leadership in China is really completely changing now in terms of how it deals with AIDS. I think a defining moment was Dec. 1, World AIDS Day, 2003, in Beijing when Premier Wen Jiabao visited a hospital with AIDS patients, shook hands, etc., had some contact that was aired tens and tens of times on CCTV, [China Central Television]. And last New Year, Chinese New Year, the same prime minister spent several days with poor farmers infected with HIV in Henan province, where they were infected by illegal blood trade.

I think the top leadership sees it now as a matter of a threat to societal stability, and the green light has been given for a major campaign. The problem is that there is still on the ground so much discrimination, denial, and the provinces have to get their act together there. But at the central level, now I feel very comfortable that they want to take it on. A thousand treatment centers are being established, centers for methadone substitution treatment in China. These things a few years ago would have been unthinkable. So there's progress.

You've been involved with this virus for decades now. Given what you know and the scale of problems still that you confront, are you optimistic?

Well, paradoxically enough, I've become far more optimistic as an individual throughout the years than I used to be, not because the epidemic is gone -- I am afraid that AIDS is going to be with us for several generations -- but because I've seen that it is possible to mobilize entire communities, that results are possible. We have cities in East Africa -- from Addis Ababa, [Ethiopia], Kigali, [Rwanda], Nairobi, [Kenya] -- where today less people become infected than five to 10 years ago, all young people. Treatment in poor countries is becoming slowly accessible.

... I've seen the best and the worst come out of people when it comes to AIDS. The worst is when it comes to continuing stigma, denial, finger-pointing -- "You've got it, you sinner," whatever. The best is when you see the heroism of people living with HIV, the social activism that comes out of it, the dedication of scientists. There's a kind of a worldwide movement coming up, and AIDS has made it within 20 years now as one of the global issues of our time, [on] a par with climate change, with nuclear threats and all that kind of things, in extreme poverty. It's in that league now. Frankly, five years ago, I didn't think that would be possible.

So there is progress, but it's not been translated yet for people. We still have 5 million new infections; we still have 3 million people who die per year. And the next five years will change that.

You said AIDS is different in terms of security of nations. Why?

The AIDS epidemic is really exceptional when you look at it in human history. No precedent for that whatsoever. One, it's still growing and growing and growing. Two, it has long-term and ripple effects. It goes across generations -- not only the young adults, the productive elements in society, but their kids being orphaned or infected to grandparents who have to take care of them. The economic losses and impact go far beyond anything that we've seen with an epidemic.

With SARS [Severe Acute Respiratory Syndrome] we've seen it, but it was short-lived, acute. With AIDS it's much worse than SARS, and it goes on and on for generations. This is an epidemic that even if we would stop it today in terms of new transmissions, [it] will have an impact on generations to come. Nobody's going to resuscitate the parents of the 14 million orphans. Nobody's going to repair the economic losses that countries in Southern Africa have experienced. So it is really destabilizing societies in a big way in those countries that have been affected in a major way, in addition to the economic loss.

And these countries -- Russia, the next-wave countries -- it has the same potential there?

I think that the same potential exists in other parts of the world. I'm just back from Papua New Guinea, near Australia, and already 2 percent of the population is HIV positive, and you see already the impact. You see it in some parts of India. There are districts in India where 4 or 5 percent -- one out of every 20 people -- are HIV positive. You see already orphans.

Last time I went to India, I saw something that I hadn't seen before -- orphans, child-headed households. And I think Russia -- who would have thought that in Europe we would have a country with a million people infected with HIV, with more than 1 percent of the adult population positive? Ten years ago nobody thought that was possible.

So the potential for the epidemic and the spread of the virus is -- we haven't reached the end yet. We are only at the beginning from a historic perspective, and we are now entering into the true globalization phase of this epidemic. We're spreading it all over the world. It's not only the West and Africa alone. It's the whole world now. …

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posted may 30, 2006

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