Peter Piot, ex-UNAIDS director and now director and professor at the London School of Hygiene and Tropical Medicine, was a keynote speaker on day two of a convention organised by the Alliance to mark its 20th anniversary.
Speaking to an audience of Alliance Linking Organisations, donors and other partners, Piot congratulated the Alliance on its anniversary, calling out three major ways it has made a difference to the AIDS epidemic: the impact of its global advocacy, its efforts to work in the areas where it can make the greatest impact (in terms of HIV transmission) and its work to strengthen the local capacity of civil society.
He warned – at the risk of sounding a bit clichéd - the AIDS response is at a critical junction. He acknowledged the optimism around new scientific developments but urged caution that the rhetoric around ‘the end of AIDS’ could translate into ‘the end of the AIDS movement’. He said, “If we drop the ball now, we may get to a situation where we can’t break the epidemic.”
In his speech at the event last week, he went on to outline what he sees as the dangerous ‘myths’ around the AIDS response today.
10 myths towards a collective state of denial
1. The end is in sight, with a variation that AIDS is over.
“I wish it were true, and it should be our goal. I am not saying there hasn’t been progress but people’s behaviour and societies are not mathematical models and cannot be predicted. Let’s stop saying AIDS is over. One day, we will be there, but not yet!”
2. All we need is better coverage of ART, which will wipe out the epidemic.
“If we have learned one thing, there is no magic bullet. Yes, there have been studies (such as HPTN052 which showed that ART can prevent HIV transmission) but it is a gigantic leap from these results to the reality of the community and is simply not yet supported by evidence.”
3. Behavioural interventions don’t work, we can only rely on biomedical prevention
“What we have to remember is that even treatment is a behavioural intervention with its strong emphasis on compliance. We should remember that for example PrEP only works when you take it!’”
4. There is no longer a need for distinct HIV programmes, integration is the answer!
“Some say all we need is health system strengthening which is ideologically driven, or supported by academic health theories. Whilst there are areas where integration will be beneficial and cost effective, such as PMTCT, we have to know what we can integrate and what not. Particularly whilst stigma and discrimination remain a hallmark of this epidemic.”
5. The epidemic is on a downward trajectory – let’s continue doing what we are doing and it will wipe out HIV
“Downward yes, but not everywhere. There are many different epidemics with their own dynamics, and these need to be dealt with individually and appropriately.”
6. Stigma and discrimination has disappeared now we have ART, and the promotion of human rights as part of the AIDS response is an unnecessary luxury which can be handled by others
“Whilst many hoped that the introduction of effective treatment would mean ‘normalisation of AIDS, there is absolutely no evidence that this is the case. Everywhere you go you can still see the devastating impact of stigma and discrimination as a result of HIV.”
7. There is no longer a need for civil society, physicians will fix this for you
“Whilst this position may have some rational ground, some of it is also medical hubris.”
8. Domestic funding will now cover all necessary costs of the response
“Some countries can definitely afford to do this – India, South Africa - but most can’t. And most won’t even prioritise health spending, so you can’t expect HIV to be prioritised within a bigger context of de-prioritisation. The reality is that many countries for many years will depend on international funding for their AIDS response”.
9. We cannot do better with current funding, and managerial and programmatic efficiency are unnecessary business concepts
“We CAN do better with available funding. In particular, we need to concentrate our resources on where the epidemics are – and then apply the usual cost-saving approaches.”
10. There is no need to continue investing in a vaccine
“Ending HIV without a vaccine will simply not be possible.”
More hills to climb
Piot quoted the late Nelson Mandela:
“After climbing a great hill, one only finds out that there are many more hills to climb”.
He acknowledged that whilst much has been achieved in the last 30 years, but said “let us not fool ourselves: the hills to overcome are huge and numerous.”
Reflecting on the way forward
Piot urged all actors in the AIDS response to go on the offensive, reminding everyone that “every day, people are still dying.” He called for a renaissance in the activism that dominated the early years. He wanted to know ‘where is the anger?’ and not just the in-fighting between different constituencies, but the agreement to work together and provide concerted leadership to move forward.
He called for a combination prevention approach, with a focus on high transmission geographies and ensuring that key populations are not left behind.
He called for greater innovation in three areas:
- In implementation, including preparing for the long term care of people living with HIV, warning “the young person who has been diagnosed with HIV today will still be living with HIV at the end of this century”.
- In financing, pointing to the fact that it is billions that are still needed to tackle the epidemic, and even though the Global Fund secured $12 billion in its last replenishment round, this is only sufficient to last for the next three years.
- In global goods, including medicines.
In summary, he said that our ambition should not only be to bring this epidemic down to the lowest levels possible in terms of reducing the number of people infected and dying until there is a vaccine, but also to play a catalytic role in convergence and other health issues.
In closing, he said “I am afraid the Alliance will remain necessary for many years to come. Keep up the great work and never give up.”
- The Alliance’s 20th anniversary convention was themed around ‘Together to end AIDS’ – read more.
- The London School of Hygiene and Tropical Medicine (Faculty of Public Health and Medicine) and the Alliance have a formal research partnership – read more.