June 2, 2000
Piot: This is the first time since these conferences started in 1985 that one has been held in a developing country -- and in Africa, which is bearing the brunt of the AIDS burden. The world's attention is now focused on AIDS in Africa, which was not the case two years ago at the last World AIDS Conference in Geneva.
And we can learn much from Africa that will help us in developed countries as well -- for example, in minority communities, in strategies for prevention education, and in how to provide care in resource-poor environments.
ATN: What do you see as the major issues likely to dominate the discussion in Durban?
Piot: First, access to care for people in African and other poor countries. How can we offer something more than nothing, as is the case today, to those infected and living in the poorest countries of the world? The challenge at the conference will be to get away from simple solutions for complex problems like care.
The recent offers by pharmaceutical companies, and the negotiations between UNAIDS and five companies on getting the prices down for antiretrovirals and drugs for opportunistic infection, is one part of a potential solution. There are also calls for producing generics. I think both are necessary.
The second issue that will dominate is the question of how to sustain prevention efforts in developed countries when people do have access to antiretrovirals -- and how to sustain this effort in resource-poor environments as well.
Today more resources are becoming available for developing countries -- both from the local governments, and from the international community. So how to best use these opportunities is no longer academic, and will become a major issue.
And the Durban conference will also cover basic science advances -- and clinical developments, around viral resistance, adherence, when to start treatment, and many other areas.
ATN: How do you see the conference theme this year, "Breaking the silence?"
Piot: When the conference chose that theme we were in a different time, before the breaking of the silence by many African leaders in the last 12 months. But still, in many countries with hundreds of thousands or millions infected, only a handful of people living with HIV have come out publicly and are accepted in their societies. In this situation it is hard to imagine an effective response to the epidemic, either in prevention or in offering care.
And we need to break the silence around the world's responsibility. It will be one of the great moral tests of our time, how the richer countries are finally going to take responsibility and assist the poor nations in containing the AIDS epidemic -- not only to do good, but also in the interest of the whole world.
ATN: How is UNAIDS working to improve access to drugs for opportunistic infections in developing countries?
Piot: In access to care, our priority is drugs for the prevention and treatment of opportunistic infections. It's not there today -- and we could achieve important results. We know from the pre-antiretroviral era in the West, and also from trials in developing countries, that we can extend life and improve quality of life by prevention of tuberculosis, and by co-trimoxazole prophylaxis. This is important not only for individuals -- perhaps adding two years to one's life -- but also, with a heterosexual epidemic and large families, when parents die there are many orphans. Another two years means more time for the children to be with their families, be in school, and so on.
UNAIDS is helping countries to set standards of care -- meaning the consensus in a particular society on what care we will offer our fellow citizens with HIV, and what we believe is affordable with public funding, so that we will invest in training healthcare workers and in making sure these particular drugs are available, and so that people who need this care will know they have a right to it.
UNAIDS also invests in healthcare infrastructure, especially in training programs with community groups.
In Africa, for example, we have pushed for access to co-trimoxazole as a prophylactic drug for people living with HIV. We are also investing heavily in training and availability of voluntary counseling and testing, which is the bridge between prevention and care. Perhaps 95% of people with HIV in the developing world have no clue that they are infected.
And we are negotiating with pharmaceutical companies to bring down drug prices.
ATN: Concerning the pharmaceutical companies, what about the recent situation where the South African government computed that even with the 85% reduction offered on paper by some of the companies, the government still could not afford to treat its population?
Piot: I agree with that, for antiretroviral therapy. But it is not true for prevention and treatment of opportunistic infections.
And it illustrates that the price is not everything. Even at 10% of current price, about $1000 per year (per person for antiretroviral treatment) is more than many countries can afford. But it certainly is an option for some middle-income countries, in Latin America for example, or in some Asian countries.
We believe that government should invest far more in care for people with AIDS, focusing on opportunistic infections.
ATN: What about the recent U.S. government proposals for increasing funding and other AIDS efforts?
Piot: We applaud the recent increases in funding for international AIDS by the U.S. government. I think this will set the trend for other rich countries, for the European donors and for Japan.
I hope that this epidemic will continue to be treated as a bipartisan issue [in the U.S.], and that the response will be sustainable. And I hope that political dialog with other countries will be included.
It's not only a matter of money; the governments of the affected countries also have to invest in HIV activities. You need people, and you also need goods like drugs, condoms, test kits, and so on. Often international assistance is necessary because the goods have to be paid for in hard currency. I hope that the U.S. will work with other nations, and with the United Nations, in pursuing these goals. It is going quite well at this time.
The message is, sustain the effort, and make sure that the money goes to communities, and to efforts that can make a difference.
With greatly increased resources, and with an expanding set of players, coordination of efforts will become more important than ever. This is one of our major mandates in UNAIDS.
ATN: How can U.S. activists and AIDS service organizations make an impact on the global epidemic?
Piot: Last year was a turning point, when AIDS activists in the U.S., the Congressional Black Caucus, and others were able to improve and increase the support for international AIDS.
There are several reasons why domestic and international AIDS activism should join. The reason we have been very successful as activists is that there has been strong solidarity among people living with HIV and people in affected communities. This solidarity should be expanded throughout the world. It will be necessary that those in rich and poor countries join hands.
Also, in the U.S., many communities come from somewhere in the developing world; from the Caribbean for example, or from Africa. This provides a direct bridge between the U.S. and some of the countries that are most affected by the epidemic.
And everywhere people need to strengthen community activism and responses. We strongly believe in the importance of community-to-community dialog and support, which will benefit both sides.
ISSN # 1052-4207
Copyright 2000 by John S. James. Permission granted for noncommercial reproduction, provided that our address and phone number are included if more than short quotations are used.
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