Prof. Peter Piot has been involved with HIV from its first discovery in humans as a researcher, clinician and UNAIDs official; His new book tells the story nearly 35 years since it became a pandemic.
By JUDY SIEGEL-ITZKOVICHWorld AIDS Day(photo credit: Courtesy)
Almost 35 years after AIDS (acquired immunodeficiency syndrome) first propelled itself into public awareness as a fatal viral disease that then affected mostly homosexuals, drug users and hemophiliacs, it has evolved into a chronic disorder. As long as those infected by the human immunodeficiency virus (HIV) swallow daily their “cocktail” of antiretroviral drugs, they have a good chance of living with AIDS. Without it, they are doomed to die within a decade.Believed to have originated in non-human primates in West-Central Africa and transferred to humans nearly a century ago, AIDS was first observed in humans only in 1981. Since then, it has expanded to heterosexuals as well as homosexuals and hard-drug users. However, it no longer infects hemophilia sufferers, whose blood infusions are screened for it and is liable to be passed on from mother to child from childbirth and breastfeeding.HIV has killed nearly 40 million people around the globe, becoming the worst epidemic since the Spanish flu pandemic that between 1918 and 1920 infected 500 million and ended of lives of as many as 20 percent of them.But even though AIDS is a less-discussed subject in many countries that offer antiretroviral drugs, there are still 35 million chronic carriers around the world. As there is no cure or preventive vaccine, it will remain a fact of life for decades to come. At a time when 7,000 people are infected with the virus and 5,000 people die from AIDS-related conditions every day, scientists and public health officials can’t claim to have defeated it.In Israel, HIV is hardly discussed except when the Health Ministry releases statistics to mark World AIDS Day on December 1 or when it hits the headlines in the context of refugees and foreign workers from countries where HIV is endemic.A new book by one of the world’s leading expert on AIDS has just been published by Columbia University Press in translation from French to English.Titled AIDS Between Science and Politics, the $22, 198-page hardcover volume was written by Prof. Peter Piot, the founding executive director of UNAIDS and co-discoverer of the Ebola virus.Piot was also president of the International AIDS Society and former undersecretary- general of the UN and currently is the director of the London School of Hygiene and Tropical Medicine and a professor of global health. This volume is his 16th book and joins his memoirs, No Time To Lose: A Life in Pursuit of Deadly Viruses.Dr. Laurence Garey, a Swiss anatomist and former member the Court of Examiners in England’s Royal College of Surgeons and of the Council of the Anatomical Society was the distinguished translator of the new book into English.There is almost no one more qualified that Piot to write an authoritative book on AIDS, as he has been involved as a scientist, clinician and fighter against the human disease from the beginning.Originally based on 10 lectures he delivered at the College de France in Paris in 2009 and 2010, the book expanded and updated them to reflect the latest medical literature and new topics about AIDS.THE AUTHOR begins with a quote from French historian Marc Bloch that “misunderstanding of the present is the inevitable consequence of ignorance of the past. But a man may wear himself out just as fruitlessly in seeking to understand the past if he is totally ignorant of the future.”Piot notes that the AIDS pandemic was not only catastrophic to the health of millions around the world but also “was one of the most disruptive events that marked the turn of the 21st century.”It was disruptive “in terms of international relations, global access to new technologies and public health policies” around the world. He found that found that “science does little good when it operates independently of politics and economics, and politics is worthless if it rejects scientific evidence and respect for human rights.”Piot describes the first years from 1981 when the emergence of AIDS was “marked by the stigmatization of those living with AIDS – homosexual men, drug users and people with hemophilia, as well as Haitians and Africans.“That era is not over, but it is now subtler.Discrimination and stigmatization explain at least partly the gap between what is possible – greatly reduced levels of infection and deaths – and the continuing global epidemic.”Today, women in the Third World are more vulnerable than ever.“In one community in KwaZulu-Natal, not far from Durban, 40% of pregnant women are seropositive, and the new infection rate is still between 5% to 10% a year, so that young women who are starting their sexually active life have a 50% risk of HIV infection after 10 years and death from AIDS 10 years after that because treatment is not always available,” stated Piot.“Much of our progress is due to scientific discovery and treatment innovation, with the introduction of highly active antiretrovirals (ARVs) being the most spectacular game changer,” he writes. “It is not an exaggeration to compare this breakthrough with the discovery of penicillin opening the antibiotic age. [The cocktail] has changed the lives of millions of people living with HIV, as well as how the world perceived AIDS and the epidemic. HIV infection was no longer a death sentence, and there was hope that one day the epidemic could be stopped.”Despite these scientific advances, “the overwhelming majority of patients in developing countries had no access to new medications. HIV continued to spread seemingly unhindered across the world, and patients continued to die. An absence of political will, denial by leaders in the most affected countries, and a lack of funding all fueled the mounting death toll, especially in sub-Saharan Africa.”According to UNAIDS, about 13 million people are now receiving the antiretroviral cocktail, which was first available in 1996. The rate of deaths from AIDS dropped by 35% between 2005 and 2012.New HIV infections have declined by 38% between 2001 and 2013.HE CALLS the years 2000 and 2001 “the tipping point” when the cost of antiretroviral treatment – thanks to some pharmaceutical companies and philanthropic organizations such as the Bill and Melinda Gates Foundation – made the cocktail available to the developing world. Although the cost of treatment has declined to affordable levels, there still is no universal access.But it is not being wiped out, continues Piot.“The end of AIDS is not in sight, considering the large number of new infections and deaths. The historic successes should encourage a redoubled effort at prevention, treatment and research, with a long-term increase in finance” of the war against HIV.While there is no specific mention of Israel and its neighbors, Piot does say that North Africa and the Middle East “have the lowest infection rates in the world.”The societal context is different, with strict control over sexuality, and male circumcision – which reduces the spread among males – is the norm. “Randomized controlled trials in South Africa, Kenya and Uganda proved that circumcision diminished the risk of acquisition in men by 50%.”“If we have learned one lesson over the last 30 years, it is that there is no silver bullet for HIV prevention,” he writes. “Only a combination of interventions, adapted to the local level – with sufficient coverage, adherence and duration – have an optimal impact on the spread of HIV.”Breastfeeding is the only way for poor, Third World women to feed their babies, thus the problem of not transmitting the virus to their babies via breast milk is significant.In poor populations facing infectious diseases such as those that cause diarrhea and who have access to inferior health services, breastfeeding until the age of 12 months was best for infant survival.In the West, the cocktail can prevent infants from contracting HIV from their mothers. But in sub-Saharan Africa – which has 11% of the world’s population and an incredible 24% of people infected with HIV, mother-to-child transmission of HIV remains around 20% in several countries.Free needle-exchange programs for drug addicts in the West have reduced this route of infection considerably.Piot does not mention the successful effort spearheaded in Israel to encourage African and other men to undergo circumcision. As many former immigrants from Russia and other former Soviet republics have undergone ritual Jewish circumcision here, this country is expert at performing the surgery safely on adult males.HIV in the US has “evolved,” notes Piot.Initially it overwhelmingly affected gay white men, but now it is far more diverse in terms of populations at risk. While it is most widespread in Africa, especially the sub-Saharan part of the continent, AIDS has spread to Asia-Pacific countries. More than a third of new HIV cases occur in Burma, Cambodia, Thailand and Papua New Guinea. Preventive programs such as disseminating condoms have been very successful, reaching 100% of all sex workers there.“An often-raised question is whether differences in the distribution of HIV in the world reflect differences in sexual behavior among countries and cultures. The reply is equivocal, for the relationship between sexual behavior and transmission is complex,” he states.PIOT ADAMANTLY refuses to accept a world in which high levels of HIV infection are taken as a matter of fact and demands that the incidence of infection be minimized as much as possible through prevention (with condoms and sex education) and treatment until an effective vaccine is developed.As millions of people in the underdeveloped world still die of AIDS, there are millions of orphans who have to be raised by somebody else – causing significant harm to families and the economy. In Tanzania alone, 45,000 experienced teachers who died of AIDS had to be replaced with younger ones over four decades. In other countries, many health workers died from AIDS and new ones had to be trained to take over from them.A short history of AIDS has shown above all that when politics, science and service delivery work in synergy, mountains can be moved to save lives across the globe, he writes. “The world is now entering a new phase in the fight against AIDS: the armamentarium for prevention and treatment is more powerful than ever, and HIV incidence and mortality are declining in much of the world.”But, he goes on, there are the first signs of fragility with a rise in incidence in previously successful populations, while high infection rates continue to prevail in key vulnerable communities and regions.“Despite some real achievements, the human toll in terms of a high level of new infections and deaths remains unacceptably dramatic,” he writes. In addition, it will take decades to repair the damage caused by AIDS, from lost generations and orphans to economic loss and destabilization of the fabric of society, Piot concludes. “A truly exceptional effort by society as a whole will be required to reach very low levels of HIV infection and for the [affected regions to realize their] full potential.”There may now be a narrow window of opportunity “to capitalize on scientific advances and on political momentum to accelerate the positive trajectory toward reducing the global epidemic to low endemic levels,” he writes with some optimism.
