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The cost of silence

Peter Piot, assistant to the Secretary General of the United Nations, has been the executive director of the Joint United Nations Programme on HIV/AIDS (UNAIDS) since it was established in 1994. Previously he was associate director of the World Health Organization’s World AIDS Program. From 1980 to 1992, he taught microbiology and served as head of the Department of Immunoinfectious Diseases at the Institute of Tropical Medicine in Antwerp, Belgium.

Piot has held several teaching positions at universities in his native Belgium. He has earned numerous awards throughout his career as a scientific researcher and is credited, along with a team of collaborators, with discovering the Ebola virus and participating in the preparatory work that identified the AIDS virus. He has published more than 500 articles and 15 books.

IDBAmérica: With the launching of two major U.N. initiatives–Global Crisis-Global Action and the new AIDS Fund–the epidemic is finally capturing the political attention and leadership that it so direly needs. What do you see as the outlook for the immediate future?

Piot: We are now 20 years into the AIDS epidemic and we have reached a stage where I believe we have a reasonable chance to plan for success rather than simply witness a catastrophe unfolding before our eyes. This new stage is the result of the emergence of a new type of political leadership that has been lacking in virtually all countries over the past 20 years.

The U.N. Special Session on HIV/AIDS is a good illustration of this point. At the same time, however, we need to take into account what is happening in the countries. When the Caribbean prime ministers met last February within the CARICOM framework, AIDS was on their agenda, and it was then that they launched the initiative known as the Pan Caribbean Partnership against AIDS. This unprecedented event shows that the countries’ highest levels of leadership are taking this problem very seriously. We are seeing a paradigm shift from AIDS as a medical curiosity and health program to something that is a threat to national security and an obstacle to countries’ development. This has been a total shift. It was 20 years in coming, but it is never too late.

IDBAmérica: Within the global picture of AIDS, how do you see the situation in Latin America and the Caribbean? We have heard and read many stories about Africa, Asia, and other parts of the world. Has the problem received due attention in this region?

Piot: Outside of Africa, the countries of the Caribbean–for instance, Haiti and The Bahamas–have the highest percentages of persons infected with the virus, and the figures continue to increase dramatically. Fortunately, public awareness has grown considerably and the silence has finally been broken. We are only at the beginning of a vigorous response, and it is not yet commensurate with the magnitude of the problem. When I look at the participation of heads of government in the U.N. Special Session, the Caribbean was very well represented, almost at the same level as Africa. In contrast, Latin America’s presence was very uneven, with most countries being represented by ministers or lower-ranking officials, despite the fact that the epidemic continues to spread in this region through intravenous drug use, transmission between men, migration, and poverty, especially in Central America. Brazil is the exception in that it has been a shining example in its response to AIDS through prevention, education, and efforts to provide infected persons with proper medications at affordable prices. Overall, though, the political response needs to be strengthened.

IDBAmérica: AIDS has become part of the political agenda in many parts of the world. How about in Latin America and the Caribbean?

Piot: In most countries of the region, AIDS is still considered the exclusive domain of the ministry of health. Of course it is a health problem, but we know from experience that to mobilize society as a whole, an effort must be made by all sectors of society. We need the top leadership to get involved. It is important that the education system be on board, as well as the legal system, churches, and the business community. That is not happening yet, except in Brazil. This is the task that lies before us for the coming years, and this is where the partnership with the IDB is going to be extremely valuable.

IDBAmérica: The IDB conducted a public awareness campaign on domestic violence to sensitize both elected leaders and the general public about this "hidden social stigma." Should the same be done with AIDS?

Piot: When I accepted this position at the time UNAIDS was created five years ago, my key objective was to sensitize the global political leadership about this problem. We started with the region most affected by AIDS, which is Africa, and the results are visible today. What has to happen now is to break the silence among leaders, not only heads of state but also mayors, bishops, and business leaders. They all need to understand that AIDS is affecting their business, the future of the country, the future of young people, and that it should be the priority for the coming years. This is where I see the IDB’s work to be of synergistic value.

IDBAmérica: How good are the statistics on the AIDS epidemic in Latin America and the Caribbean?

Piot: There are few issues in society where we have such good information as for HIV. We know, for instance, that in the Caribbean roughly a half million people are living with HIV. Each year, we publish estimates of new infections. We simply have not used the figures enough for advocacy and for sensitizing the population about how much AIDS is costing society. This is a very expensive problem and the cost of inaction is enormous. Recently, the University of West Indies, together with UNAIDS, found that the AIDS problem was going to cost Trinidad and Jamaica five percent of their gross national product. These are hard figures that should make leaders think twice before they say it is a problem that affects only marginalized people. This is everyone’s problem.

IDBAmérica: When people hear about the new AIDS Fund, what do you want them to understand? What is it for and who will be part of it?

Piot: Following on the call to action by U.N. Secretary General Kofi Annan, we are in the middle of discussions to establish a global fund against AIDS. The sobering reality is that the developing world needs between $7 billion and $9 billion each year to contain this epidemic, to prevent new infections, and to provide treatment to those who are already infected. Today, roughly $2 billion per year is being invested. That leaves a huge gap, but there are many ways to bridge that gap. One is to create a global fund, because we believe we can attract new resources from the private sector and channel them efficiently to the community level.

But a fund is only good if there is money, and we have to see how governments and the private sector react. As for the mechanisms that are to be put in place, I feel it should be a fund where decision making is as close as possible to where the action is–decentralized and at the level of each country–because needs vary from continent to continent and from one country to the next.

Furthermore, the fund will not be the only mechanism for fighting AIDS. There are loans, domestic spending–although in many countries, governments are not investing enough in this area. Here, too, I think the IDB can help us to coordinate different sources of funding to ensure that enough money is being spent.

IDBAmérica: If you were to talk to a political leader from the region about his or her responsibility regarding AIDS, what advice would you give?

Piot: The first point I would make is the need to break the silence. Without openness about AIDS, about what drives the epidemic, which is mainly transmitted through sexual contact, there is no way that any nation can tackle this seriously. Second, they should make sure their government puts the necessary means at the disposal of those who are in charge of AIDS, including public and private agencies, NGOs, and AIDS activists. And third, I would recommend that they make sure that all members of the government are fully engaged in the fight against AIDS and are making their contribution in all sectors, namely health, justice, education, and labor.


IDBAmérica: Your position gives you an overview of the whole problem. What would be the best-case scenario for Latin America and the Caribbean in the next few years?

Piot: The best-case scenario would be that every single country in the region recognize that AIDS is a national priority; that leaders from government, the business world, and churches break the silence about AIDS; and that we all work together to make sure we see a decline in the rate of infection.

The U.N. Special Session is setting targets for all countries. For me, one of the most important ones is a decrease in the rate of infection among young people. Another one is to provide treatment for people with HIV. If we can achieve these objectives, the number of new infections could be brought down over the next five years. We have to plan for success. A big AIDS epidemic–or a greater AIDS epidemic–is not unavoidable. We can save millions of lives if we act now. The later we wait, the more expensive it will be, and the more people, especially young people, will lose their lives.

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