International Treatment Access and Research, How You Can Help -- Interview with Dr. Peter Piot of UNAIDS

The recent International Conference on AIDS in Vancouver demonstrated a greatly increased interest of U.S. AIDS activists in access to medical treatment for people throughout the world. At stake is not only the life and health of the 90% of persons with HIV who now cannot get modern medicines, but also the best possible care for those who do have access. This is because effective treatment in the developing world will require scientific testing of traditional and accidentally discovered treatments; and if any of them are found to be effective (as has happened frequently in the history of medicine) they would become available for use together with pharmaceutical-industry drugs.

On September 30 AIDS TREATMENT NEWS interviewed Peter Piot, M.D., executive director of the Joint United Nations Programme on HIV/AIDS (UNAIDS), which brings together six UN agencies in a common effort against the epidemic, on what can be done to improve treatment access throughout the world, and improve research on natural and traditional medicines.

AIDS TREATMENT NEWS: What is UNAIDS doing to make AIDS treatments more accessible?

Dr. Piot: There is now a major shift in international AIDS work. Until very recently, the programs have focused exclusively on prevention, with hardly anything being done on care. Some programs still maintain this policy. We are trying to change it; we advocate with governments, and with AIDS programs in the countries we work with, that they not deal only with prevention. That is the first step. With over 22 million people infected today, it would be obscene not to pay any attention to care. And successful prevention programs have been linked with care and support for people living with HIV and patients with AIDS.

Our staff is now covering 80 countries in the developing world, and that is part of their priorities, to put AIDS care and access to drugs higher on the agenda.

We must be realistic in what we can achieve. In the least developed countries, the newest antiretrovirals will not be a feasible option, if they have sometimes only ten dollars per year per person for health care in general.

There are other countries -- such as Brazil, Thailand, South Africa -- that are near the top of the income distribution of developing countries; there, access to the latest new antiretrovirals and other drugs is not a naive dream. We are working with the governments to try to negotiate lower prices, by bulk procurement for example. Also, we are supporting some local initiatives with non-governmental groups, community organizations, to set up a buyers' club, for instance.

Most of what we are doing is to promote wider access to generic drugs, to many drugs that are affordable for prevention or treatment of opportunistic infections, or palliative care. Even this is not being done; I believe that about 90% of people with AIDS in the world do not even have access to this kind of standard of care. We learned that preventive therapy for tuberculosis, the number one killer of AIDS patients in Africa, costs about $15 per year. It is affordable to people either if they have to pay themselves, or if the government or some organization budgets for it.

How to we improve this kind of access? We work with the governments, the ministers of health, pushing them to put it on their budgets. Also we work with the private sector, the non-governmental sector, which is becoming a bigger part of the healthcare system.

One of the biggest obstacles to good care is inadequate training of the doctors. They are overwhelmed, they have to deal with so many other major problems; therefore we need to invest more in their training, to help them with very simple ways of diagnosing opportunistic infections, and alerting them, for example, that patients should be on TB prophylaxis. This educational effort with healthcare personnel has not happened in most countries.

ATN: What can be done to develop less expensive treatments by improving research on traditional and natural medicines? People call and write us about proposed herbal remedies which might be antiviral; it would be easy to test them in a few people and see if their viral load went down. How could such research be organized?

Piot: Such treatments are often country-specific; they are being used in one country but not elsewhere, or nobody has heard of the treatment outside of a country. Our representatives first check what it's all about, because a lot of this is not in good faith. If the interest does look serious, if it is not just someone trying to make money out of the misery of others, we try to bring them in contact with individuals who could do some preliminary assessment. You do not need to start with big trials. But we have not done much in this difficult and diverse field. India or China, for example, have a very long tradition with these medicines. We hope to work with institutions like the Chinese Academy of Traditional Medicine.

To move treatment access forward, one has to work with a number of stakeholders. For example, in July we made plans for what UNAIDS would do in improving access to drugs, working with persons from government, from community groups, groups of people living with HIV, to get a better sense of what is possible. How can we learn from AIDS activism in the Western world? How can some of its approaches be used in some developing countries, especially where a very high proportion of the adult population is infected? The political issues in this work are as difficult as the technical problems.

ATN: Where do we go from here in developing worldwide AIDS activism? What could activist organizations do in the U.S. and other countries? What can individuals here do to help?

Piot: The first issue is awareness that there is a very important international impact of this epidemic. Activists in North America or Western Europe often have an agenda that is purely domestic or local; this is understandable as there are many problems. But also there is much to offer to our colleagues in developing countries. So raising the awareness among the domestic activist community that AIDS has a global dimension, that there is a role to be played for local activists in the whole international arena, is really important. That can only come from within. People like Eric Sawyer from Housing Works in New York, Paul Boneberg and GAAN (Global AIDS Action Network), and the National Council for International Health are trying to do this; much more has to be done.

AIDES in France, the very big AIDS service and support organization, has developed partnerships with AIDS activist groups and NGOs (non-governmental organizations) in neighboring countries, mainly Algeria and Morocco, but also in Poland. There are many migrants from North Africa living in France. Perhaps you could do something similar in the U.S., linking up with groups in Mexico, the Caribbean, where a large proportion of the population is coming from, and support them. Not necessarily with money, but also lessons learned; shortening the learning curve on how to be effective in activism is very important. I'm not sure that enough is happening at that level in the U.S. We in UNAIDS would be very open to working with such initiatives. Linking up with colleagues in other countries makes it concrete, not limited to theoretical discussions about international AIDS work.

ATN: How did AIDES get started in this?

Piot: I believe that it is the vision of Arnaud Marty-Lavauzelle, the chairman of AIDES and also a member of the governing board of UNAIDS, that made this possible. In the last two years they developed more and more international work. It is not their primary mandate, of course. But because they are confronted with people living in France who are from various other countries, they started working in the countries of origin of these people. That is a concrete link, and very helpful in doing a better job, since there is a big service component; it is not only an activist group, it has counseling centers, and provides home care and other services. That has been a very successful program. For those working in New York and Miami, it is clear that linking up with the Caribbean would be an obvious thing to do.

ATN: Few if any U.S. organizations have made it part of their mission to work with NGOs in the countries of origin of their clients. It would be a natural step to take.

Piot: It's concrete, and it would be very helpful for people in these countries -- working with community organizations for prevention, and also for access to care and drugs. The U.S. is surrounded by countries where standards of care for people with HIV are not where they should be.

From UNAIDS headquarters in Geneva, we are supporting networks of groups -- GNP+ (the Global Network of People Living with HIV), ICASO (International Council of AIDS Service Organizations), ICW (the International Community of Women Living with HIV/AIDS) and others; and within countries, we are pushing that activist groups, NGOs, community groups, be involved in development of national policies. This is not now the case in most countries, although it is in a few, like Brazil.

Today the gap is immense between people with HIV who are rich or living in a rich country, and the overwhelming majority who can only dream of the new treatments. There is a need for a strong strategic alliance -- even more, I believe, after the Vancouver conference and the recent breakthroughs with protease inhibitors and other drugs.