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Dr Peter Piot Interview 3 - June 16, 2010

This is the third interview in an oral history with Dr. Peter Piot, Executive Director of the joint United Nations Program on HIV/AIDS (UNAIDS), and Under Secretary-General of the United Nations, on June 16, 2010 at the Omni Shoreham Hotel in Washington, D.C.. The interviewer is Victoria A. Harden.

Harden: When we ended the last time, we were talking about the late 1990s, just after UNAIDS was launched, and how you were working with business leaders, religious leaders, and leaders in the military services to get their support. I want to begin with the UNAIDS HIV Drug Access Initiative in 1997.  Would you tell me about the idea at that time that administering antiretroviral therapy was too difficult to be provided in poor countries and how you had to change people's minds on this?

Piot:    So often, overcoming cynicism and skepticism is at least as important as building the evidence that something is possible. The administrator of USAID  at the time had even said that Africans don't have a watch, can't read the time and so on, so they can't take these drug regimens. That points out at what level the discussion was, or how low it had gone. 

There was also a very interesting coalition of public health experts, international development experts, and clinicians here who said, let's not do this because it's either too expensive, there are other priorities, or people don't know how to take the drugs.  So I decided that we should go for a demonstration project, in showing that it was possible, in a resource-poor environment. And this is how the Drug Access Initiative was born.  The price of antiretroviral drugs was still far too high. 

There were very difficult dialogues with the pharmaceutical companies, who were also skeptical for many reasons. For one, Africa is not a market for them. Sub-Saharan Africa represents about one or two percent of the global market for pharmaceuticals. It's not on their radar screen. They were also concerned that the drugs would not be used properly, and so on. But particularly they believed that there was no market there.

So what I did was talk with the CEOs of pharmaceutical companies, particularly in Davos, because I could approach them directly, without all their lawyers around them.  Lawyers are, of course, among the ones who prevented the CEOs of thinking creatively--thinking outside of the box.  I convinced them that I would set up a demonstration project in Uganda and in Côte d'Ivoire, in Abidjan.  These were the first programs offering antiretroviral therapy in Africa, apart from some private physicians or wealthy people in South Africa.  That was before any of the NGOs, I mean, nongovernmental organizations like Médecins Sans Frontières began to work with AIDS.  They would do a lot of good work afterwards.  It’s ironic that it was a UN organization which started with something normally done by activists.  I got approval from the board of UNAIDS to do that as a kind of a research project but with no promise for anything further.

It helped to do two things. One, we could demonstrate, without doubt--and there was a very careful evaluation done by CDC in Uganda, and then by the French National Agency for AIDS Research in Abidjan-- that implementing a regimen of antiretroviral drugs was feasible. That was a major victory, and adherence to treatment was actually better than found in US patients.  Maybe that was because people in Africa are definitely not spoiled when it comes to access to treatment.  It was so precious that they took it exactly as prescribed.  Secondly, it allowed us to build a relationship with pharmaceutical companies who would see that we were serious.  That led to some reductions in price of antiretrovirals. The cost went down from about $12,000 to about $7,000, $6,000, which was still far too high. 

Harden:  One question.  Was the price arbitrary? Or was it reflecting the cost of development?

Piot:  No, the price was set at what the market can bear. I mean that's how the price of medicines is often set.  Of course you've got the R&D and the return on the investment and all that.  But the prices are set by what insurance systems are willing to pay.   These same drugs, now you can buy them for less than $100 per person per year.

Harden: Per person per year.

Piot:    Yes. But the first price reductions by any standard were not bad. I mean, if you can get a 40% price reduction when you buy a house or a car, that's a very good deal. But for poor people, there's no difference between $7,000 and $12,000. It's like for me, you know, if somebody's assets are a billion dollars or fifty billion dollars, it might as well be the same for me.
So the initial price reduction was not a solution.  We were criticized by AIDS activists, who alleged that we were in bed with the pharmaceutical industry, that the price was still too high.  The latter was true, the former not true. How can you make progress if you're not communicating with those who are producers of the goods?

Harden:  What did you learn about public relations and dealing with all these different groups? The AIDS activists obviously wanted something done now, and you had to take it a step at a time. Do you think the activists served a positive function?

Piot:    Starting with your last question, the activists have been essential in many things. In mobilizing money for AIDS, in promoting research and accelerating clinical trials in this country, and in putting AIDS on the political agenda, which was essential to generate the money. Without the AIDS activists I don't think we would have been able to achieve what we've achieved.

Having said that, it was not easy for somebody like me, who also had a bit of an activist background, to be accused of not doing enough.  Emotionally I agreed with them. I said, “Yeah, they're right. Nobody should die from AIDS now that there's treatment.” But the manager, the realist and the politician in me said, “There's no way that we can turn around the world overnight.”
What did I learn?  One is that you should always stay in touch with the activists.  It's a diverse group also. Some are more extreme than others. Second, one must not be paralyzed by the activist tactics of communication. Sometimes it was actually even helpful that they were accusing me of not doing enough because I could use that with my bosses, and with industry, saying to them, “Look, there's even worse than me!” I was already putting pressure on them, and I could then argue that if we didn't come to a deal, they would have to confront activist anger in a more direct fashion, and they would be more vulnerable. 

So I was always keeping the dialogue open, listening, learning. Sometimes we could even coordinate our activities. I would always make sure that the activists would know before anybody else what my plans were, what I was going to do. And they sometimes did the same for me. We got advanced warning. "We're going to storm whatever," or "We're going to issue a press release denouncing this and that company, and NIH, and UNAIDS." And so we had a symbiotic relationship, in a sense. One could not live without the other, could not make progress without the other.  The activists, deep down, know that without institutions fighting for the same things, progress would not be possible.

Harden: So there was not a lot of personal animosity.

Piot:    Yes, some activists went very personal and sometimes that hurt, in the sense that I always said we're fighting for the same thing, we're here for the same cause.  When I saw some of the press releases or emails or, in 2006, a web site called "Peter Piot, Puppet of the Donors" dot org.  It said that I sold out to donors and wanted to reduce the budgets for AIDS.  I mean it was absolutely, absolutely false. That is when you say, gosh, is this how it works?  I work my guts off day and night, and no good deed remains unpunished?

Harden: Jim Curran told me he got hate mail at home.
Piot: Me too--hate mail, and questions about how much big pharma paid me, and this and that. It's very hard.

Harden:  It's hard on the family too, I would think

Piot: I think Jim got unfairly treated. I saw this at conferences, and I know he was under pressure from the administration of the time. He was totally committed. I admire him enormously, especially at how he remained sane.  He's a nice guy, and he is not resentful. I learned from him in terms of how to handle that sort of situation.

Harden: You were also advocating for greater involvement of people who were living with AIDS. Why were they the key to getting things done?

Piot: They were important for several reasons. One, they know it's about their lives. So -- I often use slogans, sound bites in my head. One is, “There's nothing for the people without the people.”  I mean, there is a tendency in public health that the experts know it all, we get together in a room and we declare this is what’s good for the world and then try to shove it down people's throats. And then we're surprised when it doesn't work.  No business would do that. If you want to sell soap, then you talk to people, to the consumers.  Let's say it’s the women who buy the soap, so we ask, “What do they want?”  We don't do that in public health. We think we are the experts. It's probably part of the medical hubris, which is one of the big problems in health and in medicine, I think.  We can have another discussion about that!

So it's about their lives. They know best what's good for them, how to deal with it. Secondly, they’re a political force. And thirdly I always thought that we can probably have better and more efficient and more effective programs by working with those who are affected by AIDS. At the end of the day, there may not be any interest in AIDS in the world, but the people living with HIV will still be there. And they will be the ones who will fight for their rights and for access to drugs and so on.  Also, at a personal level, in my meetings and my daily interaction with people with HIV--we have several working inside UNAIDS--I have friends.  They kept me going. These kinds of jobs are very lonely jobs. You're criticized all the time. When you achieve something, it's somebody else's success, and every failure is your failure, no matter where it occurred in the world. That's not easy, and to keep me going, during my travels in any country, one condition for a visit was that I would have a meeting with people living with HIV.

Today that's easy, but in the '90s, even early 2000s, in many countries that was not so easy, because they were rejected, stigmatized. They can be gay men, or drug users, or sex workers, or whatever, and not the most appreciated groups in societies in general.  Their stories are often heartbreaking, but they are not often “the lady died” syndrome, where you have a baby with AIDS in your arms, but I respect their courage and their creativity. They found solutions where nobody else was going to help them.  They were a major source of inspiration for me, and they still are today.
Harden: In the year 2000 you coined the phrase "social vaccine" or "social immune system" to describe what societies needed to do to curb the epidemic. Could you expand on that?

Piot:  In the early days of the epidemic we put a lot of emphasis on behavior change.  Individuals should “behave,” you know?  We counseled, “Don't have unprotected sex, or don’t have sex,” and so on.  As I thought more and more, however, I said, “Why do we have this mega-epidemic in Sub-Saharan Africa. Why? 

Particularly in southern Africa. What are the factors there?”  Research was showing increasingly that they don't have more sex that in the US, it's actually the other way around. On the average the average American has more sex partners, lifelong, than the average African. So I said there's something going on here. And also I realized that we emphasized individual behavior but ignored the environment.  Even sex is not something that happens in a cultural and societal void.  The best example of this problem is the status of women. In many societies women have no say over their own sexuality. There's a lot of sexual violence. So I came to believe that we needed to change some norms in society.

Here we get very close to moral judgment. In the beginning, I struggled with that because I'm the type of person who says, whatever people want to do with each other, if it's consensual it's their business, and if they don't involve me I don't care.  It's like always being in favor of same sex marriage and so on, like what we have in my country, Belgium.  It doesn't affect me. It's not my problem. That's the way it is. But I started really thinking that there are also certain norms in society that we have to change to make a safer road. And that a societal norm should not be that abusing a woman is socially acceptable, as it is in many cultures. That has to stop.  Or that homosexuality is illegal or is even punished by death in some societies. Besides the fact that these things are not helpful for HIV, they're fundamental human rights. So I was saying that this is where this societal vaccine comes from. And these of course are long term goals that require a long term perspective. You don't change social norms easily. But it's possible to do.

For example, there are success stories regarding “circumcision” of women--genital mutilation of women. There are societies now where they still have rituals, but they've become symbolic rituals without the cutting. Probably a lot of our religious rituals go back to a time when they were very bloody type of affairs, but now they are more symbolic. So we can do something about it.

There is a need for a change.  In the gay community where there is, sometimes, anonymous sex.  I said, “We should discuss that also as an issue of social norms.”  But that also caused criticism.  All of it becomes very touchy when you get into the moral side and away from the science.

Harden: It seems to me that 1999 was the year when everybody began to wake up and understand AIDS as a problem. In 1998, UNAIDS had produced the first global AIDS report. And in World AIDS Day 1998, you've already told me about South African leaders speaking out for the first time: Nelson Mandela.  Then there was recognition in India in February of '99 and on and on. There was a quote I saw somewhere in Science saying “Peter Piot has a seemingly impossible job.” Can you tell me about this transition period?  Did it make your job easier?

Piot:    After the Geneva AIDS Conference, I can’t remember which year that was, but I felt that we had not made any progress, and I was bit  discouraged also, which I couldn't show publicly. But I said we need to change strategy here. And what I started seeing more and more is that only a political strategy was going to make a difference. I came into this as a scientist, as somebody with an academic background, even if I had been working with the community.  I convened a meeting, kind of a secret meeting, in Talloires, near Geneva, in France, with some people from the AIDS community but also others who were outsiders.  They included Bill Roedy, the president of MTV, and Larry Altman, the medical journalist for the New York Times, and so on. The condition was that there would be nothing on the record. We have no records.  What we came up with there was a conclusion that we need to go political, and we need to mobilize the top leadership in the world.  We believed that we need to bring the AIDS issue to the Security Council, because the only two things that matter in national politics are security and the economy. And the rest, as they say in French, is literature. And if there is money left then we can talk about other things. That's not so pleasant, but it is reality.

We decided that we should bring AIDS to the Security Council, to the Organization of African Unity, etc., etc.  I changed gear and became more of a politician than a scientist.  In the earlier years of UNAIDS, we invested a lot in collecting the data, collecting the evidence, developing the demonstration projects. But they were not leading anywhere. I think that, in the end, the new strategy worked.  We also decided to go beyond the regular AIDS community.  We wanted to go more often to Davos and involve the business community. We also went to non-traditional health businesses, not only to the pharmaceutical industry but also to an Anglo-American big company that employed over a hundred thousand miners in Africa and which had a big AIDS problem.  We started offering antiretroviral therapy to their employees, because their bottom line was affected by so many AIDS cases.  We launched a whole initiative with the military. And the military are an interesting bunch in the sense that once you convince them of something they don't struggle with the moral problems of condoms or whatever. They say, “Okay, if that's a threat to my combat readiness,” as they call, or to my boys, “you tell me what we've got to do and we'll do it.”
So we worked with the peacekeeping operations, with the military. This strategy resulted in a special session of the Security Council, and Richard Holbrooke was instrumental in setting that up. Holbrooke was an ambassador to the UN.  I had met him, and because he was the American ambassador, and I had heard that he was going on a trip with the Security Council to Central Africa to look into the civil war near the great lakes.  And I thought, “Here we have an opportunity.” I made sure that wherever Holbrooke would show up, there would be a person with HIV there, talking about AIDS.

When he came back, he said he wanted to see me. He said, “This is really a bad problem, we've got to do something, etc.”  It was his idea that we could use the opportunity that in January 2000, the US had the presidency of the Security Council. It's a rotating presidency. The presidency doesn't mean much in one sense, but it does offer you the opportunity to set the agenda. So Holbrooke planned to set the focus on Africa in general, for that month. Now this is November 1999.  And since Holbrooke didn't know much about AIDS, between Christmas and New Year when everybody else was eating turkey, sleeping, and traveling away from New York, Holbrooke, his team and myself literally with a couple of people in Geneva, pulled together this special session. We wrote background papers and so on. It meant I had no holidays then, but it was worth it, retrospectively, although at the moment I didn’t know that.  I had already tried so many things that didn't work.

So there it was, on the sixth of January the first meeting of the Security Council of the new millennium was held. It was chaired by then-Vice President Albert Gore, himself. And it was about AIDS in Africa. And so by the time all the ambassadors came back to New York, it was a fait accompli. There had been a lot of resistance in the Security Council to talking about AIDS because it was not a classic security issue. The Security Council talks about war and peace. It's the only body in the UN that has that power, even if its decisions are not always respected.  But still, the Security Council can declare sanctions against a country, and so on. It's not like the rest of the UN which has basically no power like that. And so most countries, except for the US, didn't want to bring “soft” issues to the Security Council.  Putting AIDS on the Security Council agenda was, I think, a historic contribution of Dick Holbrooke in this. And he's a bulldozer, so he got it through. It helped to be coming from the most powerful country in the world.

Harden: By doing that you made AIDS a security issue.

Piot:    A security issue and it opened many doors, because it opened doors to discussions with heads of state, and people said, “Oh, wow, if this is discussed in the Security Council, it must be serious.” Which when you think of it is totally ridiculous but that's the reality. That's politics.

Harden:  This decision to make AIDS a security issue was one outcome of that informal retreat you held at Talloires, France.  Would you list the people who were at that conference—I believe there were no records kept for it, either.

Piot:    Talloiresis right on Lake Annecy. Very nice area. Tufts University has a house there, so that's what we used. Dr. Luo, the Minister of Health of Zambia was there. Duff Gillespie, who was then the Director for Health of USAID and is now at Johns Hopkins was also there, and Daniel Tarantola, who used to work with Jonathan Mann. There were some AIDS activists and colleagues from the UN.

Harden:  It just seems to me that that was a key meeting and it would be interesting to note who the people were who contributed to changing the agenda to politics. And why did they not want a record? They wanted to be able to speak frankly, I presume?

Piot:    I felt that people should be able to speak freely, because I wanted to have everything discussable, including criticizing UNAIDS. It was sometimes hard to swallow, for me also, because they were very critical. We did some role plays and all that. It was also fun.

Harden: The informal interaction is often where decisions really get made.

Piot:    Yes. Exactly.

Harden:  Let’s talk about Thabo Mbeki in South Africa. He apparently supported AIDS work initially when he was Nelson Mandela's deputy president, but in 2000 he embraced Peter Duesberg and the AIDS denialists. You met with him in April 2000. Would you describe him to me as a leader and talk about that conversation?

Piot:    Yes. I had met Thabo Mbeki the first time in 1995, when I did my first public appearance as director of UNAIDS. I was at a conference of people with HIV in Cape Town. He was then Deputy President and he gave a terrific speech and I had a good discussion with him. He's a man who is really very intelligent and a bit on the reserved side; sometimes more British, I feel, than African, in terms of how he interacts with people.  I was also impressed, and I think as the President he's done a lot of good things--there's no doubt.  As Deputy President he was in charge of many things. I have nothing but good to say about him on that side. When I started hearing rumors that he was embracing Duesberg's theories, I was really puzzled.  My approach to something like this is usually, okay, this is a problem, so let's go and talk to him. Let's first hear whether what people tell me is true, because he hadn't made any public statement about this, as yet. Duesberg and his friends were saying that Mbeki was on their side, but it was all indirect information.

Through his wife Zanelle I was able to obtain a meeting with him outside his regular agenda, on a Saturday evening in March 2000 at his residence. I was in Nigeria when the news came that I could see him.  But there was no direct flight to South Africa then, so I had to fly back to Zurich to get a flight to South Africa.  It was a killer trip. I went straight from the airport to his residence, the State House; it must have been like 9:30 or  10:00 in the evening when I arrived. The President was working on his speech for the Africa-Europe summit in Cairo on foreign investments in Africa and a plea for more private investment in Africa, which of course is absolutely necessary. And he asked me to help with the speech, to look up information from books and reports from the UN Development Programme.   I thought, “This is quite interesting.  The President writes his speeches himself.”  He had a speechwriter with him to start, but he sent him home before finishing the speech.

When we finally got around to talking about AIDS, the discussion didn't go very well. We spoke for several hours, until really late at night, and basically he claimed that HIV doesn't exist. I said, but, you know, you can see the virus under an electron microscope.  He said, “Those are all artifacts.”  Through his discussions with Duesberg and by surfing the Web, he knew a lot, but it's not enough to know 95%.  It's true that in electron microscopy, you see all kinds of things that are artifacts.  It's true. He said, “Koch's postulates have not been fulfilled.” He made points that I tried to clarify for him, but I obviously failed. And at the end he said, "Look. Don't you know that this is a conspiracy against us Africans by the Western pharmaceutical industry?" He claimed that AZT was what's toxic and what actually causes AIDS. I mean, the whole Duesberg theory--he embraced it completely. I was really devastated by that. I also was extremely frustrated because in general I can convince people about things I know about.  I don’t argue about moral issues, because they are people’s private beliefs. Immediately after our meeting,  Mbeki wrote a very long letter which he sent to the Secretary General of the United Nations, Kofi Annan, my boss; Tony Blair; Bill Clinton; and so on. That was rough for me because he accused us, without naming me and UNAIDS, of fabricating AIDS, of racism, of fascination with African sexuality and all that kind of thing.

Harden:  One of the theories that I had heard about, one of the reasons he embraced this is simply that it was sort of an overwhelming problem, and if you could just say it didn't exist then you didn't really have to address it. Did that ring true?

Piot:    Even until today it has tormented me: why?  He's really an intelligent man. Originally I thought AIDS must be indeed overwhelming for him, and for economic reasons, the country he was president of could not afford to provide treatment at the drug prices of the day.  But wishing AIDS away is denial. Denial has a very important survival function in our lives, for everybody. But it was not the economics--books have been written about it now. It was some deep belief; and as often with this kind of denialism, or revisionism, conspiracy theories come up. It's very common, whether it's about anti-Semitism, or anti-climate change. I don't really know.  Identifying the reason is probably more of a task for psychologists and psychiatrists than for historians. But his position did a lot of harm.  It resulted in the unnecessary deaths of hundreds of thousands of people because he delayed the introduction of antiretrovirals. If there was one country in Sub-Saharan African that could initially afford to fund the drugs, it was South Africa.

Since then, South Africa has developed the largest antiretroviral treatment program in the world, so President Jacob Zuma and the interim president undid the Mbeki decisions.  There was also this horrible Minister of Health, Manto Tshabalala-Msimang,with whom I was always at odds.  She rallied her colleagues, African ministers, against UNAIDS, against me, also trying to make sure South Africa would not introduce antiretroviral treatment. It was terrible. It culminated in 2001, I think, when we launched this accelerating access initiative.  Drug access initially was sponsored only by UNAIDS, but the accelerating access initiative also had WHO sponsorship.

Harden:  Could we pause for a moment and go back to July 2000, the 13th International AIDS Conference in Durban. Mbeki spoke and then you spoke, and the scientific community spoke; and I noted that the Durban conference put AIDS treatment for everybody on the global agenda. You really solidified the scientific community against the denialists here. But they still thrive.  Recently, Harper's published an article by one of the people who denies that HIV causes AIDS, while you and the scientific community say, "They are killing people with the denialist arguments.”  The debate really goes deep.   Another benchmark in 2000 was the Group of Eight announcing an ambitious plan on infectious diseases, which I noted served as the seedling of the Global Fund. Would you comment on all these events?

Piot:    The Durban AIDS conference indeed was a defining moment, in the sense that first of all it was the first time that this mega-conference happened in a developing country; I mean in Africa. And the activists had been very active. I mean, South Africa already had millions of people with HIV, and the Treatment Action Campaign led by Zackie Achmat was emerging as a mass movement. And of course they have a history of having struggled against apartheid, and most of the people who were the leaders of the Treatment Action Campaign came from the ANC in the clandestine days.  They had their axe to grind with their Minister of Health  and their government, which refused treatment. It created an enormous momentum. 
The opening ceremony was an extremely painful event for me, personally, and in general, because of Mbeki. He came and read two pages out of an old WHO annual report about poverty and health. It was not only very boring but an attempt to make the point that the real problem was not AIDS but poverty. And of course, we know that poverty is a main driver of many diseases, and it's certainly so in Africa. But there was dead silence when he finished. Normally, also, I should have spoken before Mbeki. The protocol is such that the most important person speaks last and declares the conference open. But when he arrived, his handler said that the president wanted to speak first.
I also had an agreement that I would go with President Mbeki in his plane to Togo, where there was the summit of the Organization of African Unity, where they would discuss AIDS. It was the only way for me to go from Durban to Togo, to have a private plane, which I don't have but the president has. So when Mbeki arrived at the stadium—this was a cricket stadium in Durban--one of his staff members said there was no place for me--the plane was already full--and that the president would speak before me.

I guess he wanted to avoid having to listen to me say AIDS exists and HIV causes AIDS and all that kind of thing. Before Mbeki, Nkosi Johnson spoke, a ten-year-old, twelve-year-old kid with HIV, with AIDS.  He gave a very, very moving talk.  Many people had tears in their eyes.  He was such a courageous boy. Mbeki spoke next, and then I had to speak. I mean, Mbeki disappeared and I just had to pump myself. What a disaster. But that's where I made my call to move from the "M" word to the "B" word. What I meant by that, I said, let's stop talking about millions of dollars.  Let's start talking about billions. That's what we need. This created a lot of unhappiness among donor agencies. The USA, I believe, was very upset; the Brits, the Europeans. They said that's irresponsible, the money is not there. And I even got a letter from all the donors, saying that I shouldn't count on more money; that funding for AIDS was going to decrease, etc. I have that letter. It was a fax, and I copied it, because faxes fade.

Gro Brundtland came to that meeting. Dr. Brundtland, who was Director General of WHO, was booed because she said that treatment was too expensive for Africa. WHO was not that engaged yet. But it was a good experience because she changed her mind. Good people can change their minds, you know.  She changed her mind. And that is when UNAIDS started working together with WHO.

Harden:  What did she do for you? I have a note that she was active in pressing big pharma to lower the prices of AIDS drugs, but were there other particular things she did?

Piot:    What she did was support what I was doing, because previously, I was doing all that work alone. And so in Davos, in 2000, 2001, we went together to see CEOs of pharmaceutical companies, asking for price reductions.  She lent her prestige as Director General of WHO but also former Prime Minister of Norway--I mean, she is an important figure. But afterwards, we both thought that we had wasted our time.  I remember meeting with Ray Gilmartin, the CEO of Merck, after Roy Vagelos. Jeff Sturchio was there, was sitting next to him. Gro and I were making the case for reducing the price, etc., and Gilmartin said, “No way, my shareholders won't want it, my board will be against it, etc.”

After we left the meeting, Gro and I had a drink, I mean a coffee or something.  We said “Well, we'll try again next year.”  But a few weeks later, Gilmartin called and he said, “Okay, you convinced me, I'm with you.”

Harden: Did he say why he changed his mind? He just went back and thought about the big humanity issue?

Piot:    The humanitarian part he saw, but I think he also saw that not acting would be bad for Merck’s reputation.  We had said, “We can help you  prevent having the drugs that will be sold at lower prices in Africa reappear in illegal markets.  We knew that some people would try to make a lot of money doing that.  So we assured him that we believed in intellectual property protection as a driver for innovation.  Maybe that's also what convinced him, I don't know. But then we started with the a Accelerating Access Initiative, which was WHO and UNAIDS, with some other UN agencies and five pharmaceutical companies, it led to major price reductions all over the world. Then the Indian generic producers also came onto the scene.  All that drove down the price tremendously, and that made treatment discussable.

But going back to your other question, in 2000, Japan had the presidency of the G8, Group of Eight. There was a summit in Okinawa and Kyushu, and there was lobbying from all kinds of groups including us. A decision in principle was taken to establish some funding mechanism, global funding mechanism to combat infectious diseases, particularly AIDS, TB and malaria. But there was nothing operationally yet.

Harden: But this G8 meeting was also, I believe, when you got people to sign a statement that AIDS was a threat to the world economy.

Piot: Yes, but also at that meeting we had the richest countries in the world. Without money it doesn't work. So it was very important to get them to commit.  I think, when you look at the history of the G8, that this is where they have made the biggest contributions--not so much on security but in  launching a number of health initiatives. It's good.

Harden:  In 2001, you start to see political support for AIDS work, and the UN General Assembly held a special session on AIDS, and I think you or someone else said that "Suddenly we were playing in the big league."

Piot:    Yes, that's from me.

Harden: You called it a defining moment. Tell me about it.
Piot:    Retrospectively it was a tipping point. There were several things going on: in March, in Barbados, the prime ministers of the Caribbean agreed to launch the Pan-Caribbean Partnership Against AIDS. That's at the level of the prime ministers. They're the leaders in their countries in the Caribbean. Then in April was the Organization of African Union had a special summit in Abuja, hosted by President Obasanjo from Nigeria. Nearly all presidents were there, including Mbeki, but he didn't say much then. And they broke the silence about this. They recognized, "We Africans, we have a problem." Which is extremely important, because they'd been in denial before and it became really difficult, because besides Museveni in Uganda, Kagame from Rwanda, and Diouf from Senegal, all the others: "Oh, we don't have a problem." And they didn't want it handled. And so the African ownership started there in a big way, and Kofi Annan, being an African, gave a speech there, which was also in retrospect historic in the sense that he called for a war chest of $7 billion per year to defeat AIDS.  We had given him that figure from UNAIDS.  He asked me, “Are you sure that figure is correct?” I said, “Sure,” but frankly it was a bit of a gamble. But it worked. And then in June there was a UN General Assembly special session on AIDS, which at the moment itself was for me a nightmare, because for the activists, there was  never enough. But I had made sure that activists were being allowed in the General Assembly for the first time! They spoke even. We brought gay men to speak, to address the General Assembly, we had people living with HIV and so on. That was a quite a revolution for that body because it's a very stiff, very formalistic type of environment. So that was actually fun, I must say also, but I was under all kinds of pressures. There was a big dispute about representation of gay organizations, because so many countries are so homophobic. And there was a vote on the floor of the UN General Assembly about whether the International Gay and Lesbian Human Rights Centre would be allowed as an observer in some satellite meeting. I mean, really not even a co-player, and we won by one vote only. I think today we might even lose.

So there were a lot of side fights, but the main thing is that there were over forty heads of state, heads of government, and they agreed on a roadmap, the Declaration of Commitment, which set targets for the world in terms of AIDS, except for treatment. There was no consensus on treatment. We could not get agreement that treatment should be accessible. The only countries in favor of that were the Rio Group, so that's the Latin American countries, the Caribbean countries, and France and Luxembourg. All the rest were against it: the US was against it, all the Europeans, the Africans. They said universal treatment is too expensive, we can't afford it, it's impossible.

Harden:   But the people who were for it went ahead and did it on their own, did they not, for their countries?

Piot:   Yes, but it was not possible to have a UN resolution about it, and that was a big disappointment, but that's the way it is. But there was a roadmap, and these heads of state, they went home and they said, "Okay, I'm now in charge." It elevated the problem of fighting AIDS from a public health or a medical issue to a top political issue. And at the same time you have the Caribbean heads of government, the presidents of Africa, the G8. So indeed we were in another league. And that generated the money. When you look at the curve of our funding for AIDS in the world over time, 2001 is--

Harden:  the inflection point.

Piot:  That's true, but we didn't know it at the moment, and I was concerned it would all be just talk. But as Bill Clinton once said about the UN, as long as we talk we don't kill each other.  It was a defining moment because the next year the global fund became operational. President G.W. Bush asked in a State of the Union for money from Congress for AIDS, in 2003. So suddenly there was the political commitment, price reductions, and available money--so let's say the stars became aligned. That was important according to our ancestors, to succeed in life, eh? The stars are to be aligned.

Harden: Maybe it's just that finally all your hard work started to pay off.

Piot:   Yes, of course, that's what it is. I think so. And not only me, but others also.

Harden:  What was UNAIDS doing at the country level at this point?

Piot:   At the same time we were doing the political heavy lifting, we needed to build the organization. I always thought, okay, we've got the global scene and talks and conferences, but at the end of the day it's in the community and in the countries that things will have to happen. So we need to make sure that each country has a plan, sets targets, has a budget, trains the people, and so on.  Therefore, UNAIDS needs an office in these countries. We had country program advisers, whose names changed to UNAIDS Country Coordinators.  We tried to get the whole UN system to work together, which is still not the case, basically. That's been the most frustrating part of my job besides Mbeke and Putin. The refusal of the Russian authorities to deal with drug use in any human way and not just treat them as criminals only is one of my most frustrating issues.   As far as collaboration between various agencies is concerned, AIDS is the best example that the UN has. But it could be so much better. I found often a handicap to have to do all this political fighting everywhere, and at the same time, cover my back, you know?
Harden:  We talked mostly about Africa, but you mentioned Putin. And let's talk about what was happening in the rest of the world for a while.

Piot:  Right.  In the beginning of the century, of the millennium, or in the late 90s, HIV started spreading in Asia.  We were very concerned that with the size of the population in Asia, this would give rise to an African type of epidemic. There were projections made by epidemiologists without many actual data points. We overestimated the size of the problem in Asia and the potential for spread. We've been criticized for that, but it was not a conspiracy. Some people say that this was deliberately done to attract more money. That is something impossible, however, even if I wanted to do it, because these estimates are reviewed by literally hundreds of people before they are published. If you would try to influence that, there would always be somebody who would stop it. That's just not feasible, because somebody would call the press and the news would appear in the newspaper the next day.

Harden: Tell me about how good the data were or not, in terms of different countries. I mean, most countries don't have CDCs, and I don't know how they arrive at their statistics.

Piot: In general, Africa had fairly good data. We know that today, because there's far better surveillance and there are demographic and health surveys and so on, population-based samples, and the prevalence of HIV can be relatively high, making estimates more accurate. In some countries it was slightly overestimated, in some slightly underestimated, but roughly speaking, it was okay. In Africa.

Harden: Coming through their own health systems?

Piot:    The CDC and UNAIDS organized what we call sentinel surveillance, which was mostly following the evolution of HIV prevalence in pregnant women in – in clinics.

Harden: Okay, so it was the Western world that was gathering the data, then.

Piot:    Not really, it was done in collaboration, except in a country like South Africa, which had a fairly good system already, inherited from the apartheid days.  Then the problem was Asia. And Asia, why is it a problem? Because of the huge denominator, the huge populations, and much lower HIV prevalence rates than in Africa .  HIV carried an enormous taboo.  Many countries didn't want to deal with it--India, China, and so on.  In a country like India, say roughly over a billion people, we had only about 100 sentinel surveillance sites over the country, nearly all in urban populations, whereas the majority of people still live in rural areas.  So we had to extrapolate data from the sentinel surveillance sites, and that led to an overestimate, so there it was not so accurate.

Harden:  When did the Indian government change? Tom Quinn talked about how they just refused to admit AIDS was there.

Piot:  Definitely by the time we had the Security Council debate on AIDS, the Indian ambassador to the United Nations made a speech and denied that India had an AIDS problem.  In January 2000, it was still at that stage. India actually had already a national AIDS control organization, which was doing quite good work, but it was at a technical level.  The political level was still in denial.

In China it was the same thing.  I've been working with China since the early 1990s. I'd been thinking, how do you influence policy in China through the Communist party? In India, it's NGOs, the media, and government bureaucracy, more like here. We tried to  influence the Communist party of China. And in the end, it worked. We built a relationship, cross-documented some of the problems, and positioned AIDS as a threat to societal stability, and the Chinese leadership is very, very concerned about that.  In the end, in June 2005, I was invited at the last minute to address the Central Party School of the Communist party in China. I am still the only UN official that has ever addressed them.  Until then, only leaders of other Communist parties could speak there.  I gave a speech about AIDS as a threat to society.  I was thinking, “I need to talk about human rights, I need to talk about the same things that I would talk about if I would give the speech here, but the way of saying it must be different in a communist country.”  I've always tried to be very consistent in what I say. If I meet the pope, I say the same thing as when I meet a government official, but I may need different packaging.  I used the famous speech by Mao Zedong on contradiction, and said, “To deal with AIDS in society, we need to deal with drug use, with prostitution.”  Of course they are against the law, but in order to protect the whole of society we have to work with them. The people involved are engaging in illegal behavior, but they're not necessarily criminals, and so on, etc. etc. I mean, with dialectics, you can – you can go a big way.  The previous day I had met with the Prime Minister, Wen Jaibao, and I was ready for a very difficult discussion. But his opening remark was, “I guess drug users, they're – they're patients, they're not only criminals.” That was a breakthrough.

Harden: That was a breakthrough!

Piot:    They never went that far in Russia, you know? Anyway, in one week, the government, the state council, issued decrees about how to deal with AIDS, and they were literally taken from UNAIDS publications. This tells me that the decision came from the top. The normal legislative work in China is all bureaucratic, and we know that.  But in China, they decided, “We're going to have 300 methadone centers. We're going to have needle exchange. We're going to do this and that”. And you know, they set a target, and in one year, there were 300 centers. I'm not saying that they’re functioning perfectly, but that's the power of the party there.

Harden:  Has it had a big impact on AIDS?

Piot:  I think so, yes. But still, China is one country, two systems. On the one hand, the police are still cracking down on drug use.  So if you are a drug user with bad luck, you end up in a reeducation center for years, or you are  locked up and go through drug withdrawal cold turkey.  If you are a lucky drug user, you end up in a drop-in center for drug users, where you get methadone and clean needles.  These two scenarios can happen in the same city.

Harden:  Tell me about Russia.

Piot:  Russia provides an example of an epidemic we underestimated. We overestimated what was going on in India and China. In Russia, we underestimated. In Russia, the epidemic is driven by injecting drug use.  There's a huge heroin epidemic in the former Soviet Union which exploded in the late 1990s all over the former Soviet republics. Ukraine has an HIV prevalence which is close to 2% in the average population. It's not as bad as in Washington, DC, but still.  I went several times to Russia, and I said, “There's no way we can stop AIDS if you don't deal with your drug problem.” Dealing with the drug problem is, of course, making sure people don't use drugs, and that's okay, that's what we need to achieve, but those who are using them anyway, make sure that they get access to clean needles. It’s the same debate as here.  
In the U.S., methadone therapy is one possibility for heroin addicts.  In Russia, you've got a specialty in medicine which is called narcology. And it's a specialty of physicians dealing with addiction, drug addiction--narcologists. And they are absolutely against methadone. They say you replace one addiction with another, and that's not acceptable. And it is illegal in Russia. So they put people in jail. They beat them up. It's gross violations of human rights. And HIV continues to spread.

Harden:  Do Russia and China have treatment centers for getting antiretrovirals to AIDS patients?

Piot:    Yes. In China that was part of the policy. It took a while, but it was more a logistic issue than a matter of principle. But in Russia, it depends on who you are. If you're a drug user with HIV, it's unlikely you will get access to drugs, because they put you in jail. They don't give you any treatment. And you die.

Harden:  It's very interesting that in Russia drug addiction is the main transmission route, not homosexuality.

Piot:  Well, there is of course also transmission in the gay community, but it's an incredibly homophobic society– there are gay killings, these homophobic crimes. Homosexuality is largely underground, which makes it very difficult to reach the community with AIDS information.

Harden: But if you, let us say, are a closeted homosexual in Moscow, and you get AIDS, can you get treatment?

Piot:    You can, yes, you can. And at state expense. There are special treatment centers. But you're registered, there is no confidentiality.

Harden: In 2002 the first specific target of “3 by 5” was set for expanding treatment to three million people by the end of 2005. And the responsibility for treatment within UNAIDS moved from the secretariat back to the World Health Organization.  What was going on with this move?

Piot:    One of my great frustrations was that the WHO was not initially engaged in AIDS, yet it's called the World Health Organization. It changed gradually, when Gro Brundtland became Director General and after her visit to Davos, and when we started together the Accelerating Access Initiative. But it's when Lee Jong Wook became Director General of WHO, and brought in Jim Kim [or, in Korean naming convention, Kim Young Jim], who is now the president of Dartmouth College. He was an AIDS activist, basically. It was Jim Kim's idea of this three by five, to set targets, and I agreed with Brutland to move responsibility for treatment to WHO, because treatment is really a medical issue. We didn't have enough resources in the UNAIDS secretariat.  We were working on treatment in UNAIDS when  I moved it into WHO.  UNAIDS funded it. We were one of the biggest funders of WHO.  I think it really made a difference. The problem is that the AIDS program in WHO had—what was it?—eleven different directors during the time that I was head of UNAIDS.   This is an illustration of the problem.  Except for a very short period when Lee Jong Wook was Director General, AIDS was never really at the top of WHO's concerns, and after he died, the AIDS division often got lost in the bureaucracy.   I don't know how familiar you are with WHO, but the regional offices were fighting the center, I mean, they spent so much time on internal battles that they had little energy for AIDS.

Harden: But Dr. Lee supported AIDS therapy?

Piot:    Yes he did.  Despite the fact that we were both candidates for becoming Director General of WHO and we both went through several rounds of voting—what was it? There were several rounds between him and me before the U.S. changed its vote from me to him.  But that was fine.  We worked well together. But unfortunately he collapsed and died.  I think one of the reasons for that was that he couldn't cope with the regional directors, and with efforts to keep the organization all together, but that’s another story.

Harden: In 2003, AIDS got another significant increase in funding, because PEPFAR [U.S. President’s Emergency Plan for AIDS Research] was announced.   I believe that this is the point at which you had to deal with U.S. limitations on needle exchange and one third of the funds had to be used for abstinence-only education programs. Tell me about that, and whether there were restrictions on the money you got from other places like the United Kingdom.

Piot:    We never got restrictions as a multi-lateral organization.  On the one hand, Bush's PEPFAR budget request for $15 billion for AIDS was a true game-changer in the global response to AIDS. Without that money, the Global Fund would have been a mini-fund, a small fund, because the US is the biggest donor to the Global Fund. Without that money, treatment programs like the ones we rolled out would not have been possible. 

Harden:  Do you know what made him decide to create PEPFAR?
Piot:  I think the creation of PEPFAR was influenced by some of the evangelicals, such as Rick Warren, and then there's Michael Gerson, one of Bush’s speechwriters.  People like that. Tony Fauci definitely, played a part, also. I think that Bush is personally, genuinely interested and committed to this. And I think on the political front, he also needed something nice, something good, to balance out the wars he conducted, no?  By saying that, I'm interpreting things from my perspective.

Harden:  But there was no direct lobbying by UNAIDS to get that PEPFAR money set up?

Piot: We were very much involved with it, very much.  For example, when you look at the legislation, it used UNAIDS figures to justify the levels of requests for money.  We did a lot through Tony Fauci, and we were in daily contact with both the White House and NIH.  USAID was sidelined.  And so my dilemma was speaking up to defend PEPFAR.  In Europe that was not well taken, because people hated Bush so much for other reasons that that was not an easy thing for me to do, but I said, “Look, you have to judge people on what they do.  My job is about AIDS, and they're making a difference, they're saving lives.”  I went to see Randy Tobias, who was named as head of PEPFAR. We had lunch in a hotel in Washington before he was appointed. We have a common friend, Jim Morris, who is the head of World Food Program, and is also from Indianapolis.  Jim is a Republican and worked with Eli Lilly when Randy was the CEO.  The relationship between Randy and me clicked, and we made a kind of a pact that we would work together, and we agreed also to disagree on certain issues:  abstinence-only prevention and the need for needle exchange. We agreed that these two things would not prevent us from working together to save people's lives. We would put these differences aside. I was thinking that a president in US system can only be in office for eight years maximum, so there will be another president in 2009, and maybe he'll change his mind on these issues. 

I think that PEPFAR has done enormous good. It's one of the best things that the US has done in terms of foreign policy. And NIH played a big role, which is also very unusual. And then I also became close friends with Mark Dybul, who was Randy’s deputy and became the US global AIDS coordinator after Randy resigned in 2006.  Mark was the first openly gay man to serve as an assistant secretary of state.  Within the political divide in the US, I could sometimes play a role as intermediator, being non-American and from the outside, when there was not much dialogue between the two parties.

Our UNAIDS office here in DC was headed by Michael Iskowitz, who came from Ted Kennedy and was a liberal Democrat.  He played a major role in the legislation, and he had significant links to powerful Republicans in Congress.  He got conservative Senator Orrin Hatch to support the UNAIDS contribution, and on the Democratic side we also had Ted Kennedy.  It was an exciting time, and I learned a lot about working across ideological borders, and understanding that people can come from a different perspective than I do and still do good things.  I even went to speak in Rick Warren’s Saddleback Church in Orange County, California.  My friends were not happy about this, but I said, look, you know?  Everybody should be part of the solution, and we need a global alliance. I learned that. And it became a brilliant alliance, from the evangelicals, the born-again people, to atheists.
It's remarkable, isn't it?  Because of this broad alliance where people forgot about the differences they have, we could make progress. If all constituencies had decided that they were going to fight with each other, nothing would have happened. This is, I think, George W. Bush's historic contribution.

Harden:  Your very success in making AIDS “cool” and getting money had one downside, in overburdening poor countries with visitors and reports and all these things. Can you tell me about your efforts to deal with that?

Piot:    Yes.  The good news is that so many people and groups became interested in AIDS.  They flooded African countries, particularly, with missions, with technical support, with their own offices, and so that in the end, people who were in charge of AIDS programs or ministers of health, they started complaining. They said, “Look, we have no time to do our job. People are here, generally polite, our foreigners are well-received and treated and so on, but that leaves little time to do the program work.”  So I asked Sigrun Mogedahl, a former deputy minister of international development in Norway, to go around and ask people in countries in Africa, “What's the problem here? How can we solve that?” Out of that came the policy that we call the Three Ones. We wanted to establish a system that increased efficiency and ownership of the AIDS program by the African country, but also left the space for each funding actor to have its own part, because US Congress, for example, was not going to change its earmarks and accountability systems, and the Brits were not going to change, and so on. So the Three Ones were an effort to square the circle.  I had just finished looking at a book of Chinese propaganda posters from the time of Mao Tse-Tung and was impressed with how good the Chinese communists were on sound bites. So in imitation of this strategy, I said, “We will propose the Three Ones: One strategy for a country that all donors will support rather than each having its own strategy; One coordinating body to set up target goals; and One country-level monitoring and evaluating system. 
We had a meeting about this at the World Bank, in the margins of the spring meetings of the International Monetary Fund, where ministers of finance come together.  We had worked very closely with Randy Tobias's office (PEPFAR), because if the Americans would not agree on this, it's just a theory. That was not easy, because there is no tradition in US international development efforts to work with others. It did not matter whether a Democrat or Republican was president; the Americans administered their international aid alone.  Randy was in favor of the Three Ones, so he had to sell it internally.  I'm really grateful for him, that he was able to get the Americans to sign on.  This meeting at the World Bank was co-chaired by Randy Tobias, myself, and Hilary Benn, who was the British Secretary of State for International Development. They were the two big donors, and I was the midwife, the broker for the program.

It worked in most countries, even though it was a major culture change in international aide programs.  It works in countries that are fairly strong, like Rwanda and Ethiopia.  In a country with a weak system administration, like Tanzania, it doesn't work very well. You need to have an official who can say, “This is our country. You're very welcome here, and we appreciate what you're doing. Without you we can't do it. But these are our priorities. And, to use an example, it's fine if you can only give us still water.  We also need sparkling water, and that maybe the Brits can give. We don't care, as long as we have it.” In Brazil or in India or in Thailand, that's how it works. But in weak African countries, the donors often still do what they want.  AIDS has been the pioneer in having different donor countries work together. AIDS has been a pioneer for many things.  UNAIDS has broken down walls for all kinds of things
Harden:  Another wall that got broken down after fierce debate in June 2005 was the comprehensive policy on prevention. You called this, “a true milestone in the response to AIDS.” Tell me about it.

Piot:    That is probably a bit exaggerated, because I said that in a speech. It is a milestone, because for the first time there was an international consensus about what to do in terms of prevention, and we succeeded in neutralizing opposition to condoms and opposition to needle exchange. The policy was endorsed by a formal board of the United Nations, the Programme Coordination Board of UNAIDS. That’s very different from the situation when a bunch of prevention experts come together and agree or don't agree--usually don't agree, these academics and researchers. But this was a political statement. And it drew a very fine line. The difficulty focused on the abstinence-only policy of the US, issues relating to condom use and  needle exchange. In the meantime, I'd done my homework and prepared this.  I spent about eight or ten months working on it, and all the UNAIDS board members agreed to the prevention policies – either neutralized opposition or promised that they would look the other way, or actually changed their policy, like China changed.  This was June 2005.   China changed its position, and the US didn't even know. When they saw it, it was too late. The Russians sent someone who was very junior and just  didn't say anything. The position on homosexuality was a tough one for some of the developing countries. So the negotiations were very, very sensitive.

Harden:  In all of that, and in trying to empower women, you had to deal with one of the most sensitive social issues in the human condition--that is, sex.  Have you seen major changes in how people think about sex? You said people can change their behavior, but I want to look at the future now. Will we defeat AIDS through human behavioral changes, or will we have to have a vaccine?

Piot:    Well, we don't have a vaccine now--that's very clear. And I'm not that optimistic that we will have one in the future.
Harden:  I haven't been optimistic either. Dr. Gallo is optimistic, but –
Piot:    Yes, he is always – he has been optimistic for the last 25, 30 years. And I am an optimist by nature. I'm the chair of the Global HIV Vaccine Enterprise, so I'm quite deeply involved in the effort.

Harden:  Are you referring to the IAIDS Vaccine Initiative, or is that a different thing?

Piot:    That group is part of our organization. The Global HIV Vaccine Enterprise brings together NIH, the Gates Foundation, International AIDS Vaccine Initiative, and the Wellcome Trust.  The Global HIV Vaccine Enterprise doesn't do anything itself, but it provides a platform for information exchange and for collaborations and so on, around vaccine, because otherwise institutions may not work together.

Harden:  Let me throw a question to you, that was presented to me at a meeting in Milan. Bocconi University was collaborating with the International AIDS Vaccine Initiative, and they wanted to know about NIH vaccine work, which was why I was there. During the discussion, several people proposed that if only the money available for vaccine could be spread as widely as possible, somebody would come up with an idea that would solve the problem (“let a thousand flowers bloom” was the philosophy). And my thinking was, that's not the way it will happen.

Piot:    I agree with you.

Harden:  I think there are very few people in the world who can actually work on an AIDS vaccine with any hope of success.  But the philosophy driving the vaccine effort evokes major critiques of the International AIDS Vaccine Initiative.  Where does the Global HIV Vaccine Enterprise fit into the effort?

Piot: We're bringing the world’s HIV/AIDS vaccine field together for two reasons. One is that there is not enough data sharing, information sharing, in the HIV vaccine world. It's extremely competitive. Everybody's hoping to find the Holy Grail, or win a Nobel prize, and they worry about protecting intellectual property.  I think we need more of a Manhattan-style project. It’s  not the money--of course you need money. But billions have already been spent, particularly through NIH.

Harden: Pardon me for interrupting, but a Manhattan-style project assumes the basic science is there and all that is needed is implementation.  Is that true?

Piot:    The basic science is not there, or – it may be there, but we don't know where it is. What is needed is a combination of more basic research--that's what NIH is focusing on after the AIDSVAX debacle.  What the Global HIV Vaccine Enterprise wants to focus on is creating synergies of the knowledge that we have, and testing it.   A couple of years ago, I launched  a project called AIDS 2031. Why 2031? That'll be 50 years after AIDS was first identified.  I got the idea in Toronto, at a meeting marking 25 years of AIDS.  I said we need to reflect on the past 25 years, but what about the next 25 years? And the long-term? We've got all these people in treatment. How are we going to sustain that?  Who's going to pay for that? Do we have third-line, fourth-line drugs if resistance develops to first and second-line drugs?  Can we count on the sustainability of behavior change? Will there be a change in social norms?  There were so many questions and not so many answers.

Today we can say that there are major achievements. Five million people are on antiretroviral therapy in developing countries.  There is a decline in new infections in many places. But we've done some modeling, and it seems under the most favorable scenarios, in the absence of a vaccine, and with conventional medical intervention, we will still have a million new infections in – per year, in 2030, 2031.  The biggest concern I have now is that there will be a decline in interest in AIDS, some kind of fatigue, even with the Obama administration. And there also may be a bit of complacency.  This is the paradox in politics.  Once you've got some initial results, you think, okay, it's done, we can move to the next thing. But we'll need decades of efforts, and that's going to require extraordinary leadership, and resources. With the current fiscal crisis, those are going to be a challenge.

Harden:  Well, let's finish up by talking about you. What made you decide to leave UNAIDS when you did, at the end of 2008?

Piot:    On the formal side, the rule is in the UN at that level that there's a limit, you know, it's ten years. I'd done ten years, and I had asked Kofi Annan for a two-year extension instead of four additional years, but he said, if I give you two years, people will think that I'm not happy with your performance, and that's not the case, so I’ll give you four years and you can always leave earlier. That was the formal process.  Any sort of “President for Life” designation is not a good idea. That's the unwritten rule. 
But then second, I thought that I had achieved what I could achieve at UNAIDS and that it was time to pass on the baton to somebody else. I wanted to go back to academia, to research, to use my brain for thinking. And also, I wanted to use my experience for teaching. I love teaching--passing information on to the next generation. I also wanted to see whether we could apply what we've learned from AIDS to other health problems, for example, cardiovascular disease, diabetes--all huge epidemics in the world. Plus, heading an agency like UNAIDS is a very rough job.

Harden:  You are at Imperial College London now.

Piot:  Yes, but I'm moving.  As of October I'll be the director of the London School of Hygiene & Tropical Medicine. I'm leaving Imperial. It was not in my plan, and I've never changed jobs so rapidly, but the pull factor was too powerful. There was no push factor, because I'm happy at Imperial. It's a great place. Good science.  The London School is the largest school of public health and certainly of global health outside the US.

Harden:  So you have not slowed down in the least
Piot:  No, not yet.

Harden: Thank you so very much for this oral history.