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Virology: Journal of the plague years

Mark Dybul applauds the latest chapter in an account of a life at the leading edge of HIV research and policy.

AIDS Between Science and Politics

Columbia Univ. Press: 2015. 9780231166263 | ISBN: 978-0-2311-6626-3

Virologist Peter Piot's AIDS Between Science and Politics is a terrific follow-up to his highly acclaimed memoir No Time to Lose (W. W. Norton, 2012). It demonstrates the deep intellectual lessons of a lifetime at the cutting edge of science and politics. Piot's narrative ranges from his thrilling, on-the-ground experiences in remote regions of Africa as a young scientist and member of the team that identified Ebola, to the high-altitude reflections of his years as executive director of the Joint United Nations Programme on HIV/AIDS (UNAIDS).

Credit: Illustration by Andrea Manzati

Three messages underpin the book's nine chapters. One is that the HIV epidemic generated an unprecedented local and global response, recast many development and health paradigms, and ultimately triggered treatments that have saved millions of lives. The second is that progress was made only when various scientific disciplines, on-the-ground implementation strategies and politics were aligned. And the third? That AIDS is not over.

Piot observes that HIV is one of the most devastating plagues in history, reducing life expectancy in countries such as Botswana by around 30% — and wiping out decades of gains in health and development. Even in places that have not been affected on that national scale, it has devastated groups of the most marginalized and vulnerable people, including men who have sex with men, transgender people, people who inject drugs, sex workers, prisoners and others. Piot also points out the links with historical injustices such as the 1948–94 apartheid in South Africa, where the social fabric was so badly damaged and the mistrust of the authorities grew so deep that it exacerbated the outbreak of the epidemic.

Piot traces the early days of the response to HIV/AIDS, when governments closed their ears and wallets to the growing epidemic. People with the virus rallied to fight for attention and resources, with increasing energy and sophistication. Remarkable individual and community action effected a breathtaking shift from a paternalistic, government-only approach to development and health, to one in which partnership and inclusivity provided a more effective response.

From such a heady climate were born the Global Fund to Fight HIV, Tuberculosis and Malaria in 2002 and the US President's Emergency Plan for AIDS Relief (PEPFAR) in 2003, both aiming to provide funding for programmes in countries most affected by the diseases. Perhaps of even greater significance was the growth of multisectoral local institutions, including national AIDS councils in dozens of countries, often reporting to the head of state. And there has been an increase of billions of dollars in domestic financing for HIV/AIDS response. As a result, many millions of lives have been saved and lifted up.

The theme of effective partnerships that span disciplines, politics and theologies (religious, scientific and otherwise) permeates the book, and is reflected in its title. The science is complex, as are the politics, and they are intimately linked owing to social elements, and the discrimination and stigma they engender — what Piot calls the challenge of “sex, drugs and rock and roll”. Data, modelling and advocacy were essential to move national and global politics, but political leadership also drove a demand for scientific advance, data and results.

At a national level, Piot praises former president of Botswana Festus Mogae for his personal leadership in declaring, in 2001, that HIV was a threat to his country's existence. Mogae dedicated significant national resources to antiretroviral therapy at a time when much of the global health community scoffed at the viability of such a programme in Africa. These moves were strengthened by an alliance with the Bill & Melinda Gates Foundation and with pharmaceutical giant Merck, creating what Piot deems perhaps the most successful and impactful public–private partnership in history. At the global level, Piot singles out the push by then-UN secretary-general Kofi Annan for the creation of the Global Fund, and George W. Bush's efforts towards the inauguration of PEPFAR.

Piot is honest about failures. He cites an effort he pioneered in the mid-2000s to engage the US and European pharmaceutical industries in expanding access to antiretroviral treatment for people in low-income countries. The opposition came from a diverse group of people and institutions, including academics and political activists, who feared that participation by the pharmaceutical industry would be geared towards increasing profits, not expanding access.

He is also clear about the need to remain focused and vigilant. In his view, the epidemic could be significantly reduced with sufficient resources, channelled to where they would make the most difference. This is the heavy baton that has been picked up by Piot's successor at UNAIDS, Michel Sidibé.

AIDS Between Science and Politics is a must-read for anyone interested in the HIV/AIDS epidemic. More broadly, it offers lessons — and interesting anecdotes — useful in the response to Ebola and indeed to every challenge in global health and development.

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Dybul, M. Virology: Journal of the plague years. Nature 520, 618–619 (2015). https://doi.org/10.1038/520618a

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