AIDSWEEKLY Plus, Monday, 27 October 1997
Daniel J. DeNoon, Senior Editor

Sometimes Peter Piot must think nobody is listening.

His animated state-of-the-AIDS-epidemic lectures have been featured at every world AIDS conference and at the last several opening sessions of the American Society for Microbiology's Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC).

Each lecture is more frightening than the last, because of the awful pace at which the AIDS pandemic continues to expand. Each lecture is more disturbing than the last, because of the terrible consequences of the world's failure to control this preventable disease.

"The situation is grim, very grim," Piot said in the opening address to the 37th ICAAC, held September 28 to October 1, 1997, in Toronto, Ontario, Canada. "I am here to tell you that this epidemic is not over - far from over - and we will have to deal with it for generations to come."

But the Belgian infectious disease specialist, since 1995 head of the joint United Nations Program on AIDS (UNAIDS), remains surprisingly upbeat.

"It would be wrong to underestimate the grounds for optimism," Piot said.

He predicted that safe vaginal microbicides will soon provide a new tool to help prevent sexual transmission of HIV. He is also convinced that efforts to develop an HIV vaccine will eventually bear fruit. And he still believes that governments can be convinced to institute effective prevention programs using existing technologies.

"Prevention works in the here and now," Piot said. "It is necessary to keep up the pressure on government for improved prevention and care."

Universal antiretroviral treatment with existing AIDS drugs is impossible: it would cost $300 billion to treat every adult who currently has HIV infection, and 8,500 new infections occur each day (about one every 10 seconds).

UNAIDS has therefore adopted a strategy to improve access to generic drugs, particularly those used to treat sexually transmitted diseases (STDs), but also those used to treat opportunistic infections and to provide palliative care. As the tuberculosis epidemic follows the AIDS epidemic like an evil shadow, drugs for TB treatment and prevention are also needed.

In areas where sufficient health-care infrastructure exists, UNAIDS seeks to improve access to antiretroviral drugs. In other areas, the first task is to build or improve the health-care infrastructure. These tasks are particularly important in preventing mother-to-child HIV transmission - "one of the top priorities today," Piot said. This can be achieved in three complementary ways: by providing pregnant women access to voluntary HIV testing and counselling; by providing pregnant women with AZT; and by avoiding breast- feeding, which Piot said can reduce the risk of vertical HIV transmission by a third.

As AIDS is an STD, is seems incredible that most societies seem to hide their heads in the sand when it comes to making a sustained effort to change sexual behavior to reduce HIV transmission. Piot noted that in countries where such efforts have been made, notably Switzerland and Uganda, there have been positive results, such as a documented later age of first sex.

"By applying very vigorous campaigns, sustained and on a nation-wide basis, behavior can be changed," Piot said. "Good sex education in schools works and does not increase sexual activity. ... After careful, socially marketed condom campaigns, men do take up the use of condoms."

The UNAIDS chief does remain pessimistic that governments have the will to prevent HIV transmission by intravenous drug use.

"It's scientifically proved that needle exchange works," he said. "But this has been controversial in every nation. More is needed than mere needle exchange."

This is not the first time Piot has made these recommendations. They are much the same as those he made early in the epidemic, when relatively few people had died of AIDS and relatively few were infected. They are much the same recommendations he made two years ago, since which time some four million residents of India have become infected with HIV.

Piot's frustration showed when he spoke of the AIDS epidemic in sub-Saharan Africa, an epidemic he was one of the first to identify. Africa is the continent currently most affected by the epidemic, particularly the nations in the east and south with a secondary focus around the Ivory Coast.

For some nations, such as Zimbabwe and Malawi, AIDS is more of a disaster than an epidemic. In city of Harare, Zimbabwe, about half the residents are infected with HIV.

"If this were an earthquake, aid would come immediately," Piot noted with obvious irony. "But this is a silent earthquake."

He noted that more than 20 percent of 16-year-old girls in Harare are HIV positive.

"We should not be naive and should take prevention measures before children are sexually active," he said.

This is not now happening. Half of non-pediatric HIV infections - nearly 4,000 per day - occur in youths between the ages of 15 and 25 years. And new infections among gay men, particularly young men, are on the rise in the U.S. and Canada.

Mortality due to AIDS is not just increasing, it is accelerating. The 1.5 million AIDS deaths in the last year puts the disease in the same range as malaria and on a heading to overtake tuberculosis, the world's leading killer at 3.5 million deaths per year.

In areas outside of Africa, the epidemic is spreading explosively. Infection rates are as high as 27 percent in Brazilian sex workers and perhaps even higher among men who have sex with men.

The pattern, Piot said, is nowhere more evident than in eastern Europe. First, there was a "dramatic" increase in syphilis followed by an equally dramatic increase in cases of HIV infection. Driven by explosive spread of the virus among intravenous drug users, heterosexual HIV transmission increased and became a driving force of its own.

"This is a pattern we are seeing in all countries in the region, and it is a deja vu," Piot said.

"The future of the epidemic is in Asia," Piot continued.

"The jury is still out in China. There are several epidemic foci of HIV in China, and these are very new."

Overall, AIDS has reversed trends toward worldwide development - one reason why the World Bank is one of the most prominent participants in UNAIDS. For example, in the worst- affected regions of Africa, the disease has shortened life expectancy by 25 years.

These facts and figures are enough to discourage anybody. But Piot points to them as lessons learned.

"We have learned that it is possible to do something, but that this will require strong leadership," he said. "We shouldn't be afraid of pushing prevention efforts that work."

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