No Time to Lose:

Of infectious disease, science, politics and institutions

Peter Piot

ESCAIDE

Stockholm

5.11.2013Improving health worldwide

www.lshtm.ac.uk

My lessons from Ebola, 1976

• Time , place, person!• Poverty driving disease• The power and challenges of international

collaboration• EIS : US field epidemiology • Good intentions can be dangerous

Global HIV prevalence in adults, 1985

UNAIDS/WHO, 2006

Prevalence of HIV Infection,2012

Piot and Quinn, N Engl J Med 2013; 368:2210

Lessons from STD and HIV research

• The power of combining epidemiology with clinical and laboratory sciences

• Pre-eminence of social determinants, economics, politics and human rights

• Opportunities and challenges of international collaboration

• Europe needs a CDC• Weak EU support for global health research

Non-viral resistance

• Experts: in public health and health services, essential medicines, international development

• Institutions: development agencies, World Bank, European Commission, WHO, Unicef

• Politicians: Ministers of Health and of Finance• Denial about HIV : e.g. President Mbeki• Lack of ambition

“the brutal fact was that those who could pay for Africa’s AIDS therapy - the pharmaceutical industry by way of price cuts, and rich-country tax payers by way of foreign aid – are very unlikely ... to do so”

(W McGreevy, World Bank,1998)

Treatment Action Campaign (TAC)Treatment Action Campaign (TAC)

Leadership

Former President Fernando HenriqueCardoso of Brazil.

1988 Drugs for opportunistic infections provided

1991 Zidovudine provided

1996 Free and widespread distribution of ARV

UN Secretary-General Kofi Annan,Al Gore, Vice Presidentof the USA, chaired thefirst debate on AIDS as amajor security issue at theUN Security Council inJanuary 2000.UN Photo

Prices (US$/year) of antiretroviral regimen in Uganda: 1998-2003

UNITED NATIONSGENERAL ASSEMBLYSPECIAL SESSION ON HIV/AIDS

25 - 27JUNE2001

United Nations

April 13, 2023UNAIDS 23Source: UNAIDS, 2010

Resources available for HIV in low- and middle-income countries, 1986-2010

People on ART in low and middle income countries (UNAIDS,2012)

Source: UNAIDS, 2011

Lessons from the AIDS response

• Evidence: both size of the problem and of solutions • Human rights as driver• Unified strategy • Political strategy • Bring solutions• A brilliant coalition • Activism by people affected

• Never take no for an answer!

Lessons from the chameleon

• Focus on your goal• Be flexible, while sticking to goal• Constantly process intelligence• One step at a time• Timing is everything

How AIDS invented Global Health (A.Brandt, NEJM 2013)

• Disrupted divide between prevention and treatment

• New forms of disease advocacy and activism• New global funding• Changed the cost of essential medicines • Recognised basic human rights • Major boost for global health research and

academic interest

HIV incidence and deaths England, 1981-2010 (PHE,2012)

New HIV infections 2001-2012

In some countries the entire AIDS treatment budget comes from international sources

Percentage of care and treatment expenditure from international sources

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

AlgeriaSeychelles

EgyptCongo

BotswanaLesotho

MoroccoAngola

ChadGabonBenin

SenegalSwazilandCameroon

UgandaBurundi

GhanaTogo

KenyaBurkina FasoSierra Leone

NigeriaCote d'Ivoire

MaliGuinea

MozambiqueGuinea-Bissau

MalawiEritrea

NigerCentral African Republic

RwandaDemocratic Republic of the Congo

0% 10 20 30 40 50 60 70 80 90 100%

Partners PrEP FTC/TDFPartners PrEP TDF

73% (49; 85)

39% (6; 60) CAPRISA 004 TNF gel

iPrEx FTC/TDF 42% (15; 63)

TDF-2 FTC/TDF 63% (22; 83)

FEM PrEP FTC/TDF 0% (-69; 41)

Efficacy of primary and secondary ARV-based prevention studies

62% (34; 78)

VOICE TDF

96% (77; 99)HPTN 052

HIV-diagnosed

Linked to care

Retained in care/Eligible for ART

On ARTAdherent to ART

0102030405060708090

100

United StatesMozambique

Perc

ent

The HIV Treatment Cascade Piot and Quinn, NEJM 2013;

How well equipped is Europe for the next challenges?

• New health challenges will emerge• Many countries have weak institutional capacity • Financial crisis has weakened Europe’s public

health and response capacity• Challenges beyond infectious diseases • Use regional funds to strengthen public health

institutions • Need to expand mandate of ECDC

Emerging infections

Declan B. Polio risk looms over Europe. Nature 2013; 502: 601

Europe needs a strong, autonomous Centre for Disease Control and Prevention , working with strong autonomous national Centres, addressing both infectious and chronic diseases

Science

Politics Services

EmpowermentDevelopment

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