Global Policy Forum

By Barbara Crossette

Peter Piot, the epidemiologist who has been coordinating an international campaign against AIDS since 1995, is spending less time worrying about the price of drugs and more about the shortage of condoms. Dr. Piot said he feared that attention had shifted from the front lines of the fight, the thousands of communities where the most basic means of prevention are still beyond the reach of the poor and vulnerable.

"We feel strongly that the response to AIDS has to be a balanced one: prevention and treatment," he said. "In the current climate, people forget that. I'm really getting tired of the fact that a terribly complex problem of treatment and care for people having HIV is reduced to the price of anti-retroviral drugs."

Those are fighting words to his critics. As the United Nations prepares for a special General Assembly session on AIDS from June 25 to June 27, the first session ever held to discuss a disease, a coalition demanding that access to treatment be declared a basic right is planning to demonstrate in New York that week.

The coalition, the Global Treatment Access Campaign, will demand a war chest of $16 billion to fight AIDS, a cancellation of third world debt and an end to American efforts to protect drug companies from patent challenges in poor countries. Secretary General Kofi Annan has asked countries to create a fund of $7 billion to $10 billion above the current money available for AIDS, which is now approaching $1 billion.

Dr. Piot, a Belgian and an expert on Africa who was among those who first identified the ebola virus and later saw some of the first effects of AIDS in Congo, said that before money on that scale could be spent in the poorest countries — if indeed it can be raised — more effective prevention, testing and delivery systems must be put in place.

A strategy on how to use the global fund has now been devised and will be presented to the UNAIDS board by the beginning of June, he said. The fund, to fight not only AIDS but also tuberculosis and malaria, will be collected and distributed through a venture involving United Nations agencies, the World Bank and the International Monetary Fund, he said. But all decisions about how the money should be spent will be left to experts within the recipient countries, and the headquarters office will deliberately be kept very small, with no more than 10 administrators, Dr. Piot said. Under the plan to be presented to the UNAIDS board, he said, the World Bank, part of the United Nations system, will hold the money but not control it or attach conditions to it.

Recently, Joseph Kabila, the president of Congo, a country struggling to emerge from civil war, went to the UNAIDS office in Geneva to ask for help in starting an AIDS program, Dr. Piot said. "The Caribbean, the second most-affected region, is now waking up," he added, and he has moved on to planning campaigns for the next epicenters, Eastern Europe and South Asia, particularly India.

For some countries that means persuading governments to recognize vulnerable groups often kept in the shadows, among them gay men and sex workers. An anti-establishment protester in his youth, Dr. Piot now argues for maintaining good relations with pharmaceutical companies. "We work with everybody who's part of the problem to find a solution," he said. "I think that very soon the issue of the price of anti-retroviral drugs will be off the table."

Then, Dr. Piot said, "We start with the real problem: building the infrastructure." Expensive health care systems are not necessarily the first or only priority. "For AIDS you need more than health care, you need the school system, you need all the communications," he said.

"The government sets policy," Dr. Piot continued, "makes sure there are resources and all that, but it's not government that's going to promote condoms in gay bars at night — nowhere in the world. To promote condoms you don't need doctors. You use commercial outlets, all these kiosks with women selling soap, beer, cigarettes — that's where people go for condoms, not to a clinic."

At the grass roots, where many will never have access to anti-retroviral drugs, condoms are also in short supply. "Not only male condoms but female condoms as well," Dr. Piot said, adding that very conservative views about women block the development and distribution of female condoms. "This seems to me — and maybe this is too strong of a statement — a really sexist approach, not thinking that women need something also that's under their control. Let's make sure that we increase the options for women to protect themselves — and increasing means from zero to one option."

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