Interview with Peter Piot, UNAIDS Executive Director

AIDS threatens the lives of 80 million Africans by 2025, according to three scenarios spelt out in a new report by UNAIDS. A further 90 million could be infected by that time. In an interview in the Ethiopian capital, Addis Ababa, UNAIDS chief, Peter Piot, however told PlusNews that the future of the epidemic would be determined by our actions today. Below are excerpts: QUESTION: How did you come up with these three scenarios? ANSWER: The three scenarios are the outcome of the committed work of over 100 eminent Africans from all works of life. Some you wouldn’t think they could bring something to the table but when it comes to AIDS I still have to discover one discipline, one type of sector that does not have something to bring. Q: What can the scenarios tell us? A: These scenarios have great potential to improve both our shared understanding and our collective response to the AIDS epidemic in Africa. They give us three diverse but equally plausible visions of the likely future of the AIDS epidemic in Africa. Each of them is sobering but on the other hand I think they are an enormous source of hope for me. By providing this unusual ability to look into the future they allow us to understand which cause of action will lead to the best result. As we sometimes forget the future is defined by what we do today. Q: What key insights do these three scenarios offer? A: The scenarios confirm that with the AIDS epidemic Africa is facing an unprecedented and exceptional crisis, and a challenge that we have never seen before, I would say, since slavery. It is so exceptional in its scale, complexity and the consequences across generations; it really is a mortgage on Africa’s future. The future of much of Africa is literally dependent on how it responds to the epidemic today. The crisis is so unprecedented in severity, longevity and its impact that as societies and individuals we really don’t know exactly how to respond. There is no pattern, there is nothing we can follow. But I think we are getting on the right track now. Q: Do the scenarios offer hope? A: The scenarios confirm that in the clearest terms possible that this is anything but a hopeless or inevitable situation. Through determined efforts today, particularly by building on the collective strengths of African nations, the trajectory of the AIDS epidemic in Africa can be profoundly changed for the better, saving millions of lives. This I would say is the core message of these scenarios. Q: And what of the response? A: The scenarios show that our efforts must be compatible, short-term pragmatic solutions and a long-term strategic response. Up to now we have mainly been reacting and running after the crisis and behind the virus. We now have to enter into a phase of being proactive and being strategic. Of course the core element of the short-term response now is keeping people alive, all those who have been infected, that is to save not only them and their families but whole economies, making sure there is more investment in prevention, but in the long term making sure the young generation remain HIV-free. These scenarios focus on addressing the epidemic’s root social, economic and politician causes. Gender inequality is one that comes out very strongly throughout these scenarios, poverty and income inequality and Africa’s marginalisation in the world. These scenarios show clearly that we can only truly bring AIDS under control as part of a wider effort to end Africa’s under-development. Q: Which scenario do you think is most likely? A: It is unpredictable. As we can see the responses are different from country to country. It will be mostly a patchwork of different scenarios across Africa. These are scenarios we want to use for policy information in countries. Q: Is progress being made? A: As compared to a couple of years ago a lot of progress has been made and things are accelerating in what we are doing and also making sure that AIDS is part and parcel of our core development strategies. But if the response to AIDS continues to be fragmented and as it is today, it is going to cause not only tens of millions, but will also really jeopardise African development in a big way. So the tough choices that need to be made are not tough choices 20 years from now but tough choices today because the longer we wait the tougher the choices will be. Q: Is too much emphasis being placed on abstinence and being faithful following recent research from Uganda showing a drop in prevalence due to greater condom use? A: The recent study from Uganda suggests the success in bringing down new infections, which is absolutely real, said it is from people dying and only using condoms. This is from one study. All other studies from across Uganda show it is a combination of factors. One of the strong messages out of the scenarios project is that there is not a magic bullet; it is not one action that is going to fix this epidemic, whether that is abstinence or whether that is condoms, you really need the combination. In the specific case of Uganda, what had happened is that young people have postponed the first age of sexual intercourse, there are fewer partners and there is a massive increase in condom use. And I think indeed that sometimes the role of condom use is underplayed. I don’t know of a single society that has been successful in bring down the number of new infections without massive condom promotion. But that in itself is not enough. Saying that it would only be abstinence and being faithful is really being fairly naïve about the realities of life. Q: Does that mean, as a policy, abstinence, being faithful and using condoms (ABC) is now outdated? A: I think you need to fully role out this so-called ABC but for many women it is irrelevant, many women are infected by their sole sex partner and that is their husband, so marriage was not made for abstinence to say the least if fidelity has to come from the other side and imposing a condom on your husband is, for any country in the world, a problem. So we have to make sure that we incorporate in our AIDS work a change in social norms.