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|Listening to Patients: Targeted Intervention Research to Improve STD Programs|
|Young People and STDs: A Prescription for Change|
|Prevention As Policy: How Thailand Reduced STD and HIV Transmission|
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|Mobilizing Pharmacists for STD Control|
|In the News|
|Q&A - New U.N. Program Promotes Multisectoral: Approach to AIDS Prevention|
|Women's Forum - Opinion Women, Children and STDs: Addressing the Other STD Epidemic|
|Policy Profile: Haitians Reach Consensus on National STD Guidelines|
The new joint United Nations Programme on HIV/AIDS (UNAIDS) coordinates the HIV/AIDS activities of its six cosponsors: the United Nations Children's Fund (UNICEF), the United Nations Development Programme (UNDP), the United Nations Population Fund (UNFPA), the United Nations Educational, Scientific and Cultural Organization (UNESCO), the World Health Organization (WHO) and the World Bank. UNAIDS Executive Director Peter Piot, a physician and scientist from Belgium, discusses the challenges ahead and his goals for the program.
Dr. Peter Piot, UNAIDS executive director
You've said that UNAIDS' strategic plan is based on what we've learned from more than a decade of responding to HIV/AIDS. What have we learned?
We've learned several things. One is that the dichotomy between prevention and care is not useful. We can't afford to focus entirely on prevention any longer. Another is that we must try to reduce people's vulnerability to HIV through societal action.
But I think the main lesson of the last decade is that the HIV/AIDS epidemic is no outbreak. It's no longer a question of advising people to be careful for a few years until the epidemic is brought under control. Now we know that people will have to live with HIV risk throughout their lives and will need protection options for each stage of their lives.
On the other hand, we are not powerless against HIV. There have been successes in several countries, often where there is strong community involvement. Some communities in the developing world have managed to stabilize or reduce transmission rates. In Australia and some northwestern European countries, this has even been achieved on a nationwide scale.
How is UNAIDS different from WHO's Global Programme on AIDS?
First of all, the new program brings together six agencies. It has become clear that this epidemic is too complex to be tackled by one single approach. In institutional terms, in the U.N. system that means that it has to be dealt with by several agencies, in a coordinated manner.
The UNAIDS program will also be much more multisectoral in its scope, involving all sectors of society that can affect the course of the epidemic or are affected by it: the health and education sectors; ministries of trade, finance, planning and development; nongovernmental and community organizations; people living with HIV and AIDS; research institutions; and the business sector.
How will this program bring the six agencies together to make this multisectoral approach a reality?
In every country the U.N. agencies will form a Theme Group on HIV/AIDS, with representatives, first of all, of the six agencies, but also of other U.N. agencies, sitting around a table and talking to each other. That's the most basic level of coordination: at least you know what the others are doing, which is not always the case at the moment. And that is true, frankly, not only in the U.N. system but also for bilateral donors and ministries in a country.
Second, we will encourage countries to have an AIDS strategy that incorporates the different sectors.
Does that mean you'll be helping countries revise their national AIDS plans?
Yes. We're reviewing on a country-by-country basis the needs in terms of finances, human resources and technical support and the available resources. This will happen over a two-year period.
Could you give me examples of how a plan might be different- reflecting the multisectoral approach?
Multisectoral plans already exist in several countries, actually. Let's take the example of Tanzania, whose second medium-term plan already involves numerous sectors.
In Tanzania the prime minister and the first vice president's office oversee district-level implementation in collaboration with the Ministry of Community Development and many other ministries, with NGOs providing social support to people living with AIDS and their families, and with political parties, which have been successful in national mass mobilization. The ministries of Health, Education and Culture, Labour and Youth Development, Defense and National Service, Information and Broadcasting, and Home Affairs all play a role in HIV/AIDS prevention. Companies are involving young people in designing, planning and implementing activities to minimize rural exodus and risk behaviors among youth.
That's the level of involvement UNAIDS will try to emulate.
At the international level, how will you coordinate the HIV/AIDS work of each agency?
We're the AIDS program of the co-sponsors. We won't replace their work at the country level, but at the global level, most of the AIDS-related activities of the six agencies will be subsumed under UNAIDS.
On the other hand, some AIDS-specific activities will have to go on in the different organizations-for example, WHO will have to integrate AIDS-related policies and considerations into its blood safety activities. So each organization will maintain a small capacity, which in most cases will mean two to three professional staff, to push AIDS on the agenda of the organization.
Many people have talked about the need for a multisectoral approach to HIV/AIDS. How can the U.N. make it work?
I think that a multisectoral approach will only work when the different sectors see that it is in their self-interest to do something about AIDS. So I think this is our job, to convince them that it is really in their interest.
So UNAIDS' role is advocacy?
Advocacy is one of our four main roles. The others are research and development of policies-identifying what we call international best practice, or the most effective responses to the epidemic-and providing technical support to help countries incorporate these policies, strategies and actions into their response, as well as the coordinating role I described. As the world's advocate on AIDS, we'll advocate not only for more resources but also to keep HIV/AIDS on the agenda.
Do you think this program will give you greater leverage to find more resources for HIV/AIDS prevention and care?
Leverage, yes, but not necessarily to have the resources ourselves. My goal is to have more money spent by the cosponsors and by the countries themselves on AIDS.
The money that's available for development is shrinking worldwide, so it's a matter of better using our funds. For example, with care, you can do a lot without dramatically increasing resources-unless you start talking about antiretroviral therapy. We can improve quality of life by training personnel, by providing prophylaxis for certain infections or treating the most common health problems, and by organizing community support. One has to find solutions that are locally affordable.
Given the recent findings in Tanzania of dramatic reductions in HIV transmission as a result of improved treatment of sexually transmitted diseases, what will UNAIDS do about STDs?
We will promote effective existing approaches to diagnosing and treating STDs and stimulate more research in this area. For example, UNAIDS is the secretariat of the STD Diagnostic Initiative, which seeks to develop affordable, simple and rapid tests for the diagnosis of the most common STDs.
UNAIDS will also assist countries in their planning for STD control. This requires addressing a number of issues, such as the availability of effective and affordable drugs, involvement of many health care providers, lack of access to information, prevention of infection and adequate services for women in the developing world.
You said we must reduce people's vulnerability to HIV. How will UNAIDS do that?
Nine out of ten people with HIV today live in a developing country and HIV incidence is growing in poor or marginalized communities in the industrial world. Every day thousands of people become infected because of societal factors, such as poverty, migration, civil disorder and the inferior status of women, that make it harder for them to protect themselves from HIV.
AIDS has become a real development issue. We know that poverty, for instance, is an underlying factor driving women into prostitution, but can we as an AIDS program, with our small budget, do something about that? The answer is yes. We can advocate for changing laws-for example, inheritance laws should change. Breaking the silence around certain issues, that's another thing we can do. And building coalitions with human rights activists, with the women's movement.
In a speech last year you said the new program cannot and should not become a vehicle for alleviating poverty or ending discrimination-a new way to right all wrongs. What did you mean by that?
Human rights is an example. Many groups deal with human rights, but they rarely have HIV/AIDS on their agenda. We can work with them to make sure that they address HIV/AIDS and discrimination against people living with HIV/AIDS. But we're not going to solve all the human rights violations, and it would not be appropriate to focus only on human rights violations.
We have an immediate problem. If we wait until we have a perfect situation in terms of women's status and ending poverty, tens of millions of people will have died from AIDS. We need immediate protection as well. I think one has to work on both and not lose perspective.
What are some of the other challenges facing UNAIDS?
We still have no vaccine and we won't have one ready for mass distribution before the twenty-first century. Even if we could magically stop all transmission from that time on, it would be very hard to prevent the disastrous personal and societal repercussions from the illness and death of millions already infected.
Another challenge is that there is still a lot of denial-denial and a lack of political commitment. Many governments are hardly spending anything-not spending a cent on AIDS-even though it's one of the major obstacles to development.
What are your main goals as head of UNAIDS?
One is political commitment to this epidemic from world leaders, translated into financial support for their AIDS programs and also speaking up about AIDS, just like President Museveni is doing in Uganda, mentioning AIDS in every single speech.
Another goal is to run an efficient U.N. operation that makes optimal use of the resources we have. I think we'll be able to do that through better coordination and relying more on local people and local resources.
And third, I want to see a slowing down of the spread of the epidemic. I'm sure, at least in certain parts of the world, we can do that. We're gaining momentum. But the great danger is that the effort will be interrupted, that the donors will give up. It would be a shame to do that right now.