Since the development of the first antiretroviral treatment in the mid-1990s, Aids has slowly transformed from an unrelenting fatal disease into a more or less controllable one. But Aids can only be fought if the patient takes his medicines on a daily basis – and that’s where the shoe pinches.

The Aids epidemic is far from over, particularly in Africa, where only one in two patients have access to antiretroviral treatments. This year, two million people will die from Aids. The situation is particularly grave in sub-Saharan Africa, and experts wouldn’t venture to say that things will improve in the near future.

On the other hand, things have improved a lot during the past 12 years. In 2000, only 200,000 patients in the developing world had access to antiretroviral treatments (almost all of them lived in Brazil). Also that year, only one in a thousand Africans with HIV received treatment.

So the numbers indicate that strong progress has indeed been made. And that’s all due to one big evolution: the sharp decrease in the price of antiretroviral treatments, from $14,000 (€11,400) per patient per year in 1995 to less than $100 (€82) now. That’s still a lot of money for most patients in Africa, but with the help of governments setting up national programmes to give (almost) free access to Aids medicines, things are finally moving in the right direction.

Merit goods

The international effort for delivering access to antiretroviral treatments to as many Aids patients as possible – especially to those in developing countries – is one of the most drastic changes public health has ever seen. During the past decade, big pharmaceutical companies like Merck and GlaxoSmithKline, who develop the treatments, have changed their business model completely.

When nowadays a new medicine comes on the market, prices for developing countries are immediately put in place. Aids treatments have been transformed from exclusive goods for people in prosperous countries into “merit goods”, something available for everyone in need on the planet.

These are the words of Peter Piot, former director of the Joint United Nations Programme on HIV and Aids, or UNAIDS for short. The 63-year-old Flemish microbiologist and doctor led the UN programme from its foundation in 1994 until 2009, when he was succeeded by the current director, Michel Sidibé. Piot was born in Leuven and raised in the village of Keerbergen in Flemish Brabant. He studied and graduated in Ghent before moving to Antwerp.

He witnessed first-hand how Aids emerged as a new and strange epidemic at the start of the 1980s, after which it slowly but firmly gripped the world – particularly Africa. Now Piot has published his memoirs, No Time To Lose, in which he gives his account of his “life with Aids” – first as a microbiologist in the field in central Africa, later in the safe and clean Geneva offices of UNAIDS.

It’s an extraordinary read, and even in the second half, where Piot talks about his bureaucratic life within the UN, he manages to keep the reader captivated. What sticks in one’s memory is not just the remarkable story of Aids, but also Piot’s determination to improve the lives of Aids patients wherever he could.

Unknown infection

From his first trip to Zaire (now Democratic Republic of the Congo) in 1976 until he left UNAIDS three years ago, Piot has fought infectious diseases. For the longest part of that period, his direct enemy was Aids.

But in 1976, it was not Aids that drew 27-year-old Piot, a microbiologist at Antwerp’s renowned Institute of Tropical Medicine, to Africa. On a regular Tuesday in September, a package arrived at the institute: a blue flask containing two blood samples from a Flemish nun who was too ill to be evacuated from Zaire.

The accompanying note stated that the woman suffered from an unknown infectious disease, which caused severe hemorrhagic fever and life-threatening internal bleeding. When Piot opened the flask, he saw that one glass tube was broken and the blood had mixed with the surrounding ice water.

It’s just one of the several frightening incidents that Piot mentions only briefly in his memoirs, but which make the reader’s hair stand on end. (Later Piot will prick himself on a needle containing blood from a dying Aids patient, and in the remote jungle of Zaire he will only escape from a helicopter crash by coincidence. So it’s a surprise that he ever survived to write his memoirs.)

The nun didn’t survive, and neither did thousands of people in central Africa. With colleagues from Belgium, the US and France, Piot flew to Zaire to investigate the first outbreak of a virus that would later be known as Ebola.

Encounter with death

Starting from scratch, he learned how to set up field laboratories and hospitals, and how to deal with patients who could not be cured. All these skills became crucial when he returned to Africa a couple of years later, when he found himself in the frontline of the battle against another new and unknown disease, caused by a far more sophisticated virus: HIV. That first trip to Africa changed Piot forever. “It was a straight encounter with death. We had to store bodies that were totally swollen because of the heat – even with a gas mask, the stench was unbearable. It was an unreal experience and it kept me awake for several nights. And when I returned after two months, I really needed time to get used to normal life,” he recalls.

But these horrible experiences in Africa also reshaped his personality. “Actually, the best that can happen to you is to be confronted with death – without dying. After that you won’t lose any more time on things that don’t really matter.”

You remember a lot of details of that first trip to Africa, and of the rest of your professional life. Did you keep a diary?

“I have been keeping notes, mostly for practical reasons, and not with the intention to write a book. During my time at UNAIDS, my collaborators kept detailed notes of all meetings and trips, as is the custom in the civil service. All that helped a lot for writing this book, but the strong emotional moments and the funny anecdotes were engraved on my memory.”

In 1979, you performed an autopsy on the body of a Greek fisherman who died from acute meningitis. You now suggest he could have suffered from Aids. Did you miss a chance to be the first to describe Aids?

“In 1985 we found – because we kept his blood samples – that the man had indeed been infected with HIV. He was one of several similar patients we saw before the first reports of Aids in the US were published. Yes, you might say we missed the opportunity to be the first to identify the new syndrome.”

When and where exactly did HIV originate in Africa?

“There is now strong genetic evidence that HIV jumped from chimpanzees to humans in the early 20th century, possibly in central Africa – though probably in countries north-west of Congo. How the virus then spread across the Atlantic remains speculative.”

Aids has lost a bit of its deathly character due to the development of antiretroviral treatments. How do you foresee the future?

“Thanks to these treatments, people with HIV can now have a life expectancy similar to that of people without HIV. However, only half of people with HIV in immediate need of treatment have access to these drugs in developing countries. So we still have a long way to go, and continuing political and financial commitments will be key for decades to come. In addition, there are nearly two new HIV infections per year for every person who has new access to treatment, which means the gap between those who need treatment and those who have access to it is becoming wider. Aids is not over by any means, and we need to persevere with our efforts.”

At school, people are taught that Aids is one of the most dangerous diseases of all, and that you cannot take enough precaution. Isn’t that exaggerated?

“It is correct that the risk for heterosexuals acquiring HIV in Belgium is, fortunately, small. But let us not forget that there are two to three new infections every single day in our country, and that new infections are on the rise among gay men. In addition, we are seeing an increase in other sexually transmitted infections.”

You are director of the London Institute for Tropical Medicine. Why London and not Antwerp?

“The London school is the leading institution in global and public health in the world, and I feel very privileged to have an opportunity to lead it.”