A Pandemic’s Story of Tragedy and Success

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Beyond the absolute number and distribution in given regions over time, national AIDS programs seek to understand which groups are affected by recent infection, as this is where the efforts for HIV prevention should be focused.

—Peter Piot


Title: AIDS Between Science and Politics

Author:  Peter Piot

Publisher: Columbia University Press

Publication date: May 2015

Price: $29.95; hardcover, 216 pages

AIDS is a global phenomenon that recognizes neither national boundaries nor social strata. The AIDS pandemic was one of the disruptive events that marked the turn of the 21st century. Who could have predicted the worst pandemic in modern history since the Spanish influenza, when in June 1980, a syndrome of unknown origin was described in just a few lines about five homosexual white men in the United States? And, despite major advances in prevention and treatment, HIV/AIDS is expected to kill about 1.5 million people worldwide this year.

Not only does AIDS still pose a major public health crisis, it remains a pointed issue in socioeconomics and politics, all of which are covered in great detail in a book by Peter Piot, aptly titled AIDS Between Science and Politics.

The author, Professor Piot, has a formidable pedigree. He is Director of the London School of Hygiene and Tropical Medicine, former Under Secretary General of the United Nations, founding Executive Director of the Joint United Nations Programme on HIV/AIDS (UNAIDS), co-discoverer of the Ebola virus, and former President of the International AIDS Society. Although the book is a bit arid, it is chock-full of valuable information and deep introspection about global health policy, making it a good choice for those readers of The ASCO Post interested in international health issues.

Transmitted largely by sex and intravenous drug usage, AIDS is a disease that still battles with stigmatization. As Professor Piot writes, “Early AIDS research was stifled because of a deep prejudice and stigmatization of those living with the virus: homosexual men, illicit drug users, people with hemophilia, as well as Haitians and Africans. That era is not over: Although now subtler, discrimination and stigmatization explain at least what is possible and the continuing global epidemic.”

A Closer Look at Epidemiology

Public health policy books generally are telephone book–thick tomes that lose through boredom all but the most ardent fan of the genre after several chapters. Professor Piot does not make that mistake. AIDS Between Science and Politics is a compact work, broken into short chapters and then into subheads. It is presented in a linear style, with a bit of history first and then a terrific explanation on the epidemiology of HIV/AIDS, which oncologists fond of statistics will find interesting.

In simple language, the author describes how HIV numbers are estimated in a heterogeneous and still-evolving population. He also breaks down the infection rates into treatment strategies, again offering good content for the oncology community, in that it’s akin to organizing a tumor registry in a developing country. The approach is similar to the work well-known oncologists such as Larry
Schulman, MD,
and Bruce Chabner, MD, have done in sub-Saharan Africa.

Professor Piot explains, “Beyond the absolute number and distribution in given regions over time, national AIDS programs seek to understand which groups are affected by recent infection, as this is where the efforts for HIV prevention should be focused.”

Although the advent of multidrug cocktails such as highly active antiretroviral therapy has made HIV/AIDS a manageable disease, it is expensive and must be taken every day for life. In this section about epidemiology, the author ends with this sobering line: “The future of the HIV epidemic depends on numerous unknowns, and no model can fully determine the extent of long-term changes, either in prevention or treatment.”

Still a Hyperepidemic for Some

In the United States, we had an AIDS crisis that erupted into a sociopolitical movement, championed by movie stars and politicians. It was a convulsive national process that took time and understanding, but eventually prevention strategies were implemented and efficacious drugs developed. The author reminds us that AIDS is still a hyperepidemic in parts of the world, such as Southern Africa, which is experiencing an exceptionally severe AIDS epidemic, with adult HIV prevalence rates up to 24.7% in Swaziland.

It’s sobering to read that the Southern African region accounts for more than one-third of all people living with HIV in the world. More sobering is that AIDS, unlike breast or prostate cancer, is largely preventable. Like lung cancer, which is largely caused by smoking, AIDS has a main driver of incidence: sex. The author points out (rightly so) that lung cancer has been stigmatized as a “preventable” disease, putting blame on smokers who develop the disease. Given that HIV is mainly transmitted sexually, Professor Piot wades into the thorny area of searching for a clue to the massive AIDS burden in Southern Africa, and it proves to be one of the most interesting sections of the book.

When he looks at each parameter of sexual behavior separately, such as the number of partners, frequency of commercial sex, and age at first sexual intercourse, studies have shown little difference with other regions of the world. After looking at various sociomathematic models, he states what seems obvious: “A reduction of concurrent sexual partners and the total number of sex partners (which is extraordinarily high in Southern Africa) should be part of any HIV prevention program.”

This is important epidemiologic research, which is generalizable over many preventable disease states. In the United States, we’ve seen the results in behavior modification in smoking-related lung cancer; because of science-driven public policy, smoking dropped from 60% of the population down to 18%. The United States has also seen a huge drop in the incidence of AIDS, due largely to public health information stating the simple message: Do not have unprotected sex and engage in intravenous drug use.

Unfortunately, the author softens his thesis about irresponsible sex driving the AIDS epidemic in Southern Africa, concluding that it is unlikely there is a single cause for hyperendemic HIV infection in Southern Africa. He adds, “Apartheid in South Africa, and its ramifications in neighboring states, has played a determining role in the current sexual behavior, hence the spread of HIV.”

Social Justice and Moral Imperatives

After fully examining the historical and sociopolitical context of the AIDS pandemic, Professor Piot does a fine job of breaking down the enormous financial burden this disease places on developing countries, calling for AIDS treatment to be classified by the World Health Organization as a basic human right. He makes a compelling argument.

However, toward the end of this book, the author’s bent on social justice and moral imperatives lead him into areas that are ripe for criticism. “Often HIV is a motive for preexisting discrimination. Thus foreigners or immigrants are suspected of having introduced the virus and contaminated the healthy population. Prostitutes are stigmatized as a vector of infection…homophobia is one of the most common forms of structured discrimination.”

He concludes with a short chapter on how to prevent discrimination, which many readers may find preachy and ineffective. No doubt his heart is in the right place, but these final messages, not backed by data, stray from his solid scholarship and dilute the power of this otherwise well-researched and worthwhile book.  ■