The International HIV/AIDS Alliance has published a "debunk the myths" posting featuring Peter Piot. So I have taken the opportunity to add my responses to his below. It is almost as if we were both being interviewed.

Jamie

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10 myths about the AIDS response
17 February 2014
Aids Alliance

In his keynote speech, Peter Piot called on the AIDS movement to take a cold, hard look at the lessons learned, and counter what he sees as the dangerous myths that could lead to a collective state of denial.

Peter Piot, ex-UNAIDS director and now director and professor at the London School of Hygiene and Tropical Medicine, was a keynote speaker on day two of a convention organised by the Alliance to mark its 20th anniversary.
Speaking to an audience of Alliance Linking Organisations, donors and other partners, Piot congratulated the Alliance on its anniversary, calling out three major ways it has made a difference to the AIDS epidemic: the impact of its global advocacy, its efforts to work in the areas where it can make the greatest impact (in terms of HIV transmission) and its work to strengthen the local capacity of civil society.

He warned – at the risk of sounding a bit clichéd - the AIDS response is at a critical junction. He acknowledged the optimism around new scientific developments but urged caution that the rhetoric around ‘the end of AIDS’ could translate into ‘the end of the AIDS movement’. He said, “If we drop the ball now, we may get to a situation where we can’t break the epidemic.”

In his speech at the event last week, he went on to outline what he sees as the dangerous ‘myths’ around the AIDS response today.

10 myths towards a collective state of denial

1. The end is in sight, with a variation that AIDS is over.

Piot:“I wish it were true, and it should be our goal. I am not saying there hasn’t been progress but people’s behaviour and societies are not mathematical models and cannot be predicted. Let’s stop saying AIDS is over.  One day, we will be there, but not yet!”

[him] moderator: AIDS is only one outcome of chronic HIV infection. The 'end of AIDS' and 'AIDS free generation' are mostly cliches originating in America that disguise the fact that AIDS incidence will decrease with improved treatment access, but that the end of most epidemics of HIV infection is not in sight.

2. All we need is better coverage of ART, which will wipe out the epidemic.

Piot: “If we have learned one thing, there is no magic bullet. Yes, there have been studies (such as HPTN052 which showed that ART can prevent HIV transmission) but it is a gigantic leap from these results to the reality of the community and is simply not yet supported by evidence.”

[him] moderator: Agree that there is no evidence that 'treatment as prevention' works in the community.

3. Behavioural interventions don’t work, we can only rely on biomedical prevention

Piot: “What we have to remember is that even treatment is a behavioural intervention with its strong emphasis on compliance. We should remember that for example PrEP  only works when you take it!’”

[him] moderator: Agree that all prevention and much of care has a behavioural component. The sad fact is that very few strictly behavioural interventions have been shown to have an impact on the number of sexual partners or condom usage in men. And none in safer injecting for people who use drugs.

4. There is no longer a need for distinct HIV programmes, integration is the answer!

Piot: “Some say all we need is health system strengthening which is ideologically driven, or supported by academic health theories. Whilst there are areas where integration will be beneficial and cost effective, such as PMTCT, we have to know what we can integrate and what not. Particularly whilst stigma and discrimination remain a hallmark of this epidemic.”

[him] moderator: Agree. Treatment could also be integrated. But prevention among key populations will require a separate response until condom protected sex and safe injecting become the norm in key populations.

5. The epidemic is on a downward trajectory – let’s continue doing what we are doing and it will wipe out HIV
Piot:“Downward yes, but not everywhere. There are many different epidemics with their own dynamics, and these need to be dealt with individually and appropriately.”

[him] moderator: Most epidemics that form the global pandemic are decreasing as incidence is decreasing. Some, such as the 'national epidemic in Myanmar', are decreasing too slowly. And others, such as the ones among gay men in some Asian cities, are increasing. Indonesia is of concern. There are other small 'national epidemics' that may be increasing. Pakistan, Bangladesh, and the Philippines. These brush fires can be brought under control.

As for continuing what we are doing ... yes we have to increase coverage and work more efficiently. When HIV incidence decreases enough it will become endemic rather than epidemic. And then we will need to change our tactics. Cambodia should probably do this now.

6. Stigma and discrimination has disappeared now we have ART, and the promotion of human rights as part of the AIDS response is an unnecessary luxury which can be handled by others

Piot: “Whilst many hoped that the introduction of effective treatment would mean ‘normalisation of AIDS, there is absolutely no evidence that this is the case. Everywhere you go you can still see the devastating impact of stigma and discrimination as a result of HIV.”

[him] moderator: Discrimination is still practised by health care providers, by members of key populations themselves, and by others. There is only a very small evidence base for what works to decrease it. Butterflies and flowers have not been shown to work.

7. There is no longer a need for civil society, physicians will fix this for you.

Piot: “Whilst this position may have some rational ground, some of it is also medical hubris.”

[him] moderator:  I don't know what 'rational ground' Piot has in mind. This is pure hubris.

8. Domestic funding will now cover all necessary costs of the response

Piot: “Some countries can definitely afford to do this – India, South Africa - but most can’t. And most won’t even prioritise health spending, so you can’t expect HIV to be prioritised within a bigger context of de-prioritisation. The reality is that many countries for many years will depend on international funding for their AIDS response”.

[him] moderator: Right he is. Funding for prevention among key populations is not a priority for any government.

9. We cannot do better with current funding, and managerial and programmatic efficiency are unnecessary business concepts

Piot: “We CAN do better with available funding. In particular, we need to concentrate our resources on where the epidemics are – and then apply the usual cost-saving approaches.”

[him] moderator: Agree. We can do much better with the available funding.

10. There is no need to continue investing in a vaccine

Piot: “Ending HIV without a vaccine will simply not be possible.”

[him] moderator: It is nice to agree to end this exchange. Thank you, Peter.

Piot quoted the late Nelson Mandela: “After climbing a great hill, one only finds out that there are many more hills to climb”.  He acknowledged that whilst much has been achieved in the last 30 years, but said “let us not fool ourselves: the hills to overcome are huge and numerous.”

Reflecting on the way forward

Piot urged all actors in the AIDS response to go on the offensive, reminding everyone that “every day, people are still dying.” He called for a renaissance in the activism that dominated the early years. He wanted to know ‘where is the anger?’ and not just the in-fighting between different constituencies, but the agreement to work together and provide concerted leadership to move forward.

He called for a combination prevention approach, with a focus on high transmission geographies and ensuring that key populations are not left behind.

He called for greater innovation in three areas:

In implementation, including preparing for the long term care of people living with HIV, warning “the young person who has been diagnosed with HIV today will still be living with HIV at the end of this century”.

In financing, pointing to the fact that it is billions that are still needed to tackle the epidemic, and even though the Global Fund secured $12 billion in its last replenishment round, this is only sufficient to last for the next three years.

In global goods, including medicines.

In summary, he said that our ambition should not only be to bring this epidemic down to the lowest levels possible in terms of reducing the number of people infected and dying until there is a vaccine, but also to play a catalytic role in convergence and other health issues.  In closing, he said “I am afraid the Alliance will remain necessary for many years to come.  Keep up the great work and never give up.”

http://www.aidsalliance.org/NewsDetails.aspx?Id=291690&mkt_tok=3RkMMJWWfF9wsRons6nIde%2FhmjTEU5z16eQrXqC0gokz2EFye%2BLIHETpodcMTcNgMbrYDBceEJhqyQJxPr3DJNUN0ddxRhbkDQ%3D%3D