UNAIDS: Peter Piot Waves Goodbye - What Will The Future Hold?

Main Category: HIV / AIDS
Article Date: 26 Dec 2008 - 1:00 PDT

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Head of UNAIDS Peter Piot steps down at the end of 2008 after 11 years in the job. In a Special Report in this week's edition of The Lancet, executive editor Pam Das and senior editor Udani Samarasekera look at the legacy left by Piot, and the direction that new leader of UNAIDS - Michael Sidibé - should take.

A senior UNAIDS source thinks that the solid collaboration shown between UNAIDS and the Global Fund throughout Piot's tenure could see the two merge at some point, possibly with GAVI as well. Some experts believe the appointment of a new leader is a time for reflection, and that Sidibé must make UNAIDS evolve and adapt to the current-global health architecture for it to survive. Others think it should be "shut down and rolled back into WHO - where coordination of the global response to HIV/AIDS initially began." Devi Sridhar, a politics fellow at Oxford University, believes much has changed since 1996 when UNAIDS was born. She says: "The global health landscape of 2008 is radically different to back then, and in line with this change, UNIADS needs to evolve to stay relevant."

The Special Report describes how UNAIDS was initially an experiment, born out of WHOs early failures in the field of HIV/AIDS. Yet the fledgling agency itself ran into difficulties early on, in particular in how it managed the financial support to individual states. It also struggled to provide technical support and advice to countries. Michael Merson, director of the Global Health Institute at Duke University, Durham, NC, USA says: "All these factors made things difficult for UNAIDS in the beginning and right at the time when the pandemic was peaking and expanding dramatically."

But eventually UNAIDS found its feet. It now has 280 staff in its Secretariat in Geneva, plus 621 staff in seven regional teams and 81 country offices. The agency's budget was $469 million in 2008-09. And UNAIDS' achievements under Piot have been many. The organisation has been praised for making non-governmental organisations part of its governing body and for working with civil society groups to lower the prices of antiretroviral drugs. Sridhar says: "It has also brought HIV/AIDS into the security realm, resulting in UN Security Council Resolution 1308, as well as General Assembly Special Sessions (UNGASS) on HIV/AIDS." But most would agree that true to its core mandate, UNAIDS' greatest achievement has been as an advocate, promoting and arguing for a strong global response to HIV/AIDS and increasing spending for the disease to $10 billion in 2007. Piot has been crucial to this achievement.

Others feel that Piot's legacy will be mixed. His 'AIDS exceptionalism' - that is, promoting the disease over other health problems - has won him both praise and criticism. Some say he has not been political enough during his tenure. More specifically, there has been criticism that UNAIDS has been too passive in challenging HIV/AIDS policies born out of ideology rather than evidence; and that the rights of high-risk groups have not been championed. These include the criminalisation of homosexuality, the exclusion of illicit drug users and sex workers from health services, that a substantial percentage of funds be devoted to abstinence only, and the reinstatement of the global gag rule related to abortion, which has made it more difficult to integrate HIV/AIDS into reproductive health services.

Elizabeth Pisani, HIV epidemiologist and journalist, who worked for UNAIDS in the late 1990s, says most of the weaknesses of UNIADS come from its ill-conceived structure. She says: "It is beholden to its co-sponsors…It has failed to coordinate its co-sponsors because they have no desire to be coordinated." Furthermore, over the years, many experts have questioned the scientific basis of UNAIDS' annual epidemiological estimates, complaining that the burden of HIV/AIDS globally was overstated. But perhaps the biggest failure in the response to HIV/AIDS has been HIV prevention. Piot admits he should have pushed prevention efforts sooner. But he adds: "In the early days thousands of deaths a day were so overwhelming and needed immediate action that treatment had to take precedence."

Other criticism is that some experts also believe that UNAIDS has paid little attention to the epidemic in men who have sex with men. And many feel that the responsibility for HIV/AIDS estimates and surveillance should be given to WHO or a wholly independent and objective scientific committee not appointed by UNAIDS. One expert told The Lancet that these data are not subject to the routine scrutiny that regular epidemiologists in the field would give them. He said: "[UNAIDS] staff do not interact with advocates of other diseases and become increasingly narrow and sectarian, viewing exponents of other views as dissidents. If, for example, estimates had stayed with WHO, they would have been reviewed and challenged by experts and champions of other diseases who would have alerted them to basic errors."

So what does the future hold? There is talk that the organisation needs a major overhaul - meaning making it smaller, leaner, and far better managed. Another expert told The Lancet: "There is a widespread perception that previous appointments and promotions were due largely to perceived individual loyalty to the outgoing Executive Director." He suggests that all major positions should be re-competed on merit, with an open selection process and an emphasis on recruiting the best, most qualified, most objective scientific specialists. Piot himself believes the key challenges for his successor will be to sustain the visibility, money, and leadership on AIDS. He says: "That will require a very skilful combination of politics and not making any compromises on the scientific evidence and the human rights components."

Full Special Report: http://press.thelancet.com/UNAIDSfinal.pdf

Source:
http://www.lancet.com

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