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May 15, 2006 issue - If it's Saturday, this must be Nairobi. Dr. Peter Piot is blinking into Kenya's brilliant savanna sun. The 57-year-old Belgian has just crawled off an all-night flight from Geneva, and he's stumbling through an industrial slum called Majengo. He's due in Rwanda tomorrow night to lead a gaggle of dignitaries through a week of official visits in two countries. But today's outing is not a protocol event. It's more like a pilgrimage. On the eve of the AIDS pandemic's 25th anniversary, the man charged with steering the global response has come home to a place where he learned how to fight it. Majengo doesn't look like a medical mecca. It's a ragged jumble of mud-brick huts and open-air markets—a place where traveling traders hock secondhand T shirts and women sell sex for pennies. But this forlorn district, known formally as Pumwani, has been a seedbed of discovery for two decades. It was here, in a small clinic for sexually transmitted diseases, that researchers first realized HIV was spreading in East Africa and that circumcision and STD treatment could help slow it. This is where scientists discovered that some people are essentially immune to the AIDS virus, remaining HIV-negative even after years of constant exposure. Most important, this is where an ebullient, 90-pound nurse named Elizabeth Ngugi showed the world how to turn mere victims into advocates for health.

When the Majengo clinic opened its doors in the early 1980s, nobody came. After years of being demeaned by imperious doctors, the district's 2,000 sex workers had stopped seeking treatment—even free treatment—for chancroid, syphilis and gonorrhea. And most had learned not to push condoms on their clients. If a man objected—and most did—he could simply take his 50 shillings next door. "Nobody had ever gone to these women and said, 'You are human!' " Ngugi explains as Piot embraces old friends. "So I walked in the mud and I talked with them in the alleys where they work. I said, 'Hey! Do you have a problem with sexually transmitted diseases? We are here! We won't judge you. You are children of God'." Penicillin wasn't all she had to offer. Ngugi suspected the men would settle for safer sex if the women presented a united front, and experience proved her right. Condom use shot from 4 percent to more than 90 percent as the sex workers banded together—an increase that has prevented some 6,000 to 10,000 new HIV infections every year since. "You can't just tell people to make better choices," she concludes with a husky guffaw. "You have to give them the power and the tools."

Piot was here when it happened, and the experience informs his vision as the director of UNAIDS, the United Nations' Joint Program on HIV/AIDS. "If we've learned anything in 25 years," he says as a bodyguard shadows him through Majengo's cacophonous streets, "it's that communities can take control of this problem. Our role isn't to rescue them. It's to support them." But how? The question has never been more urgent. Worldwide, some 5 million people are now contracting HIV every year, and 3 million are dying of AIDS—90 percent of them in developing countries. How did the situation get this dire, and what are the prospects for turning it around? Piot's life offers a window into both questions. As a doctor and a scientist, he watched world leaders deny the problem for nearly two decades. As an advocate, he has recently helped spark an explosion of money and concern. But as an officeholder, he now faces an even more daunting challenge. He calls it "making the money work." Can $8 billion and a bundle of good intentions put an end to AIDS? The hurdles have never been higher, but Piot has never felt more hopeful. This is his story.

The Kinshasa Connection
Piot's style doesn't say "under-secretary-general of the United Nations." He's a gangly academic with an easy smile and a soft, melodic voice. He favors jeans and tropical shirts over crisp suits. And though he travels among presidents and prime ministers, he seems most at home among researchers and grass-roots activists. He grew up in a small Belgian farm town called Keerbergen, idolizing the reformers who were then freeing Africa from centuries of colonial rule, and he left home at 18 to study medicine at the University of Ghent. "My professors assured me there was no future in infectious disease," he recalls, "so of course that's what I chose as my specialty." He married after medical school, and accepted a research post at the Institute of Tropical Medicine in Antwerp. That's where he encountered the parcel that would determine the course of his life. It arrived in the fall of 1976 from Kinshasa, Zaire, the capital of the former Belgian Congo. It contained pieces of a dead nun's liver.

The nun had died of a deadly new hemorrhagic fever that had broken out in Zaire's remote interior. The disease ran a fast course from fever and diarrhea to bleeding, shock and organ failure, and its cause was still a mystery. As Piot and his colleagues puzzled over the tissue samples, the World Health Organization called to ask if someone could join the task force that was gathering in Zaire to investigate the outbreak. Within days, the scruffy 27-year-old found himself in the middle of a central African rain forest, quarantining terrified patients and wondering whether he'd soon suffer their fate. "All we knew at first was that people were dying," he recalls. "Was it food? Water? Sex? Mosquitoes? We didn't have a clue." The investigation yielded a brand-new pathogen—the dreaded Ebola virus—and Piot went home with a new respect for the killing power of sex. By collecting semen samples from men in stricken villages ("A challenging assignment," he recalls. "Our hand gestures didn't seem to ring any bells."), the researchers had identified sexual contact as one route of transmission. If sex could spread a virus this deadly, what else could it spread?

It was a ripe moment to ask that question. STDs were on the rise worldwide during the late ' 70s, and Piot had no trouble finding opportunities to study them. He spent the next couple of years in Seattle, helping University of Washington researchers track outbreaks of everything from gonorrhea and syphilis to herpes and human papillomavirus. Gay men were being hit especially hard, and their problems were even more diverse. Shigella, giardiasis and amebiasis all raced through the bathhouse circuit—and in 1981, something even stranger turned up. Shortly after returning to Antwerp, Piot read a report from Los Angeles describing five young men—all "active homosexuals"—who'd suffered months of thrush, fevers and weight loss before dying of pneumocystis carinii pneumonia. Something had ravaged their immune systems, but the doctors had no idea what it was. They speculated that "some aspect of a homosexual lifestyle" might play a role.

That impression stuck as the epidemic grew, but it was soon clear that this was more than a gay plague. Needle users, hemophiliacs and transfusion recipients were soon falling sick all over the United States and Europe. And in France and Belgium, many of the early patients defied all of these categories. They were ordinary middle-class heterosexuals—and they all happened to come from equatorial Africa. In the fall of 1983, Piot and a Belgian colleague joined four Americans on a three-week trip to Kinshasa to see what was going on. And as Piot tells the story, the truth was evident the minute they saw the sprawling wards of the city's Mama Yemo Hospital. "It was a punch in the stomach," he says. "People just my age were packed two and three to a bed—even under the beds—and they were all dying." By monitoring newly admitted patients for three weeks, Piot's team confirmed that AIDS was spreading through heterosexual contact in Zaire. The British medical journal Lancet published their findings a few months later, flanked by a similar report from neighboring Rwanda. "[Our] findings strongly argue that the situation in central Africa represents a new epidemiological setting for this worldwide disease," Piot's team concluded—"that of significant transmission in a large heterosexual population." There it was: a dead-on description of what was in store for Africa and the world. Unfortunately, country after country would spend the next 15 years trying to deny it.

It Can't Happen Here
By the end of 1983, aids cases were turning up in 28 nations, and a scientific gold rush was beginning. Piot spent the mid-' 80s shuttling between Antwerp and Kinshasa, where he helped U.S. and Zairian health experts launch a prolific research effort known as Projet SIDA (Project AIDS). Around the world, the pace of discovery was brisk. Over the next few years, French and American researchers zeroed in independently on the virus responsible for the disease—a slow-acting retrovirus apparently descended from similar pathogens that infect African primates—and the first HIV blood tests reached the market. By 1986, scientists had also discovered that AZT, a failed cancer drug, could help keep the virus in check. HIV would prove far too clever for a single-drug treatment, but the finding set the stage for a biomedical revolution.

Politically, the progress wasn't nearly so brisk. Dr. Joseph McCormick, one of the Americans who took part in the groundbreaking Kinshasa study, was among the first to hit a wall. When he returned from the three-week investigation, his bosses at the CDC were so awed by the findings that they gathered around a speakerphone at the agency's Atlanta headquarters to brief an assistant secretary of Health in the Reagan administration. "I tried to spell out everything as simply and as clearly as possible," McCormick recalls in his 1997 memoir, "Level 4." "There followed a long silence on the other end." The Health and Human Services official spent the next 20 minutes arguing that McCormick was surely mistaken about heterosexual transmission, and suggesting that he explore the role of mosquitoes in spreading AIDS. McCormick tried explaining that mosquito-borne illnesses don't cluster around sexual contacts, but that was a nonstarter. "I was stunned by the depth of denial," he writes. "If AIDS was going to have an explanation, it would have to be more politically and socially acceptable than the one we had to offer." Reagan himself never publicly used the word "AIDS" until 1987, when he started advocating abstinence-only prevention efforts—along with rules barring HIV-positive visitors from entering the country.

The response was no more encouraging in other countries. Despite exceptions like Uganda—where bold, broad-based awareness campaigns helped contain HIV after it broke out ferociously during the ' 80s—most political leaders greeted the waves of bad news with walls of silence. Kenya hadn't heard much bad news when Piot arrived in 1985 to spend a year working in Nairobi's Majengo district, but the country was obviously vulnerable. Majengo was a magnet for impoverished women from Tanzania's hard-hit Kagera region (which borders Rwanda and Uganda) and a pit stop for truck traffic from all over central Africa. Was HIV incubating silently in this hothouse? To find out, researchers analyzed blood samples from 90 local sex workers. An astounding 66 percent of them tested positive—as did 8 percent of the men treated at a nearby STD clinic and 2 percent of health workers from around the city. The New England Journal of Medicine published the finding in February 1986, and Majengo's sex workers launched their now famous prevention effort. When Piot and a Canadian colleague discussed their work with a British newspaper, the government responded by detaining them. "They held us in a room while the officials debated whether to expel us from the country," he recalls. "It was like we'd leaked a state secret."

Messages and Messengers
As officials at the world health Organization watched the disaster unfold, a sense of dread set in. Someone needed to shake the world to its senses, but the agency wasn't set up for advocacy, so the directors started looking for someone who could help. They got what they bargained for when they hired Dr. Jonathan Mann, the young American epidemiologist who had headed Projet SIDA in Zaire. "Jonathan was the first rock star of global health," says Dr. Jim Yong Kim, a Harvard physician and veteran AIDS warrior. "No one in this field had ever electrified people the way he did." Mann joined the WHO in 1986, and managed in just three years to build a global AIDS program with 400 staffers supporting dozens of national initiatives. But Mann's star fell as fast as it rose. The donors who backed his $90 million-a-year effort cooled on it as they realized it wouldn't yield the quick results he advocated. And in 1989, the WHO got a dour new director named Dr. Hiroshi Nakajima, who had little interest in AIDS and no use for Mann's showmanship. Their relationship went from bad to unbearable, and it ended on March 11, 1990, when Mann submitted a bitter resignation and headed home to the United States. He would die just eight years later when a Swissair flight crashed en route from New York back to Geneva.

Piot worked closely with Mann during the ' 80s, and still reveres his energy and idealism. But as strategists in the fight against AIDS, the two men had a fundamental difference. Mann believed—as many experts still do—that standardization was the key to an efficient global response. He dreamed of concocting an effective model for tracking, preventing and treating HIV infection—and delivering the whole package to hard-hit countries with the urgency of disaster relief. Piot doubted that blueprints conceived in Geneva, however enlightened, could fully address the unique circumstances that make different countries and communities vulnerable. "Coming in from the outside to hang up posters doesn't work," he says. "You have to convince people that they have rights worth fighting for, and that progress is feasible. That's when tests and posters and condoms start to make a difference." Piot had seen that happen in Majengo, and by 1992 he'd seen it in other places as well. In Europe and the United States, gay men were taking to the streets to promote safer sex and demand better medicines. In Uganda, a local support group called TASO had spawned a national network to care for patients and orphaned children. In Kolkata, India, prostitutes as poor as Nairobi's were uniting to demand safer working conditions. Could a U.N. agency nurture such efforts on a global scale? When Mann's successor offered Piot a post at the WHO's beleaguered AIDS program, he stowed his test tubes and moved to Geneva to find out.

The WHO program continued to wither after Piot arrived in 1992, and a bold new idea started to circulate. AIDS was now killing a million people a year—and the impact was growing as children lost parents, schools lost teachers and economies lost workers. Several U.N. agencies were now wrestling with the consequences, but no one was coordinating their efforts. The new idea was to fold the WHO initiative into a broader one—a joint U.N. program on HIV/AIDS. UNAIDS wouldn't belong to one agency but would lead them all in a cohesive response to the pandemic. Dr. Michael Merson, the WHO veteran who inherited Mann's program, actively pushed the new scheme, and the United Nations approved it in late 1994. In theory, the path was now clear for a bright new era in AIDS control. "I thought we could mobilize the whole U.N. family," says Merson, now dean of the Yale School of Public Health. "I thought we could work together rationally to address sex work, drug use, underdevelopment—all the issues that fuel this epidemic." Piot was jazzed, too. After considering a half-dozen prominent AIDS fighters to head the new program, the United Nations named him the founding director.

It's the Economy ...
The warm feeling didn't last long. "The games started the minute UNAIDS was created," says Merson. "The resistance came from everywhere." Countries that had supported the new program were suddenly more interested in keeping it cheap than in making it work. Foreign-aid officials from the United States and Britain were especially aggressive, seeking to limit its budget to $40 million a year and confine its operations to Geneva (a demand that prompted a shoving match between Piot and a senior British official at an early public meeting). The mood was no friendlier inside the United Nations, where the joint program's turf-conscious partners escaped oversight by starving their own AIDS programs. The WHO, the World Bank and UNICEF all slashed their AIDS budgets after UNAIDS opened for business in 1996, and things didn't improve much during the 1990s. Piot was still an outsider among high-level policymakers, and unsure how to engage them. "I probably should have been bolder," he says. "I didn't know how much access I had."

So he pulled back to work on what he calls "the evidence base." He sought out local initiatives that might teach large lessons—that needle-exchange programs reduce infection rates among drug users, for example, or that treatment is feasible in places that lack well-equipped medical facilities—and supported them with small grants. He also dispatched scientists to help governments and relief agencies reconcile the jumble of statistics on the disease and its impact. The picture that emerged from that exercise was devastating. In 1997, UNAIDS estimated that 30 million people were living with HIV worldwide—an increase of 8 million over the previous year's spottier estimate. AIDS had killed some 2.3 million people in the past year, and the virus was now racing through the South Asian countries of India, Bangladesh, Nepal and Burma, where an estimated 3 million people were now infected. But if this technical work impressed health experts, it was largely lost on politicians and the media. As Greg Behrman notes in his 2004 book, "The Invisible People," America's international AIDS budget averaged just $100 million a year throughout the ' 90s, even as the domestic tab rose to $10 billion.

Then, as the millennium approached, Piot had an awakening. "I asked myself what political leaders really care about," he says. "The truth is, it's not health. It's economics and security. Health is what they talk about if there's money left at the end of the day. I realized I needed to lift our cause out of that arena." So he honed a new pitch, and started courting diplomats, business leaders and the foreign-policy establishment. AIDS was no longer just a humanitarian crisis, he argued. If it continued to eviscerate schools, health systems and civic institutions in poor countries, it would undo decades of economic progress and threaten global security. Suddenly, he had an audience. In January 2000, U.S. Ambassador Richard Holbrooke and Vice President Al Gore took the issue to the U.N. Security Council, which held its first-ever summit on a disease. The U.N. General Assembly followed in 2001, convening delegates from more than 100 countries for a five-day special session on AIDS. In a 20-page declaration, countries once trapped in denial now acknowledged the disease as "one of the most formidable challenges to human life and dignity" and embraced ambitious goals for responding to it.

Declarations are cheap, of course, but the new millennium brought money as well as promises. AIDS deaths had plummeted in the United States and Europe during the late'90s as drugmakers developed new anti-HIV medicines and researchers learned to combine them in potent cocktails. The cost of those drugs fell precipitously at the start of this decade, yet 95 percent of the developing world's 6 million ailing patients still lacked access to them. "The point came where sitting back to watch people die was just too obscene," says Dr. Allan Rosenfield, dean of Columbia University's Mailman School of Public Health. "The question changed from 'What can we do with the resources we have?' to 'What will it take to address this crisis?' " The first breakthrough came in 2002, when 50 countries came together to create the Global Fund to Fight AIDS, Tuberculosis and Malaria. Then, in 2003, President George W. Bush announced a separate U.S. program with a five-year budget of $15 billion. U.N. agencies renewed their commitments as well, and in December 2003 the WHO tapped Harvard's Jim Kim to launch a worldwide treatment crusade. The so-called 3 by 5 Initiative, which UNAIDS cosponsored, fell short of its target (3 million on treatment by the end of 2005), but it helped triple the number of people with access to drugs (from 400,000 to 1.3 million) in just two years.

The Endgame
No one denies the urgent need for more treatment. "Here we are in 2006," says Stephen Lewis, the Canadian firebrand who serves as U.N. Secretary-General Kofi Annan's special envoy for AIDS in Africa. "Fewer than 10 percent of HIV-positive pregnant women are getting the simple interventions that could keep them from infecting their babies. Only 20 percent of the people who need drugs have access to them. There comes a point where we need to stop the meetings and discussions and just get the goddam thing done." But as agencies and activists rally to that call, they risk losing sight of a larger challenge. Treating AIDS may restore lives and revive hope, but it's not a strategy for ending the epidemic—not when 5 million people are still contracting HIV each year. "If we don't get serious about prevention," says Dr. Seth Berkley, director of the International AIDS Vaccine Initiative, "the demand for drugs will drown us."

Vaccines, microbicides and other new technologies may someday make prevention easier. But the job is no more glamorous today than it was when Elizabeth Ngugi started walking the alleys of Majengo two decades ago—and the issues are no less contentious. Moral consensus is easy when a sick child needs lifesaving medicine, harder when deep-seated biases and beliefs need rethinking. But Piot believes that a workable consensus is achievable. The secret, as he defines it, is to find small patches of common ground to stand on. "The people who fight with each other over condoms and abstinence are all fundamentally pro-life," he says, citing the news that Pope Benedict XVI is reviewing the Roman Catholic Church's blanket ban on condoms to prevent HIV transmission within marriage. "If we can all agree that sex should not spread death, then we can reason with each other on how to keep that from happening. And if condoms are pro-life in one situation, maybe they're pro-life in other situations."

That's a modest foundation for optimism when 40 million people are living with the AIDS virus and 8,000 are dying every day. But Piot figures that you build on what you've got. The global picture may look grim, he says, but the seeds of success are everywhere. Until recently, Uganda, Thailand and Brazil stood as lonely beacons of hope. But infection rates are now falling in many parts of East and central Africa—and Kenya's HIV prevalence has declined by half since the mid-1990s. "I've been tooling around Africa for a long time," he muses over a nightcap in a Rwandan hotel bar, "and I can tell you things are changing. I see it everywhere I go. Men and women are feeling less helpless and ashamed. Whole communities are standing up to take their destinies in hand. If we can tap that energy and combine it with the resources of the rich world, I think we're going to see tremendous progress over the next few years." If it can happen in Majengo, it can happen anywhere.