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Belgian doctor, Peter Piot, the former executive director of UNAIDS, is moving onto new challenges following his nearly 13-year tenure at the agency. Piot, now a Fellow and senior advisor of the Gates Foundation, will head up a new ground-breaking Global Health institute at Imperial College in London in April. He is also a driving force behind the aids2031 initiative, intended to outline the future of the disease over the next 25 years. Looking back, Piot explores the key issues regarding AIDS, including the need to mobilize the public - and the media - to take advantage of the scientific knowledge that has been acquired so far.

For Dr. Peter Piot, both a medical specialist and a scientist, dealing with AIDS over the past 25 years has been a challenge. Piot predicts that the next quarter century will be even more difficult. “When I look back at how we handled AIDS,” he says, “it is not that some things failed, and others worked. It is that we began acting on a massive scale far too late.” As Piot sees it, the results show that what we are doing is still not enough.

The Belgian-born, former head of UNAIDS - the coordinating agency for the disease of the United Nations - warns that unless the international community develops a new approach, it will fail to halt the epidemic. This is particularly true in Africa which has been the hardest hit by the pandemic. The key to the future, Piot maintains, is better leadership and more effective prevention. That means involving the public with the media as a key tool.

Piot points out that even if the international community, which has already poured billions of dollars into fighting HIV/AIDS, is unable to completely eliminate it, the disease can be reduced to an acceptable level in a number of countries. Piot elaborates: “By that we mean a level with which we can live.” Not all countries, however, will be so lucky. Reducing HIV/AIDS to a sustainable level will require difficult choices in how we approach the future. It will also require a far more open and widespread debate focusing on prevention. “This is crucial,” Piot says, “But it has not happened yet.”

Today, an estimated 32 million or more people (figures vary) are living with AIDS. Of these, four million people, one in eight, are receiving anti-retroviral treatment. The idea is to use a combination of several drugs at the same time to deliver a knock-out punch, essentially attacking the retrovirus on multiple fronts so that it cannot defend itself. Treatment is not a cure, but it can keep people alive for years, if not decades, enabling infected parents to continue providing for their children, and, if they are lucky, to live long enough to see them reach adulthood.

For many people and some countries, however, retrovirals are either too expensive, or difficult to obtain. If real progress is to be made in the years ahead, Piot points out, there will need to be a much greater focus on prevention.

One of the major challenges in dealing with AIDS in the coming 25 years is that success will depend on applying the medical knowledge that we already have rather than counting on dazzling new scientific breakthroughs. Discipline and routine will be the key, and the challenge will be to keep the public involved over the long haul. “Quite frankly, this is not very sexy,” Piot says. “It will be much harder to inspire people and to keep them interested. Up until now, it has been relatively easy.”

Piot also points out that the generous funding that AIDS has managed to garner over the past decade may not be there in the future. Growing competition with other issues, such as climate change, is certain to compete for scarce funds. The current financial crisis is another problem as government donors and other traditional sponsors cut back, prompting the need for the private sector to become more involved.

As a result, a growing number of experts believe that it makes sense to mainstream AIDS by integrating it into basic health approaches, especially in Africa where stigmatism often discourages people from seeking help. Up till now, they say, AIDS has been regarded by some, particularly in North America or Europe, as a “unique” disease deserving its own special attention. The reality in many parts of Africa, where the majority of people are confronted by poverty or the lack of clean water and sanitation, suggests that society can ill-afford to differentiate among killer diseases, whether AIDS, malaria or dysentery.

What is different at the end of the first decade of the 21st century, Piot insists, is the ‘how.’ “People need to understand what AIDS is all about and what needs to be done.” For him, this means "involving the expertise of communications and marketing professionals, such as Procter and Gamble. That is what good business does.” Furthermore, he considers increased emphasis on public awareness as crucial to creating profound change in the struggle to control AIDS.

Until now, efforts at promoting prevention have produced only moderate results.  Prevention, however, will begin to play a more central role in the coming years. “We have no other option until we find a vaccine,” Piot adds. “It’s not rocket science.” The challenge is to persuade governments, the private sector and the population-at-large to support more effective action.

Overall, Piot observes, society has been gaining against AIDS. The turnaround began fairly recently in 2006 or 2007. “A smaller percentage of people are dying, and unless more people get infected, we’re looking at containing it,” Piot says. “But it is still at an unacceptable level.” The decline in the rate of new infections corresponds directly to the massive rollout of antiretrovirals. An average of two million people die from AIDS-related diseases every year while an additional 2.5 million are infected. “People are learning,” Piot says, “that unless you have treatment, you die.”

While the largest AIDS-infected population is in Africa, emerging economies like India and China are also beginning to come to grips with its impact on these societies. For the moment, Piot points out, the incidence of AIDS is relatively low compared to their overall populations. “But this means one needs to act now before it gets out of hand,” he says.

As Piot sees it, societal norms need to change, particularly with regard to sexual habits. The most difficult issue is homosexuality, but drug injection is also a problem, especially in Pakistan and Afghanistan. At the same time, he notes: “We have already seen a big change in attitudes. People are talking more about AIDS and what it can do.”

Piot contends that the spread of AIDS in these areas can be affected by a variety of factors. In Africa, the disease is spread by men with disposable income. In China it is by poor people who inject drugs. Ironically, the country where AIDS is in the steepest decline is Zimbabwe, which was the first country to adopt a large-scale community prevention programme. It is generally felt that the real reasons for the decline is a general decrease in sexual activity brought on by the crisis that is affecting the whole country.

Another pivotal issue for the global spread of AIDS in the future is migration. In China, for example, some 120 million people are part of a floating population that constitutes a geographically mobile health risk. In Africa, population pressure is driving young men and women to emigrate to neighbouring countries or Europe. Piot believes that coping with the diversity of factors affecting HIV/AIDS will increasingly require tailored prevention programmes. “There needs to be a global brand for AIDS prevention,” says Piot, “but one that can be customized to be understood locally.” The concept resembles MTV, which maintains a global brand, but presents itself slightly differently in each country.

As part of the 2031 initiative, Piot is convinced that it is essential to take a closer look at the role of gay communities, especially sex between men. It is necessary to identify where it has been driven underground and where is it coming out in the open. While AIDS has been spreading relatively slowly in Asia, it is increasingly important to understand the mechanisms of how it is spreading, and to identify the developing trends. Even if the overall percentage of people in Asia remains relatively low, Piot points out, "we are still talking about a huge number of people."

The future course of the pandemic is unpredictable. New trends, for example, are  emerging in Africa with regard to gay sex, a hidden phenomenon until now, but believed to represent 5-8 percent of the population. Far from abandoning the struggle against AIDS, Piot plans to use his new Global Health Institute at Imperial College in London to take the fight to a new level, reaching out to both policymakers and general populations.

Moving beyond a purely medical approach, Piot intends to use media, public advocacy and social analysis in an innovative initiative designed to improve public awareness and to change the way the world perceives the disease. The institute will also take a comprehensive approach to other diseases such as tuberculosis and diabetes which have a growing impact, especially in Africa.

For Piot, who is extremely well-read in literature and has a firm grasp of a broad array of scientific subjects, this is the continuation of a decades' old personal struggle. This began in Africa in 1976, when Piot and a team of doctors and researchers were sent to what was then Zaire to investigate the outbreak of a mysterious hemorrhagic disease that was rapidly killing off villagers. They discovered a new and deadly virus which he and his colleagues named “ebola”after a nearby river. Despite the danger, Piot had flown to the site of the epidemic in order to escape the endless discussions by health and government experts in Zaire’s capital, Kinshassa.

When he and his fellow investigators walked towards the stricken clinic, where the victims had been brought, he encountered a crowd of villagers standing next to an ordinary clothesline that served as a “cordon sanitaire” marking the limits of the quarantined area. “If you step over that rope,” a terrified Congolese told him, “You will die!” Piot smiled and stepped over the line. The incident is symbolic of the rest of his career. A photograph in Piot’s office at UNAIDS shows him in the midst of fellow doctors and villagers standing next to the rope.

On the surface, ebola and HIV/AIDS would not seem to have much in common. In fact, it was very fitting that Piot has devoted so much time to both diseases, which rank as among the most deadly health threats confronting the human race today.

HIV/AIDS is arguably the deadlier of the two. It certainly has the largest impact on public health. Ebola, which is particularly virulent, kills its victims so quickly that epidemics tend to burn out before they have a chance to spread over a wide area. Victims die a horrible death, but there are not that many and epidemics are relatively easy to isolate and bring under control. In contrast, HIV/AIDS is more lethal on a larger scale because it takes so long to reveal itself that it can spread over a huge area before the danger becomes apparent.

The BBC recently produced a half-hour documentary looking at HIV/AIDS as a perfect example of Darwinian evolution. The retrovirus multiplies thousands of times faster than ordinary viruses. Scientists had worried that it might eventually mutate into a form that could become much more contagious. One fear is that it could  spread by air, but Piot says that so far there is no sign of that happening.

Piot’s reputation was already firmly established before he took over UNAIDS. “I actually got involved in this area by first working in Africa on sexually transmitted diseases,” he explains. “I took part in a mission to Kinshasa in 1983 to see whether an emerging virus there was the same as one described in the United States. We were seeing hundreds of patients from Africa in Antwerp. We figured that as these were people who could afford to come to Europe for treatment, there were probably thousands more we did not know about. When we got there, the majority had AIDS.”

Because Piot had taught public health at the Institute of Tropical Medecine in Antwerp as well as the universities of Nairobi, Brussels and Lausanne, many of the doctors now working with Medecins sans Frontieres, International Red Cross, the World Health Organization and various health ministries around the world have come to know him in the course of their careers.

In the 1980s, Piot launched a series of collaborative projects in Africa, such as Ivory Coast and Kenya. He also set up the first international project on AIDS in Africa, effectively putting the current understanding of HIV infection in the region on the map. Piot’s strong advocacy has encouraged numerous world leaders to treat the phenomenon not just as a disease but in the context of social and economic development as well as security. He has also helped develop a common worldwide action against AIDS.

Nevertheless, Piot is not without criticism for having turned UNAIDS, which was initially intended to serve as a modest coordinating body into a major agency in its own right, treading on other agencies’ turf-ruffled feathers. “The whole point of UN reform and efficiency is to reduce bureaucracy,” says a senior International Labour Organization official. “Why is UNAIDS doing WHO’s job?” The history of UNAIDS actually dates back to the days when WHO sought to control debates - and policy approaches - within its own organization on how to deal with the disease.

Despite these past tensions between the two organizations, the UNAIDS secretariat is currently headquartered in its own recently-built multi-story building opposite WHO headquarters. Today, UNAIDS has offices in some 80 countries around the world.

Now almost 60, Piot believes that the fight against AIDS is entering a new phase which will be far trickier than anything previously experienced. It will be far more difficult in many respects than the past decade or so when the disease benefited from rapidly expanding worldwide concern and funding. The danger now is that the fight against AIDS risks being lost as public perception moves from an absolute death sentence to a chronically manageable disease.

What complicates matters is that AIDS is not just a medical problem. Cultural, social and economic factors influence it as well. “Initially, the big problem was across-the-board denial about the disease itself,” says Piot. “Particularly in the United States, Europe and western countries, it was seen as a disease of shame and homosexuals.” The people most likely to suffer were considered “marginal” by mainstream society. The result was panic followed by isolation. In Belgium, for example, the police were not allowed to hire people with AIDS. Nor could any foreigner be given a scholarship.

Today, AIDS is considered to be primarily an African problem. Significantly, it was only in 2001 that a special session of the UN General Assembly tackled the issue, the first time in fact that a health concern was discussed in New York. In retrospect, the meeting may seem like a case of too little, too late, but it did result in the creation of the Global Fund Against AIDS. This has since become the Global Fund Against AIDS, Tuberculosis and Malaria and is based in Geneva.

At the same time, the Bush administration in the US launched the Emergency Plan Against AIDS. Both efforts, along with others by other philanthropies like the Gates Foundation, have had a significant impact. But it is only a start in building a global defense against what has actually become one of the world’s truly global diseases.

Piot’s concern, as he moves to establish the new global health center, is that other threats ranging from the current financial crisis to climate change may lull us into forgetting just how dangerous and unpredictable HIV/AIDS really is.

Edward Girardet, a former correspondent of The Christian Science Monitor,  and William Dowell, previously with TIME, are both experienced journalists  focusing on conflict, humanitarian and other global  issues. They are currently writing a book on the future of AIDS as part of the aids2031 initiative.