Biography
Piot, the eldest of four children, grew up in the Belgian village of Keerbergen. His mother worked in her family’s construction business and his father was an economist who became a senior civil servant in the Department of Agriculture, promoting Belgian agricultural goods abroad. Piot nurtured a fascination with Father Damien, a Catholic missionary who worked with lepers in nineteenth-century Hawaii. He started studying engineering at the University of Ghent, but soon switched to medicine, as this would better fulfil his desire to travel and help people, particularly in Africa. He developed an interest in microbes and studied clinical microbiology. When he considered specializing in infectious diseases, his professor of social medicine told him that there was no future in this field: ‘They’ve all been solved’ (Piot 2012: 6). Piot finished his studies in Ghent in 1974, inspired by a course at the Institute of Tropical Medicine in Antwerp. To write his doctoral thesis, he became a research assistant in the microbiology laboratory of Stefaan Pattyn at the Institute. In 1976 a thermos with blood samples was flown in from Kinshasa, Zaire (later Democratic Republic of Congo), related to an unidentified virus and a mysterious epidemic with hundreds of victims in the Yambuku region. The Institute conducted virological examinations and observed a cytopathic effect on vero cells with an isolate that looked like Marburg virus. The World Health Organization (WHO) had noted a similar outbreak in southern Sudan and instructed Pattyn to ship all biological material and samples to a better equipped English laboratory, which sent them on to the Centers for Disease Control (CDC) in Atlanta in the United States (US). Pattyn continued examining some material he had retained. Piot felt they had to go to Zaire to check out the epidemic, but they did not have travel funding. The CDC reported that it was a new virus, which did not react to Marburg antibodies. Because the Americans and others were going to Zaire, the Belgian government felt pressured and funded Pattyn and Piot’s travels.
Piot stayed over three months, being the least experienced among the specialists of the International Commission on Haemorrhagic Fever in Zaire, among them CDC Chief of Special Pathogens Karl Johnson, American Joel Breman and Zairean Health Minister Nguete Kikhela. Piot drew from his practical laboratory experience and translated for Johnson, who did not speak French. He volunteered to visit the epidemic zone and coped with rough conditions, difficult travel connections and numerous meetings, which he detested. Life in Belgium, where his wife was pregnant, seemed far away. The observations revealed that reused syringes had helped to spread the virus. Two survivors were located and their blood allowed the identification of antibodies. Antwerp colleague Guido Van Der Groen installed a field virology laboratory. The now-identified virus was named for a local river: Ebola. The last Ebola victim in Yambuku died in November 1976. Piot remained to keep watch for new cases and used the time to learn what information local women and men were reticent to share with medical professionals. As the International Commission’s Director of Operations, he hired people for the distribution of food and equipment. With Breman as his mentor, he ‘was finally learning epidemiology in practice’ (Piot 2012: 89). Piot handed post-outbreak surveillance responsibilities over to CDC medical epidemiologist David Heymann and returned home just before Christmas.
In 1977 Piot participated in a WHO mission to Swaziland focused on sexually transmitted diseases (STDs). He designed a flow chart to help nurses identify diseases without laboratory tests. Because this was an area where he could contribute, he started his doctoral work on STDs. In addition to his work at the Antwerp Institute he began seeing patients in the Clinic for Colonials and Seafarers and was co-founder of the International Society of STD Research, a group of young people aiming to transform the field. He obtained two fellowships in the US in 1978. He took a CDC training course in Atlanta, where he met Johnson again, and drove with his wife and son to Seattle to work with King Holmes at the University of Washington, the main researcher applying scientific methodology to the study of STDs at the time. Holmes worked with a variety of specialists. Piot learned about modern microbiology, American society and fundraising. He also worked on gonococcal plasmids and bacterial taxonomy in the microbiology laboratory of Stanley Falkow, a mentor for life. He returned to Antwerp in 1979 and opened a small STD clinic at the Institute. He began to appear in the news media, as he noticed a rise of chlamydia among heterosexuals and serious epidemics of STDs in the gay community. In 1980 he finished his thesis in Antwerp, set up a foundation to fund research projects and established, together with Ugandan Herbert Nsanze and Canadian Allan Ronald, an enduring international research and training collaboration at the University of Nairobi, using a new antibiotic for chancroid treatment. While men dominated research in Africa, most researchers engaged in Nairobi were women, which resulted in research on the effect of infections on pregnancy outcomes and infertility.
In 1981 a new syndrome related to gay men in the US was discovered, whereas Piot in Antwerp saw similar effects among both male and female patients without homosexual contact but with an African connection. The disease name became Acquired ImmunoDeficiency Syndrome (AIDS) in 1982. Piot found no interest from funders to check developments in Central Africa, but together with Thomas Quinn, who represented the National Institutes of Health (NIH), and Joseph McCormick from the CDC, two rivalling US institutions, Piot became the team leader of a joint investigation in Zaire, together with Bila Kapita of the Mama Yemo Hospital in Kinshasa. They found cases of what they thought to be AIDS but their article in The Lancet (July 1984) was met with scepticism, as at the time AIDS was considered a homosexual disease, with Africa being irrelevant. Researchers also took time to accept that HIV (Human Immunodeficiency Viruses) could be transmitted from women to men. Piot’s research grant proposal for the NIH was not funded as the CDC started a project to study AIDS in Zaire in 1984, known as Project SIDA (after the French acronym for AIDS), led by US epidemiologist Jonathan Mann, who saw that the epidemic would have a major impact on society. Mann contacted Piot and agreed that the Antwerp Institute became a partner in Project SIDA. Piot insisted that the project needed to invest in training Zairians, found Belgian resources and pioneered mother-to-child transmission studies as well as prevention of HIV among sex workers. Project SIDA became the largest biomedical research project in Africa and was overseen by Jim Curran (CDC), Anthony Fauci (NIH) and Piot.
Apart from the complex relationship between the two US institutions, relations with the WHO were also problematic. Director-General Halfdan Mahler saw AIDS as a problem of wealthy countries and as less dangerous than tropical diseases, while the WHO Regional Office for Africa refused to be involved. Yet in October 1985 the first conference on AIDS in Africa took place, followed by the creation of the Society for AIDS in Africa (1989), making Piot a member of the new community of African AIDS researchers. By the time 85 countries had reported cases of AIDS to the WHO, Mahler approached Mann, who agreed to leave Project SIDA and set up the WHO’s Global Programme on AIDS (GPA) in 1986. Piot supported Mann’s visionary GPA work but declined to join his team. He was increasingly becoming a manager and, still in his academic phase, briefly moved his family to Kenya to teach at the University of Nairobi (1986-1987). He became a notable speaker at international AIDS conferences, engaged with non-governmental organizations (NGOs) of AIDS activists, was elected President of the International AIDS Society (1991-1994) and became chair of the WHO’s GPA Steering Committee on Epidemiology and Surveillance. After Mann had left the WHO in 1991, because Director-General Hiroshi Nakajima restricted his room of manoeuvre, Piot helped successor Michael Merson to develop strategies. Piot succeeded in making the department for STDs a GPA division which improved working relations within the WHO. Merson asked him to join the GPA, but Piot did not concur until he realized that bringing AIDS under control required global policy action, while Mann had made him aware of the merits of the WHO’s influence, including attracting financing to support AIDS response in developing countries. Piot took a sabbatical leave from his work in Antwerp and moved to Geneva to work for the WHO in August 1992 as Associate Director of GPA. He had to reorganize the GPA research component and oversee the new division for STDs. As the GPA was tasked with the prevention of AIDS and providing solace to patients, he found Janssen Pharmaceutics willing to help, but WHO lawyers were not yet ready to deal with the private sector. Piot felt useful and, although still planning to return to Antwerp (he felt annoyed that WHO rules made his wife ineligible for full health insurance), agreed to stay for another year.
Given the disenchantment with the WHO’s management and efforts taking place to reform the United Nations (UN) System, it was argued that AIDS needed a higher profile organization. This resulted in the Joint United Nations Programme on HIV/AIDS (UNAIDS), with several UN specialized agencies as cosponsors. Piot was not part of this development, but he was approached to become the new entity’s head. He initially declined, but the lesser quality of other candidates, his strong bond with the AIDS community and support from some countries changed his mind. Some UN agencies seemed to sabotage him, but during the campaign more countries supported him, as did the WHO and its regional directors. On 12 December 1994 the Committee of Cosponsoring Organizations elected Piot as UNAIDS Executive Director, followed by UN Secretary-General Boutros Boutros-Ghali’s formal appointment. Piot immediately began to reflect on how to design the new organization, set to be operational in January 1996, first reflecting on its stakeholders. While cosponsoring agencies wanted Piot to be accountable to them, he opted for an executive board with representation from governments, people living with HIV and NGOs. Most of his staff came from the WHO’s GPA and were guardians of the WHO culture, but Piot managed to leverage their financial and administrative prowess. Later he stated that he should have broken more radically with the WHO bureaucracy. He recruited a committed senior team from a wide range of backgrounds, with whom he designed the core functions, structure and name of UNAIDS at a brainstorming seminar. Piot’s daughter designed the logo: a red ribbon over the UN logo. Unlike GPA, UNAIDS would not engage in research, but focus on political and resource mobilization, knowledge translation, policy development, evaluation of policies and action on AIDS and dissemination of good practices. Piot ordered media training for all senior staff, as UNAIDS had to speak clearly and with professional skill. He faced resistance to his work programme from the WHO, which wanted to keep its power over most issues. UNAIDS was also hindered by the lack of willingness of cosponsoring agencies to support proposals for unified approaches across the UN System. Piot learned diplomacy and negotiation on the job. His efforts to broker agreements among governments with diverse interests showed evidence of a learning curve thanks to the help of friendly diplomats. Australian Richard Butler, President of the Economic and Social Council, pushed through a resolution that UNAIDS was principally accountable to the member states (hence, not the cosponsoring agencies) and set up a Programme Coordinating Board to oversee the work. This board included representatives from community groups and people living with HIV: the first time a UN entity had civil society representatives on its board, albeit without voting rights. The process set down a legal foundation Piot could work with. However, the launch of the financial campaign on World AIDS Day, 1 December 1995, in New York failed because UNAIDS had not told UN Headquarters security that outsiders were expected and they were refused entry.
To deliver a credible message and build a global constituency UNAIDS needed solid data on HIV, success stories and clear strategies about what to do against the epidemic. Piot had to lobby hard to obtain a slot for his unknown agency at the 1996 International AIDS Conference to present the first attempts at standardized statistics, combined with the news that a combination of several antiretroviral drugs, taken simultaneously, could significantly prolong life and delay the onset of AIDS symptoms. The treatment, however, was incredibly expensive, particularly for developing countries. The next challenge was to unify the world’s AIDS strategies, including those of partner agencies. UNICEF and the WHO had problems with mother-to-child transmission of HIV, as they encouraged breastfeeding, while promotion of clean needles, methadone substitution and the use of condoms (all means to prevent HIV transmission) were often controversial. Establishing national offices to oversee the work at country-level created tensions with the WHO and UN Development Programme. Cooperation improved when new leaders were appointed, among them Jim Wolfensohn (World Bank) and Carol Bellamy (UNICEF). UNAIDS persuaded South African President Nelson Mandela to deliver a plenary address on AIDS at the World Economic Forum (WEF) in Davos in 1997. In 1998 Piot organized a brainstorming session with several outsiders to take the work of UNAIDS to its next phase, as the organization’s impact on the epidemic was negligible and it was constantly under attack from donors and activists.
Piot learned that UNAIDS was out of touch with political power and had to build a broader coalition beyond doctors, researchers and activists. He developed a strategy to influence ministers of finance through a more precise definition of the economic impact of AIDS, engaging the UN Security Council for its political clout, making UN Secretary-General Kofi Annan the world’s AIDS advocate and bringing AIDS to forums such as the WEF, G8 Summits and regional international organizations, while also connecting better with the AIDS community. He now concentrated on global diplomacy, including visiting heads of state. He reached an agreement with the Vatican that it would refrain from statements about condoms and AIDS prevention and UNAIDS would refrain from criticizing the church. US diplomat Richard Holbrooke helped to bring AIDS to the Security Council in 2000, where its destructive impact was discussed as a new threat to peace and security which needed a coordinated response, with UNAIDS developing long-term strategies to address the spread of the disease. This made ministers of finance more interested in economic losses due to AIDS and impacted the cosponsoring UN agencies. In June 2001 a Special Session of the UN General Assembly, attended by activists and NGOs, discussed detailed targets for the fight against AIDS, including the creation of a global health fund. African support and Annan’s connecting public call to action for a war chest to win the war against AIDS resulted in the UN’s creation of the Global Fund to Fight AIDS, Tuberculosis and Malaria in January 2002.
Given the need for universal access to antiretroviral treatment and the related high prices, Piot developed a strategy to guarantee that treatment would also be brought to Africa. He first needed to demonstrate that it was feasible to provide antiretroviral therapy to people in poor countries and then started to negotiate lower prices. Taking his Board members to an AIDS project in Kenya in 1996 resulted in the approval of pilot projects, which eventually showed that compliance with the therapy in developing countries worked, occasionally even better than in Europe and North America. In his discussions with senior figures in the pharmaceutical industry Piot proposed a new social contract, based on reasonable profits in high-income markets and new essential drugs at cost to developing countries. He also engaged in the issue of generic versions of antiretrovirals as developed in India. The WEF was a forum to discuss these issues, while WHO Director-General Gro Brundtland and Annan helped to convene meetings with pharmaceutical CEOs in the early 2000s. AIDS groups however turned against ‘Big Pharma’. The launch of the Accelerating Access Initiative with several UN agencies in 2000 was a paradigm shift, resulting in both media coverage worldwide and considerable reduction of prices. The remaining problem of sufficient funding was solved by the creation of the Global Fund (2002) and US President George W. Bush’s Emergency Plan for AIDS Relief (2003). The Global Fund’s genesis implied that UNAIDS, with some 600 staff and offices in over 60 countries, was no longer the only actor in the field. Piot pivoted and differentiated UNAIDS as the global guardian of the disease, focused on high-level political advocacy and evaluating the impact of programmes on the ground.
When Brundtland announced in 2002 that she would step down from the WHO at the conclusion of her term the following year, some suggested that Piot run as her replacement to impact the WHO’s AIDS policies. Piot was not interested, but eventually engaged in the campaign. In 2003 he lost to Lee Yong-wook by one vote in the fifth round, which strengthened his political standing. Later that year Piot, Lee and Richard Feachem of the Global Fund launched ‘3 by 5’, the initiative to provide antiretroviral treatment to three million people in developing countries by 2005. Piot spent much time with donor countries as UNAIDS had no guaranteed budget from the UN. He also sought to make funding available for various affected populations, including for HIV prevention among drug users to AIDS-related human rights violations, and highlighted problematic situations of people living with AIDS in specific countries, including China, Russia and South Africa. Piot found making UN agencies work together the hardest part of his job. The high turnover of WHO staff and executive heads implied instability. Annan renewed his appointment as UNAIDS Executive Director and UN Under-Secretary-General for another four years in 2005. In 2008, however, Piot announced that he would be stepping down at the end of his term (31 December 2008), aware that AIDS still was on the global agenda but also proud of what he had achieved. Michel Sidibé from Mali succeeded him on 1 January 2009.
Following a six-month term as Senior Fellow at the Bill & Melinda Gates Foundation in 2009, he wrote his memoir No Time to Lose (2012). Piot returned to academia, serving as Director of the Institute for Global Health at Imperial College London (2009-2010) and Director of the London School of Hygiene & Tropical Medicine (October 2010-July 2021). During the 2014 Ebola epidemic in western Africa he advised WHO Director-General Margaret Chan, but he was also chair of a 2015 independent panel that critiqued the WHO’s response to the outbreak. In early 2020 he criticized the WHO’s delay in declaring the novel coronavirus outbreak a Public Health Emergency of International Concern. In March he fell ill himself and was hospitalized for a week. In June he became Special Advisor on Covid-19 to European Commission President Ursula von der Leyen.
