The Wisdom of Whores

It’s not often that proper reporters put their own reaction to the story they are working on front and centre, but it can be revealing. Have a listen to this wonderful From Our Own Correspondent from gay BBC journalist Paul Henley reporting from the frontlines of Russian homophobia.

Without whining, Henley gives a wonderful flavour of what it is to be hated by people who don’t even know that they hate you. For me, the encouraging thing about this story is that the wall of hostility that Henley is obliged to bang his head against in Russia is new to him. Had he been born even 30 years earlier in the UK (and maybe still now in many parts of the United States) the blanket of homophobia would be woven, consciously or not, willingly or not, in to his life and his soul.

It’s not at all encouraging if you are Russian, of course, or Ugandan, or from one of the many other countries where self-appointed moralists like to stick their prurient noses into other people’s bedrooms. But the fact that Henley can broadcast his sexuality to the 180 million people who listen to the BBC World Service and make many of us feel proud of him means that in some countries, at least, we have come a very long way in the right direction.

The good side of homophobia is the vanishing side.

The always provocative Unspun asks how it is that Indonesia’s minister of health is shocked at the country’s HIV prevention failure. It’s a good question, most especially since before becoming minister of health just a few months ago, Nafsiah Mboi spent six years at the helm of the National AIDS Commission.

The failure was highlighted in the new UNAIDS report on the state of the epidemic. They estimate that the rate of new HIV infections in 2011 was more than 25% higher in Indonesia than it had been a decade earlier. That raises some questions for me: is an increase of more than 25% in HIV incidence (i.e. new infections) over 10 years really so shocking? Is the rate of new infections in Indonesia still increasing today? How do we know?

1) How shocking is an increase of 25%?
It rather depends on what the original rate was. The fact is, Indonesia had virtually no HIV epidemic in 2001, except in drug injectors and waria sex workers. In other words, the baseline rate of new infections in the largest risk populations (female and male sex workers, their regular clients, and gay men) was extremely low. If you go from four new cases a year to five new cases a year you increase by 25% but add only one new infection. If a high prevalence country goes from 11,000 incident cases to 10,000 cases, it has decreased by nine percent but added 1000 new cases. Which is the bigger prevention failure? I’m not saying that HIV prevention in Indonesia is a great success story; quite the reverse (see below). I’m just reminding people to beware of relative measures.

2) and 3) Is the rate of new infections in Indonesia still increasing now? How do we know?
The fact is, we don’t. Indonesia, which in the early 2000s built up quite a strong surveillance system, has seen that system break down rather badly, in part because of the effects of decentralisation and in-fighting between government departments which means that people who should be running the system are busy squabbling over project funding, and in part because of the small-mindedness of some of the donor-funded NGOs, who cared more about measuring their own little efforts and sucking up to their own pet partners in government than about supporting strong and transparent national systems. We can’t measure new infections directly, so incidence estimates are based on models that use information about overall infection rates (prevalence) from several years for several different population groups, together with information on risk behaviour, in some case. I’m frankly surprised that UNAIDS even published an incidence estimate for Indonesia, given the shockingly poor quality of the data available in the last 5 years. I note that they shied away from giving estimates for many of the other large countries with similarly diverse epidemics and patchy data: Brazil, China and Russia.

That HIV prevention failed in Indonesia is indisputable. The failure was totally unnecessary, but sadly inevitable given the choices the country and its “development partners” made. When infection rates were still low we measured very high levels of risk behaviour in key groups. We did very little about it, and what we did was more often driven by institutional needs and development fashion than by the needs of the people at risk. We kept measuring risk and infection and saw that risk was not falling and infection was rising. We spent lots of time and energy getting more money, then threw the money at the same failed approaches (including, in the most iniquitous example, treating people’s STIs with drugs we knew didn’t work because the Ministry of Health, the WHO, the drug companies and their various cronies couldn’t get their shit together to change the outdated national guidelines on treatment).

If what data we have are to be even remotely believed, there does appear to have been some success reducing new infection rates among drug injectors. But by 2009, three years into Nafsiah Mboi’s tenure as head of the KPA, Indonesia had sucked 60 million dollars into its HIV coffers, for that year alone. How much of that was spent on HIV prevention for gay men, a sizeable group in whom infection rates had rocketed from under 3% in Jakarta when I did the first study in 2002 to over 8% in 2007? A princely US$ 23,000. It’s not at all shocking that HIV prevention doesn’t work if you are simply not doing it. Or if you are doing the kind of thing Indonesia is mostly doing, pictured above. The poster reads: “Don’t ruin your life for just a moment’s pleasure. HIV/AIDS. You can get it, you can prevent it.” Does it tell you HOW you can get it, HOW you can prevent it? No. And there are even worse examples out there.

Here’s something that I found shocking: UNAIDS chief Michel Sidebe was in Jakarta just a couple of months ago. What did he talk about? Not the gay men, junkies, waria, rent boys and clients of hookers that make up four fifths of the Indonesian epidemic (the majority of other cases being in female sex wokers). Or at least not according to newspaper reports of his visit. No, he talked about the importance of protecting innocent women and babies through sexual education for young people, most of whom are at practically zero risk. (Reminder, you can’t get HIV by having sex, even unprotected sex. You can only get HIV by having unprotected sex with an infected person. As long as they stay away from the trade, most young heterosexuals in Indonesia can have as much sex as they like without risk of HIV infection.)

The highest UN official for HIV comes to Indonesia and stresses the importance of prevention for people who are not at risk, and Ibu Naf wonders why infections continue to rise in the groups that are at risk. Please deh! Someone should write a book about this.

Oh wait, I already did….

Note: This is a cross-post from Elizabeth’s Indonesia blog, tales and observations from my current project. Though I planned to be back in the public health business round about now (November 2012), Indonesia has rather swallowed me up and I won’t be back in the day job for a while yet.

I learned this today from a subscriber to the Asian gay website Fridae, who was irritated by my tone in an post-midnight interview with Ng Yi-Sheng, a fabulous Singaporean poet. I am more than willing to accept that being snarky about other people’s sex lives is an irritant. But I’m not sure how it leads to this:

I’ve never had to fumble lubily with a condom packet, huh? The potential assumptions about my behaviour are manifold. Here are some that occur to me:

1) I never use condoms
1a) because I’m a slob
1b) because I don’t have sex with people who have penises
1c) because I don’t have sex.

2) I never use lube
2a) because girls (I?) don’t need it even when they are in their late 40s
2b) because girls (I?) never have anal sex
2c) because I don’t have sex

3) Uniquely on the planet, I can always tell which side of a condom is out
(I refer Mr. Tereisias to p 208 of The Wisdom of Whores)

4) I don’t drink alcohol or take party drugs

All of these assumptions are wounding to the core. But it gets worse: not only do I not have boozy but protected sex with boys who might like lube: I NEVER WILL!

Perhaps I’m being over-sensitive because I’ve just put another birthday on the clock, but I’m crushed. Truly crushed. And bent on the sweet vengeance that comes with proving someone wrong on every count…

On a quick sabbatical from my sabbatical, I’ve dipped back to London for the month of July. How better to spend my first Saturday night than at my local theatre, watching a show called “Bitch! Dyke! Faghag! Whore!”.

The night before, I indulged in the things I’ve missed most over the last nine months — good wine and pork products — under giant banners reading:
LESBIAN
Mayor of London
and
TRANS
Mayor of London

in Trafalgar Square. London’s most public square was getting all gussied up for Satruday’s Pride parade. We take it for granted now that boys dressed in black latex and pink feather boas kiss in public, but in a show that’s just turned 20 Penny Arcade, aka Susana Ventura, reminds us how very hard fought a victory that was. She and I differ, perhaps, on how that past should shape the behaviour of later generations, those who have mercifully not been condemned to live in closets and funeral parlours, but differences are what good drama are all about. And Penny reminds us, too, (particularly in a funny opening riff on the current “controlled for gain” morass) of how far we still have to go. All wrapped around some of the most heart-stopping pole dancing you’ll see outside of the Olympic gymnastics ring.

Have a pint or two and go see for yourself.

I’m nearing the end of the first (nine-month long) leg of my Indonesian Odyssey and I don’t feel much closer to understanding the heart of this torturously complicated but endlessly fascinating nation. I’ve done my best to try and sum up some of my thoughts in the June issue of Prospect, one of UK’s more intelligent monthly magazines.

For what they are worth, you can now read my reflections on culture, corruption and corpses on Prospect online. And no, Oliver, I don’t think it is at a crossroads…

[Crosspost from Portrait Indonesia]

As part of the Makassar Writers’ Festival, I’ve been asked to give a talk about HIV in Indonesia at the faculty of public health at Hasanuddin University. I’m reluctant. I’ve been wandering Indonesia without any thought of focusing on HIV for over eight months now. In that time I’ve met a surprising number of widows, orphans and middle-aged couples who have lost a child. Only one of those deaths has been HIV related. The rest are all in traffic accidents, mostly involving motorbikes.

That’s not entirely surprising. Bike ownership in Indonesia is booming, with 8.1 million new motorcycles crowding on to the country’s shockingly bad (and already crowded) roads last year. It’s perfectly common to see primary school kids driving motorbikes; it’s very rare to see a primary school kid in a helmet. And the industry is not exactly doing a lot to promote norms of safe driving. Here’s how Suzuki was pimping its new (quite girly, automatic transmission) model in Bau Bau, Southeast Sulawesi, last weekend.

Reporting of road accident related deaths is even worse than reporting of AIDS deaths in Indonesia. But working on best estimates, death contracted on the roads far outstrips death contracted in bed or while shooting up. Some 32,000 people died because of road accidents in Indonesia last year alone, a quarter of them teen-aged boys, and 60% of them on motorbikes. Ten times as many were injured badly enough to alter their daily lives. That compares with just over 5,000 Indonesians reported as having died of AIDS, ever. Let me repeat that. Over 30,000 road deaths a year, versus 5,000 or so AIDS deaths over the last 25 years. And yet Indonesia spent US$ 69.2 million preventing HIV infections and AIDS deaths last year, 60% of it taken out of the wallets of taxpayers in other countries, much of it spent very badly indeed. Indonesia does have a national road safety action plan, but, according to the Director of Road Safety in the Ministry of Transport, it has no dedicated budget to cut death on the roads. If I didn’t know better, I might console myself that HIV is not much of a problem in Indonesia precisely because of the prevention spending. Sadly, that’s not true. I also recognise, of course, that death tolls are not the only basis on which to make public health decisions. But it doesn’t take a very sophisticated observer to see that HIV programmes in Indonesia are grossly over-financed relative to other important killers and maimers, notably road death. (Then there’s smoking, but that’s a whole nother post…)

It doesn’t seem like this problem is likely to evaporate. Though the motorbike industry is wringing its hands over the effect that a perfectly sensible new restriction on credit will have, I’m not seeing it in the field. The Suzuki mob were offering new bikes for a downpayment of just 350,000 rupiah (about US$ 38.00). If that meets the 25% deposit requirement of the regulations, which came into effect this month, then it is a VERY good value bike, despite being girly. Even by the most pessimistic estimates, there will probably be another 6.5 million bikes and over 800,000 more cars on the roads by the end of this year compared with the start. Remove the several thousand that will be reduce to scrap by crashes, and its still a huge net addition.

For an idea of how far Indonesia has to go in making its roads safe, check out this presentation by Eric Howard. There’s lots he doesn’t mention — the political incentives to finance the building of sub-standard roads, the fact that Indonesians think road safety campaigns are just another way for policemen to extract bribes — but there are some priceless photos that show just why for most Indonesians, it’s probably far more dangerous to make your way to work or to school than it is to have sex.

[Cross-post from Elizabeth's current project, PortraitIndonesia.]

© Kompas/HANDINING

Wednesday was a sad day for Indonesia, and for me. It marked the death of Endang Sedyaningsih, who encompassed what is best in the women everywhere: courage, determination, integrity, compassion and humility. It is a rare combination at the best of times; in the Indonesian cabinet, where Endang held the position of Minister of Health, these qualities are nothing short of exceptional.

I’ve been pretty rude about Indonesian doctors lately. Endang counts among the “several smart friends who were once great doctors”. Unlike many ministers in Indonesia, she knew her territory inside out. For three years, she worked as head of a rural health centre in Nusa Tengarra Timur, the poorest province in Indonesia. She gave up doctoring in favour of public health and research, a choice that I predictably enough applaud, not least because a lot of her research was among sex workers and other marginalised groups. Indeed her thesis at Harvard centred on the lives of the women who sold sex in Kramat Tunggak, Jakarta’s largest red light district. She argued for improving health services for the women that worked there. Jakarta Governor Sutiyoso, seeking to burnish his credentials with Moslem voters, responded by bulldozing the area and building a gopping mosque and Islamic centre in its place. When Kramat Tunggat was closed in 1999, HIV prevalence among brothel and street-based sex workers in north Jakarta was 0.4 percent. Since the rise of the mosque and the dispersion of the sex trade, it has risen to 10.5 percent.

Endang was fearless both physically (not many of my colleagues were prepared, as she was, to brave the Jakarta traffic on the back of my motorbike…) and politically. During the reign of her controversial predecessor, Siti Fadilah Supari, Endang had to put up with a lot of flack because the national health research institute she headed cooperated closely with foreign researchers in trying to develop vaccines against bird flu, which has a higher case fatality rate in Indonesia than in any other country. For Siti, this cooperation amounted to collaboration with the enemy. Her book “It’s Time for the World to Change! God’s Hand Behind the Bird Flu Virus” is actually more about the hand of the CIA behind the virus – a mish-mash of conspiracy theories which were such an embarrassment to the Indonesian government that the book was eventually pulled from bookshops.

Leading the research programme for the Ministry of Health, Endang kept her head down and got on with her work. In her eyes, finding a vaccine that could protect millions of her fellow countrymen from a strain of flu that killed eight out of 10 of those infected was more important than whipping up populist anti-Americanism to score cheap political wins. When she was appointed health minister in Indonesian president Susilo Bambang Yuduhyono’s second cabinet, the press showered her with nonsense about being a CIA plant. Again, she kept her head down and got on with her work, trying especially to improve services in the far-flung corners of the nation so often overlooked by those trapped in the political spider’s web of Jakarta.

Endang was an Indonesian nationalist in the truest sense of the word: not a knee-jerk Xenophobe, but someone who consolidated learning, skills and relationships acquired around the world and used them in the service of the men, women and transgenders of the Indonesia she loved so much. I am angry that she was taken from us by lung cancer at the age of only 57, but am proud to have called her a friend.

Spain. With the possible exception of the one I’m trailing around now, it’s my favourite country on earth. For many reasons, including a sense of social solidarity and the fantastic pragmatism of Spanish women. Madrid’s sex workers have been displaying both, refusing to sell sex to bankers until those blood-suckers start lending money to the small businesses that need it most.

I’m particularly thrilled with the timing of the strike; it seems somehow fitting that it coincides with the publication in Spanish of La Sabiduria de las Putas. Four years after The Wisdom of Whores was first published in English, Sexto Piso is publishing it in Spanish. This makes me happy in part because my favourite bookshop in the world, Madrid’s Panta Rhei, will now have a Spanish version to put on their shelves (though my humble tale of sex and taxation will feel dowdy among the fabulous art and design books that are Panta’s stock in trade).

For a brief moment, I worried that Sabiduria would seem very dated. For better or for worse (for worse, I guess) and despite the change in regime in Washington and a growing recognition that countries need to “Know their epidemic”, there’s an awful lot in the book that is as relevant today as when I first drafted it six years ago.

Sabiduria is being published mainly because of the determination of Javier Rio Navarro, a Basque epidemiologist who, with the stubbornness of his tribe, takes on tasks that would make Hercules faint. He established Bilbao’s first safe injecting room for drug users, for example. And he translated The Wisdom of Whores. He’s now banging his head against various (hard) walls in Central America, trying in particular to get mental health services to people who are constantly beaten up or beaten down by their street-based lifestyle. (pdf) I thank him with all my heart for making La Sabiduria possible.

A statue outside a health centre in Enarotali, in Indonesian Papua

[Note: I'm still on sabbatical. But even on sabbatical, one sometimes thinks about sex... For reflections on democracy, corruption and other dirty subjects, see my other blog, from which this is a cross-post.]

Reading the newspapers in cities across Papua, Indonesia’s easternmost province, I cannot help but notice the full-colour ads for penis extensions. In only half an hour, with no invasive anything, men can see their organs grow, thicken, harden, for ever. The ads are explicit about the results, down to the last half centimetre; clients can choose both the length and girth of their organ, up to 20 cm by 6 cm (the more modest promise diameters of just 5.5). All of this with just some magic oil and a few prayers, guaranteed free of side effects. The “Specialists in Vital Organs” promise services for women, too, tightening up our fannies “until you are like a maiden again”. And for both sexes, they will pray away our sexually transmitted infections.

Why the obsession with sex organs, and why especially in Papua? Are people encouraged by the blatantly erotic sculptures that are common in these parts? Do migrants from other parts of Indonesia feel inadequate on arrival in Papua, or do they feel the magic will be especially potent in the nether regions of the nation? And isn’t it mildly ironic that all of the people offering their dick-swelling charms claim to be from Banten in western Java, where mystics sometimes break their fasts by eating light-bulbs? They offer other mystical services too: tying down your spouse, implanting a protective aura, ensuring you get promoted or elected. But most of their force is expended on delivering: “What other people only promise, we prove with results that are Large and Long”.

It turns out that the penis obsession is not, in fact, confined to the tens of thousands of immigrants from the rest of Indonesia who have been sucked east by Papua’s booming economy. I learned this when I asked a Papuan nurse in one of the province’s largest hospitals what brought men to outpatient services. Three things, he said: injuries resulting from violent fights, injuries resulting from traffic accidents, and prison. Prison? Do people get sick in prison? “No, that’s the penis stuff.” Prisoners, Papuans and others, are operating on one another’s members — inserting ball bearings and biro parts, threading hair through the urethra. A doctor friend who ran an STI clinic in Papua for many years says he saw a lot of penises embellished with horse hair, but the nurse said since that’s in short supply in prison people weave ornaments from their own locks. Not surprisingly, many of these go septic, hence the hospital visits.

My doctor friend blames the porn industry for the penis-plumping craze. “People watch these porn films where everyone has a giant dick, and they begin to think that that’s the norm.” Certainly porn films are enough of a norm in Papua to have their own nickname: “film o-ya”. The name derives from the script, which in many films does not go much beyond the repetitive groaning of “Oh yah!, Oh yaaaaaah! Oh yaaaaaaaaah!

A more serious aside: data newly released by the Indonesian Ministry of Health show that one in four of the Papuan women who are selling sex to their men-folk on the streets of the Papuan highland town of Wamena are infected with HIV, while well over half have another STI. Perhaps because condoms don’t fit snugly over the horsehair, three in four of these infected highland women are not using protection with their partners. You don’t need an epidemiologist to tell you what happens next…

Note: This post appeared over at Elizabeth Pisani’s new blog, “Portrait Indonesia”. “Wisdom of Whores” is still on hiatus as she travels Indonesia in preparation for her new book, but we thought that WOW readers might appreciate this particular post. If you’ve not done so already, please do go over to Portrait Indonesia and have a look around. You can get the RSS / Atom feed here.

AIDS prevention poster in Southeastern Maluku, 2011

I have a collection of daft AIDS posters going back years, but I’m glad to say they are getting harder to find. This one, in Saumlaki, the main town in the remote Tanimbar islands, was thus a great find. The headline reads: AIDS: there’s not yet any cure! On the right is this helpful information:

AIDS!!!
You can’t avoid it by:

• Choosing your sex partners on the basis of their appearance
• Drinking/injecting antibiotics, alcohol, or herbal medicine before and after having sex
• Washing your sex organs after having sex

Some, including the South African president Thabo Mbeki and uber-philanthropist Bill Gates would take issue with the last point. I, of course, would take partial issue with the second — you can avoid AIDS by taking medicine, you just can’t avoid HIV that way. But the most egregious part of this ad is the illustration.The population of Tanimbar is largely Melanesian. Overwhelmingly the highest HIV risk for them is the sex they might have on their frequent money-spinning travels to neighbouring Papua. Indonesian Papau, rich in minerals, forests and much else, is swimming in cash. It is also swimming in HIV; it’s epidemic looks more like East Africa 15 years ago than it does like any other part of Indonesia today. And it is populated not by pointy-nosed tourists with straight blonde hair but with flat-nosed Papuans with crinkly black hair.

Most AIDS posters are pretty useless, in my opinion. But this poster associates HIV with Western tourists slow-dancing under the palm trees — an “other” that most people here will never come across, while saying nothing about commercial sex in high risk areas (Papua, but also with the local transgender (or waria) population). Those are very real risks that many certainly do face, at least if Astuti, one of the latter, is to be believed. She excused herself early from a grilled fish dinner because her phone rang. Not her Blackberry, that’s for friends and family, but her “HP selinkungan” (cheating phone). In Tanimbar from neighbouring Kei for around a year, she hasn’t had a day without clients. And though she has helped distribute condoms and promote testing in other cities around Indonesia (in some of which one transgender sex worker in three is infected with HIV), she’s seen no sign of an HIV prevention programme in Tanimbar. By maintaining the fiction that something is being done about HIV prevention in Tanimbar, this poster is a lot worse than useless. It is actively dangerous.

Much has been going on in the world of HIV, sex and drugs in the last month or so; the US marines recruiting at gay community centers, more mysteriously disappointing study outcomes for PrEP, encouraging news about the effect of microbicide gels against herpes, a new super-easy condom with a brand name that will put off anyone who cares about staying power.

I’ve ignored it all. That’s in part because I’ve discovered a site that really says everything that needs to be said about HIV prevention. Particularly insightful, in this post entitled “usefulness connected realizing hiv indicators”, is this gem:

“For that faculty your body gets very suasible to numerous germ infections and so the indicators are sure not e’er the HIV symptoms. The true unique method to aver that a soul is with HIV is the HIV checking.”

I don’t think I can add to that. Which is my polite way of saying that I’m taking a sabbatical from HIV and epidemiology. I plan to spend the next year or so travelling around Indonesia, eventually writing a book about this wonderful and mad land. Which has it’s own fair share of Bad English, as you can see over at my new blog, Portrait Indonesia.

I’ll be spending a lot of time out of range of wi-fi etc., but will try and post at least weekly. If you’d like to follow my progress, you can sign up here.

For now, on the subject of sex and drugs, it’s over and out. Thanks for taking an interest over the last four years.

It’s not that often that I sit reading the FT on a Tube full of morning communters. Even less often that the Pink Paper (no, boys, not THAT Pink Paper) carries full page ads from the Purveyors of Porn. The ad is pimping a new internet domain ending: .xxx (Slogan: Coming, now!)

The porn industry is positioning itself anew (they don’t excuse the pun, so I wont either) as responsible citizens, protectors of children and the integrity of your credit card details. Re-registering your porn domain with a .xxx extension will make it easier to filter, keeping it away from kids and the easily-offended. Since all .xxx domains will be screened daily by Mcafee, they will be virus-free. The xxx admin folks will also enforce standards of financial transaction probity, apparently. In the meantime, they stand to make an awful lot of money themselves. But here’s my question: what does it say that the ad was placed, as a FULL PAGE, in the world’s most prominent financial organ? Perhaps that purveyors of porn have more to invest than the rest of us?

Certainly, the porn industry could do with brushing up its image after the recent kerfuffle over HIV transmission on porn film sets. Though plenty of people are demanding the introduction or enforcement of condom-only porn shoot rules, I suspect they are on a hiding to nowhere. Isn’t the whole point of porn that is is a bit transgressive? If condoms were sexy, we probably wouldn’t have reached over 60 million HIV infections to date. Goody-two shoes safe sex is rarely enough the stuff of our reality; it is almost never the stuff of our fantasies.

The Salon piece acknowledges this. It fails to stress another important point. Most of the on-set transmission of HIV occurs right after the infected person themselves became infected. This is a time when there is tonnes of virus floating around the body and it is very easily transmitted. It is also a time when antibodies have not yet developed. Since the standard HIV tests are for antibodies rather than the virus itself, they will miss these very new, very dangerous infections. Indeed it was a classic case report from the porn industry that confirmed in life what we suspected from lab work about the dangers of early viral load.

Possible solutions: set a minimum time between shoots of six weeks. That way, if someone gets infected on one shoot, they’ll test positive before the next one. Another solution would be to invest some of the massive profits of the porn industry in testing actors for the HIV virus itself, rather than for antibodies. Both of these solutions seem unlikely, given the profit imperative of porn, but in my mind they are both less improbable than condom-only porn.

One thing that interested me about the .xxx ad was that they are offering, for a small, one-time fee, to BLOCK names from being used with an .xxx extension. Do you think I should sign The Wisdom of Whores up to prevent our good name from being abused?

Apologies if this post looks odd. My first attempt to post from an iPad.

Selling sex is an odd profession, full of fiercely independent mavericks who are happy with a very flexible life outside the mainstream, while equally happy to moan about marginalisation. And there’s a fair bit of moaning going on in Bonn at the moment, after the local government installed “pay and display” tax machines for people who sell sex on the streets.

The move has put the spotlight on something I’ve always been mildly irritated by: the voices that lobby for decriminalisation of sex work, while objecting to legalisation. For those that don’t spend their days splitting hairs over such issues, here’s the difference, as I understand it. Decriminalisation allows me to sell sex without fear of arrest or penalty, while still whining about being marginalised and having special needs. Legalisation means I can sell sex in the same way that I can sell software or plumbing services, which means doing a whole lot of paperwork, paying a whole lot of taxes, and being subject to whatever boring occupational health and safety regulations are appropriate to my trade. In other words, there’s nothing special about me at all.

Prostitution has been legal in Germany for nearly a decade. Rules, regulations and taxes are the downside of that. On the upside, some people can get sex on social security, to support their mental health. But even in Germany, there’s a gray market. People working in brothels are better at doing their paperwork than people who freelance on the streets, it seems. In a pre-emptive attempt to collect tax from cash-in-hand street workers, the Bonn government is collecting a flat €6 a night from each of them. Stick your debit card in the machine, get your ticket for the night and you’re off.

According to Der Speigel, the city government is hoping to earn €200,000 a year from this venture. That’s an average of around 90 permits a night — one paid-up street worker per 1,160 men aged 15-64 (I’m blithely assuming that most of the buyers are male, regardless of the gender of the seller). Predictably, a sex worker rights group is complaining that the flat-rate tax is unfair. Others pay income tax on a sliding scale depending on what they have earned — why should hookers have to pay up in advance, even if they don’t get any clients in a given night?

Well yes. At recessionarry prices of maybe €30 a trick, a €6 tax is a lot if you average one trick or fewer per working night. But with Germany’s base tax rate at 14%, if you average at least a trick and a half per worknight, you’re ahead of the game compared with sellers of software or plumbing.

Of course no-one likes to pay taxes. It’s just the price of not being marginalised.

Thanks to Jonathan Beard.

Trawling through an old paper lying around in a hotel lobby in Jamaica, I found this pastor’s reflections on gay men. Jamaica has the dubious distinction of being a world leader in homophobia. Now a senior police officer, Fitz Bailey, had said that most of Jamaica’s booming lottery and credit card fraud businesses are run by gays. Apparently 12 of the 14 men arrested for these crimes in 2007 volunteered to the cops that they were gay. Both he and columnist-pastor Mr. Dick think this is a scientific fact worth sharing with the public. Indeed, Rev Devon Dick suggests that gays are whining about negative stereotyping.

What is therefore needed is an analysis of Bailey’s data. Why are persons in homosexual relations prone to be in illegal lottery scams? Is it because they are faced with discrimination at the workplace and cannot get or retain a legitimate job? Or are they suffering disproportionately because of the economic hardships? Is it that their lifestyle requires big bucks?

Additionally, some persons who appear to be sporting a homosexual lifestyle have been noticed to shop in groups. Is it that they are proud of the lifestyle and want to flaunt it, or are they afraid of violence and feel safe in a group? It seems to me that there needs to be more research done on persons within this community.

Not surprisingly, Jamaica’s lonely gay rights group, J-FLAG, was concerened that this would give homophobes one more reason to beat the shit out of gay men. Much more surprisingly, Jamaica’s top cop was also upset by the statement; although Bailey refused to retract it, his boss apologised on behalf of the Jamaican police.

It happens that J-FLAG has roped Miss Jamaica and her gay brother into a new campaign that aims to start chipping away at homophobia:

I’m in two minds about it. On the downside, the phrase “unconditional love” implies loving someone despite some hideous deformity in their character. I love my brother even though he’s… (sharp intake of breath, try not to hold your nose)…gay. On the more positive side, it does make sense to try and start from where the target audience is, and it’s clear that most of the target audience in Jamaica are very far from being ok with gay brothers. So far, indeed, that the national TV station has refused to carry the ad.

I’m interested that Rev Dick felt the need to point out that Jamaican political satirist Owen Blakka Ellis, who has had the gall to say that being gay isn’t so bad, was a “returnee from Canada”. Obviously he’d be pro-gay, then, Canada being a paradise for over-entitled whiny gays, seems to be the implication. It’s true that Canada’s at the other end of the gay stigma spectrum from Jamaica.

I have been accused (with some justitification) of being impatient with people who pull the stigma card when they have things so relatively easy. But this beautifully written, nuanced essay about young gay men in Canada from Michael Harris reminded me that “relatively easy” does not mean “easy”. The tornado that was AIDS has been more or less dissipated by treatment in Canada, but the wreckage it left has indeed shaped the landscape for another generation. Read it, please (pdf here).

It’s no surprise to anyone that I’m interested in viruses. Many know of my on-going affair with Indonesia. Some will have heard me obsess recently about using art to make people think differently about science. And a handful will know of my growing interest in digital media.

Conveniently, Icelandic singer Björk has brought all those interests together into a single tidy package. Her new Biophilia album is a great big muscial sciencefest. One of the first “single” apps released is called “Virus”. Just when you thought there was no new angle on soppy songs about codependent love, she’s written a song about, well, a virus, and its interaction with host cells. Among the lyrics:

“The perfect match, you and me
I adapt, contagious
You open up, say welcome”

It’s played on a sort of mish-mash adaptation of a gamelan, Indonesia’s favourite instrument. And its being released as an app which people are invited to remix, play with, adapt, take forward. Which doubtless has many in the music industry wondering: if this mutate into something truly virulent, how soon will it kill its host?

First PReP worked for gay men, and we were happy. Then it didn’t work for straight women, and we were sad. Now, two big studies in heterosexuals have shown it can work for straight couples, and we are deeply confused. Or at least I am.

Taking anti-HIV pills every day cuts the risk of infection by 63%, said CDC researchers in Botswana. It cuts infection by up to 73%, said University of Washington researchers working in Kenya and Uganda. That’s great news, of course.

Here’s why I’m confused. The larger of these trials was conducted in 4,758 “discordant couples”. [I earlier incorrectly reported that both trials were in discordant couples. The CDC trial in fact recruited 1,200 sexually active uninfected heterosexuals, regardless of their partner status. Full inclusion and exclusion criteria here]. That means researchers in the large discordant couple trial knew that one person was infected and the other uninfected. They chose to give drugs to the uninfected person, to see if it would stop them becoming infected. And it does, in over 60% of cases. But another recent study shows that if we give the drugs to the infected partner, the one who might actually need these same drugs because they have HIV and need it surpressed, it cuts infection by 96%. So in the case of discordant couples, it seems to make much more sense to give the antiretrovirals in question to the infected partner.

That leaves us with the question: who should get PReP? Right now, there are not enough antiretrovirals to go around to treat all the sick people who need treatment. If we’re going to use them selectively for prevention, we should start with the most effective use, which appears to be early treatment of the infected partner in discordant couples. We could also give them to people who aren’t in a couple but who know that they’re likely to get around a bit and might want to stay safe without using condoms. That’s potentially a lot of people; it will stretch our purses. But more than that, it will stretch our political will. Let’s face it, HIV has reached eye-watering levels in many sub-Saharan African countries because both voters and governments have been in deep denial about their own, and their neighbours’, propensity to have sex with someone who is not their single life-time partner. Some people, including influential religious and community leaders, even continue to believe that giving out condoms encourages licentious sex. To them, giving out ARVs will surely mean encouraging licentious unprotected sex (if you’re anti-condom, is that better or worse?).

So who is PReP for? We’ve got a better option for discordant couples. We’re not going to want to give it to randy adolescents. We know it works for gay men, but some of the countries where the trials took place would rather thump or jail gay men than protect their sexual health. We’ve no idea yet if it works for drug users (though a deeply unethical trial by CDC in Thailand will tell us that soon.

Of course PReP will find its niche; when people actually take it it works really well (though not as well as abstinence, when people actually abstain, or condoms, when people actually use condoms). We’ll find out a bit more about just how well at the annual AIDS circus in Rome next week. I’ll look forward to learning what the actual incidence rates in the studies were, and more about sex differentials and adherence. But I think we would be unwise to rush around talking about massive roll-out of PReP before we actually figure out who it works for in the real world.

As an aside, the results have a huge potential impact for Gilead, manufacturer of both Viread (bascially tenofovir, one of the pills that worked in the trial) and Truvada (the tenofovir – emtricitabine combination that was the other). Gilead has come over all generous and has started letting Indian and other developing country companies copy their products. They’ll take a 5% fee; if we really do go for a massive roll-out of PrEP, that will keep drug costs down globally, while giving Gilead extra cash for very little effort. A win-win situation for which they should be congratulated.

A second aside: The CDC trial is confusing in a different way. In December 2009, CDC announced it was terminating the trial of Tenofovir for HIV prevention because they’d had so many drop-outs that the trial would be unlikely to show results even if they doubled the size of it. They kept it going not as an efficacy trial (testing Tenofovir against a placebo) but as a safety and behavioural trial (clocking how good people were at taking their pills, looking for side effects etc.). So it was quite surprising to find them leaping forward with efficacy reults, of which more details here.

Thanks to Eva for pointing out my error.

Last night, I was sitting in a Brooklyn restaurant chatting with a Famous Artist and his life-partner, the Respected Historian. In just about third bottle territory, a huge cheer went up from the table next to us, crowded with 20-something year-old straight hipsters. The cause of their excitement was an incoming Tweet: gay New Yorkers can now get married.

I was thrilled. I was also thrilled that these young New Yorkers were so thrilled, and so engaged. I thought it vaguely interesting that the Famous Artist and the Respected Historian were shruggy about the whole thing. I guess when you’ve lived in a same-sex partnership in New York for a couple of decades, you’ve outlived the marriages of many of your straight friends and you’ve fought to bring partner-rights into the workplace for fellow faculty members, it doesn’t seem so life-changing. But New York is an important voice in an important nation. It is high time that it raised that voice in recognition of the fact that no-body should, just because of who they choose to sleep with, be denied the right to agonise over prenuptual agreements, to spend an irrational amount of money on a symbolic ritual ahead of which one stresses about the guest list, the menu, the wardrobe, to argue about whether to file taxes jointly or separately, to wonder whether to get divorced before or after the kids graduate.

New York is has also finally passed a bill that ensures that no-one helping a drug user survive an overdose can be prosecuted for possession of drugs or works. Since overdose is one of the most important causes of “accidental” death in New York, and thinking you might wind up in jail is an important disincentive to call an ambulance for a struggling mate, that’s an important step. Now all we need is for the New York State Assembly to pass a bill that prohibits the use of condoms as evidence for prostitution. Apparently the New York Police Department are unhappy with the bill. Other police forces that have proven more enlightened on this issue include those nice cuddly boys in the Police Force of the Union of Myanmar (Burma, to the stubborn). Surely if they can swallow it, so can NYPD.

I’d write more about this but today happens to be New York Pride. I’m suspecting it will be a good party.

Do we really need research to demonstrate the blindingly obvious? Yes, if you believe that people who call the political shots will change their mind on the basis of a published study (something about which I am skeptical) So here we have it: research published in the International Journal of Impotence Research shows that guys over 40 are less likely to have droopy dicks if they are fit. I’d say that’s no surprise to the many millions who use the work “fit” as polite bar-room slang for “fuckable”.

As a result of this groundbreaking research, we can put numbers on things that even the smallest amount of participatory research might have taught us: guys who are flabby are over four times more likely to droop than those who are fit. What’s interesting to me about this research is the conclusion: “This study reinforces the concept that healthy habits have a direct effect on erectile function.” No mention, at least in the abstract, of the organ that affects sexual performance more than any other: the brain. If you’re flabby you’re more likely to feel generally droopy about yourself, less likely to be in a position where your erectile function even gets put to the test, and more likely to be anxious about it when you do get the chance to perform.

Here’s another research question: what’s the likelihood that research such as this will have people trading in their blue pills for gym passes? Or that the public health industry will ever change its incentive structure so that people stop getting rewarded for publishing “so what?” papers?

For some time now, I’ve been waltzing around casting doubt on the “treatment is prevention” mantra, the idea that putting people infected with HIV on meds sooner will reduce new infections, despite pretty good observational evidence that people on treatment are less likely to infect their partners. If I had been praying at the altar of the randomised controlled trial for more reliable evidence, my prayers would now be answered: a trial involving 1,763 couples in 13 countries has found that putting heterosexuals on meds earlier cuts the chances that they’ll pass on HIV by 96%.

That’s huge. So huge that the study was stopped early. We still don’t have many details about things that I would find interesting — how good were people at taking their pills, did they people on meds have more or less unprotected sex than people who weren’t on pills, etc. — but it seems incontrovertible that if you’re infected with HIV, one way to protect your sex partners is to start taking antiretrovirals when you’re immune system is still in relatively good shape.

I’m still left with two major questions. First: it is clear you’ll protect your partners, but will you protect yourself? What do we really know about the long-term effects of taking antiretorvirals early for your partners’ benefit? We’ll get more information about that from another trial by the same group, but they’re not scheduled to report for another five years. People who got treated earlier in the the treatment-as-prevention trial were just as likely to die during the course of the study as those who didn’t, though encouragingly, they were signigicantly less likely to get sick with TB. It may well be that starting meds earlier is good for the infected person as well as for those they shag.

Second major question: this study (known as HPTN 052) has made it clear that an HIV infected person whose CD4 count is between 350 and 550 when they start treatment is less infectious than a person who doesn’t start until their cell count falls below 250. For those individuals, treatment is prevention. But does that necessarily mean that expanding treatment will reduce new infections at a population level? For an interim period, at least, it may well not. Before I’m accused of raining on the parade yet again, I want to point out that the same question was raised by Myron Cohen, the principle investigator of HPTN 052 in an e-mail exactly a year ago. Speaking of a stampede towards using earlier treatment as a means of prevention, in part as a result of a lot of “utopian” modelling, Myron said:

“I am not convinced that this will all come out the way it now appears, and we do not yet know how to measure population level benefit of ART, if it is to occur.”

Logically, if you reduce the infectiousness of every infected person by 96%, new infections will fall very dramatically. But we know that can’t happen. It certainly can’t happen overnight. It’s worth noting that genetic analysis of the virus shows at least 18% of the new infections in the study (and possibly up to 28% — not all the analysis is finished) came from someone who was not the “regular partner” recruited into the study. Until everyone gets treated sooner, those infections will continue. Indeed some will continue even with universal earlier treatment, because some will probably have come from people who are newly-infected, very infectious and unlikely to be treated. That’s a continuing worry in places where the all-too-visible face of AIDS-related emaciation, disfigurement and death prompted a change in behaviour; less sex, fewer partners, more condoms. As expanded treatment removes that visible death-mask, communities revert towards pre-AIDS behaviours. Where condom use rose rapidly, for example among gay men in rich countries, it has fallen back since relatively early HIV treatment has been universally available. The effect may be less pronounced in the hyperendemic countries where behaviour has not changed all that much, but it’s something to watch out for. More unprotected sex with a variety of partners also pushes up STIs, and an active STI can in turn unleash spikes of HIV in the genital fluids and undermine the protective effect of antiretrovirals. Note that I’m not talking here about the behaviours of discordant couples who have been to counselling and are on HIV treatment, I’m talking about people who believe (or assume, or just hope) that both they and their partners are negative.

It’s perhaps worth clocking that researchers shifted their original “deferred treatment” threshold to a CD4 count of 250 (from 200) when the WHO treatment guidelines (and the national guidelines of many countries they were working in) shifted. They did not, however, change it again when WHO guidelines were revised upwards again to 350, because “the second revision was not readily adopted by all of the countries participating in the study, primarily due to a lack of drug supply.”

The fact that 1.8 million people died of AIDS in 2010 confirms that many countries have trouble getting drugs even to those people who depend on them for survival. Getting them to the larger number who might benefit from them as a transmission risk and TB reduction measure will be harder still. That will eat into the potential prevention gains in two ways — obviously people who don’t have drugs don’t have lower viral loads. But relatively healthy people who sometimes have drugs may present more of a transmission risk than those who never do, because HIV tends to spike upwards into a brief, highly infectious phase when treatment is interrupted. Frequent interruptions can undermine the effectiveness of the drugs; resistance is another source of nasty, infectious spikes in viral load. Though we don’t yet have any information about adherence, we can assume that people in the HPTN 052 trial had uninterrupted access to meds, and we know from the study protocols that they were actively encouraged to keep taking them. We also know that they deliberately excluded drunks, people with drug problems, people with mental problems or “Any condition that, in the opinion of the study staff, would make participation in the study unsafe, complicate interpretation of study outcome data, or otherwise interfere with achieving the study objectives”. In the real world, we can expect a more erratic drug supply, sloppier adherance and bouncier viral loads. That may will turn in to protection of far less than 96%.

Overall, more people on treatment means, we hope, more people living longer, healthier, more sexually active lives. That also means more opportunities for sex with someone when viral load is spiky, and thus for onward transmission over HIV. Add together more unprotected sex with people who may be in not-yet-treated primary infection, and more sex during times after the start of treatment when HIV is bouncing around because of STIs, treatment interruption, treatment failure or whatever. If the sum of those two adds up to more than the sex a person has between the time their CD4 count hits 550 and the time it would otherwise have hit 250, new infections are likely to rise, even if earlier treatment reduces transmission during that notional window to zero.

That is absolutely no reason at all not to push to use antiretrovirals to reduce infectiousness in people who are infected. I am persuaded that we should be doing that, and I think HPTN 052, with its relatively sober threshold for starting even the “early” treatment points us in the right direction. But I think it will be a long time before we have the cash and the systems in place to make this an effective prevention tool at the population level. And since none of the other prevention tools we have are working very well at the population level either (at least in unpaid sex of any persuasion), we certainly can’t declare victory quite yet.