On individual measures that are often indicators of women’s ability to make their own choices and decisions — educational level, for example, we see a strong correlation too, both at the national level:

and at the household level:

So, in countries where women are more equal to men on measures of workforce and political participation as well as education, there’s more HIV than in countries where women are more constrained. In countries where women are more educated, there’s more HIV. Within countries, more educated women are more likely to be infected with HIV.

Multiple concurrent partnerships: we’re crap at defining them, and therefore at measuring them. The imporant issue is simply: how likely is an infected person to be having sex with an uninfected person in the relatively short periods when viral load is high? These periods are more frequent where other STIs (and especially HSV2) are high. But the highest viraemia is right after someone first becomes infected. So anyone who has several partners in the two of three month window in which they themselves were infected are most likely to pass on the virus to others. If enough people (men AND women — it has to work on both sides of the equation in a heterosexual epidemic) have multiple partners in that time, you have the potential for a hyper-epidmic. Without it, you don’t.

Here are data from the first round of national surveys of HIV-related risk, way back in 1989-1991. The dark bars are people who reported that they had more than one REGULAR partner in the previous year. I.e. more than one person to whom they were married and with whom they had been having sex on an ongoing basis for a year or more. You can see that there’s something of a difference between countries in Africa and those elsewhere.

For your interest, I’ve also put in what people think their partners do. In almost every case, men report fewer partners than their wives think they have. I.e., women think men are pigs. And women report more partners than their husbands think they have. Men labour under the illusion that women are angels.

Ho hum.

Yesterday, I sat at the TED conference in California and watched David Cameron pledge to make policies that support prostitutes.

He didn’t say it in those words, exactly, but he did promise firmly to make policy that “goes with the grain of human nature”. That would be a massive change for the UK: Labour’s old fashioned feminists have allowed their best intentions to get the better of their common sense. That’s saddled us with laws that put prostitutes lives AND livelihoods in danger.

David Cameron is a politician on the stump, so everything he says should be taken with several grains of salt. But the the goody-two-shoes meddling of the likes of Harriet Harman and Jaqui Smith has become so tiresome that maybe we should take Cameron at his word, and hold him to it. Political bondage, in the best possible sense…

So Jacob Zuma is sorry about having unprotected sex with someone three decades younger than himself, who is not one of the five women he’s married. That’s a little better than last week’s “You should be proud that I’ve admitted paternity and paid a fine. What are you all so uptight about?” HIV activists are pretty upset. Me, I prefer to see what he’s done as a good thing.

I’m not one to get uptight about extramarital sex. But I am not president of a country where one in five adults is infected with a still-fatal sexually transmitted virus. Mr. Zuma has rubbed South Africa’s nose in the fact that he racks up as many sex partners as he can, and he doesn’t use condoms.

How is that a good thing? Well, it allows us to say the unsayable: countries get the HIV epidemics they deserve.

Want a hyper-epidemic? All you need is a tradition of polygamy AND high levels of female autonomy. Big Men have their little network of wives and/or lovers. Women buy in to duty sex for the status and security, but get to run their own little networks on the side, for the fun of it. That has been the pattern in South Africa, Swaziland, Botswana, Zambia, Zimbabwe and a number of other countries where more than one adult in seven has HIV.

But woe betide anyone who points this out. At best, you are insensitive to cultural traditions. At worst, you are perpetuating racist myths of the hypersexualised African male, blah, blah, blah.

Now South Africa’s president is unrepentantly living the myth. He has been married five times, and is currently shared by three wives (one of the others killed herself). He’s got another fiancée in the wings for good measure. In 2006 he was acquitted of rape charges, and now we find he’s bonking the daughter of an old mate who’s running the World Cup organising committee. This puts him in good company. In neighbouring Swaziland, where one adult in three has HIV, the king sets an example by taking a new teenaged wife every couple of years — a baker’s dozen so far.

Here’s another thing that Mr. Zuma’s behaviour has laid bare: HIV is a preventable infection. Good governments prevent it. Bad ones hide behind the very culture, tradition and customs that allow the virus to spread, and then throw their hands up when prevalence get so high that HIV will continue to spread even if behaviour does change.

The saintly Nelson Mandela was unforgivably slow to do anything to address the sexual behaviours that were spreading HIV. His successor Thabo Mbeki compounded the problem by simply denying that the sexually transmitted virus was in any way linked to a four-fold rise in death rates among young adults. Besides spotlighting his sexual escapades, Mr. Zuma used his 2006 rape trial to give us a new perspective on how to stay HIV-free. Sorry I had unprotected sex with an HIV-infected woman he said, but don’t worry about me, I had a shower afterwards, so I won’t catch anything.

Unfazed by his flagrant disdain for his own health ministry’s HIV prevention efforts, (or by the pack of corruption charges that stalk him, or by his growing posse of wives) the people of South Africa support Jacob Zuma anyway. It’s a healthy democracy, and that’s their right. But I think it is time that voters in other countries stopped subsidising the fatally bad behaviour of South African leaders. Why should Americans give South Africa over half a billion dollars of PEPFAR money a year, in part to promote abstinence, monogamy and condom use, when the electorate of the country supports a man who is the embodiment of the behaviours and attitudes that spread HIV? Because, you might argue, the government of the richest country in Africa, which is also pocketing over US$ 160 million for HIV from the Global Fund, can’t even organise itself to keep anti-retrovirals in stock. I’d say that’s all the more reason to stop propping up bad leadership on HIV.

This post is for Dot and the thousands of other hard-working health care professionals in South Africa who have to pick up the pieces.

Does this signal a new wave of common sense in HIV prevention in the United States? That’s certainly what we expected when Obama was elected. During his campaign, for example, he recognised that sterile needle programmes cut HIV infection among injectors, saving lives and money, and pledged to end a ban on funding those programmes from federal coffers. So cities such as his home town of Chicago, pictured in the map below, will now be able to use central money to provide clean needles to the inner city injectors that need them most. As long as they set up in one of the grey spaces. In the cemetary, in other words.

(Click to enlarge)

On this fantastic map, which comes from Yale University’s Dr. Russell Barbour by way of Stop the Drug War, the red areas are the parts of town where it would be illegal to operate a federally funded needle exchange under new rules proposed by Congress. The Drug War Chronicle provides an interesting history of the needle exchange shenannigans. Essentially, Obama did not remove the ban from a budget bill because he thinks policy shouldn’t be made through sub-clauses in budget bills. Democrats on the committee discussing the bill disagreed, and dropped the ban. Then Republicans, not willing to give up the idea that the availability of clean needles would have us all racing to start shooting up smack, decided to protect the innocent by forbidding needle programmes within 1,000 feet of “a public or private day care centre, elementary school, vocational school, secondary school, college, junior college, or university, or any public swimming pool, park, playground, video arcade, or youth centre, or an event sponsored by any such entity”. That’s the red bits on the map of Chicago above. Here’s Dr, Barbour’s map of needle exchange exclusion zones in San Francisco:

This is clearly just a way of pulling the rug from under any effort to increase access to clean needles. We’ve come to expect this kind of implaccable opposition from conservative Drug Warriors in the United States. We used to expect the Brits to be more rational about their drug policy, and the UK has, thank God, held on to its policy of providing clean fits for anyone that needs them. But with the sacking of the government’s independent advisor on drugs David Nutt for repeating his independent advice after the government chose to ignore it, I’m not so sure.

I’m not even going to wade in here about whether or not idependent scientific advisers to government should shut up after their advice is ignored, but I will commend to you a wonderful paper by Dr Nutt on the dangers of Equasy, (pdf) an irrational addiction to horse riding. This has been seized on by many who have not read it as an example of his inappropriate analyses. Irony, where art thou?

The US Drug Warriors also joyously seized on the latest round of anonymous surveillance of HIV among drug injectors in Britain, sending out an e-mail crowing about rising rates of HIV and drawing a link between that and the fact that the UK was the first country in the world to have national injection safety programmes. My next post will put those rather one-eyed claims into perspective.

The fact that raids on over 800 brothels didn’t net any traffickers doesn’t mean that there isn’t anyone in the UK selling sex against their will. But (I’ve said it before and in today’s Guardian I say it again) trying to wipe out the sex trade completely only makes things worse for the minority who are forced into it.

There is little one can do to change the minds of those who object, viscerally, to the commodification of sex. And the numbers will always be open to dispute, as they are with any illegal activity. But a lot of good researchers have spent a lot of time and effort trying to get a handle on trafficking in the sex trade — you can find excellent references here and here, and there’s a pretty good discussion thread over at Badscience. It’s like the massive, hidden HIV epidemic in the Middle East — if we haven’t found it after two decades of looking, maybe it really isn’t so massive after all.

For those who don’t have time to read the whole Guardian article, I’ll pull one key quote from a cop:

The head of the UK Human Trafficking Centre, Grahame Maxwell, who is chief constable of North Yorkshire, acknowledged the importance of the figures: “The facts speak for themselves. I’m not trying to argue with them in any shape or form,” he said.
He said he had commissioned fresh research from regional intelligence units to try to get a clearer picture of the scale of sex trafficking. “What we’re trying to do is to get it gently back to some reality here,” he said.
“It’s not where you go down on every street corner in every street in Britain, and there’s a trafficked individual.
“There are more people trafficked for labour exploitation than there are for sexual exploitation. We need to redress the balance here. People just seem to grab figures from the air.”

**UPDATE** The Guardian has published more interesting contributions to the debate, including the opinions of people who sell sex for a living.

With Halloween coming up, and in contrast to the hysteria around migrant sex workers, I offer this seasonal celebration of migrant pumpkin pickers in Canada, courtesy of Ickaprick.

It’s like this. Ms Harman, who is Deputy Leader of the UK’s ruling Labour Party, wants whats best for working girls. Punternet does too. (For those who use the term “john”, a punter is a man who buys sex). Ms. Harman wants to reduce trafiicking of women into sex work. Punternet does too — that’s why it provides links to allow men using the site to report women that they suspect might be under age or working against their will. Is that why Ms Harman decided to give the site such good publicity, more than doubling its hits to an eye-watering 2.7 million a day according to the Financial Times? From the vote of thanks she’s had from sex workers working on both sides of the Atlantic. you might think so. But no, the good democrat was actually appealing to California Governor Arnold Schwarzenegger to shut the site down (the server is, apparently situated in the land of free speech).

No surprise to regular readers of this site; it is all part of Nanny Labour’s ongoing campaign to wipe out consensual trade in sex which, the views of sex workers themselves notwithstanding (see comments), always amounts to exploitation. But it did bring the idiocy of this policy to the notice of mainstream commentators such as the FT’s Matthwe Engel, which can only be a good thing.

Other issues of cultural politics I had to try and explain: why I am addicted to a radio soap opera that has been running for nearly 60 years. That’s right, The Archers, originally billed as “the everyday story of country folk”, now rebranded appallingly as “contermporary drama in a rural setting”. I tried to explain that bracketed between the unchanging theme tune “Tum ti tum ti tum ti tum…” came all the burning issues of the day. My mate rolled his eyes and went back to blogging about really burning issues, like rectal gonnorhea. Then, on Friday, he apologised. He “just happened” to turn on the radio when The Archers was on (that’s how I started too — a slippery slope to a lifelong struggle with Archers addiciton). And bingo: Ian gets beaten up because he’s gay. You could argue that Ian gets beaten up because he tries politely to get a bunch of drunken football louts to shut up. But they called him a “bender”, which is surely enough to blow the homophobia flag up the pole. (You can listen to the episode until 16/10/09.) The question that is not exactly burning up the message boards is: why did Ian not want to report the assault to the police? Might he suspect that the cops in a rural setting might have rather uncontemporary views about anal sex between men? You’ll just have to tune in to find out…

So we’ll have more pregnant teenagers, more ill-equppied child-mothers, more kids being poorly raised by resentful single parents whose own opportunities in life were cut short for lack of a pill or a condom. None of which leads to great health outcomes for either mother or child. Is it any wonder that the world’s wealthiest country trails the likes of Cypress, Morrocco and the Dominican Republic in health care?

If this depresses you, this gem from Paul Hipp might cheer you up.

Thanks to Txema and Kim Thomas.

AIDS activists need to change not only their tune but their name. What we need is HIV activism, not AIDS activism. Because with the treatments that are now widely available in Western Europe and North America, AIDS is vanishing fast. While it continues to kill millions of people in Sub-Saharan Africa, where two thirds of people with HIV live, in most industrial countries it now kills a few hundred people a year at most. As long as treatment is available and effective, AIDS will remain largely a thing of the past in the rich world. But if drug-resistant strains develop and spread — and there is a real possibility they will — we’ll be back to the carnage of the late 1980s and early 1990s. Only very much worse, because there are so many more people now living with HIV in the West. And there are more people living with HIV in part because people aren’t dying of AIDS any more (a good thing) and in part because we are doing so very badly at prevention (definitely not a good thing). Brand new HIV infections are on the rise again among gay men in Germany, the US, the UK, Australia, Canada, Spain, Switzerland, the Netherlands — just about everywhere we’ve can measure it. That really is shocking.

Does it seem churlish, then, for me to be criticising the new prevention campaign in Germany? Some respondents to a comment I wrote in The Guardian think so. But I’m critical precisely because we need more good prevention that addresses local realities. The local realities in Germany are:

1) we are already effectively preventing AIDS, through treatment
2) we are failing to prevent HIV
3) the vast majority of the sexual transmission of HIV happens between men in anal sex

What Germany needs is campaigns to encourage gay men to avoid an inconvenient life-long infection (HIV) that is expensive to treat and can be most easily prevented by using condoms in sex. That is not what Malawi or Washington DC or Buenos Aires need, but it IS what Germany needs. What the Das Comitee ad gives the German public is a campaign to encourage heterosexual women to avoid a killer disease that in their local reality barely exists. “Shock value” is all very well, but if you are shocking the wrong people about the wrong things, you’re not going to prevent many HIV infections. And that’s what we need to do, now more than ever.

The IAS conference on HIV Pathogenesis, Treatment and Prevention in Cape Town, South Africa produced its usual crop of second rate abstracts on issues currently fashionable in the HIV industry — gender, health systems strengthening, scaling up — along with the inevitable calls for more cash. The IAS also runs the biennial international AIDS conferences — giant circuses full of amusing but expensive set-pieces: protesting sex workers, singing orphans, earnest celebs. There’s so little science at those conferences that a lot of researchers have abandoned them in favour of low-key, high-science meetings such as CROI. It seems IAS is trying to claw its way back on to the scientific platform with the pathogenisis sub-conferences. Perhaps we’ll see more good sense from the organisation now that it is coming under the spell of the inimitable Robin Gorna.

Among the conference’s silliness was a study of the protective effect of circumcision in anal sex between men in Soweto. It’s hard to tell much from an abstract and this came from a good research team so perhaps I’m being unfair. This cross-sectional study (picked up by IRMA) reports results for men who only ever act as tops in anal sex with other men. Not one iota surprisingly, the results are exactly the same as for men who only ever act as tops in vaginal sex with women (i.e. all men who have vaginal sex): uncircumcised men are four times more likely to be infected with HIV.

What does that tell us? Almost nothing of any use in HIV prevention programming. Over 13% of the guys in the study had HIV. In the very high prevalence settings of Southern Africa, guys (and boys and infants) should be getting snipped regardless of their eventual sexuality. We don’t need more clinical trials of exclusively insertive MSM to prove that, especially since 80% of these blokes are also shagging women. But the South African study doesn’t mean gay guys in other parts of the world will necessarily be protected by circumcision. In this study, three quarters of respondents said they were only ever tops. (If you believe them, spare a thought for the remaining quarter; they must be getting poked painfully frequently just to make the numbers add up.) If you don’t believe them it may well be because that degree of role separation is unusual in many gay communities. Indeed one of the reasons HIV spread so rapidly among gay men is that the very people who are most likely to get infected (because they’re taking it up an orifice not designed for the purpose) are also most likely to infect others (because they give as good as they get). Heteros don’t have that flexibility, and that slows transmission down.

For practical purposes what we’d like to know from the Soweto data is: does circumcision protect men who have anal sex against HIV regardless of whether they are a top, a bottom, or “versatile”?

More silliness from Canada on needle exchange, but some good news from the States on that front, too. Of which more after I’ve unpacked more boxes. In the meantime, this comment on trafficking hysteria from another member of the Silliness Police over at Preipheries.

The day before the UK release of Bruno, Sasha Baron Cohen’s swish along the catwalks of homophobia, the UK’s House of Lords voted to allow Brits to criticize homosexuality. Gay groups are painting this as a victory for homophobia. Christian groups say it is a victory for free speech. I say, on balance, that it is a victory for common sense.

The debate focused mostly on the difference between criticism and incitement to hatred. Is it wrong to teach schoolkids that it’s OK to thump anyone who they think is a sissy? Yes, just as it is wrong to encourage violence against anyone with the “wrong” skin colour. But should people face prosecution for open debate about the pros and cons of gay marriage, nuclear families with same-sex parents and the like? Surely not. We may not like people who are crtical of the things we hold most dear, but our society is built on their right to criticise our views, and ours to criticise theirs.

For my part, I would be more than happy to criticise (possibly even thump!) the self-righteous prig who told The Moral Maze that she didn’t think that gay people ought to be allowed to work as gardeners in Christian schools. (Replay of programme available until 18/07/09) I kept willing one of the panelists to ask her what she thinks Christ would have done (or indeed did do) if any of that tight little band of apostles was gay. I find her views pretty offensive, but I don’t think she should be locked up for expressing them.