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.

So instead, I’ll have a rant about something that is somehow still shocking to me: the lengths to which loopy anti-abortion groups in the United States will go to deprive women of safe contraception and sexual health care. The target, once again, is Planned Parenthood. Over a one-week period last month, men went in to the sexual health service providers clinics in 11 cities, claiming to be sex traffickers seeking services, including abortions, for the underage girls they’ve enslaved. That would be a really dumb strategy for a real sex trafficker — in the US, even more than in Britain, the authorities are under pressure to find the army of enslaved girls that the abolitionists conjure up at every turn. It’s a well-hidden army; though a massive UK crackdown led to over 500 arrests related to selling sex a while back, it didn’t yield a single trafficker. Not that that has stopped the abolitionists’ conjuring. Shame on The Guardian for not referring back to its own excellent investigative work in this area.

Planned Parenthood immediately suspected that no trafficker would be that dumb. Certainly not 11 traffickers in different cities in a week, when such a thing had never happened before. Though it smelled like a hoax, they dutifully reported the alleged trafficking to the FBI and asked for an investigation. Now Loopy anti-abortionist group Live Action has admitted, with some pride, to their juvenile prank. They’ve released two of their “undercover” videos, to which they’ve they added juvenile-prank-style title screens.

My personal favourite: “Planned Parenthood Gets the Pimp Discount for His Underage Sex Slaves”. I will say that the clinic manager in New Jersey sails pretty close to the wind. But then which of us who has tried to provide services for people in need who have nowhere else to go does not bend the rules? As Planned Parenthood says: “Falsely claiming sex trafficking to health professionals to advance a political agenda is an astoundingly cynical form of political activity.”

Compared to this, the standard operating procedures in the AIDS world — using Global Fund money to buy 4x4s for officials — seem somewhat tame.

Update: (or rather backdate). Steve sent me this interesting reminder of an earlier assault on Planned Parenthood. Sigh.

Pictured above is the miraculous Ceragem massage bed. Promoters of a clinic in South Africa claim that the bed cures AIDS. That’s great news, of course. But why stop there? A truly visionary charlatan would see much greater possibilities. We know that post-exposure prophylaxis works — that taking antiretrovirals very soon after exposure can prevent HIV taking hold in the body. The big HIV news of 2010 is likely to be that pre-exposure prophylaxis works too — we can prevent HIV taking hold by taking antiretorvirals shortly before we do something dumb like have sex without a condom with someone who’s likely to be infected. What’s the obvious gap? Since most HIV infections are contracted in bed, we could run this miracle bed-cure into pending exposure prophylaxis: let’s prevent HIV taking hold at the very moment that people are swapping infected body fluids. Just have sex in one of our massage beds and you’ll never need to think about latex again. I’m looking forward to hearing from the venture capitalists among you…

Thanks to Babe for pointing me in the direction of this great business opportunity.

Michael tells the story more patiently than I’d be able to. As several people pointed out, including Dharmawan, Willem and Catherine. Read. Really, please read. What Michael doesn’t say is that Indonesia has pocketed more than US$ 400 million in foreign taxpayers’ money to deal with HIV so far, and has another US$ 130 million from the Global Fund on the table. And it can’t even assure treatment in the big, well-funded, teaching hospitals designated to provide ARVs. No need to point out that treatment is the EASY bit, the big, politically popular success story. People need it because we fail so badly on the cheaper, easier prevention services, like making sure that kids who inject heroin in Indonesia don’t also inject HIV. If it doesn’t make you angry that we’re using your money so badly (if you’re a European or North American tax payer) or serving your needs so poorly (kalau seandenya anda orang Indonesia, apalagi orang Indonesia yang terinfeksi HIV…), this blog’s no place for you.

The first step backwards is of course that counterfeit drugs usually don’t work very well. But people who take them presume, at least until they get hopelessly sick, that they are working. They believe their viral loads are falling, and they believe that they are getting less infectious. We already know that people get sloppier about using condoms it they think they are not infectious (or, if they are uninfected, that any HIV-infected partners will be on meds and not infectious). So it’s not encouraging to think that those may be the very people whose viral load is bouncing skywards because they are on ineffective medication. Oh, and that resistance is almost inevitably going to rise because people will be on and off “real” medication depending on the supply.

The second step backwards is that this kind of thing gives the self-appointed guardians of Big Pharma’s bottom line a new cudgel with which to bash generics and compulsory licensing. And sure enough, there they are today, wielding the cudgel on the op-ed pages of The New York Times. (Note the source of Roger Bate’s funding…) Conflating generics with counterfeit drugs is like conflating sex work with trafficking. One provides services people want at a price they agree to pay, the other is illegal and dangerous. But waging war on the first is almost certainly going to make it harder to wipe out the second.

Malawi is suspending its payments to HIV-infected civil servants because so many uninfected people are trying to cash in, according to AFP (via Cryton Chikoko). A third of Malawi’s 120,000 civil servants have registered as HIV positive. That puts HIV prevalence among government workers at twice the national rate of 14 percent.

Infected civil servants top up their salaries by US$ 35 a month –that’s a 50% slab on top of their average earnings — enough to make many of us change our behaviour. Obviously enough to overcome the stigma that is so often said to stand in the way of any effective HIV programming. It reminds me of stories that surfaced in China when the government started providing free schooling for the kids of people with HIV. China being China, it wasn’t long before there was a secondary market in HIV-infected blood.

Stigma exists because we allow it to, because we reinforce it by tiptoeing around it. The bulldozer of personal incentives can break through stigma in exactly the same way as it can break through corruption, poor productivity and other areas of human endeavour. If we have to bribe our way into greater openness about HIV, why not?

Well, maybe because peverse incentives are a dangerous thing. We want to make it worth people’s while to be more open about their HIV status, without making it worth their while to be infected with HIV. And we don’t want to do anything to reduce the motivation that uninfected people have to protect themselves (which, judging from high rates of new infections in many populations, it already pretty slim). This came up in an interesting discussion I had with the Oxford Global Health group recently. One person mentioned that people in South Africa who get disability payments linked to their TB infection are reluctant to be fully cured, because they don’t want to lose the payments. I’m all for using bribery to change attitudes and behaviour. But one does have to remember that the sword of incentives can have many edges.

Robert Ochai, director of the trailblazing AIDS support organisation TASO, has noticed that some of group’s the 23,000 treatment clients are giving up their HIV drugs because they have been “cured” by faith healers, according to a report in The Monitor. Apparently, faith healing has become big business in Uganda.

“Several Pentecostal churches in the country, more so in Kampala, invite the sick, including those with Aids, for spiritual healing. Some churches promise miracles, sometimes in exchange for their patients’ valuables. The most publicised case is of Ms Frances Adroa who claimed last year that she was tricked by pastors of the Universal Church of the Kingdom of God into offering her car to the church. She later sued the pastors after her condition deteriorated and they refused to return her car,” reports Kakaire Kirunda.

Eating in to family finances is bad enough. Deliberately encouraging people to give up life-prolonging therapy is far worse. But the effect on the epidemic as a whole could be catastrophic, too. If a person is on antiretrovirals, it is critical that they stay on them (or, to use the AIDS Inc. jargon, that their “compliance” is high). If they stop taking them for a bit, because they run out, forget, can’t be bothered, feel rotten or whatever, the amount of virus in their blood shoots up. That damages the immune system and makes it more likely that they’ll get sick, it increases the likelihood that the virus will mutate into drug-resistant forms, and it makes it much, much more likely that they’ll pass their infection on if they have unprotected sex.

Partly because of the extraordinary level of support provided by organisations like TASO, compliance among Ugandans on ARVs is very high. Undermining it in the name of God and Mamon is beyond cynical, it is downright wicked. In this regard, the “faith healers” are no better than witch doctors or traditional healers who sell expensive herbal cures for AIDS.

For an insight into the complicated relationship between traditional beliefs, modern medicine and faith, I urge you to read Johnny Steinberg’s book Sizwe’s Test, to be published soon in the UK under the less interesting title Three Letter Plague. He’s writing about South Africa rather than Uganda but he does so with depth of feeling and great humanity. It’s thought-provoking, and a lovely read.

One in five of the people newly diagnosed with HIV in the UK last year were diagnosed with AIDS at the same time. That means they’d probably been walking around with HIV infection for eight or nine years without ever being tested. Thinking they were uninfected, they might have had more unprotected sex than they would have if they knew they had HIV. Certainly, they’ve got a higher chance of dying in the next two years than people who got diagnosed and put on treatment earlier on. So yes, we want to get more people tested sooner.

The thing is that we’ve got a pretty good idea who is most likely to be infected in Britain. Gay men and people who have come to the UK from sub-Saharan Africa. People who inject drugs. The people that all of those people have sex with, plus people who are having unprotected sex with lots of other people, and who are thus getting infected with other sexually transmitted infections. The new testing guidelines very specifically say that all of these people should be offered HIV testing, routinely, every time they come into contact with the health services. They’re listed in sections A and C in the bit of the guidelines that I’ve coped below. (One group not included is people in prison, even though prisons are one of the places where drug users are most likely to be in contact with health services.)

So far so (really very) good. But then the but. The guidelines also recommend testing just about everyone in the areas of the country where more than one in 500 adults is currently known to be infected with HIV (the B section below). This makes very little sense. More importantly, it creates a smokescreen behind which medics can hide. Instead of engaging with their patients, talking to them about their sex lives, assessing their risk behaviour, giving advice about healthy behaviour, they just offer HIV tests to every school teacher in for a hip replacement, every maiden aunt moving to a new job in an area favoured by gay men. You can tell by the wording that some of the people involved in drafting the recommendations were reluctant to impose this unnecessary cost on local health authorities. They should have fought harder to keep it out.

Who should be offered a test?
A. Universal HIV testing is recommended in all of the following settings:
1. GUM or sexual health clinics
2. antenatal services
3. termination of pregnancy services
4. drug dependency programmes
5. healthcare services for those diagnosed with tuberculosis, hepatitis B, hepatitis C and lymphoma.

B. An HIV test should be considered in the following settings where diagnosed HIV prevalence
in the local population (PCT/LA) exceeds 2 in 1000 population (see local PCT data†):
1. all men and women registering in general practice
2. all general medical admissions.
The introduction of universal HIV testing in these settings should be thoroughly evaluated for acceptability and feasibility and the resultant data made available to better inform the ongoing implementation of these guidelines.

C. HIV testing should be also routinely offered and recommended to the following patients:
1. all patients presenting for healthcare where HIV, including primary HIV infection, enters the
differential diagnosis (see table of indicator diseases and section on primary HIV infection)
2. all patients diagnosed with a sexually transmitted infection
3. all sexual partners of men and women known to be HIV positive
4. all men who have disclosed sexual contact with other men
5. all female sexual contacts of men who have sex with men
6. all patients reporting a history of injecting drug use
7. all men and women known to be from a country of high HIV prevalence (>1%*)
8. all men and women who report sexual contact abroad or in the UK with individuals from
countries of high HIV prevalence.

HIV medicine advertising: In the toilet

As competition to treat people for HIV has hotted up, pharmaceutical companies have started dumping on one another. Using innuendo and not-quite-stated factoids, they are beginning to imply that the rival camp has something to hide (something they’ve no doubt learned from political campaigns). Those other drugs are toxic, discolouring, inconvenient. Activist groups and HIV bloggers such as Peropheries are upset, but I wonder if Big Pharma might actually be doing us a favour.

I first saw the loo ad above looming down at me in a huge, back-lit poster form while I was wandering around New York one evening recently. It’s from Bristol Myers Sqibb — they make Reyataz, an antiretorviral which apparently doesn’t send you to the loo every two seconds. Sadly not true of Kaletra, made by rival Abbot Laboratories. Though this ad doesn’t actually point the finger, it’s a pretty good start as smear campaigns go. This and other examples have been picked up in a story by The Wall Street Journal, relayed by the always helpful Kaiser Family Foundation.

Treatment activism groups are upset because they think negative advertising might discourage infected people from taking their meds at all. That seems to me unlikely — the runs is an unpleasant but relatively small price to pay for an AIDS-free life. I do think we have a right to be upset about what these cut-throat smear campaigns tell us about what the marketing gurus think is acceptable corporate behaviour in our hyper-capitalist world. But I also think that the relentlessly upbeat advertising that has been the norm for HIV meds for years now might be just as damaging. The message: “Don’t worry if you get HIV, you can still go rock-climbing with your friends at the weekends”, has surely contributed to the “so what?” attitude that has led to rising risk behaviour and HIV rates among young gay men in many places. Perhaps inadvertently, Big Pharma is now sending a different message: being on HIV meds for the rest of your life may not be such a painless thing after all. As I said, I don’t think these ads are going to discourage people who are already infected from taking their meds. But they might just help on the prevention front, by signaling to uninfected people that it’s perhaps worth making a bit of an effort to stay that way.

And it is happening in the northern Nigerian state of Bauchi, according to the BBC’s Shehu Saulawa. The Red Cross conducted a survey of sex workers in the conservative Islamic state, identifying around 320 of them. The next thing they knew the women were being rounded up by the Sharia commission, the defender of Islamic virtue, at least according to the BBC correspondent. (The Sharia commission denies the women were being arrested, saying that its staff were simply “supervising”, because “In every nook and corner and cranny, illegal acts were being committed contrary to Sharia law”).

According to the Beeb story, between 75 and 100 of the 320 women have so far tested positive for HIV. It’s not clear who’s doing the testing, but that’s a prevalence of between a quarter and a third of sex workers infected, “so far”. Horribly high, but not out of line with what’s happening elsewhere in the country. The long awaited report on the 2007 HIV surveillance round (pdf) is finally out: one in two women working in the brothels of Kano and FCT are infected with HIV. The lowest recorded rates are in Lagos, at just under one in four.

HIV rates are astoundingly high among gay men in Nigeria, too (again, close to a quarter of gay men in Lagos are infected) though somewhat surprisingly they are lower among drug injectors. And gay men don’t fare any better than sex workers at the hands of Bauchi’s morality police. Earlier this month a judge slung 18 cross-dressers in jail for messing with sharia law banning homosexuality. If there’s one thing we’ve learned in 15 years of dealing with HIV, it is that even where patterns of sexual networking allow for it, HIV will only spread through the “general population” if it first reaches a critical mass within sub-populations with the highest turnover of partners: sex workers, gay men and drug injectors. In other words, in any epidemic, but especially one where many adults do have sex with several long-term partners but HIV is currently concentrated among people with highest risk, it makes sense to invest in prevention for these groups.

Oh, we’ve learned something else, too. If you try to squash these groups rather than engage with them, HIV rises. What has Nigeria (and its major HIV funders, the United States and Global Fund) made of these lessons? Well, in 2007 The US invested 53 million dollars in HIV prevention, according to the PEPFAR website.

“Prevention activities in Nigeria include prevention of mother-to-child transmission (PMTCT), abstinence and be faithful (AB) programs, blood and injection safety, and other prevention initiatives, including activities focused on high risk populations.”

High risk populations? Hurrah! But no, it doesn’t mean sex workers. Rather, PEPFAR Nigeria singles out “girls who marry at a young age, causing their sexual debut to occur at an early age. This group, which has a mean age at first marriage of 14.6 years, is a vulnerable and largely underserved population…”

The Global Fund doesn’t fund prevention at all, except for the “innocent babies” thing. Though the clarion call these days is “Know Your Epidemic”, it doesn’t seem to translate into “Do The Right Thing About Your Epidemic”. And when the “knowing” it bit ends up with people getting slung in jail, you’ve got to wonder whether it’s worthwhile collecting all those data.

Thanks to Sean Lyons for the Bauchi tip