© 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.

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.

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?

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.