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.

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?

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.