Thanks to Txema, who is always ready to make a girl smile.

My favourite, gloriously rude comment came from The Bathhouse. It summarised my “inflammatory and simplistic” argument thus:

1.) The AIDS mafia want treatment to replace prevention in Africa because they think that people on ARVs are less infectious, therefore reducing the spread of HIV.
2.) What the fools don’t realise is that people are most infectious soon after having contracted HIV so the screening is unlikely to help identify people in time
3.) Availability of treatment makes people less worried about HIV and so indulge in more risky behaviours
4.) Treatment is bad and people who think it is a good idea are optimistic simpletons

I’m prepared to accept, more or less, that the first three contentions are inflamatory and simplistic summaries of the argument I made. But how you get from that to “treatment is bad” is beyond me. How observing that new HIV infections have been rising among gay men since treatment became widely available makes me homophobic is a bit of a mystery to me too. We’ll have to stick that label on researchers in an awful lot of countries: data from Australia, Canada, England, Germany, the Netherlands, New Zealand, Spain, Scotland, Switzerland and the United States support the claim. A good recent review can be found here. For those that don’t want to bother reading a whole paper, here’s a picture to look at, from Scotland.

The graph shows newly-identified infections. That’s not a true measure of new infections, because it depends on who gets tested. And obviously there was more of an incentive to get tested after treatment became available. But why would that affect gay men selectively, rather than drug injectors and heterosexuals? The fact is that drug injectors don’t want to share needles whether or not they face the threat of HIV. So becoming less worried about HIV does not lead to an increase in needle sharing. Gay men, on the other hand, just like straight men and women, would often really prefer to have sex without a condom. The threat of AIDS is a pretty big disincentive to unprotected sex. The threat of HIV is a lesser disincentive. The uptick among heterosexuals has been less pronounced than among gay men simply because in Scotland, prevalence is far lower among heterosexuals. So any drop in condom use in sex between men and women will result in relatively fewer new infections.

Does that make me homophobic? Not unless someone’s been giving out the black-and-white glasses. In the same way as saying that more treatment means more people living longer with HIV does not make me anti-treatment. No-one who has seen friends die because they live in a place where they couldn’t get treatment could possibly be anti-treatment. We should be expanding treatment for its own sake. We also know that treatment reduces viral load among those who take it regularly, and who don’t have other STIs (athough any amount of viral load in someone who is kept alive through treatment is, whether you like it or not, higher than the viral load of someone who has died because they didn’t get treatment.) Treatment is GOOD, in its own right. We don’t need to build computer models based on entirely unrealistic assumptions in order to justify the need for more treatment. We DO, however, need to face the fact that until now, more treatment has been associated with more new infections. The world does not exist in black and white, in treatment OR prevention. The fact is, as we expand treatment, we need to expand other forms of effective prevention, too.

Can the wicked witch go back to her coven, now?

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.

Thanks to Seif, who has yet to take me shoe shopping…

I found it slightly depressing that I’m out of the denominator (they only look at data from 18-32 year olds). But I was particularly delighted by this graph:

It looks at the effectiveness of showing clevage in your profile picture. The bad news is that all women’s pulling power falls over time. But Apparently, showing clevage bounces up your chances of getting a date more the older you get. Men, depressingly, don’t lose out on dates as they age. Unless they’re trying to show off their six-pack. Abs shots are less successful the older you get.

Now tell me data analysis is not sexy…

Thanks to Nico, who is definitely in the denominator, but has tragically stopped sharing his wisdom with us.

The other night, I was dining with someone who didn’t know their acronym from their elbow. I had to explain MSM (mice that have sex with mice; no, wait…) and had a special rant about LGBT. For the unitiated that’s Lesbian, Gay, Bisexual and Transgender. It just trips off the tongue, doesn’t it? And it is just about as elegant conceptually as it is linguistically. Those groups don’t actually want to hang out together very often (except, perhaps, where they’re bidding for HIV funding). It’s a bit like forming a trade association for Doctors, Actors, Farmers and Tailors — DAFT.

Inspired by Indonesian petrol stations, which sell “Elpiji” (LPG, liquified petroleum gas), I’ve started writing this most annoying acronym as “Eljibiti”. But The Onion has done it better, in this hilarious spoof report on Gay Pride. LAGALABATATA — the Los Angeles Gay And Lesbian And Bisexual And Transvestite And Transgender Alliance. Like so much else in The Onion, it is so funny because it is so close to the truth.

Thanks to Roger for the smile.

The question was raised for me while I am here in Thailand by a comment on an earlier post. It pointed out that US taxpayers, through CDC, are funding a trial among drug injectors in Thailand that withholds the very thing we know will prevent most infections: sterile needles.

CDC, on its website, points out that withholding clean needles is “consistent with Thai government policy”. And yet the agency itself recognises that needle distribution programmes reduce HIV infections. The Helsinki declaration on medical research ethics says that if you’re trying out a new drug or procedure, you’ve got to try it against the best available alternative.
In the past, I’ve argued that it is reasonable for us to read that as “the best alternative feasibly available in the country where the study is being done”. There’s no point trying a drug designed for use in a developing country against a developed-country regimen which is likely to be better, but which couldn’t ever be offered in the study country because it requires too much money, technology or expertise to administer.

The “we’re using the Thai standard of care” argument is very convenient for CDC researchers. After all, they need quite a few people to get infected, so that they can see if significantly fewer people get infected if they’re using the trial drug, tenofivir.* CDC’s other tenofivir trial, among women in Botswana, has just been downgraded, because the research team has realised that it is not getting enough infections in either group for it to be able to measure a difference. That’s in part because of very high drop-out rates — already a red flag for a prevention method that obliges you to take a pill a day for as long as you’re at risk.

We know that an adequate supply of sterile needles, and the freedom to use them without fear of arrest, can cut HIV infections dramatically among injectors. If the CDC study in Thailand gave enough needles to injectors, they probably wouldn’t have enough infections to give them a trial result. And the tenofovir-based prevention method that’s being tried is a method that could be used by other groups too — gay men and sex workers and other heteros at high risk of exposure, for whom we don’t have such easy prevention options. So you can understand why researchers are reluctant to push the envelope on providing decent prevention to study participants. But in this case, the “local standard of care” argument really doesn’t wash. It would be perfectly feasible for Thailand to provide injectors with clean needles. The country has the technology, the money and the health systems to do that. The only block is a political one. It’s bad enough that Thai authorities live with this blind spot in their otherswise quite pragmatic HIV prevention programme. The US has been just as bad at home, although there’s now light at the end of the tunnel for safe injecting programmes in the US. All the more reason that US researchers (and taxpayers) should refuse to compound Thailand’s unethical policy with unethical research.

*Info on the trials: The Thai and Botswana trials aim to investigate whether uninfected people can take a daily dose of antiretroviral drugs to stop themselves getting infected with HIV if they are exposed to the virus through sex or needle-sharing with infected people. It’s know as Pre Exposure Prophylaxis or PrEP, and you can find our a lot more about it here.

An appeal would fly in the face of the data (which show that Insite reduces overdoses and many of the other frankly nasty things that happen to people who live with addiction to injectible drugs). It would fly in the face of pragmatism — up just one flight of stairs from the safe injecting room is a drug treatment centre which works to help people get off drugs when they’re ready to try. Detox is never an easy thing to achieve; our best bet is to have really strong links between services for current injectors and services that help them stop. But most of all it would fly in the face of any remaining self-respect that Canadians might have about their political system. Because although the newspapers talk of “the Harper government” doing this or that, Canada actually has no government right now, or at least none that answers to the normal description of parliamentary democracy. What right, then, does Harper have to be prosecuting court cases that waste tax dollars and lives?

Harper’s bully boy tactics may work for Insite in the end, though. HealthCanada is typically mealy-mouthed about an appeal, saying: “While the government respects the court’s decision, it is disappointed with the outcome. The government is reviewing the decision carefully. Until this review is complete, it would be inappropriate to speculate on future action on the part of the government of Canada.” But it’s very clear that a Liberal government would not keep banging its head against the wall of common sense that Insite represents. And by sending parliament packing until March, Harper may just have signed the death warrant for his own “government”. That would be good news for Insite users and other Canadians alike.

Thanks to Miriam for bringing this to my attention while I’m in distant Vietnam.