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Responsible porn hits the Financial Times

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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.

08/09/11, 06:28. 5 comments

Taxing times for Bonn’s street hookers

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.

31/08/11, 12:25. 7 comments

Unconditional homophobia? Jamaica and Canada at the extremes?

Trawling through an old paper lying around in a hotel lobby in Jamaica, I found this pastor’s reflections on gay men. Jamaica has the dubious distinction of being a world leader in homophobia. Now a senior police officer, Fitz Bailey, had said that most of Jamaica’s booming lottery and credit card fraud businesses are run by gays. Apparently 12 of the 14 men arrested for these crimes in 2007 volunteered to the cops that they were gay. Both he and columnist-pastor Mr. Dick think this is a scientific fact worth sharing with the public. Indeed, Rev Devon Dick suggests that gays are whining about negative stereotyping.

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).

23/08/11, 02:00. Comments Off on Unconditional homophobia? Jamaica and Canada at the extremes?

Björk does a few of my favourite things

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?

16/08/11, 12:09. Comments Off on Björk does a few of my favourite things

PrEP makes no sense for discordant couples – corrected

First PReP worked for gay men, and we were happy. Then it didn’t work for straight women, and we were sad. Now, two big studies in heterosexuals have shown it can work for straight couples, and we are deeply confused. Or at least I am.

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.

15/07/11, 06:50. 4 comments

Proud in New York

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.

25/06/11, 05:00. Comments Off on Proud in New York

Fit guys are less floppy: no shit, Sherlock department

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?

18/06/11, 05:49. 5 comments

HIV treatment really IS prevention, but…

For some time now, I’ve been waltzing around casting doubt on the “treatment is prevention” mantra, the idea that putting people infected with HIV on meds sooner will reduce new infections, despite pretty good observational evidence that people on treatment are less likely to infect their partners. If I had been praying at the altar of the randomised controlled trial for more reliable evidence, my prayers would now be answered: a trial involving 1,763 couples in 13 countries has found that putting heterosexuals on meds earlier cuts the chances that they’ll pass on HIV by 96%.

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.

19/05/11, 03:13. 2 comments

Brazilians I approve of

A couple of weeks ago I was talking condoms with the good folks at DKT, an inspiring company that sells condoms and contraceptives, and has fun doing it. There are many things I like about DKT. Not content to suck at the nipple of the tax payer, they actually make money selling products people want in many markets. They use that cash to subsidise programmes in other countries, where both generating and meeting the need for condoms and other contraceptives is a harder (and more expensive) sell.

One of DKT’s most successful markets is Brazil, not least because they give away a year’s supply of Prudence condoms to scads of voluntary testers, who twitter and twatter about flavours, shapes, sizes and the rest. They’re not above bonking us over the head with guerilla home videos, either. This one, I think is self explanatory.

“With a year’s supply of free condoms, any place is the right place.” Indeed. Though I could wish I spent more time in the right any place…

Other things I like about DKT: although they work in 16 countries, shift over half a billion condoms and some 75 million other contraceptives a year, they have a head-office staff of just four people, all, I’m guessing, with a sense of humour. Their penchant for fun and puns goes back a while; I’ve hung on for 15 years to a T-shirt promoting their Trust condom brand in Vietnam. It was a time when the Vietnamese currency, the Dong, was suffering a bit, and the government was running a campaign to restore our trust in it. DKT Vietnam turned the government’s “Put your trust in the dong” slogan on its head. Allow me to demonstrate:

11/05/11, 10:00. Comments Off on Brazilians I approve of

Of penises and pasta-measurers: sex ed in the dark ages (circa 2011)

Thirty years ago next month, the first reports of the illness that came to be known as AIDS were published. Five cases, all among young gay guys in Los Angeles. Since then, we’ve racked up over 60 million HIV prevention failures worldwide. But new draft guidelines on safe sex advice proposed for the UK suggest we’ve learned almost nothing from three decades of failure.

The guidelines, proposed by the British Association for Sexual Health and HIV are depressing, at very best. They seem to assume that it is the duty of health professionals to protect people from their own bad behaviour, in part by informing them of every possible risk, however marginal. They seem also to assume that the sort of people who take significant risks on a regular basis care about their long term health prospects. We don’t. And that comes from someone who today happens to be wearing a T-shirt embazoned with a slogan picked by algorithm on the basis of answers to 10 behavioural questions. Mine reads: “Runs with scissors”, but it might equally have read “Cycles without a helmet”, “Shags without a condom” or “Rolls her own cigarettes”.

The guidelines available here in pdf form, are open for public comment for another week or so. I would strongly urge people (especially people who’ve ever used a sexual health clinic) to look through them and put in their tuppence worth. The full text of my own comments is available in a doc file here.

In summary, I’m upset that we are still telling people to use condoms every time they have anal, vaginal or oral sex, even though we know perfectly well that that’s no more feasible than never having sex at all, for the same reason: for most of us, consistent condom use in every act of sex involving every orifice with every partner type at every age and level of sobriety is not feasible because it is not desirable.

I’m upset that we don’t give more practical and nuanced advice that people are more likely to act on. Example from my response:

“If you don’t have a condom handy, or don’t want to use one, then oral is your safest bet”. More useful still to a random gay man would be: “Do you have HIV? Yes? Then try always to use a condom if you’re top in anal sex. It would be great if you could use one if you’re bottoming too, but it’s less important, especially if you’re good about taking your meds. Don’t worry too much about oral, though it’s best if you don’t come in some other guy’s mouth. Definitely don’t come in his mouth if he’s just been to the dentist, or looks like he needs to go!”

I’m upset that we’re using evidence selectively. The guidelines imply there’s evidence that condoms work, and no evidence that abstinence works. In fact, condoms work and abstinence works even better, when they are used consistently and correctly. The more important evidence is around whether the promotion of condoms or abstinence lead to their consistent and correct use. Frankly, there’s very little recent evidence from the UK that condom promotion works very well; what worked in an age when HIV meant AIDS and an ugly death does not necessarily work in this post-AIDS age.

And I’m upset that, not content with giving clients information they won’t act on, we’re suggesting things that service providers won’t act on either. Sizing your clients up for condoms using a pasta measurer? Really?

I hate to wish HIV a happy 30th birthday, but I think at this rate it can expect to stay alive and well for several decades to come.

05/05/11, 01:00. 7 comments

Brave New Reuters? Apparently not

Regular readers know that I have little time for the uber-correctness that tries to wipe sex out of our daily loves and lives. But I am more outraged than usual at the price paid by journalist David Fox, one of the best conflict correspondents in the business, for an off-colour remark made in what he thought was a private chat. Reuters new bosses fired him, with no right of appeal.

I used to be proud to have worked for Reuters. It was an organisation of clever, brave people dedicated to reporting the truth in often difficult situations. I continue to be proud to have spent 10 years living with David Fox. His determination to give a voice to the men, women and children who are the pawns in conflicts not of their own making definitely took a toll on our marriage. I learned to recognise the lock-down mood that followed yet another assignment in Rwanda, Ethiopia, Iraq, Albania, Afghanistan. I laughed at the sick jokes that go with the daily reporting of incomprehensible grimness. As anyone who has worked as a surgeon, doctor, cop, undertaker or soldier knows (and as comments on Reuters’ imperious behaviour reflect) gallows humour helps you cope with shitty situations. I work on a sexually transmitted infection that has killed 30 million people; I can do a tasteless joke or two of my own. But along with the wisecracks came top quality journalism. I never failed to be moved by the stories David filed for an employer increasingly short of brave people who could be dropped in to a disaster area with equipment charged, functional, and ready to file. Read his coverage of the refugee crisis in Zaire and try not to weep.

So short is Reuters of people with David’s experience and competence, that they pulled him from his new post as bureau chief in Indonesia to help out with the coverage of the tsunami in Japan. He crunched his great height into an economy seat on an overnight flight and went to work on not enough sleep. An old mate, chatting with him on line in the middle of the night, made a crack about the effect radiation might have on the already bald David. David responded to a fairly classic disaster crack more or less in kind, although bringing women and Brazilians into the comment definitely upped the level of vulgarity. Most of the reporting of this incident has pussied around what David actually said and he will doubtless be appalled if I’ve let the cat out of the bag. But I feel the need to say that I can see why women might be upset; we’re all in a total quandry about our pubic hair these days. Though the subject is virtually taboo even in girl-talk, we spend inordinate amounts of time agonising in private: to wax or not to wax, landing strips yes or no? The constant dilemma of whether to disclose your status before you take your clothes off, the shocked looks if you strip before you tell. For the record I believe that men will soon lose interest in having sex with women who have tortured themselves into looking like pre-pubescents. In this context alone, I’m a proud defender of bush.

Still, it’s not a subject that most people want to engage with, least of all when facing an overwhelming human tragedy in the middle of the night. David can be a bit of a lad — it goes hand in hand with volunteering to report from the front line — but he is neither a sexist pig nor an insensitive idiot. He thought he was replying only to the mucker who had made the crack about his hair falling out. Fatally, though, he sent the comment by mistake to a Reuters-only chat room, populated at that hour by a couple of dozen people. Everyone’s worst nightmare. He realised his mistake right away and called the IT people within minutes to try and get the comment erased. It seems the techs at one of the world’s foremost electronic communications agencies were unable to help.

For an unintended slip of a keystroke conveying a silly, laddish comment to a small number of staffers in the middle of the night, a slip which he tried instantly to rectify and for which he apologised without reservation, David was fired. Let me repeat that. Thompson Reuters fired a brave, loyal journalist who has put himself on the front line for the company time after time after time for 20 years, because he mistakenly shared a gallows-humour joke with an internal audience.

Is that a company to be proud of?

26/04/11, 09:32. 17 comments

The PReP roller-coaster: no good for women?

Just as we were getting all excited about giving people antiretorvirals to protect them against HIV infection, a large trial of pre-exposure prophylaxis (PReP) in women is being shut down because the pills are unlikely to prevent HIV.

It’s a huge disappointment to those who were hoping that the pill-a-day-to-avoid-a-pill-a-day solution might drag us out of the despond that we’ve been in as we contemplate 2.7 million new HIV infections this year. That’s the same number as were newly infected when I started in this business 15 years ago. The only real change is in the cost of our failure: that’s increase over 70-fold.

The study, well conducted by my former employers Family Health International in four countries, is at odds with a study released last November, that showed that a daily dose of Truvada, a combination of two antiretorvirals in pill form, cut the risk of infection among gay men by over 40%. The earlier study did show that — surprise surprise — taking pills to prevent HIV doesn’t work unless you actually take your pills. Though virtually everyone said they took their pills, a later analysis of blood samples showed that wasn’t true. We don’t yet have that same analysis for the new trial in women (dubbed FemPrep), so although 95% reported taking their pills, it’s possible that real adherence was much lower. More than possible: likely. All women in the study were taking contraception, but there was a 9% pregnancy rate, apparently much higher in women on the pill than women on injectibles (we don’t yet have the actual numbers). That suggests that some women aren’t all that good at taking one pill a day (I’m one of them; thank God for implants), let alone two.

There’s a real possibility that antiretrovirals taken through the mouth and processed through the digestive tract aren’t as effective at preventing HIV from finding an entry point in the vagina as they are in the rectum, hence the difference between the trials in straight women and gay men. If that’s the case, it ups the ante for putting ARVs directly into your fanny (using fanny in the English sense!). We know from the Caprissa trials that antiretroviral microbicide works vaginally (though not necessarily rectally). But we only know that it works if you “shoot up” both before and after sex; in theory, at least, that is what was being tried. In practice, we know (well, strongly suspect) how unlikely it is that women will actually do that on a long-term basis. We now desperately need trials of a one-shot vaginal microbicide. Because for all the talk of “bio-medical solutions” the confusing results of recent HIV prevention trials remind us that most bio-medical solutions have a very strong behavioural component. Pills that “work” if you take them are no good if they make you feel so sick, so choked, or so fed up that you don’t take them.

One of the things that pleased me greatly about the FemPrep trials was that researchers made sure that the women who volunteered for the research knew about the disappointing results before the press or the scientific community did. There are more details from the study teams about how they interacted with participants on this interesting conference call, arranged by the ever-helpful AVAC network.

This post must end the way these posts seem always to end, with an underlining of the shockingly high rate of new infections in the study overall: five percent of women became infected, despite the fact that they were given female and male condoms, were regularly screened for other sexually transmitted infections and treated as necessary, and counseled up the wazoo. It’s a reminder of how badly suited the tools in our current toolbox are to the job of HIV prevention, and a caution about expecting much more from other behavioural interventions such as the use of pills or gels.

22/04/11, 07:31. 1 comment

Rap against rape: protecting the NHS

Health finance, food policy and the meltdown of the NHS. Why rant about these in the pages of the BMJ when you can do it so convncingly in rap?

Thanks to SH for engaging.

15/04/11, 12:20. Comments Off on Rap against rape: protecting the NHS

Of memories and domination

For reasons largely nerdy, I was wandering the London Book Fair today. It put me in mind of books I’ve read recently, and those I can’t help but revisit. Caught in the spider’s web of my memory is Joshua Foer’s Moonwalking with Einstein, a book in small part about memory and in large part about memorisation techniques. But under my skin, in much more persistent and uncomfortable ways, is Ariel Sands’ out-today Never the Face.

Foer’s book is delightful, if not ultimately all that memorable (for more, see my grown-up review in Prospect last month). But it does make the point that turning events, names, even playing cards into graphic sexual images tends to make them a lot more memorable, at least to the 20-something year-old blokes who tend to dominate the world memory championship circuit. I’m obviously not a 20-something year-old bloke, and I admit to not yet having read the final published version of Never the Face, a first novel by the publicity-shy Ariel Sands. But I can say that the sexual imagery (and its psychologically complex provenance) of an early draft is deeply etched in my memory in ways I sometimes wish it weren’t.

Daphne Merkin, who regaled New Yorker readers with the joys of spanking, describes it thus:

“Never the Face is a story in the tradition of 9 1/2 WEEKS – about the twisted corkscrews of desire, the hearkening after the call of brute submission and dominance that is the dark side of romantic attachment. Rarely has this skewed version of love been portrayed with the clarity and daring that Ariel Sands brings to it; her rendition makes for compulsive and disturbing reading.”

I can’t say more than that. Read it and (possibly) weep. Certainly, you’re unlikely to be unmoved.

11/04/11, 10:21. Comments Off on Of memories and domination

Dirty pictures? Apple spreads filth about gays

It wasn’t until Eve ate the apple proffered by the snake in the Garden of Eden that she became ashamed of her nakedness. But a couple of recent decisions by Apple have made me wonder whether their censors are the real snakes.

The screen shot above shows a small corner of Filth Fair, a new, quite clever word game app commissioned by the somewhat staid scientists at The Wellcome Trust to go with their new Dirt season. On the left, the app before the Apple censors rejected it. On the right, the revised version. Even then, it has a 17 age rating; though the censors don’t have to give reasons for their decisions it appears that they remain upset about the use, hidden within the painting/puzzle of the words sex and pornography.

I remind you that these censors sit in a country which allows pregnant girls to marry at 14 in some states. To see a fig leaf on your phone, though, you have to be 17.

The Apple censors didn’t apparently, think there should be any age restrictions on homophobia. A recent app from Exodus International that seeks to cure people from the affliction of being gay was released with no age restrictions. Needless to say, there was quite a bit of protest. I’m glad to say that sense beat the censors, and the anti-gay app has been removed.

If you’re in London, I’d urge you to visit the Dirt exhibition. Perhaps because of my own dirty mind, I got roped in to writing a chapter for the book of Dirt, that goes with the exhibition. There’s quite a lot of fun stuff in it, quite apart from the sex and drugs bits.

23/03/11, 08:03. 1 comment

Is polio the next Netscape?

Wiping out diseases: it’s a seductive goal. And like many of the best serial seducers, it’s ultimately hard to pin down. The eradication fashion item for this season is polio, the Lothario sporting it is Bill Gates.

Mr. Gates says we can eradicate polio in two years; that just a fifth of the time that it took his Internet Explorer to eradicate Netscape.

Gates has certainly put his (foundation’s) money where his mouth is, some 300 million dollars over the next couple of years. And he has some very good brains working on crushing the bug. But my own feeling is that the virus will be rather harder to wipe out than the browser that we all loved so well.

As I imply in an essay in this month’s Prospect, I suspect the only way we’ll achieve Mr. Gate’s goal is by defining “eradication” as wiping out wild-type polio. But that leaves us with the quandry of what to do about the weakened-but-still-live virus in the oral vaccine, the only vaccine we can afford to use in the countries where polio still circulates. Once re-established among kids who weren’t properly immunised despite dose after dose of vaccine (usually because they shit it straight out with their chronic diarrhea), it can revert to become as virulent as it ever was in the wild.

To get rid of that we need to switch to expensive, cumbersome injectible vaccines, or develop a killed vaccine that is cheap and easy to deliver. It’s not clear that it’s worth spending money on either. As richer countries re-evaluate their development spending (as the UK did today — nicely summarised by IDS’s Lawrence Haddad) we need to focus on what delivers greatest bang for buck. Hunting down the polio virus that hangs out in guts, drains and labs and crushing it makes jobs for epidemiologists, but it sucks time and money from other things that kill, maim and ruin the lives of far more than the 1,000 or so people who now get polio each year. Improving drains, making roads safer and diagnosing treatable infections earlier aren’t as sexy as wiping out polio, but we should allow ourselves to be seduced by them more often.

01/03/11, 09:01. 2 comments

Sex and sports: it must be spring

Young bucks locking body parts in a battle for supremacy: it’s that time of year again. Six Nations rugby time, of course. But also the time that many species pull themselves out of their winter torpor and start looking to spread their DNA.

London’s Natural History Museum celebrates with an exhibition of a Sexual Nature. For those who can’t make it to Kensington, Isabella Rossellini has made little sex-pods available on line. Here’s her take on young bucks:

Rossellini also offers charming, two-minute insights into the sex lives of spiders, sea-horses, dolphins and others, courtesy of the Sundance Channel. If your interest in the sex lives of other species is piqued by these vignettes, I would urge you to go to the (unacknowledged) source: Olivia Judson’s Dr Tatiana’s Sex Guide to All Creation. Judson is an evolutionary biologist and sometime New York Times columnist who takes joy in the pleasures of creation, and who infects others with her enthusiasm for life. Give her more than two minutes: you’ll be richly rewarded.

17/02/11, 04:24. Comments Off on Sex and sports: it must be spring

Scandal: clinic cares for hookers

I’ve been taken to task for not commenting on the ink-blot of corruption that is spreading inexorably across the Global Fund for AIDS, TB and Malaria. But really, the revelation that dosh sloshed out by the GFATM gets swilled into politicians’ pockets is about as exciting as the discovery that FIFA board members accepted a free dinner or two from Russian oligarchs before awarding the World Cup to Moscow. As the AIDS mafia has joked for years, it’s not called the “ATM” for nothing.

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.

07/02/11, 01:39. 2 comments

Sex workers (and their grannies) speak up

On the one hand, Canada bans Dire Straits. On the other, it fills the streets with posters aimed at extricating sex workers from social non-existence. Halifax group Stepping Stones is running an ad campaign reminding people that hookers are mothers, daughters, brothers, friends. They are also PhD students, civil servants, dental hygienists, actors and many other things when they’re not with a client, and shiatsu therapists, shrinks, grief counselors, actors and many other things when they are. Oh, and criminals (though it is my burning hope that this won’t be true in Canada by the end of the year).

It’s that criminalisation which creates stigma and the need for campaigns like this; the stigma in turn makes it hard to run these campaigns. The Chronicle Herald reports that ad agency Extreme Group‘s staff used their own grandmothers and Sepping Stones employees for the campaign because “regular” models didn’t want the job.

Also fighting invisibility are sex workers in Ottawa. There, Chris Bruckert and Frederique Chabot worked with members of prostitute group POWER to publish a synthesis of what sex professionals said about their work, and (perhaps more importantly) their work-life balance. Many of the comments reminded me just how hard it is to maintain that balance in any profession which society deems an identity rather than an occupation (film star, Royal, hooker). Here’s Janette, talking about how the police treat her when she’s not working:

“I was showing my new neighbour around, walking him up to the food bank. And as we were walking, one cop turned around and told the young man I was with ‘Do you know you are with a prostitute? You could get in trouble for that’. He yelled at the cop ‘She is my neighbour and I don’t care what she does for a living, she is helping me out. She is still a person’. I was so embarrassed. That did bring tears.”

You can read the whole (.pdf) report here. Stepping Stones have published a similar volume, which I haven’t yet read, called Sex Workers Talk Back.

31/01/11, 06:13. 2 comments

Dire Gays: whining Canadian gets MTV song banned

It’s not that I think Canada is an over-protective nanny state full of cry-babies who had their sense of humour excised at birth and wouldn’t recognise irony if it bit then on the bum or anything. But really, scrubbing the airwaves of Dire Strait’s “Money for Nothing” because it uses the “F”(aggot) word is a bit much.

The song was banned by the Canadian Broadcast Standards Council after a solitary Eljibiti radio listener whined that it bruised their fragile soul.

Every reader my age knows the “MTV” song virtually by heart — boneheaded delivery men being grumpy about the absurd amounts of money made by boneheaded musicians with more mullets than talent. The offending lyrics include the following:

“See the little faggot with the earring and the makeup
Yeah buddy that’s his own hair
That little faggot got his own jet airplane
That little faggot he’s a millionaire”

Our Sensitive Soul found this “extremely offensive” and labeled it “discriminatory”. Since the complainant says they are a member of the Eljibiti Community, I’m assuming they consider it to be offensive to gays rather than to rock stars. But that confuses me. A pop classic which won the Grammy for record of the year in 1986 portrays homophobia as a sentiment expressed by bigoted and resentful boneheads. One person in Newfoundland, who apparently has not mastered the skill of switching off the radio, considers the association of homophobia with stupidity to be offensive. And six adults of sound mind meeting on behalf of the Canadian Broadcast Standards Council spent I’m not sure how much time coming up with a 5000+ word decision that boils down to this: “The song contained a word that referred to sexual orientation in a derogatory way.”

Give me strength.

The decision makes for amusing reading, dredging as it does through the history of similar complaints. It seems that even more sensitive souls have in the past been upset by songs and skits about cigarettes (fags, to a good British sometime smoker such as myself). Of course the way Canada is going, it’s not impossible that cigarettes will soon be outlawed, with all evidence of their existence digitally excised from old Humphrey Bogart films.

In fairness, I should note that the overwhelming majority of Canadians of all sexual hues commenting on the Globe and Mail’s report of the ban think it is just plain silly. But I think I’ll try be more careful about my “hookers, fags and junkies” shorthand when I next visit Canada, just in case. I wonder if any radio listeners in Newfoundland are offended by any of these words: Big. Girl’s. Blouse.

20/01/11, 12:46. 7 comments

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