The Wisdom of Whores

These gems from the delightful “blog” of “unecessary” quotation marks need no comment. Though the comments on “this post” are quite fun.

And from my best side:

Thanks to dkj for driving me to them.

For 20 years, American governments across the political spectrum have ignored a mountain of evidence showing that needle exchanges and other safe injecting programmes are the single most effective HIV prevention tool we have. But just before Christmas, with a minimum of fuss, Congress dropped the ban on federal funding for needle and syringe programmes.

The change, buried in a massive budget bill passed by Congress in mid December and and since signed into law by President Obama, passed with very little comment in the blogosphere. But it has the potential to revolutionise HIV prevention in many parts of the US as well as in other countries. US cities and states have been allowed to provide injectors with clean needles if they (the cities and states) paid for them themselves, but in conservative states it has often been hard to get local politicians to come up with the cash. Similarly, nothing is stopping countries outside the US funding their own harm reduction programmes, but the yeay or nay of the world’s largest funder of HIV programmes can have a huge effect on what local governments choose to do (and not to do!)

Perhaps people didn’t notice the good news about harm reduction because they were caught up in the histrionics of the Drug Warriors in New York City, who are apoplectic that the health department is handing out perfectly sensible advice on how to shoot up safely.

Dubbed “Smack for Dummies” by the New York Post, the pamphlet has the Warriors fretting that young mothers might come across it in a clinic waiting room, read the instructions on keeping your veins healthy, and think: “Hmm, that looks easy. Maybe I’ll try shooting up before I pick the kids up from playgroup this afternoon”.

I’m glad to say that Mayor Bloomberg and the NY health department are both standing firm.

Also in the deluge of good news from Washington — the omnibus spending bill does not earmark any money for abstinence-only sex ed programmes that we know don’t work.

While colleagues at USAID say they haven’t had any official word on the implications of the bill for HIV funding in other countries, everyone’s optimistic that the common sense, so late to arrive, will be quickly exported.

Though I work in a world of addictions, I try and keep mine in the closet. But with others springing out of the closet right left and centre, I’m going to come clean. I’m addicted to rugby. Rugby is said (largely by people who see no glory in the bad haircuts and hystrionic dives of diva soccer players) to be the inverse of soccer, a hooligans’ game played by gentlemen. Crusty gay crusader Peter Tachell, thrilled that Welsh rugby ledgend Gareth Thomas has come out as gay calls it a “very macho sport”. And yes, it’s tough. It pits several hundred kilos of testosterone fueled meat against another several hundred kilos at crotch level. Hands grab balls, though rarely the one in play. Shorts are used as weapons, and lose their coverage. There’s none of that pansy padding which distorts body and soul of American football players. Rugby is pure, hard muscle. Which is why I’ve always maintained it is the most homo-erotic sport on the planet. If you’re not convinced, another photo from the French national team’s iconic :

Homoerotic? Moi?

I don’t mean to belittle Gareth Thomas’s courage in coming out. It’s interesting that his coach’s first reaction was to advise the Lions captain tell his team members, because he guessed (rightly) that they’d provide really important support at a difficult time. He’s not the first player to come out, but it’s rare for guys to do it while they are in the prime of their careers. Hard on the heels of that revelation, former England player Brian Moore has spoken publicly about being sexually abused as a child. I don’t know why rugby players, who have a pretty small following compared to soccer players, have so much more courage than the divas with bad haircuts. When Brazilian superstar Ronaldo got caught with three transgender hookers more than a year ago, he pleaded ignorance, saying he thought they were just vanilla whores. I don’t know if that makes me more worried about homophobia in soccer, or more worried about that a player who earns squillions on the pitch has such a bad eye for a ball….

Christmas in London — what better way to celebrate than carol singing in the streets of Soho with singers from Westmister Abbey and the International Union of Sex Workers? The Rector of St Anne’s parish in Soho swished out in front in long robes and fuschia beret but it was this banner, carried by Nico and Thierry, that really led the way. Note the trick photography — by the time we got out on the streets it was dark and floating with magical snowflakes; the boys were definitely wearing more than body paint.

Soho was full of good cheer; lots of people joined in the carolling and a couple of crusty punks pulled out descant voices that rivalled the cathedral choir’s. There was much cheering for hookers; it made me wonder how many people knew that the jurassic feminists in this Nanny government had just the month before pushed through new legislation that will make it more dangerous for women (and men, and transgenders) to sell sex in the UK.

My challenge the evening of the carol singing was to tear myself away from the Glo-ooooo-ooooo-rias in time to heat up vast vats of mulled wine. I rose to that occasion ok. My challenge for the New Year is somewhat more daunting. TED has announced the programme for its next conference in California, and I’m hugely honoured to be speaking there, in some very great company.

TED talks are not very often about sex. But the best of them can even make statistics sexy. I leave you with this classic from Hans Rosling, an ally in the war on Data Hugging Disorder, but here popping some of the bubbles of the HIV narrative.

Not wanting to be always the purveyor of bad news, I was looking forward to today’s results from the Pro2000 microbicide studies. After hopeful results in an earlier trial, I’d convinced myself the gel would prevent HIV. But it doesn’t.

It’s very depressing news from a huge, well designed and well managed study of over 9,000 women across four countries. I’m fond of saying that if you torture the statistics enough they will confess to anything (as we saw in the recent vaccine trial in northern Thailand.) But however badly you twist the arms of this study, they’re not going to scream success. For the record:

* If you exclude the women who got pregnant or stayed in the trial more than the planned period of one year, there were 130 new infections among those who used the microbicide gel, and 123 in those who used the identical-feeling placebo. Calculated as new infections per 100 woman-years of exposure, that’s 4.5 for the gel and 4.3 for the placebo, making the microbicide 5% more risky. The statisticians are 95% sure that the true effect of the microbicide is somewhere between decreasing risk by18 % or increasing it by 34 %. In other words, we can’t make any claims at all that the product works.

* If you don’t exclude people who got pregnant and look at everyone in the trial for as long as they were enrolled, you get 145 new infections with the microbicide versus 143 without: 4.6 new infections per 100 years of exposure in both. No difference. None. The true effect using this analysis is somewhere between reducing the risk of HIV infection by 21% and increasing it by 26%.

* The researchers also looked at whether women who used the gel consistently were less likely to get infected than those who didn’t. They weren’t.

It is hard to measure consistent use of microbicides in these studies, but researchers compared three sources of information: what all participants reported during study visits, whether all participants brought back used applicators, and what a sub-sample of women recorded in their detailed sex diaries. All point in the same direction: around 90% of women used the gel most of the time. That in itself might be counted a triumph compared to some earlier studies. It means that if we could find something that actually works, women would be quite likely to want to use it. All eyes will now be on the CAPRISA study which is testing a vaginal gel that has antiretorvirals embedded in it.

For my own part, I’m feeling somewhat sheepish as well as disappointed. When the results of an earlier, smaller trial of Pro2000 microbicide showed that it reduced infection by 30%, I was dismissive, bordering on rude, about the tyranny of the statisticians who said the results were “not significant”, and that we needed more research before acting.

I remain impatient with scientists who want to delay any action until we have perfect data. In the field of public health we are often obliged to do the best we can with what we have; as long as policy-makers are prepared to change their approach as the data improve we can save valuable time and lives. But in this case, the caution was well placed. Mea culpa.

Once again, it is worth drawing attention to the most basic fact in this research: 30 years into the epidemic, in a population that had safe sex counselling up the wazoo as well as universal access to condoms and other services such as STI treatment, more than four in 100 women are still getting infected with HIV. Pro2000 may not work, but just urging people to use condoms doesn’t, either. We need to keep looking for something that does.

Finally, some common sense in HIV testing policy in the US. Although you’d be hard pressed to know it from some of the coverage.

Until last Monday, America’s unfathomably illogical health service for the properly poor, Medicaid, refused to pay for HIV testing just as it refuses to pay for all sorts of other screening measures that could allow conditions to be treated early or in some cases prevented enitirely. Now, Medicaid has finally agreed to test its clients for HIV, if they fall into certain categories.

Here’s where the bad reporting comes in. This, for example, from The Goverment Monitor, which reports public sector news:

“The Centers for Medicare & Medicaid Services (CMS) today announced its final decision to cover Human Immunodeficiency Virus (HIV) infection screening for Medicare beneficiaries who are at increased risk for the infection, including women who are pregnant and Medicare beneficiaries of any age who voluntarily request the service.”

So, the two groups that they single out as being “at increased risk” for HIV are pregnant women, and people asking for a test. In fact, of people who have recently had unprotected sex in the United States, pregnant women are among the least likely to be infected with HIV.

The actual decision reads as follows:

CMS will cover both standard and U.S. Food and Drug Administration (FDA)-approved HIV rapid screening tests for:

1. Annual voluntary HIV screening of Medicare beneficiaries at increased risk for HIV infection per USPSTF guidelines:

* Men who have had sex with men after 1975;
* Men and women having unprotected sex with multiple [more than one] partners;
* Past or present injection drug users;
* Men and women who exchange sex for money or drugs, or have sex partners who do;
* Individuals whose past or present sex partners were HIV-infected, bisexual or injection drug users;
* Persons being treated for sexually transmitted diseases;
* Persons with a history of blood transfusion between 1978 and 1985;
* Persons who request an HIV test despite reporting no individual risk factors, since this group is likely to include individuals not willing to disclose high-risk behaviors; and

2. Voluntary HIV screening of pregnant Medicare beneficiaries when the diagnosis of pregnancy is known, during the third trimester, and at labor.

In other words, perfectly sensibly, pregnant women are NOT classified as at high risk for HIV infection, but are offered tests in any case since services to prevent transmission to their babies are available if need be. Now look at the list of those who ARE considered at higher risk. Again, it is mostly perfectly sensible. I’d prefer to see some sort of time stamp on number two — the overwhelming majority of Americans have had more than one partner in their lives, and most will probably have had unprotected sex with at least two of them. But that really doesn’t put them into a “high risk” category unless they are having sex with those multiple partners during overlapping time periods. Because HIV isn’t highly infectious for very long, you’d really like something more precise, such as “unprotected sex with multiple partners in any given three month period”. The biggest group at higher risk missing from the list is “men who have been incarcerated”. I agree that it is not the incarceration but the behaviours while incarcerated that put people at risk for HIV, and those behaviours are covered elsewhere on the list. But many people zone out what happens in jail — they are unlikely to report having sex with other men if it is something that they only do when they are banged up, for example. And yet we know many people in jail are infected with HIV, and we also know that many of them are having anal sex and shooting up drugs, and therefore likely to pass the virus on to other prisoners.

Another piece of good sense: the decision specifically authorises rapid tests. We know that people are far more likely to get their results and to be tied in to the support and care services they may need if they are offered on-the-spot tests, rather than having to come back or call in for results a week later. It would be nice if other countries (with generally better records on preventative medicine) followed this lead. Any Canadians reading this…?

At breakfast in Bangalore this morning, I was greeted by news of Bollywood’s first on-screen gay kiss. When they’re puckerd up like this, wouldn’t you want to? But the Indian censors may not share my enthusiasm. I am Omar will be screening at the Rotterdam film festival. Check it out and see if the kiss is in.

What’s unsustainable about paying fo sex? I guess it depends on what your budget is, and how randy you are. As Copenhagen turns its thoughts green, its mayor Ritt Bjerregaard sent postcards to Copenhagen hotels urging climate conference delegates to: ‘Be sustainable – don’t buy sex’. In response, the city’s sex workers are offering free rides to any delegate who can produce one of the offending cards, according to Speigel.

Unsustainable? Well, there’s latex to dispose of, or worse still, population growth. But on the upside sex warms you up without needing to burn fossil fuels. It’s a renewable resource. And if it’s on offer for free this week in Copenhagen, it might just provide the positive energy to break some of the log-jams in the negotiations.

I’ve followed the build-up to the conference (beautifully dissected by Sam Kinght, writing in Prospect), with some amusement. Way back when I was writing The Wisdom of Whores, a friend from the World Bank was rolling his eyes at every UN agency’s willingness to hook itself to the HIV wagon. I quoted him thus:

““The UN institutions are professional beggars, and beggars go where the money is,” he said. “So you get “culture and AIDS”, “kids and AIDS”, “fish and AIDS”. I’m just waiting for “climate change and AIDS”.”

It wasn’t until months later that I saw the first headlines linking HIV to climate change. Just recently, there’s been a UNFPA report about it, which means it’s now official. As Rasna Warahp pointed out in Kenya’s The Nation, the real link between HIV and global warming will probably be that as more funding goes to the latter less will go to the former.

An aside, since I’m mentioning both development fashion and the World Bank: I am reliably informed that that venerable institution last week headed off a bid to have every loan reviewed for the effect that it has on trafficking of persons (which in the current climate is more or less equated with trafficking of women into the sex indutry). Just sometimes, common sense does prevail.

Thanks to Ron of greencollar for sharing the determination of the Danish with me.

So another World AIDS Day (and this blog’s second birthday) has come and gone. We learned that 2.7 million mothers, lovers, children, school teachers, preachers, husbands and friends became infected with a rather fragile and still potentially fatal virus last year. Each of those prevention failures cost taxpayers about US$ 3,000. Since we’ve known how to prevent HIV for nearly three decades, that’s pretty pathetic. What we need is radical new approaches, and I’m pleased to suggest one.

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

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

Epidemiologists don’t often hit the headlines. While forensic scientists are celebrated in endless mini-series, the bug hunters merit just the occasional, mercifully long forgotten film (anyone remember Dustin Hoffman in Outbreak? I thought not). As a job, it’s just not very sexy, and most of us who plod away at it keep our wild sides to ourselves. How delightful, then, to discover that Belle de Jour, a sex icon for our times, is actually a practicing researcher with a PhD in epidemiology.

Needless to say there’s been a big kerfuffle about this. The “all prostitution is explotation crowd” are banging the drum again, anxious to entrench the image of the sex tade as nothing but tawdry. But as Catherine Stephens of the International Union of Sex Workers eloquently points out in this segment on Channel 4 News, those sterotypes are unhelpful.

(For those who are confused by Cath saying she doesn’t think practicing hookers should go public, it’s amazing how Channel 4’s hair and makeup team can nerd a girl down.)

The University of Bristol, where Brooke Magnanti PhD works, has very sensibly said that the way she chose to finance her studies does not have any bearing on the quality of her work. The university doesn’t mention that there are many other similarities between being a hooker and a research scientist. We all provide the services that the people who put down the cash demand, whether they are punters or science funding bodies.