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.

Does this signal a new wave of common sense in HIV prevention in the United States? That’s certainly what we expected when Obama was elected. During his campaign, for example, he recognised that sterile needle programmes cut HIV infection among injectors, saving lives and money, and pledged to end a ban on funding those programmes from federal coffers. So cities such as his home town of Chicago, pictured in the map below, will now be able to use central money to provide clean needles to the inner city injectors that need them most. As long as they set up in one of the grey spaces. In the cemetary, in other words.

(Click to enlarge)

On this fantastic map, which comes from Yale University’s Dr. Russell Barbour by way of Stop the Drug War, the red areas are the parts of town where it would be illegal to operate a federally funded needle exchange under new rules proposed by Congress. The Drug War Chronicle provides an interesting history of the needle exchange shenannigans. Essentially, Obama did not remove the ban from a budget bill because he thinks policy shouldn’t be made through sub-clauses in budget bills. Democrats on the committee discussing the bill disagreed, and dropped the ban. Then Republicans, not willing to give up the idea that the availability of clean needles would have us all racing to start shooting up smack, decided to protect the innocent by forbidding needle programmes within 1,000 feet of “a public or private day care centre, elementary school, vocational school, secondary school, college, junior college, or university, or any public swimming pool, park, playground, video arcade, or youth centre, or an event sponsored by any such entity”. That’s the red bits on the map of Chicago above. Here’s Dr, Barbour’s map of needle exchange exclusion zones in San Francisco:

This is clearly just a way of pulling the rug from under any effort to increase access to clean needles. We’ve come to expect this kind of implaccable opposition from conservative Drug Warriors in the United States. We used to expect the Brits to be more rational about their drug policy, and the UK has, thank God, held on to its policy of providing clean fits for anyone that needs them. But with the sacking of the government’s independent advisor on drugs David Nutt for repeating his independent advice after the government chose to ignore it, I’m not so sure.

I’m not even going to wade in here about whether or not idependent scientific advisers to government should shut up after their advice is ignored, but I will commend to you a wonderful paper by Dr Nutt on the dangers of Equasy, (pdf) an irrational addiction to horse riding. This has been seized on by many who have not read it as an example of his inappropriate analyses. Irony, where art thou?

The US Drug Warriors also joyously seized on the latest round of anonymous surveillance of HIV among drug injectors in Britain, sending out an e-mail crowing about rising rates of HIV and drawing a link between that and the fact that the UK was the first country in the world to have national injection safety programmes. My next post will put those rather one-eyed claims into perspective.

Blog comment is divided between “HIV is everyone’s problem”, “HIV is a gay problem” and “HIV is a black problem”. I have the highest respect for DC’s attempts to get to grips with this long-neglected issue, but I was frankly disappointed to hear city HIV director Shannon Hader take the “everyone is at risk” approach in an interview with NPR. So much so, that I went and made a little graph from the data:

I’ve just looked at blacks and whites, I’ve included gay men who inject drugs in the gay men data, and I’ve ignored unknown modes of transmission — the full data are in the table at the end of this post if you’re curious. But essentially, these data show fairly dramatically that in DC HIV affects black people far more than white people, and it affects gay men far more than straight men. A significant number of black women but virutally no white women are infected through drug injection, but more black women are infected because they have sex with black men. That’s the way it is, and saying that there are some infections in every demographic therefor everyone is at risk won’t change that. I should note that these are individual diagnoses, not rates — if we had denominators, the rates among men who have sex with other men and among drug injectors would dwarf heterosexual tranmission.

I was also surprised by NPR’s handwringing over low rates of condom use. Apparently, though the data are not in the report, one in three adults in DC used condoms the last time they had sex. That’s neither low nor high; it’s meaningless. We don’t need people to use condoms every time they have sex. We need people to use condoms with every partner who is remotely likley to be of a different infection status than themselves. As you can see from the graph, lots of potential partners including most white heterosexuals who don’t shoot up drugs and have sex with others like them don’t fall into that category.

One thing that shocked me in the report was the astoundingly high proportion of people who are still testing very, very late (within a year of being diagnosed with clinical AIDS, so when they’ve been walking around with undiagnosed infection for an average of eight or nine years). It’s still an astoundingly high two thirds. It does, however, look like the DC health department’s valiant efforts to increase testing and pick up more cases in settings where they are most likely to be found are bearing fruit in at least one way. The average CD4 count at diagnosis has risen from under 200 in 2004 to 332 last year. The CD4 count is a measure of how damaged your immune system is at the time of diagnosis. If the health system doesn’t catch you and put you on anti-retrovirals until it’s fallen below 200, you’ve got a much lower chance of survival than if treament starts earlier.

Michael tells the story more patiently than I’d be able to. As several people pointed out, including Dharmawan, Willem and Catherine. Read. Really, please read. What Michael doesn’t say is that Indonesia has pocketed more than US$ 400 million in foreign taxpayers’ money to deal with HIV so far, and has another US$ 130 million from the Global Fund on the table. And it can’t even assure treatment in the big, well-funded, teaching hospitals designated to provide ARVs. No need to point out that treatment is the EASY bit, the big, politically popular success story. People need it because we fail so badly on the cheaper, easier prevention services, like making sure that kids who inject heroin in Indonesia don’t also inject HIV. If it doesn’t make you angry that we’re using your money so badly (if you’re a European or North American tax payer) or serving your needs so poorly (kalau seandenya anda orang Indonesia, apalagi orang Indonesia yang terinfeksi HIV…), this blog’s no place for you.

Robert Ochai, director of the trailblazing AIDS support organisation TASO, has noticed that some of group’s the 23,000 treatment clients are giving up their HIV drugs because they have been “cured” by faith healers, according to a report in The Monitor. Apparently, faith healing has become big business in Uganda.

“Several Pentecostal churches in the country, more so in Kampala, invite the sick, including those with Aids, for spiritual healing. Some churches promise miracles, sometimes in exchange for their patients’ valuables. The most publicised case is of Ms Frances Adroa who claimed last year that she was tricked by pastors of the Universal Church of the Kingdom of God into offering her car to the church. She later sued the pastors after her condition deteriorated and they refused to return her car,” reports Kakaire Kirunda.

Eating in to family finances is bad enough. Deliberately encouraging people to give up life-prolonging therapy is far worse. But the effect on the epidemic as a whole could be catastrophic, too. If a person is on antiretrovirals, it is critical that they stay on them (or, to use the AIDS Inc. jargon, that their “compliance” is high). If they stop taking them for a bit, because they run out, forget, can’t be bothered, feel rotten or whatever, the amount of virus in their blood shoots up. That damages the immune system and makes it more likely that they’ll get sick, it increases the likelihood that the virus will mutate into drug-resistant forms, and it makes it much, much more likely that they’ll pass their infection on if they have unprotected sex.

Partly because of the extraordinary level of support provided by organisations like TASO, compliance among Ugandans on ARVs is very high. Undermining it in the name of God and Mamon is beyond cynical, it is downright wicked. In this regard, the “faith healers” are no better than witch doctors or traditional healers who sell expensive herbal cures for AIDS.

For an insight into the complicated relationship between traditional beliefs, modern medicine and faith, I urge you to read Johnny Steinberg’s book Sizwe’s Test, to be published soon in the UK under the less interesting title Three Letter Plague. He’s writing about South Africa rather than Uganda but he does so with depth of feeling and great humanity. It’s thought-provoking, and a lovely read.

Laurance quotes Kevin de Cock, a thoughtful and honest scientist who happens also to head up WHO’s HIV division, as saying “It is very unlikely there will be a heterosexual epidemic in other countries [outside Africa]. Ten years ago a lot of people were saying there would be a generalised epidemic in Asia – China was the big worry with its huge population. That doesn’t look likely.”

While it’s not clear in what context de Cock made the comments, Laurance describes them as “the first official admission that the universal prevention strategy promoted by the major Aids organisations may have been misdirected”.

Regular readers know that I specialise in railing against spending HIV prevention money on populations that were never at risk in the first place. And I believe that the UN organisations have been at fault for “beating up” the epidemic to make it look as though everyone is at risk. So I could just claim that this is a vindication of what I’ve been saying all along. But to be fair, the story is itself a little bit of a beat-up. Careful readers of the epidemiological sections of WHO/UNAIDS reports will see that they have for some time now tried to draw a distinction between the epidemic in sub-Saharan Africa and that in the rest of the world. It is the other UN organisations that are “co-sponsors” of UNAIDS that gain more from the “everyone is at risk” mantra. The agencies that deal with young people and education and migration and labour and whatnot, the ones that want to get their snouts in the AIDS funding trough without really getting down and dirty with sex and drugs.

Is de Cock saying anything we didn’t already know? No (although his comments continue to excite a bit of comment in the blogosphere, at the WSJ online for example, Slog, and Sweetness and Light. Is his admission a big reversal of WHO policy? Not really. Does it allow me (and many others who have been banging the same drum) to say “I told you so”? Absolutely!

It takes me back to the time we were trying to explain the results of a study of HIV and syphilis to transgender sex workers in Jakarta. Stats — even terrifying ones like “23% HIV positive” don’t necessarily mean much to people who dropped out of primary school, so we drew 100 waria on a graph and coloured 23 of them in red, and 17 in green, with quite a few in red and green stripes. The red ones have HIV, we said. The green ones have active syphillis. And it immediately opened up the discussion: who’s a red one? How can we tell? Only by getting your test results.

An HIV prevention organisation targeting gay men in Britain did much the same thing. They put 10 men on a poster with a who-will-you-go-home-with-tonight message: one of these men has HIV. The poster did not show faces, but a more focused part of the anatomy. I’m afraid I can’t post it on a family website like this one… Much less give many details of the same organisation’s wonderful campaign to get guys to recognise the symptoms of syphilis, and go for tests and treatment. Suffice it to say that the information came as an insert with a fabulous CD called Sex Pigs: 60 minutes of music to fuck by.

More politely, while I’m on syphils, check this delightful essay by Marlene Zuk. It discusses whether or not it is in syphilis’s own interest to leave ugly, suppurating boils on the genitals. But it’s delightful, really.

Chatting with my friend Bert who works for the World Bank, I marvelled that almost every UN agency was on the AIDS bandwagon. Bert gave me a “Well duh!” look. “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”.

Here’s the headline from The Australian:

Global warming set to fan HIV

The claim comes from Daniel Tarantola who, along with the posthumously sainted Jonathan Mann, turned HIV into a human rights issue, a development issue, a disease contracted by people who are poor and ill-educated, rather than a disease contracted by people who share needles or have unprotected sex with lots of partners.

“It was clear soon after the emergence of the HIV epidemic that discrimination, gender inequality and lack of access to essential services have made some populations more vulnerable than others,” said Prof Tarantola, of the University of NSW. “Climate change will trigger a chain of events which is likely to increase the stress on society and result in higher vulnerability to diseases including HIV.”

Australian scientist David Cooper, who’s normally rather sensible, played the “you, too, are at risk” card. “This would effect Australia too, because these infections could potentially spread. Just look at the horror that SARS and avian flu have caused.”

I’m hoping Cooper was misquoted. His comments rightly got the bloggosphere jeering. JammieWearingFool and Jimme at the Sundries Shack both made a more sensible diagnosis than the good doctors. This sort of hype keeps the cash rolling in. And of course people who work in HIV, number one on the donor fashion hit parade for so long, are worried that global warming is taking over as flavour-of-the-decade. What better way to protect your dosh than to conflate the two?

Of course other people can conflate the two as well; step forth the double denialists. To be honest, I can’t blame them. Even if there is a relationship between climate change, food security, nutrition and HIV, the “increased vulnerability” hype is beyond facile, it’s damaging. HIV is a big problem. We do need lots of money to deal with it. But we need to be dealing with it by spending that money on the people most likely to be exposed to the virus (as Australia currently does), not on making people who will never be at risk feel like the sky is falling.

Paul Watson of the LA Times spoke to Franky Setiawan, owner of Doghado Massage Parlor, who came up with the chastity pants. Setiawan “says he came up with the idea when men “bombarded” his staff with demands for sex after local authorities shut down the town’s brothels. …”We had a hard time rejecting this kind of client because they try over and over and over again, persuading our workers with their dangerously sweet words,” Setiawan said.”

By way of explanation, we’re told: “In recent years, conservative Islamic values have gained influence in a society that has long enjoyed liberal freedoms, such as easy access to alcohol, gambling and the sex trade.” But the point is surely that conservative Islamic values HAVEN’T gained influence. Men still want to drink, gamble and buy sex. And if they can’t buy sex from willing sellers in a brothel, they’ll harass potentially less willing women in a massage parlour. This “bulldoze-a-brothel-and-turn-men-into-saints” approach has failed miserably in Indonesia for more than a decade now. Sexual services just spread to places where it is harder to provide decent prevention services (and leads to desperate measures like putting women’s fannies under lock and key). Before the crackdown on the sex trade started, virtually no sex workers in Indonesia were infected with HIV. Now, in several cities, one sex worker in every ten has the virus.

I say “potentially less willing”, because many of the women who provide massages in Indonesia’s thriving spa industry don’t want to supplement their income by selling sex. Though plenty do. When mapping the sex industry at the Indonesia’s statistics bureau, we used to joke that any massage parlour with the words “bersih” (clean) or “sehat” (healthy) in its name was almost certainly somewhere you could get extra services. Though my own regular haunt is called “Bersih dan Sehat”, and I’m not aware of any added extras, despite the absence of padlocks. The point is, though, that selling sex is not illegal in Indonesia, when it’s on a willing buyer, willing seller basis without an intermediary. (Pimping is illegal.) So perhaps Pak Setiawan should be offering his employees the choice of a padlock or a condom.

Hat tip to The Headmistress.

We know blackmail can work pretty well in HIV prevention. When brothel-owners in Thailand were told their businesses would be shut down if they didn’t ensure clients used condoms, condom use shot past 90 percent and HIV and other sexually transmitted infections came crashing down. The programme succeeded because it threatened to hit brothel owners where it hurt — in the pocket. If someone is motivated by cash then you can manipulate them with cash incentives. That’s the thinking behind the Tanzanian programme, too. According to an FT editorial:

“the cash may increase the bargaining power of young women and give them an alternative to accepting money from richer, older boyfriends.”

Maybe — US$ 45 is a lot of money for a 17 year-old girl in Tanzania. But I worry that it won’t work as a bribe. We’ve painted ourselves into a corner of thinking that young women in Africa only have risky sex with older men because they want money. But I suspect young women in Africa like older men for the same reasons as young women elsewhere do — prestige, the kick of being shown off to the guy’s friends as a “trophy”, the kick of showing him off to her own friends as ditto, visits to nightclubs, rides in nice cars. Oh, and better sex that you usually get from some spotty guy your own age. Those are not things that you easily give up for the indignity of regular STI tests and a couple of cash payments.

Still, no harm in trying. And at least this is being set up as a trial, so that areas that bribe can be compared with areas that don’t bribe. I’m curious, though, that the researchers wanting to see if bribery can cut HIV transmission have decided not to measure HIV. They’re apparently going to judge the programme a success (and dole out cash) based on negative tests for other (curable) sexually transmitted infections such as gonorrhoea. Which rather makes me think that we might see a spike in sales of azithromycin and other gono drugs just before people go in to pick up their bribes.