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.

Illustration by Fernando Vicente

This week, the Great and the Good of the AIDS industry gather in Vienna for the biennial AIDS circus. With delicious irony, the conference, held right next to the barracks of the UN’s Drug Warriors, will focus in part on getting more countries to do the one thing that really works in HIV prevention — providing clean needles to drug injectors.

That means that there will be a lot of talk about the evidence base. There’s always a lot of talk at these conferences, and although I escaped Vienna just before the start of the conference (to see the inimitable Grace Jones play Lovebox), I’m as much of a windbag as anyone. While pontificating in the BMJ video (below) about the evidence base for harm reduction, I think there’s a more important point to be made to the small coterie of scientists who wash around in the larger tide of 20,000 AIDS junkies, Poz Professionals, singing orphans, dancing hookers, jostling NGO workers, bewildered journalists and UN PR-wallahs that floods these conferences.

The point, made at greater length in an essay in the Lancet (pdf), is that we can’t look at scientific evidence in isolation. [The collage at the top of this post comes from the essay. For works of both anatomical and philosophical beauty, do browse Fernando Vicente's illustrations]. Yes, there’s lots of scientific evidence that harm reduction saves lives. But there’s a huge body of political evidence, too. And that evidence suggests that politicians do what voters want, or, at very best/worst, what politicians think they can get away with. For many politicians in many countries for many years, that has meant not spending voters’ money on helping people take drugs more safely.

As long as that is true, the scientific evidence will continue to be secondary. No matter how many well-spoken epidemiologists do their bit on YouTube.

Or, for that matter, how many nice people stand at the entrance to festivals such as Lovebox handing out orange wristbands that read “Nice People Take Drugs”. As I wandered in with my happy band of blue-tongued smurfs, I reflected that if ever there was a case of preaching to the converted…
But I also take issue with the statement, which has a UNICEF lobbyist ring to it. “Most people at risk for HIV are young” does NOT translate into “Most young people are at risk for HIV”. Nice people take drugs, certainly. But are we to believe that most people who take drugs are nice? Maybe yes, maybe no; since a majority of young people in the UK take drugs, it rather depends on your view of human nature.

Still, the folks at Release who run the campaign have come up with some fun ideas. I especially like the “Politicians Drug Confessions” playing cards.

You can buy them here.

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

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

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

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

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

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

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

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

Unlike the United States, the UK has bothered to track HIV infection among large, representative samples of drug injectors (both current injectors and those in methadone and other treatment programmes) since close to the start of the epidemic. Part of this effort involved testing anonymous samples of left over blood for HIV — the samples were usually taken from treatment or diagnostic purposes and are stripped of all but the most basic demographic and risk information (age, sex, length of time injecting, recent needle sharing) before being tested with HIV. The results, shown separately for London and the rest of England and Wales are shown below.

(Click to enlarge)

Yes, prevalence for the whole of England and Wales (including London — Scotland has its own system and reports separately) has risen by over 77% in the last decade. But still, fewer than one injector in 60 is infected with HIV. If you draw the graph using a normal percentage scale, you’ll see something close to the true level of infection — still too high, of course, but not exactly an overwhelming prevention failure when compared with data from any city or country that doesn’t have needle exchanges. The graph compares what happened in the UK with what happened in Jakarta, just because I happened to have the Indonesian data handy. But it would look just the same with data from Bangkok or Moscow or even New York in the years before the city (with no help from the federal government) began to hand out needles.

(Click to enlarge)

Since I’m just a numbers nerd and obviously don’t have a great visual imagination, perhaps someone could help me out here: how can you conclude from these pictures that safe injecting programmes fail to prevent HIV?

Leave aside the fact that they used Respondent Driven Sampling (RDS), a fashionable but deeply unsatisfactory method that could more honestly be named GSS — Glorified Snowball Sampling. [An aside for nerds: if you want to know why RDS is a bad idea even for drug injectors read this fabulous paper by Greg Scott. You've just got to love the young lady who has organised a training scheme to help non-injectors fool study staff into letting them participate. Ah, the land of enterprise...] Leave aside the fact that they inexplicably excluded from analysis the 8% of the sample who knew they were HIV infected. (This is the agency that invented Positive Prevention, for God’s sake. They ought to be supremely interested in the ongoing risk behaviours of people who are already infected.) Leave aside the three year time lag between collection of routine public health surveillance data and publication of the results –a delay that borders on the unethical. Even if those problems didn’t exist, you’d still have almost nothing of interest to write home about, because the analysis is so uninformative.

The headline figure is needle sharing — close to a third of injectors who think they are HIV negative used a needle that might already have been used by another injector at some time in the preceding 12 months. We’re talking about smack and crack users here, people who inject toxic substances into their bodies perhaps as often as three times a day. In most countries, we ask injectors to think back over the last week, and even then we get some dodgy results. How US injectors can remember what they did 11 months earlier I can’t imagine.

Then there’s information about sex. For some reason, they only report vaginal sex, although anal sex between men carries a far higher risk of HIV infection in the United States than any other activity. We’re told, wide-eyed, that 62% of injectors had unprotected vaginal sex in the last year, and that 42% had more than one partner in that time. But we don’t know if the sex with multiple partners was protected, we don’t know whether the unprotected sex was with injecting partners. Despite the CDC’s pronouncement that “a substantial proportion of IDUs are at risk for acquiring HIV infection through their sexual behavior in addition to their drug use”, we actually have no way of knowing whether the sex added to their risk or not.

I could rant on with more examples of missed opportunities for useful analysis, but I guess I’ve made my point. I do want to congratulate CDC, though, on their “honesty box”. They don’t try to fudge data loss and missing values:

“During May 2005–February 2006, a total of 13,519 persons were recruited to participate; of these, 1,563 (11.6%) were found ineligible, and 46 had missing recruitment information. Among the remaining 11,910 participants, data for 1,609 were excluded: 881 who already knew they had HIV infection, 334 whose data were lost during electronic upload, 288 initial participants (whose responses were excluded as part of the respondent-driven sampling methodology), 68 who could not be identified as either male or female, and 38 who gave responses with questionable validity.”

Interesting that CDC doesn’t allow for transgender injectors. Interesting that they provide “technical assistance” on HIV surveillance to countries such as Cambodia and Vietnam who have in the past made a far better fist of the work than CDC does at home.

Bhutan is not exactly crumbling under the weight of HIV infections. Between 1993 and 2006, a total of 90 cases were reported. Each is dilligently listed by the Ministry of Health — age, sex, how they became infected, how their infection came to light, whether they are still alive (19 had died by August 2006). Perhaps that’s because this rather eccentric but extraordinarily organised little country has been quite open about the virus from the start. I remember being at a temple festival some years ago with one of the kingdom’s princesses, cheering on a giant condom in a boxing match against the HIV virus.

Now, Bhutan intends to tackle HIV among drug users in prison, according to a report in the Bhutan Observer. There’s actually no evidence of much drug abuse in prison in Bhutan (unlike in virtually every other country in the region, where prisons are widely known to be HIV factories). But still, it’s great that they are showing willing, after some chivvying at a UNODC-sponsored workshop. Prizes to any reader who can interpret this somewhat cryptic comment from the nation’s Chief of Police:

“I found the recommendations appealing, and if it helps the prisoners, we will implement it. We will have a drug research centre, religious talks and yoga after the coronation.”

(Image stolen from Downward Facing Blog, with thanks)

Nearly 40,000 men got newly-infected with this completely preventable disease in the world’s wealthiest country in 2006. Three quarters of those infections were in gay men. And while blacks make up just 14% of the US population, 35% of gay men newly infected with HIV were black. Cutting the numbers the other way, two thirds of all black men newly infected were gay and another 12% were junkies, leaving just one in five black guys infected in sex with a woman. New infections were even more rare among straight white guys — 88% of all white men newly infected in 2006 were gay, and another 6% were drug injectors; just one in 16 was infected in straight sex.

Women get infected two ways — by sharing needles when they shoot up drugs, and by having sex with infected men. Straight black men are far more likely to be infected than straight white men (not least because they are far more likely to be jailed, and, in a triumph of denial over common sense, jails in America still don’t make condoms available to prisoners). Since most Americans still have sex with people of their own race, it’s no huge surprise that black women are more likely to get HIV than white women. Nearly 15 times more likely, according to CDC. (Of the 14,000+ new infections in women in 2006, 61% were among black women, and 80% of those women got infected when they were having sex, not shooting up drugs.

Some caveats about the numbers: the national estimates are based on data from 22 states; the other states, which haven’t until very recently reported new HIV cases by name, are back-filled by applying the same ratio of new infections to AIDS cases as we see in the States for which we do have data. It’s a reasonable thing to do, for want of a better option, but it assumes that the epidemic has matured in roughly the same way in all states. Here’s the problem: two of the states with missing data are two of the worst affected and least typical, California and D.C. (ok, district, not state).

I’ve used the term “black” rather than “African-American”, advisedly. In many other countries which I follow, including the UK, Canada and Ireland, a very large proportion of heterosexual infections among black people are in fact “imported” infections. They are infections in nationals of African or Caribbean countries, and are likely to have been contracted in their home country. Of course this is far less likely to be the case in the US as a whole, but imported infections may well contribute to the high levels of infection in blacks in some of the more cosmopolitan cities in the US, including New York and Washington DC. CDC does not report infections by country of birth, but I’d be curious to see the figures.

Data quibbles aside, we’re getting an ever clearer picture of the continuing spread of HIV in the United States. Both the gay community and the black community need to demand better HIV prevention services. And those services need to be sold much more aggressively to those who aren’t currently using them, especially young black men who like to have anal sex.

In most of the world, we’ve got precious little idea how many people get infected with HIV each year. Generally, we report HIV prevalence — the number of people who have HIV right now. Some of those people will have been infected last month, some will have been infected 10 years ago. It doesn’t tell us much about what’s happening right now. What we really want is information on HIV incidence — the number of people who got infected in the last year. Recently the US has been trying out new technologies that can distinguish between an old and a new infection. That tells us what proportion of the people tested this year were infected this year; then we have to add in a guesstimate for how many people were infected this year but didn’t get tested. CDC last month published national estimates of incidence for 2006. Now New York City has published its own estimates.

And yes, New York is ahead of the curve. Whites in the city are four times more likely to be newly infected with HIV than they are nationally, Hispanics three times more likely and blacks twice as likely. Overall, half of all new infections are among men who have sex with one another. In fact among white New Yorkers, nine out of 10 new infections are among men, most of them gay. Seven out of 10 of the blacks who got HIV in New York in 2006 were men, and over half of them picked up HIV in anal sex with another man. So much for the “feminising epidemic”.

Blacks of the “post-AIDS generation” — men under 30 who probably became sexually active after effective HIV drugs became the norm in 1996 — seemed particularly hard hit. Some 46% of black men who got infected in sex with another man were under 30, compared with just 24% of whites.

New York doesn’t have any systematic estimates of the number of people in each high risk category, which makes it hard to compare rates across risky behaviours (in this respect, it is definitely not ahead of the curve, falling way behind countries such as China, Indonesia and Nepal, all of which estimate how many drug injectors, sex workers, clients and high risk gay men there are in each district nationwide). But it does look as though a “good news” story might be the comparatively small numbers of new infections among drug injectors in New York City. Just 8% of all new infections were among injectors, a flagrant success for the city’s harm reduction policies.

In the No Shit Sherlock department, I just have to draw attention to this trenchant analysis from dbTechno: “The biggest issue with prevention methods thus far has to do with people who are infected with the AIDS virus infecting those who do not have HIV/AIDS.”

Funnily enough, we started discussions with dealers about selling branded, subsidised needles in one country I worked in a while back. A couple of dealers were interested, but the cops were less keen. Pierce suggests that you might get them on side by changing the charge sheet. If you’re caught dealing drugs you still get rumbled, but if you’re selling each dose with a sterile syringe, you get a shorter sentence. Seems like a win-win situation for the dealers. After all, it is in their interests to help keep their clients alive…