Pic by Jason Cragg via DCist

Many people are thrilled that the Bush Years are almost over. Few more so than sex workers, who have essentially been declared not to exist under the administration’s HIV funding rules. Though many are disappointed that Mark Dybul will stay at the helm of PEPFAR for a while, some of us hope that he’ll do away with the most egregious of his old boss’s idiocies, starting with the “anti-prostitution oath”. So yes, we should be thrilled that Bush is out and Obama in. But I’m not sure how thrilled sex workers in DC will be at the vaccation being forced on them in honour of Obama’s inauguration.

DC has declared downtown a hooker free zone until January 25th. No work during the party or the hangover, then. Seems like a shame; in these difficult times it would have been nice to take advantage of the boost in business that will almost inevitably come with tens of thousands of out-of-towners all intent on having a good time.

Thanks to Lisa M.

And it is happening in the northern Nigerian state of Bauchi, according to the BBC’s Shehu Saulawa. The Red Cross conducted a survey of sex workers in the conservative Islamic state, identifying around 320 of them. The next thing they knew the women were being rounded up by the Sharia commission, the defender of Islamic virtue, at least according to the BBC correspondent. (The Sharia commission denies the women were being arrested, saying that its staff were simply “supervising”, because “In every nook and corner and cranny, illegal acts were being committed contrary to Sharia law”).

According to the Beeb story, between 75 and 100 of the 320 women have so far tested positive for HIV. It’s not clear who’s doing the testing, but that’s a prevalence of between a quarter and a third of sex workers infected, “so far”. Horribly high, but not out of line with what’s happening elsewhere in the country. The long awaited report on the 2007 HIV surveillance round (pdf) is finally out: one in two women working in the brothels of Kano and FCT are infected with HIV. The lowest recorded rates are in Lagos, at just under one in four.

HIV rates are astoundingly high among gay men in Nigeria, too (again, close to a quarter of gay men in Lagos are infected) though somewhat surprisingly they are lower among drug injectors. And gay men don’t fare any better than sex workers at the hands of Bauchi’s morality police. Earlier this month a judge slung 18 cross-dressers in jail for messing with sharia law banning homosexuality. If there’s one thing we’ve learned in 15 years of dealing with HIV, it is that even where patterns of sexual networking allow for it, HIV will only spread through the “general population” if it first reaches a critical mass within sub-populations with the highest turnover of partners: sex workers, gay men and drug injectors. In other words, in any epidemic, but especially one where many adults do have sex with several long-term partners but HIV is currently concentrated among people with highest risk, it makes sense to invest in prevention for these groups.

Oh, we’ve learned something else, too. If you try to squash these groups rather than engage with them, HIV rises. What has Nigeria (and its major HIV funders, the United States and Global Fund) made of these lessons? Well, in 2007 The US invested 53 million dollars in HIV prevention, according to the PEPFAR website.

“Prevention activities in Nigeria include prevention of mother-to-child transmission (PMTCT), abstinence and be faithful (AB) programs, blood and injection safety, and other prevention initiatives, including activities focused on high risk populations.”

High risk populations? Hurrah! But no, it doesn’t mean sex workers. Rather, PEPFAR Nigeria singles out “girls who marry at a young age, causing their sexual debut to occur at an early age. This group, which has a mean age at first marriage of 14.6 years, is a vulnerable and largely underserved population…”

The Global Fund doesn’t fund prevention at all, except for the “innocent babies” thing. Though the clarion call these days is “Know Your Epidemic”, it doesn’t seem to translate into “Do The Right Thing About Your Epidemic”. And when the “knowing” it bit ends up with people getting slung in jail, you’ve got to wonder whether it’s worthwhile collecting all those data.

Thanks to Sean Lyons for the Bauchi tip

Activists have done a spectacular job in slapping down the price of antiretroviral drugs in the last five years. They’ve rallied big names like Bill Clinton and marshalled huge funders like the Global Fund. Even US-funded PEPFAR, once laughingly known as Purchasing Expensive Pharmaceuticals from American Retailers, is spending money on cheap generic drugs. All the while, Big Pharma has warned that eroding profit margins by pushing prices too low will discourage new investment in research.

Roche has been careful not to make a direct connection between low prices for HIV-related drugs and their decision to stop research in the area, even off the record. And there are good reasons for the decision — they were not a huge player in HIV in the first place; less that 5% o HIV related drug sales are from Roche. Many of their drugs are designed to help people only after other, more common treatments fail. And one of their most effective products is unpopular because it has to be injected rather than swallowed.

Is Roche’s announcement a shot across the bows of advocacy for cheaper drugs? “Stop eroding the profits we want, or we’ll stop inventing the drugs you need?” It’s hard to say, but I am amazed that the question is not ringing loudly around the blogosphere. I support the achievements of groups that have fought to bring down drug prices with every fibre of my body. And I certainly find it hard to feel sorry for an industry that spends far more on marketing than it does on research, and that consistently makes its shareholders richer. But is there a point when we have to start discussing how much is enough when we press commercial firms to lower prices?

One solution to the return-on-investment dilemma of is of course to provide more public funding for the development of drugs that meet the needs of poor people and poor countries. There’s been a fair bit of progress in finding public funding for vaccine research, so it’s especially depressing that yet another vaccine trial has been canceled because researchers think it’s unlikely to produce good news.

Most of the money will be spent on drugs to keep people with HIV alive. This is necessary, and wonderful for the individuals who are getting the drugs. But it does mean that there will be more people with HIV. It also means there are more people who can pass it on. Granted, HIV treatment reduces the amount of virus in body fluids, and makes it more difficult to pass on. It also prevents AIDS, sickness and death. So it makes the consequences of HIV less visible. The evidence suggests that this in turn makes uninfected people more careless about who they have sex with, and sloppy about using condoms. And that in turn makes them more likely to have unprotected sex with someone who is infected but not yet on treatment. Newly-infected people are both most likely to be highly infectious and least likely to be on treatment. Indeed most still count themselves among the uninfected. So while treatment decreases the likelihood of infection for individuals on meds, it can increase new HIV infections across a whole population.

That’s what seems to be happening among gay men in countries where access to treatment is near-perfect: in Britain, the Netherlands, Canada, the United States and Australia, new HIV infections among gay men are rising. The effect of rising risk behaviour weighs more than the effect of lower viral loads. In Africa, it’s likely to be worse. Crappy health and transport systems and erratic incomes may mean people have difficulty getting the drugs they need when they need them. Other STIs are high too, and both of those things can send viral loads bouncing all over the place, even for those on treatment.

Of course we need to get antiretrovirals to as many people in need as possible. But if we want that to remain plausible and affordable, we have to stop people getting newly infected, too. The only developing country that’s managed to prevent new infections while putting everyone in need on meds is Brazil. The country invests very heavily in needle exchanges for drug injectors, in promoting condoms to young people, and in good health services for sex workers. So will PEPFAR copy this shining example? Uhhh, no. There’s US$ 50 billion on the table, but not a cent for clean needles for injectors. Not a cent for sensible prevention programmes in the sex trade. A full half of the prevention money (some five billion dollars in all) must be spent telling kids to cross their legs, even though we know that abstinence programmes don’t work. (If people allocating PEPFAR money in countries want to throw less than half of their prevention money into this black hole, they have to make a special report to Congress.)

There’s still a little bit of negotiating to do on the bill because the versions passed by the House and the Senate are different. (This means that the understandable jubilation over the end of the HIV travel ban may just be premature.) But if all the current amendments stick, the US tax payer may well be financing the growth of the HIV epidemic.

For a blow-by-blow account of the Senate debate, read Scott Swensen’s account.

One of the Stubborns, South Carolina’s Jim DeMint, specifically “criticized the bill’s “mission creep” into other development activities,” according to CQ Today. His solution? He’s going to offer amendments to the PEPFAR bill that relate to biofuels, oil, gas and abortions in China.

Makes sense, I guess. At least none of those are development issues.

Check out “Jesus loves you — and your orgasm”, Salon’s review of Dagmar Herzog’s book “Sex in Crisis”. In the review, Louis Bayard says that Herzog implies that the religious right has hijacked the language of the liberal left, the better to control our sexuality. The rhetoric around sex work, for example:

As recently as 2003, for example, a certain public figure was arguing that voluntary prostitution was “despicable” because it “demeans the value of women” and promotes “the severe degradation and exploitation of women, the literal rape of countless women around the globe.” Was it Andrea Dworkin? Catharine MacKinnon? The correct answer: pro-life Rep. Smith, R-N.J., whose distinctly illiberal purpose was to limit AIDS outreach efforts to prostitutes and sex workers in developing nations.

We’ve seen some of this before. We’ve seen leaders of gay communities play down the association between anal sex with multiple partners and infection (including HIV, LGV and MRSA), so finding themselves in cahoots with “everyone is at risk” profiteers. We’ve seen African leaders adopting distinctly unsecular moral rhetoric rather than talk about sex. But the point is, this is all rhetoric. It is not debate, or conversation, or discussion. It is assertion. Asserting beliefs at one another doesn’t change minds. Kids go on having sex despite having been assaulted with messages telling them not to. Preachers go on employing sex workers despite ranting about the fact that prostitution is not work. Fundamentalists of all stripes go on asserting the virtue of programmes that don’t work, despite people like me constantly asserting the opposite. (Though my assertions at least come with data sets.)

And when I hear assertions like this: “Only those women who have been premaritally abstinent will be truly, deeply, and consistently desired by their husbands in the long years after marriage … Have no sex before marriage and you will have outstanding sex after marriage.” I go on snorting in disbelief. But then in my world, I couldn’t find a large enough sample of still-married virgins-at-marriage to disprove the assertion.

So, though we’ve got little clear evidence so far that she’s right, I don’t take issue with her diagnosis. I do, however, take issue with her prescription: cross your legs. That’s right, she’s on her abstinence kick again. It’s hard to know to what extent she’s trying to suck up to George Bush, that global crusader for abstinence who’s government coughed up close to 500 million dollars for HIV in Uganda in 2006 and 2007. But even her formerly pro-condom husband has come over all wobbly about rubbers.

Uganda’s initial prevention efforts were much praised. They have also been much squabbled about. But I think most now agree that HIV transmission fell in the late 1990s because people had fewer partners, and less unprotected sex with the partners most likely to be infected. Some young women started having sex later, but the most solid data we have suggest that by age 23, the early abstainers had caught up with their peers in terms of infection rates. Unlike HIV, abstinence doesn’t last for ever.

Thanks to Adrian for pointing me to the NV article.

After a Washington Post editorial accused them of foot-dragging on AIDS funding in part because they worried that money might be used for sensible things like clean needles and condoms, Richard Burr and Tom Coburn had this to say:

When it comes to AIDS, treatment is prevention. If we fail to aggressively treat patients, we endorse the spread of the virus. By requiring that the majority of PEPFAR funds go toward treatment, we are working to prevent the spread of this devastating virus.

Let’s take that apart. “When it comes to AIDS, treatment is prevention.” So far so good. Treating HIV infection reduces the amount of virus in circulation, allows the body to restore the immune system and reduces the likelihood that other diseases, clustered under the name AIDS, get the upper hand. So treatment clearly prevents AIDS. But does it prevent HIV? Aaaah, now that’s a very different question.

The more HIV you have in your body fluids, the easier it is to infect someone else in unprotected sex or by sharing needles. So many of us have fantasised that lowering viral loads through treatment would significantly reduce HIV transmission. At the individual level, it is true. But across a population, it doesn’t seem to work like that. Countries that have near-perfect access to treatment for everyone who has been diagnosed have NOT seen new infections drop in the groups most at risk, and some are seeing them rise, especially among gay men. What seems to be happening is this: treatment is indeed preventing AIDS (and thus death). So people are less scared of getting HIV. On top of that, they assume that it doesn’t matter too much if they have unprotected sex with someone infected, because everyone who’s infected is on treatment, so they have low viral loads and are unlikely to pass on the virus. So why the hell bother with a condom any more? Unprotected sex rises.

Here’s the problem: people are most infectious when they are newly infected. And that’s when they are least likely to have been diagnosed, and are least likely to be on treatment. If condom use falls across the board, people who are newly-infected (and highly infectious) are more likely to be passing on their infection. More treatment definitely means more people living with HIV, obviously, simply because people who are already infected aren’t dying. But the data suggest that even in a world of near-perfect access to treatment, more treatment can also mean more new infections. In a less-than-perfect treatment scenario such as that found throughout Africa, we could get a messy mix of the lower concern and rising risk that comes with the PERCEPTION of treatment availability, without the advantage of lower viral load that comes with perfect treatment. In other words, it’s even more likely that new HIV infections will rise.

So yes, treatment prevents AIDS. But it may actually INCREASE HIV. And that in turn will increase the number of people that Senators Coburn and Burr need to find money to treat. Wouldn’t it be better to invest more of the money in making sure that those people never need treatment in the first place? As more people start taking HIV drugs, we need more money for effective HIV prevention, not less.

Tobias typifies the hypocrisy about prostitution which riddles the United States. He says he only paid Palfrey’s staff for massages, not for sex. And Palfrey says that to her knowledge her staff only provided massages. She said it in court. He didn’t have to. She was convicted of a number of crimes. He wasn’t. She is dead.

Tobias presided over a programme that aimed to end prostitution in the world. (I am not making that up. Check it out in the Box headed “Violence Against Women and HIV/AIDS”: “The Emergency Plan will also support interventions to eradicate prostitution”.) For a round-up of what people whose livelihoods is to be eradicated think of that, see the links to posts about Palfrey’s death on Bound, Not Gagged. The supporters of this policy argue that the willing buyer, willing seller principle which drives most of American life does not apply in the area of sex. They argue that prostitution is not a victimless crime.

This self-serving moralising, this craven hypocrisy about the trading of sex, is the real crime. It has just claimed it latest victim, in the form of Deborah Jeane Palfrey. May she now find peace.

Hat tip: Mark Zip.