So Jacob Zuma is sorry about having unprotected sex with someone three decades younger than himself, who is not one of the five women he’s married. That’s a little better than last week’s “You should be proud that I’ve admitted paternity and paid a fine. What are you all so uptight about?” HIV activists are pretty upset. Me, I prefer to see what he’s done as a good thing.

I’m not one to get uptight about extramarital sex. But I am not president of a country where one in five adults is infected with a still-fatal sexually transmitted virus. Mr. Zuma has rubbed South Africa’s nose in the fact that he racks up as many sex partners as he can, and he doesn’t use condoms.

How is that a good thing? Well, it allows us to say the unsayable: countries get the HIV epidemics they deserve.

Want a hyper-epidemic? All you need is a tradition of polygamy AND high levels of female autonomy. Big Men have their little network of wives and/or lovers. Women buy in to duty sex for the status and security, but get to run their own little networks on the side, for the fun of it. That has been the pattern in South Africa, Swaziland, Botswana, Zambia, Zimbabwe and a number of other countries where more than one adult in seven has HIV.

But woe betide anyone who points this out. At best, you are insensitive to cultural traditions. At worst, you are perpetuating racist myths of the hypersexualised African male, blah, blah, blah.

Now South Africa’s president is unrepentantly living the myth. He has been married five times, and is currently shared by three wives (one of the others killed herself). He’s got another fiancée in the wings for good measure. In 2006 he was acquitted of rape charges, and now we find he’s bonking the daughter of an old mate who’s running the World Cup organising committee. This puts him in good company. In neighbouring Swaziland, where one adult in three has HIV, the king sets an example by taking a new teenaged wife every couple of years — a baker’s dozen so far.

Here’s another thing that Mr. Zuma’s behaviour has laid bare: HIV is a preventable infection. Good governments prevent it. Bad ones hide behind the very culture, tradition and customs that allow the virus to spread, and then throw their hands up when prevalence get so high that HIV will continue to spread even if behaviour does change.

The saintly Nelson Mandela was unforgivably slow to do anything to address the sexual behaviours that were spreading HIV. His successor Thabo Mbeki compounded the problem by simply denying that the sexually transmitted virus was in any way linked to a four-fold rise in death rates among young adults. Besides spotlighting his sexual escapades, Mr. Zuma used his 2006 rape trial to give us a new perspective on how to stay HIV-free. Sorry I had unprotected sex with an HIV-infected woman he said, but don’t worry about me, I had a shower afterwards, so I won’t catch anything.

Unfazed by his flagrant disdain for his own health ministry’s HIV prevention efforts, (or by the pack of corruption charges that stalk him, or by his growing posse of wives) the people of South Africa support Jacob Zuma anyway. It’s a healthy democracy, and that’s their right. But I think it is time that voters in other countries stopped subsidising the fatally bad behaviour of South African leaders. Why should Americans give South Africa over half a billion dollars of PEPFAR money a year, in part to promote abstinence, monogamy and condom use, when the electorate of the country supports a man who is the embodiment of the behaviours and attitudes that spread HIV? Because, you might argue, the government of the richest country in Africa, which is also pocketing over US$ 160 million for HIV from the Global Fund, can’t even organise itself to keep anti-retrovirals in stock. I’d say that’s all the more reason to stop propping up bad leadership on HIV.

This post is for Dot and the thousands of other hard-working health care professionals in South Africa who have to pick up the pieces.

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.

Interestingly, I can’t find anything anywhere from anyone who has actually nicked the pills off their Mum, crushed them up, rolled them and smoked them. A politician says it feels like taking smack, but his account doesn’t sound very first hand account on either score. Tooli Nhlapo, a documentary maker with SABC, said that after they smoke the meds “The children do not know where they are and they stop making sense”.

How much sense were they making in the first place? Quite a lot, in a teen-eyed view, you might argue. Smack costs money. ARVs are free, to those who need them. It’s just a matter of getting the meds from the hands of patients to those of bored, thrill-seeking teens. More than one in 10 teens is infected with HIV in some parts of the country and bored, thrill-seeking teens are the very ones most likely to be infected. So they could stop swallowing their meds and start smoking them (especially if we press ahead with the WHO’s “potential strategy” of testing everyone annually and putting pills in the hands of every infected person right away). Others teens are apparently buying ARVs off people who would rather have cash to buy booze than take their meds. It slightly begs the question: if teens have cash to spare why don’t they just skip the extra step and get high on booze right away? Are manufacturers of alcopops missing a trick in the South African market?

It’s hard to know how much of this is real and how much is just another silly season media beat-up. I notice that the usually very sensible Treatment Action Campaign doesn’t dignify the reports with any comment. But if the reports are even partly true, it is one more strike at the heart of the prevention approach which relies on young people making sensible decisions about their long-term future in the face of diversions like sex or drugs that will deliver fun right now.

One of the coolest things about publishing a book, it turns out, is that people start doing your thinking for you. Last week, I had an e-mail from Elbereth Wentzel, a South African living in the UK who picked up The Wisdom of Whores in Edinburgh airport. She wrote to ask: what is the UK doing about HIV prevention for the Soccer World Cup, which will be held in South Africa in two years time?

Bloody good question. We know footballers like to behave badly. We certainly know England fans like to get drunk, and some of them certainly also like to get laid. And we know that women in South Africa (especially those most likely to accomodate a drunken England fan) are among the most likely in the world to be infected with HIV. I know that condom makers Durex made a special “England supporter” limited edition condom for the last World Cup. But we should be thinking of working at the club level to make people aware of the need to protect themselves if they are going to play ball while at the World Cup.

I mentioned this yesterday to a colleague at Britain’s National AIDS Trust. They’re already thinking about the 2012 Olympics, which will be in London, but the World Cup isn’t on their radar screen, any more than it was on mine. So if there’s nothing going on out there in fanland, maybe it’s time to start. Any ideas?

The Institute for Democracy in South Africa has recently published a massive tome, The Political Cost of AIDS in Africa which “reveals that the fledgling multi-party democracies in parts of the continent are being undermined by sickness, incapacity and premature deaths among elected leaders as well as within the electorate”. Well, well. Who’d have thought it?

By definition, when over one in four voters is infected with a fatal disease that kills prematurely, voters will be dying prematurely. Since testing negative for that fatal disease is not a condition of office, it seems inevitable that some of the people dying are also politicians (the study points out that HIV is never acknowledged as the cause of death for a politician, but then most non-politicians with HIV in southern Africa are not exactly trumpeting their HIV status, either). If dead voters undermine democracy, as the study suggests, then yes, HIV will undermine democracy in southern Africa. HIV won’t undermine democracy as much as the acts of some of the region’s elected luminaries, such as Robert Mugabe of Zimbabwe, of course, but hey ho…

Now reverse the question. Not “how does HIV make for bad politics?”, but “how have bad politicians made HIV?”. What is really shocking in southern Africa is that political leaders, starting with South Africa’s Thabo Mbeki, have fanned the flames of HIV with their denial, their prudishness and their lies. And those of the voters that are still alive have, for the most part, allowed them to do it. In other words, voters are getting leaders that reflect their own views. That’s democracy.

Here’s the real shocker in my opinion: Only one woman in 10 used the gel all the time. Overall, researchers estimated that women in the study used the gel in 44% of all sex acts. For years, we’ve been talking as if women were somehow better than men, somehow holier, somehow more likely to preserve their lives if given the chance. If only we had a “female controlled method” to prevent HIV and didn’t have to rely on those nasty men to use condoms, all would be well, we’ve lulled ourselves into believing. And then you give women a relatively unobtrusive product that may well protect them from HIV, and most of them don’t bother to use it most of the time.

Another disappointment was the sheer scale of infection. Over three women in every 100 became infected with HIV during the study, with no difference to speak of between the those who were assigned the candidate microbicide and those assigned a harmless but definitely ineffective gel. (Nerd Note: incidence was 3.7/100 pyo in the placebo group and 3.3/100 pyo in the microbicide group, p > 0.5). Let’s repeat that: 3.5 new infections per 100 women per year. That’s a higher rate of new HIV infections than we find among drug injectors in Bangkok, for God’s sake (and Bangkok is not exactly renowned for its effective HIV prevention for junkies). It is painfully high by any standards, and in one site the rate was close to six percent. But this isn’t what is going on in South Africa as a whole. This is what’s going on in a study where women were given fistfulls of condoms, and all were energetically urged to use them by carefully trained and highly motivated counselors. On top of that, they were screened for other sexually transmitted infections, and were treated with world-class medicines if need be, thus greatly reducing the likelihood that they’d get HIV if they did have sex with an infected partner. All the participants knew from the start that there was a 50:50 chance they might be using a “fake” microbicide, a gel which could not prevent HIV. In other words, these women had HIV prevention services that most women in South Africa could only dream of, even without the microbicide. As South Africa’s Treatment Action Campaign notes in its very sensible analysis, the rates in women without those services are likely to be higher still. That ought to be a real disappointment to everyone.

*Update*
This comment from Naomi Rutenberg, who heads the Pop Council’s HIV research programmes:

The news is disappointing and the context is dismaying. The good news is that we doubled condom use and made a serious dent in STIs for women in the trial. Also encouraging that there were fewer infections in Carraguard arm. It is important and good news that women who were in the trial ­benefited and were in no way harmed.

Carraguard is safe and we can add an antiretroviral and try again. Adherence is a challenge but 30% of women used it all or 3 of 4 times. There is most definitely a need and a gel certainly is attractive and feasible for some women. (We’re) also working on a vaginal ring.

For details about condom use, STIs, and product safety, see here. Admirably, the Population Council also posts a synopsis of the study protocol.

One thing that was new, at least to me, was the report’s claim that poorer South Africans are deliberately exacerbating their HIV infection because they need money more than they need good health. It works in two ways. Firstly, people whose who have fewer than 200 protective T-cells per milliliter of blood (in the jargon, people with CD4 counts below 200) are entitled to free antiretroviral treatment; those with higher CD4 counts are not. So some poorer people with low counts are collecting the drugs and then selling them off to people who want them, but aren’t quite sick enough to get them for free.

Secondly, people who get drugs for themselves don’t always take them properly, because the drugs do such a good job of making them better. And if they get a lot better, they might no longer qualify for disability benefits that doctors can recommend for patients who are considered too sick to work normally. So they take their drugs intermittently, but not enough to restore them to good health.

This is bad for them, obviously, because they are denying themselves good health. But it is bad for everyone else, too. Intermittent use of antiretrovirals increases the likelihood that an infected person will pass on the disease (because the amount of virus in the blood bounces back up when someone who was on drugs stops taking them). And it increases the chance that HIV will mutate into forms that are no longer suppressed by drugs.