A gaggle of studies have shown that people with Herpes Simplex Virus Type 2 (HSV-2, or genital herpes to most of us) are more likely to get infected with HIV, in part because they are more likely to have ulcers that open the door to HIV. So it was perfectly logical to think that if we suppressed the herpes, we’d have fewer new HIV infections.

The first study, among high risk women in Tanzania, was not encouraging. Now a much larger study among women in South Africa, Zambia and Zimbabwe and gay men in Peru and North America have confirmed the gloom. Treating people’s herpes doesn’t seem to make any difference to the risk of getting HIV. The study ticked all the “gold standard” boxes for this sort of research — it was double-blinded, randomised and placebo-controlled. It had a couple of weaker points, as all studies do. Ethically, researchers had to treat any episodes of herpes they saw on examination with a burst of acyclovir, regardless of the patient’s placebo status (which researchers of course didn’t know). But that doesn’t seem to be enough to skew the results.

This is a huge disappointment (and so far somewhat inexplicable). It’s important, though, to remember that this only looked at one side of the equation: people who have (the highly infectious) HSV-2 but don’t yet have (the much less infectious) HIV. The other side is people who already have both infections. It is still possible that regular antiviral treatment will make it less likely that they’ll pass either or both infections on to their sex partners.

The other thing to get depressed about was the very high rates of new infection in the study. These people had endless amounts of counseling and condoms. They had their STIs treated. They had better access to prevention services than most. And still, 4.0% of the African women, 3.5% of the men in Peru and 2.3% of the men in the US got infected (or, to be more precise for those who care about these things, the incidence rate was 4, 3.5 and 2.3 per 100 person years). If that’s the best we can manage with intensive prevention services, we’re still in a LOT of trouble.

Their discussion about the rights and wrongs of discrimination in toilets is interesting. But the “where to pee” debate masks something (to me) much more important: “where to go for health care”. When I was working with the fabulous Lenny Sugiharto and other waria in Indonesia, I learned that one of the reasons these “women with penises”/”other definition of your choice” had such phenomenally high rates of untreated STIs and other illness was that they HATED going to health services, and getting stuck in the men’s wards. Groups like Arus Pelangi are lobbying for less discriminatory attitudes among service providers, but there’s a hell of a long way to go.

Well, perhaps not everything. I couldn’t check out the clips — that would cost me US$99.99. But a look at the subject menu shows no mention of sexually transmitted infections, no mention of HIV, no mention of condoms or other contraceptives. STIs do feature prominently in a press release about the site, so these things may well be featured in the (apparently rather clinical but perfectly sensible) information available. But if I were a parent, I’d want to know that I would get information on these critically important issues before parting with my 100 bucks. In the meantime, I think I’ll just stick with the zany but informative (and above all free) Midwest Teen Sex Show.

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.

New guidance issued by the Crown Prosecution Service suggests that people can’t be convicted for one-off acts of risk or folly. The original law dates back to 1861, long before HIV, and applies to all manner of sexually transmitted infections. The new guidance stresses that
1) an infected person has to have set out to infect another person on purpose
2) the other person has to have become infected.

None of this wishy-washy exposure stuff the Americans have on the table. No infection, no case. On the other hand, a person can be prosecuted even if they told their partner they were infected, which seems a bit harsh. Caveat Emptor, and all that.

Oh but wait, there are more provisions. If it’s deliberate, you can be prosecuted for trying to infect someone, but not succeeding, a slightly different charge. And you can be prosecuted for “recklessly” infecting someone, even if it wasn’t exactly deliberate. But it means showing a pattern of recklessness. And if it was reckless rather than deliberate, then the infector can wriggle out of it if the infectee knew about the infectors infection, even if the infector hadn’t told the infectee themselves. Still with me? Oh, and the infector doesn’t really have to know about their own infection, as long as there is some indication that they ought reasonably to have known, that they were exhibiting “willful blindness” to their infection. (What those black spots all over my body? Herpes zoster? Never!) And you can’t be done for trying but not succeeding to “recklessly infect”, because then it would be deliberate.

So that’s all clear, M’Lud.

Only half of those girls are sexually active. Among those who have ever had sex, STI rates are 40%. We don’t know how that compares with past rates in the United States, because this kind of study hasn’t been done before on adolescent girls in the US. That’s in part because the government expects them all to keep their legs crossed until marriage (something they are demonstrably not doing). But those rates on infection look pretty much the same as the STI rates we see among women who sell sex for a living in several countries in Asia and elsewhere.

Black girls in the States have even higher rates. The CDC abstract doesn’t tell us how sexual activity differs by race, or what STI rates are among sexually active black girls. But since it is 48% among all African-American teens (including those who have never had sex, compared with 20% among white and Hispanic girls) we can assume it is higher than we see in many groups of sex workers in Asia.

I consider STI rates of over 40% to be an appalling indictment of our prevention efforts among professional women who have sex with several different men every week. Now we’re seeing the same rates among teenagers in American households. What does that say about the success of the abstinence-only programmes pushed by the Bush administration?

I hadn’t thought that the mid-West would have much to teach Bangkok about sex. But I’ve been looking at some of the STI figures here (in fact I’ve spent a lot of time looking at figures in this town of the body beautiful). In honour of the spiking syphilis that we’re seeing among young men in Bangkok, I offer up this earlier wisdom from the mid-West teen sex show.

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.

This silliness is particularly jarring in the face of the Philippines’ extraordinarily pragmatic, and successful, HIV prevention programme. The programme revolves around a network of Social Hygiene Clinics run by local governments. These provide regular (more or less compulsory) screening for sexually transmitted infections for all women working in “entertainment establishments”. Any infections are treated promptly, and women are given detailed information about HIV, along with tips on how to get their clients to use condoms every time. And, of course, they are given free condoms. For once, sex workers seem to be getting a better deal than poor women in other jobs.

More madness from what Salon’s Carol Lloyd calls the “anti-birth-control bozos”: the Philippines Family Media Advocacy Organization appears to be trying to ban adverstising for Frenzy condoms (sister brand to Indonesia’s Fiesta, who brought you the condom that keeps the Democarats coming) In case they succeed, here’s a Frenzy ad for you:

Some in the Philippines believe that young people will have sex just because condoms are available. That is not the case in any country for which we have reliable data, and there’s no reason to believe kids in the Philippines should be any dumber, or luckier, than kids anywhere else.