Thirty years ago next month, the first reports of the illness that came to be known as AIDS were published. Five cases, all among young gay guys in Los Angeles. Since then, we’ve racked up over 60 million HIV prevention failures worldwide. But new draft guidelines on safe sex advice proposed for the UK suggest we’ve learned almost nothing from three decades of failure.

The guidelines, proposed by the British Association for Sexual Health and HIV are depressing, at very best. They seem to assume that it is the duty of health professionals to protect people from their own bad behaviour, in part by informing them of every possible risk, however marginal. They seem also to assume that the sort of people who take significant risks on a regular basis care about their long term health prospects. We don’t. And that comes from someone who today happens to be wearing a T-shirt embazoned with a slogan picked by algorithm on the basis of answers to 10 behavioural questions. Mine reads: “Runs with scissors”, but it might equally have read “Cycles without a helmet”, “Shags without a condom” or “Rolls her own cigarettes”.

The guidelines available here in pdf form, are open for public comment for another week or so. I would strongly urge people (especially people who’ve ever used a sexual health clinic) to look through them and put in their tuppence worth. The full text of my own comments is available in a doc file here.

In summary, I’m upset that we are still telling people to use condoms every time they have anal, vaginal or oral sex, even though we know perfectly well that that’s no more feasible than never having sex at all, for the same reason: for most of us, consistent condom use in every act of sex involving every orifice with every partner type at every age and level of sobriety is not feasible because it is not desirable.

I’m upset that we don’t give more practical and nuanced advice that people are more likely to act on. Example from my response:

“If you don’t have a condom handy, or don’t want to use one, then oral is your safest bet”. More useful still to a random gay man would be: “Do you have HIV? Yes? Then try always to use a condom if you’re top in anal sex. It would be great if you could use one if you’re bottoming too, but it’s less important, especially if you’re good about taking your meds. Don’t worry too much about oral, though it’s best if you don’t come in some other guy’s mouth. Definitely don’t come in his mouth if he’s just been to the dentist, or looks like he needs to go!”

I’m upset that we’re using evidence selectively. The guidelines imply there’s evidence that condoms work, and no evidence that abstinence works. In fact, condoms work and abstinence works even better, when they are used consistently and correctly. The more important evidence is around whether the promotion of condoms or abstinence lead to their consistent and correct use. Frankly, there’s very little recent evidence from the UK that condom promotion works very well; what worked in an age when HIV meant AIDS and an ugly death does not necessarily work in this post-AIDS age.

And I’m upset that, not content with giving clients information they won’t act on, we’re suggesting things that service providers won’t act on either. Sizing your clients up for condoms using a pasta measurer? Really?

I hate to wish HIV a happy 30th birthday, but I think at this rate it can expect to stay alive and well for several decades to come.

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.

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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?

I’ve fretted before about the bill, which criminalises men who buy sex. But a fantastic lobbying effort by UK sex workers (notably the International Union of Sex Workers and the English Collective of Prositutes) has meant that the version of the bill which gets its third reading today is a VAST improvement on earlier versions. Most importantly, only men who buy sex from women who have been “subjected to force, deception or threats” can be nicked. While it’s still a wide net, it’s not one most people in the indsutry object to — no sex worker wants to work alongside colleagues who have been trafficked or forced into the business. The wording is certainly a damned sight better than earlier versions, which made it illegal to buy sex from people who are “controlled for gain”. That includes anyone who gives an agent a cut of their fees for finding clients (or for finding a publisher, a gig at Wembley, a part in the new Stephen Spielberg movie… No, let’s not go down that route).

There are other proposed ammendments worth supporting too. Catherine Stephens, one of IUSW’s most energetic and dedicated campaigners, draws attention to the following:

• new clause 4 which decriminalises anyone under 18 who is selling sex
• new clause 37 which defines a brothel as more than two people selling sex plus a maid
• new clause 38 which decriminalises “associated workers” (e.g., maids) in brothels
• amendment 6 to clause 15 which defines persistently for street sex workers as “twice a week” rather  than the current “twice in three months”
• amendment 7, which removes clause 16 (compulsory rehabilitation for street sex workers as a substitute for fines or jail time)
• new clauses 25 and 26, which, like the government amendments, require that the person selling sex has been coerced and that the client knows this.

Of course the abolitionists are yelping about the changes. If you’re a voter in the UK, you’ve got til 2pm to call your MP and ask them to support the changes, which will make sex work safer and more rewarding for people who want to do it, while helping to protect people who don’t. You can call your MP on +44 20 7219 3000 (and find out who to badger here).

Congratulations to those sex workers who have shown that reasoned, evidence-based engagement in the political process is worthwhile. You’ve brought some wisdom to parliamentarians. Of course one could be forgived for expecting a sympathetic ear from our elected representatives; they know a thing or two about selling themselves to the highest bidder…

I’m not joining the ranks of the AIDS denialists, here. I’m just recognising that in countries with very good access to antiretroviral medicines, AIDS has all but disappeared. The same can sadly not be said for HIV. Indeed HIV is rising as AIDS vanishes. The UK’s influential political monthly Prospect asked me to write about this phenomenon in the gay community in the UK, and the more I looked at it, the more worrisome it seemed. In the article, The plague is over, let’s party!, I argue that HIV continues to spread among gay men in part because “AIDS survivors” are setting standards of risky behaviour that are being adopted by a younger generation that has never known AIDS. I’d be interested to know what others think of this thesis.

That would be bad for America — the country is losing out on potentially talented immigrants and entrenching its reputation for “do-as-we-say-not-as-we-do” foreign policy. But taxpayers in other countries, countries that don’t discriminate against immigrants because they’ve got a virus or against human beings because they can’t afford private health insurance, may be picking up the tab for this HIV-phobia.

The UK has seen a rash of new HIV diagnoses among young gay men; of new cases diagnosed since 2000, 28% have been “imported” by gay men infected elsewhere. Among heterosexuals, the proportion is above 80%. Many of these people, especially the younger ones, are language students who need to be in an English speaking country. Some may have preferred to study in the States. But because of the ban on immigration for HIV-positives, they won’t even apply for visas there.

I’m pleased that the UK welcomes all-comers. I’m pleased that the country cares for people who are sick or in need of care, regardless of what is in their wallets. I think that most immigrants contribute more to a nation’s economy than they take out of it, even if they are on expensive antiretroviral treatment. But it is nonetheless likely that UK tax payers are paying for HIV treatment for an ever higher number of people in part because no-one in need of treatment can go to the States.

The biggest offenders in the drug market in jail appear to be the screws, the prison staff who are topping up their salaries by dealing smack to the people they are locking up. So there’s a surprise.

Listen to this fantastic radio documentary about drugs in UK jails from BBC’s Radio 4. Go ahead, listen.(Though be warned, there are things you wouldn’t want to try at home, like strapping steroids to your scrotum, and smuggling mobile phones in through the back door, as it were…)

With all those drugs floating around, prisons don’t seem a very healthy environment for impressionable young souls. And yet it seems that police, striving to meet targets for a charter-obsessed government, are funneling more and more young people into the criminal justice system, even for petty offences that would once have been dealt with informally. Into the system doesn’t necessarily mean in to jail, of course, but it’s the first step — it gives you a record that can make it more likely that you’ll get put away for a relatively minor offence later. Not a good idea, according to Dr Andrew McLellan, Chief Inspector of Prisons for Scotland, who complains that putting more people on short-term sentences in overcrowded jails actually makes Scotland a more dangerous place.
One bit of good news in a miserable picture: young users in the UK are less likely to be using smack or crack than their elders, by which I mean those who have hit the ripe age of 25. Of course that does mean they’re more likely than old farts of 27 to be using coke, speed and E, according to a new study fromLiverpool John Moore University.

Thanks to the always informative UK Drug Policy Centre for these tips.

Britain and Canada haven’t had such bans (in fact, the US is one of only 13 countries that erects barriers to the HIV-infected — the ban puts it in the good company of such beacons of openness as Libya, Iraq and Saudi Arabia). Have they been flooded with imported HIV?

Some in the loopier fringes of the bloggosphere, would answer with a resounding yes. In sheer numbers, the answer is certainly no. Canada welcomed over 2,400 immigrants that it knew had HIV between 2002 and 2006, according to an immigration official quoted in the Calgary Sun. That’s peanuts when set against the 1.2 million people who flooded into the country in that time. But in fact, it’s not an insignificant proportion of the estimated 58,000 Canadians with HIV (pdf). Overall, Canada estimates that around 12% of people with HIV are from countries, mostly in East and Southern Africa, where HIV is endemic. And they represent 45% of all heterosexually acquired infections in Canada. In the UK, it’s a lot higher. Over four in five heterosexual infections diagnosed in Britain are in people born in sub-Saharan Africa, and we see a similar pattern in Ireland.

We can’t say exactly where people picked up their infection. But if they grew up in Swaziland (where 43% of adults are infected with HIV) but were diagnosed in the UK (where infection rates are less than a hundredth of that), we can take a pretty good guess. In most countries that don’t bar HIV positives, there seems to be a distinction between imported HIV and new infections at home; those are still mostly in gay men and drug users in Britain, Canada and Ireland. The experience of these other countries would suggest that the US is not going to be mowed down by a wave of secondary HIV spreading out from a pebble of infection brought in by immigrants. So change the law, already!

(An aside: say what you like about random testing, at least it gives you fairly accurate figures. Antonio Maria Costa, who heads the UN drug police UNODC, thinks he can tell who’s on drugs just by looking. Speaking at a conference yesterday, he described a meeting organised by the Drug Policy Alliance as follows:

“1200 participants, 1000 lunatics, 200 good people to talk to. The other ones obviously on drugs.”

Thanks to Transform for that report.) Now back to the UK.

The drug the government is getting uptight about is buprenorphine, an opiate substitute which is widely used in drug treatment outside jail (and sometimes inside it, too). Unauthorised use of bup (aka Subutex) in jails stands at 1.9% nationally, but more than one inmate in 10 is taking it in several jails, and in some its one in five. Justice Minister David Hanson has decided to deal with this problem by forcing all jails to introduce random testing for buprenorphine (currently only around two thirds of jails do). His theory is that random testing will act as a deterrent, pointing out that use of other drugs has fallen from 24% to 9% since random testing was introduced in 1997.

Perhaps better treatment would help more. To give the government its due, the number of prisoners on substitution therapy has more than tripled in the last 10 years, but there’s still a long way to go. The prison policy update dedicates most of its drugs section to supply reduction, making no commitments for increased treatment. There’s not a whisper about allowing clean needles for injectors in prisons, of course, even though the UK taxpayer continues to fund life-saving needle exchange programmes in jails in other countries. Go figure.

While I’m on drugs, a rare bit of praise for UNAIDS. Having allowed harm reduction to teeter on the brink of invisibility, they seem to be finding their voice again. Could it be that they smell change in Washington?

On the other hand, the plan commits the government to treatment and prevention which follows evidence, not ideology. This includes “injectable heroin and methadone where they have been proved to work and reduce crime”. This will enrage people who believe that taxpayers shouldn’t be buying smack for addicts, even if it keeps the thieves from their doors.

Interestingly, amphetamines have fallen out of favour with Brits since 1996, but cocaine use (including crack) has been on the rise. Not surprising: a gram of coke costs almost exactly the same now as it did 20 years ago in absolute terms, while wages and indeed benefits have risen sharply. (More about supply, demand and pricing of drugs in this Home Office report.)

The strategy argues for better methadone maintenance programmes in UK prisons, to which I say hear, hear. Predictably, since this comes from the Home Office, there’s nothing on rolling our needle exchange programmes in jail (though it seems Scotland may take the initiative on that soon). I guess you can’t have it all. One of the things I do like about the strategy is that it doesn’t have a pigs-might-fly “Drug Free Britain” goal. Rather, it focuses very clearly on problem drug use. This, for example, from the Home Secretary’s foreword:

“Our ambition is clear. We want a society free of the problems caused by drugs”

I can think of a couple of other nations that would do well to adopt such pragmatism.