The Wisdom of Whores

Because I run a course to help mid-career scientists get their papers published in peer-reviewed journals, I’m always on the look-out for really good papers, and for really bad ones. I also keep my eyes open for bad science reporting. It’s depressingly easy to find the latter, but it just got easier.

Tom Scott has produced a series of handy-dandy stickers to put on newspaper articles. Here are a couple of my favourites, but you can see the whole set here, and even print out your own set.

What I’d like Tom to get on to next is a set of stickers to help me quickly find the crap research in peer reviewed journals. He could start with “Warning: This paper was reviewed by someone who has applied for a job with the first author” and “Warning: Reprints of this article ordered by Big Pharma will account for 18 percent of the journal’s income this month”.

Thanks to CB for bringing Tom to my attention.

The New York Times is a bit of a supertanker; it takes a while to get going on a subject. So by the time they run a drum-rolling front page story about some world-changing trend, you can be pretty sure that the trend is close to becoming the new status quo.

I’m hoping that’s true of today’s front-pager on data sharing in health research. The story hypes the idea of data sharing as a brand new one. In truth, public and philanthropic funders of health research have been working for a while to develop a common approach to promote data sharing. They’re due to publish a “Joint Statement of Purpose” on efforts to promote data sharing very soon; if they back the rhetoric up with the people and money needed to do some of the tedious work that will make shared data sets valuable and easy to use, the New York Times story could look very dated, very soon. But it’s a big if. Many scientists are still very resistant to sharing, for reasons that are quite nicely described in this article in the Chronicle of Higher Education. At least one of the major philanthropic funders of health research keeps asking for proof that more minds working on large, combined data sets will yield results faster than if everyone sits in their own labs, each collecting fragments of similar data and analysing it separately. That’s like software companies questioning whether open source code development is more efficient than proprietary code development. Oh, wait a minute…

The really interesting thing about the Alzheimer’s example described in the Times is that private companies are in the mix, too. Ultimately, academics funded by taxpayers and charities will share their data because their paymasters tell them to. If those same paymasters also do something to remove the disincentives to share data that come from using publication in peer reviewed journals as the only yardstick of success for scientists, it will happen even faster. But the GSKs and Pfizers of this world don’t think peer reviewed papers are the be all and end all, and they are certainly not signing on to any Joint Statement of Purpose on data sharing. (Our invitation to them to be part of the discussions were met with a resounding silence.) If Big Pharma has decided that data sharing is the way to go, then it’s more than a new trend, it’s the new orthodoxy.

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.

When we throw around the term “Rent Boy”, we usually mean a young man whose impeccable abs and other finery are for hire. A very privileged few of us mean a young man with impeccable abs who pays the rent. But we’ve been outdone by the Catholic hierarchy, which has combined the two but inverted the equation.

Catholic priest Rev. Kevin J. Gray, who used to preach abstinence, celibacy, humility and heterosexual norms in Connecticut (just up the road from where my mother sings in her church choir), has been done for stealing US$ 1.3 million from the Church and blowing it on expensive hotels and male escorts, according to the Associated Press. But he did more than just pay for an occasional admiring squint at their abs. He paid their rent.

My own rent boy’s reaction: “Where do I sign up?”

Meena Saraswathi Seshu was a well-to-do Indian do-gooder who was determined to save India’s sex slaves from their evil traffickers. To her immense credit, illustrated in this nice profile in The Lancet, (pdf here), she changed her mind when she learned the facts. Not so the US Congressman who tried to bully her organisation SANGRAM out of existence.

SANGRAM has long worked constructively with sex workers, to the fury of Congressman Mark Souder who stomped on USAID until they shut down funding for SANGRAM. In a letter to USAID as bombastic, self-righteous and threatening as any I have seen, Souder pontificated about the Bush administration’s record in promoting family values and women’s rights.

“There is a tragic irony in the fact that this administration seeks to elevate women in the United States to some of the most important positions in the country…; yet, USAID has funded groups outside the United States that promote the ultimate degradation of women.”

Souder might know something about the degradation of women. Six weeks ago he resigned as congressman after 15 years, admitting to having an affair with a staffer. He started off on script, apologising for the pain he had caused his supporters. But then, with breathtaking arrogance, he stuck up for his own hypocrisy, saying “The ideas we advocate are still just and right.” I’m sure his wife agrees.

Here’s the pompous windbag being fake-interviewed by his girlfriend about the importance of abstinence-only education programmes.

Of course abstinence-only programmes are only meant to work until people get married. Since both Mark Souder and his squeeze Tracy Jackson are married, they hardly count as failures of morality-based sex ed, do they?

(Thanks to Paddy Woodburn for pointing out the Seshu profile and setting me off wondering whatever happened to that windbag Souder…)

I have a confession. Behind all the sex and drugs talk, I’m just a giant data nerd. I believe that health research data collected with taxpayers’ money should be used to improve lives, not just to improve the career of a couple of scientists who got the research grant. And we’d improve lives faster if we played nicely together in the sandbox and allowed more brains to analyse the data we spend so much time collecting.

I’ve been working behind the scenes to try and help this happen, and have written about it in The Lancet, (pdf) and the Bulletin of the World Health Organisation, (pdf) (which ran quite a fun Round Table on the subject), with responses here, here,here, and here.

Now, I’m thrilled to say, the issue has been taken up by much bigger guns. An editorial in The Lancet declared the sharing of public health data “necessary, and now”. (pdf) The editorial refers to a meeting I was at in Washington earlier this month at which some of the biggest funders of public health research agreed in principle to work together to increase access to the data they pay for. We’re talking cleaned, coded, individual level data — raw ingredients which researchers with different perspectives and points of view can cook up into new solutions for health problems. There are lots of details to thrash out, but an agreement to start thrashing is a HUGE step forward.

It helped enormously that we had people in the room who have shown that data collected in household based studies can be shared without the sky falling. Osman Sankoh from the INDEPTH network showed off iSHARE , an initiative of researchers in India, Thailand and PNG which has since been joined by several African research sites. iSHARE provides on-line access to good quality demographic surveillance data that can be compared across sites. UNICEF puts its MICS household survey data online, so does DHS. Perhaps the most unexpected (and greatly welcomed) new member of the Data Liberation movement is the World Bank. The Bank has been an object of derision for years because it demands data of countries and then locks the data away in a database funded with public money. Even the governments that contributed the information, and the ones that paid for the database, used to have to pay to get anything out again. Then, in April: Boom! the World Bank threw its database open to the world.That set an important precedent; the age of free data is at hand, and no amount of whining by academics whose promotions depend on hiding information until they’ve got around to publishing papers about it will keep the new age at bay.

I have several loyal readers whose comments regularly make me laugh: this, for example. And I almost never refuse a comment unless it’s trying to sell a cure for AIDS or the commentator is too much of a pussy to give an e-mail address.

But this one, from a fount of indignation calling Himself “Derrail”, deserves its own post. The grammar alone will make you laugh. And the unwitting insights:

YOUR A FUNGUS AN EPIDEMIC AND OUTBREAKING SHOW OFF

Mental illness is an odd thing, isn’t it? By turns worrying: (YOUR A PRIME EXAMPLE OF WHY WOMEN SHOULD NEVER BE FREE TO ROAM AND SPEAK OUT IN THE PUBLIC ARENA) and amusing (YOUR FATHER FOR WHATEVER REASON REFUSED TO CHERISH YOU OR ELSE YOUR A MARX’S).

The toxic whole, sent in response to a post about sex worker legislation in Illinois, is after the jump. Prizes for the best response.
Read the rest of this post…

I’ve been taken to task for posting TED talks from the UK’s new Fearless Leader, and neglecting to post my own. Here it is, if you have 18 minutes to spare.

If you’ve only got four minutes, I would also thoroughly recommend spending it with comedian Julia Sweeney, as she has the “sex talk” with her daughter.

After I heard David Cameron promise to make policy that went with the grain of human nature, I suggested that Britain’s sex workers should vote Tory. I wasn’t joking, though I haven’t had that much luck convincing friends in the business. Now, though, George McCoy has given us a proper analysis of candidates’ position on sex work. Put in your post code for an at-a-glance view of who has voted which way, and who is promising what for (and against) people who sell sex.

As I said in my TED talk, we can use our votes to stop politicians doing stupid things that spread HIV. And violence against sex workers, for that matter.

It looks as though the effort to throw more sex workers and clients in jail in Illinois will fail, at least in this legislative session.

What better way to celebrate than by coming to a party in Chicago on Saturday night. Wear your best gold thong, and be ready for 90′s hip-hop up the wazoo.

It’s above the cafe at 230 W. Chicago Ave, starting at 8 pm on Saturday May 1st. More info here.

I’ve decided Canada is bipolar. In the couple of days that I was there this week, one province bottled and pulled the plug on a solid programme to educate school kids about sex and relationships that it had announced just days earlier. The government took contraception off the agenda at the G8, then said ok to talk of pills and coils, but no to abortion. And though drug injection in prison continues apace, and government agencies and others say prison prevention programmes work, there are still no clean needles behind bars.

Is any of this a big surprise? Not really. But it is very much at odds with Canada’s self-image as a sensible, compassionate nation, and what boy-scout-in-chief Prime Minister Stephen Harper promises the world. I made this point on CBC’s morning radio show in Edmonton on Tuesday. My interviewer, Ron Wilson, seemed genuinely perplexed that Canadian politicians might make decisions that are not always in the bests interests of drug injectors. Listen to the podcast here.

I was so surprised by his surprise that I went back and looked at what Harper says about evidence-based policy. Here it is:

“Leaders agreed to the following principles…[we will] Base our actions on the best available science and evidence-based decision-making.”

He was talking specifically about flu in that context, so perhaps he believes that flu is different from other viruses. Perhaps scientific evidence doesn’t apply to HIV, or indeed to other sexually-transmitted disorders such as unwanted pregnancy. But to me, it’s all evidence of policy schizophrenia.

More good reporting on needles in jails from my favourite Canadian paper, Xtra.

I’m in Chicago for the month of April, just as the Illinois state Senate tries to increase the penalties for buying and selling sex. The bill (which passed the House unanimously last month) will make it a felony to buy sex, so that any vet, doctor, lawyer etc convicted of the crime will lose their livelihood for ever. Which is neither here nor there to many people, unless it’s the doctor that is treating your child’s leukemia. It is avidly supported by End Demand and other abolitionists groups.

These groups look to Sweden as their model, or at least half of it. Arguing that all prostitution is violence of men against women, the Swedes in 1989 made it illegal to buy sex (even from men and transgenders, go figure). Arresting and fining punters was supposed to strike a blow against partriarchy, advance the feminist cause, and, of course, reduce violence against women. Here’s what has happened since the law was passed:

At a cost to the Swedish tax payer of over US$ 7 million a year, Sweden has, over the last four years, convicted an annual average of three people for trafficking and 18 for pimping, and has fined an average of 75 men a year for buying sex. Street-based sex work did nose-dive soon after the law was passed, then stabilised and remains constant. There’s no information about what’s happened to women selling sex in other venues, including apartments, clients’ homes, neighbouring Denmark… What we do know is that convictions for rape have increased by 28% since it became illegal to buy sex, and convictions for sexual crimes overall have increased by 68%. Some of this may be because the hoopla surrounding the law did effectively advance the Ice Queen agenda, and more women are successfully prosecuting men under the country’s incredibly vague “rape” laws. But it hardly fills one with confidence that “end demand” campaigns will reduce violence against women overall.

Chicago’s abolitionists are a strange miscegenation of paternalistic feminists (I’ll tell you when you can and can’t consent to sex, dear) and tub-thumping moralisers (extra-marital sex is bad, and convenient, no-strings, paid extramarital sex is much, much worse). They have both failed to grasp the logic that underlies the Swedish approach. If all sex workers are victims by definition, then it is hardly fair to bang them up in jail for the violence that is done to them. And indeed, in Sweden, people who sell sex can’t be prosecuted. In Chicago, on the other hand, we’re busy increasing the penalties for both the buyers and the sellers of sex. So we are:

1) depriving women (and men, and transgenders) of their right to consent to sex, if payment is involved

AND
2) depriving women (and ditto) of a living

AND
3) depriving women (and other prostitutes) of their liberty, if they get caught.

You’d think from the Chicago police department’s Rogues’ Gallery that the only people who get arrested for soliciting and prostitution are blokes and the odd trans. But that just reflects a policy decision only to put up photographs of people with Y chromosomes. If you delve into the stats a bit, you’ll find that women bear the brunt of prostitution-related arrests right now. Look at this:

It’s already illegal both to sell sex and to buy it in Chicago, and indeed all of Illinois. Making it MORE illegal on both sides, which is what HR6195 is proposing to do, is not going to change that. What it may change is the overall volume of arrests, since a felony is more likely to lead to a court case than a misdemeanour, which is what most prostitution charges currently qualify as. More court cases mean more police time in court. And since Illinois cops are paid time-and-a-half with a three hour minimum for showing their face in court, that rather increases the incentive to arrest. And as you can see from the graph above, it’s easier to arrest women than men. So my question to the good feminists of End Demand is this: How, exactly, do they think HR6195 helps women who choose to sell sex for a living?

So gay guys go on having unprotected sex after they are diagnosed with HIV, a new descriptive study of gay poz guys at a clinic in Boston tells us. Nothing new there, although it’s sobering to be reminded that one in two of the men who know they have HIV choose to bareback with someone who may be negative.

The most important finding from the Boston study is that the more recently diagnosed a guy is, the more likely he is to be exposing other people. We can’t tell from the paper if that’s something new. It may be that there’s a blast of screwing around soon after diagnosis, possibly as a reaction to it, then a calming down. The post-diagnosis binge is one of the possible explanations given by NAM’s ever-sensible Gus Cairns, posting over at rectal microbicide site IRMA.

The thing that most determines whether a poz guy will pass on HIV during unprotected sex is his viral load. We know that’s likely to be highest for the few months after he first gets infected. So if we do get better at detecting HIV early and we don’t do anything about bringing viraemia down instantly, the “post-diagnosis sex binge”, if real, would be a worry we’d have to add to the known dangers of the “slutty phase” that affects undiagnosed men as well.

Gus gives us another potential explanation:

3. The historical explanation. It can’t be about young gay men not having experienced AIDS, because it was recent diagnosis that was the risk factor, not age. But it could be about prevention fatigue that affects all ages, and lack of relevant, effective and up to date messages. The result would be that the recently diagnosed have higher risk behaviours (and have caught HIV) because they haven’t internalised prevention messages in the way that the longer-term diagnosed seem to. Does risk behaviour decline over time in the longer-term diagnosed for one reason or another (more ease of disclosure, self-education, awareness of criminalisation, catching one too many STIs, etc) or will men diagnosed today continue to be higher-risk than men diagnosed years ago?

If it’s a binge thing, behaviour will get safer over time. If it’s an “I’ve zoned out HIV messages” thing, it won’t. But there might be something else going on: The “HIV isn’t so painless after all” thing.

One of the reasons that HIV prevention messages are failing is that much of the public health world still treats HIV as though it’s AIDS, as though it is self-evident why you would want to prevent it. But now that AIDS has virtually disappeared, what’s the big deal about HIV? Why bother to protect yourself, or to avoid passing it on?

Guys who were diagnosed longer ago are more likely to have realised that HIV (like diabetes and arthritis) is actually more than a one-pill-a-day shrug-off. The ups and downs of treatment — having to call off a date because you’ve blown up like a tomato, worried that your boss will see you popping pills, having to cancel a day’s skiing because you’ve got to go for your viral load monitoring, — it can be a real pain. A pain that, on reflection, you might go out of your way to avoid passing on. That may be one reason why people who were diagnosed longer ago are less likely to expose their partners to HIV.

But treatment is improving all the time; as prevalence goes on rising and the ick factor falls, HIV becomes less and less of a pain. It seems likely to me, then, that barebacking will continue to rise. That makes people in public health crazy, of course. We have to think about resistance, a reappearance of AIDS, costs to the health system. But frankly, the guys who think HIV is no big deal at the individual level are not entirely wrong these days, at least in rich, socially tolerant countries with good health systems.

Ken Mayer and his colleagues in Boston end their paper by saying that we need “Innovative programmes that facilitate education and skills building around safer sex when MSM are relatively recently diagnosed”. But frankly, we’re never going to figure out how we should prevent HIV in a post-AIDS world if we can’t make a convincing case to the individuals most at risk that we should prevent HIV.

For more nerdy observations on the Mayer and co. paper, read more. Read the rest of this post…

Since we’ve recently been on the topic of the female brain, I’d like to mark the passing of a very great one. Daphne Park, aka Baroness Park of Monmouth, once a controler of the uber spy agency MI6, governor of the BBC and principal of an Oxford college, died yesterday. With her died an era (for the British people) and a dear and valued friend (for me, and many others).

The British press will doubtless be awash with obituaries of this remarkable woman. The Times was one of the first, and The Telegraph, which also wrote a profile of her which caused her endless amusement, was quick off the mark, too. The Times is good on her steely determination; the Telegraph better at conveying her sense of humour. Neither focus on the more boring, old-fashioned values that she embodied: an extraordinary sense of duty, an unparalleled talent for discretion. She was actually cross about being “outed” as a spy, though simultaneously pleased that she got to tell some of her extraordinary stories to a wider and often incredulous audience. Though she broke laws regularly in order to save lives and, arguably, civilisations, she had no time at all for flouting of everyday rules and conventions. When she was principal of Somerville College, she made me pay £180 in library fines for a single 2/6 paperperback that I had borrowed, lost, and not fessed up to. Tut tut. Then she allowed me to say what books the money should be spent on.

Above all, Lady Park was fiercely loyal. It was this last that made her such an inspiration to me — she found time always to be interested in the twists and turns of a much younger friend’s life, she was properly sympathetic about real setbacks but correctly pull-your-socks-up about self-indulgeance. She gave practical advice (laced with good single malt Scotch), and made us want to step up to the mark. The mark, with Daphne, was always set high. Some of us have taken our time, but all aim to be worthy of her faith in us in the end.

I’m not given to personal posts, let alone sentimental ones. But while I’m pulling my socks up, I hope some of you will discover Daphne.

I was lucky enough to go to the TED conference in California last month. Many of the better talks are already on line. My own favourite was Sam Harris on the subject of science and morality. I may have liked it because it was squeezed in that stomach-churning moment between my breakfast with local cops at the Long Beach Diner and my own TED talk. But I think his dead-pan delivery of important ironies is impeccable. Judge for yourself.

Last Friday, I went to a deeply depressing “is feminism dead” type discussion. The normally male bastion of Prospect Magazine rang with the sound of high heels, and… Oh, wait, most of the people there were feminists. Scratch the high heels, then.

Yes, yes, I’m playing to completely unjustified sterotypes. Except that they are not completely unjustified. Could I have predicted that we’d have to listen to a rant about the evils of porn, the fact that lapdancers have post-traumatic stress, the fact that women still don’t get paid enough? Yes. Did I know that when my guest introduced herself as a prostitute and dominatrix there would be brows beetled in fury that one of “them” had managed to infiltrate? Yes. The Cat among the self-righteous pigeons did (just as predictably but with much greater humor) defend her right to be heard; those who seek as good feminists to silence her pulled the normal “she’s too traumatised to know she’s traumatised” nonsense. The whole discussion was old, tired, and without obvious point. (Except to appeal for more “grass roots feminism”. Grass. So last century.) The question of whether women might be paid less because they often choose, perfectly sensibly, to spend less time at work and more time doing other things, was raised, and rather rapidly dismissed. The question of whether we might, actually, be better at some things and worse at others than men was dealt with through the curve of normal distribution. At the mean, the sexes basically have the same capacities. It’s just that men are more scattered than women, so there are more male geniuses, and more male morons. But that doesn’t mean we’re fundamentally different. Our reproductive organs are different, our hormones are different, but our brains (apart from the map-reading bits) — no way.

Then today I went on-line at my new day job. I’ve been hanging around the Wellcome Trust so much lately that they’ve given me a desk. And what’s the lead story on their website this very day? New research shows that the appropriately named doublsex gene sculpts not just the body of males and females, but also the brain. It’s just in fruit flies so far. But mammals have the dsx gene too…

Another thumbs down for the Swedish model. Not the leggy blonde, not even Sweden’s moralistic approach to the sex trade. This one is the Swedish research model, which has managed to turn the fascinating subject of on-line rating of hookers by Brazilian punters into something indescribably dull.

Actually, that may not be fair. I think this research paper is dull. But honestly, it is so incomprehensible that it’s hard to tell. It’s written by physicists at Swedish universities, and perhaps to other physicists the observations are sexy. Here’s a sample for you:

The probability distribution of the time between two subsequent
posts ΔTposts … is narrower than a power-law, but wider than an exponential or Poisson distribution, and consistent with a powerlaw with an exponential cut-off P(ΔTposts) = C exp(−α ΔTposts) / (ΔTposts + β)γ. That the distribution is broader than Poisson suggests a more complex dynamic than just sex-buyers posting independent of each other; that it is not a power-law means that the problem cannot be mapped onto other studies of human response dynamics.

Well, I’m glad the Swedish taxpayer has invested in sorting that out for us, then.

The paper makes a pretense of being important because sexually transmitted infections are passed through the networks of the sex trade. The physicists, who include glorious graphics like this:

note that the sex workers who get the highest ratings go on to have more clients in the future (now there’s a revalation). This worries them, because the more clients a girl has, the more likely she is to be exposed to diseases, right? Well no, actually. The more clients she has unprotected anal or vaginal sex with, the more likely she is to have an STI. But really, what’s the likelihood of a girl getting consistently high ratings if she’s sending clients home pissing glass? She gets high ratings because she’s not exposing them to infection.

As an aside, I was interested to note that the forum allows punters to record three specific exotic or unusual practices: anal sex, oral sex without a condom, or kissing on the mouth. Note that in Brazil, which has one of the strongest HIV prevention programmes in the world, unprotected anal or vaginal sex with clients doesn’t even make the list, very possibly because it is too rare to mention.

Thanks to Paul for putting me in the way of a paper I’d never have found, by way of Technology Review.

The test-and-treat debate has been getting a bit hot and heavy of late. I think we all deserve some light relief. I offer this:

Thanks to Txema, who is always ready to make a girl smile.

Can we treat our way out of the HIV epidemic? Yesterday I wrote a piece in The Guardian suggesting that the “Test and Treat” approach was a triumph of optinism over common sense. Today, I am a homophobe, a media slut, a cherry-picker of data and over 120 other things, mostly nasty.

My favourite, gloriously rude comment came from The Bathhouse. It summarised my “inflammatory and simplistic” argument thus:

1.) The AIDS mafia want treatment to replace prevention in Africa because they think that people on ARVs are less infectious, therefore reducing the spread of HIV.
2.) What the fools don’t realise is that people are most infectious soon after having contracted HIV so the screening is unlikely to help identify people in time
3.) Availability of treatment makes people less worried about HIV and so indulge in more risky behaviours
4.) Treatment is bad and people who think it is a good idea are optimistic simpletons

I’m prepared to accept, more or less, that the first three contentions are inflamatory and simplistic summaries of the argument I made. But how you get from that to “treatment is bad” is beyond me. How observing that new HIV infections have been rising among gay men since treatment became widely available makes me homophobic is a bit of a mystery to me too. We’ll have to stick that label on researchers in an awful lot of countries: data from Australia, Canada, England, Germany, the Netherlands, New Zealand, Spain, Scotland, Switzerland and the United States support the claim. A good recent review can be found here. For those that don’t want to bother reading a whole paper, here’s a picture to look at, from Scotland.

The graph shows newly-identified infections. That’s not a true measure of new infections, because it depends on who gets tested. And obviously there was more of an incentive to get tested after treatment became available. But why would that affect gay men selectively, rather than drug injectors and heterosexuals? The fact is that drug injectors don’t want to share needles whether or not they face the threat of HIV. So becoming less worried about HIV does not lead to an increase in needle sharing. Gay men, on the other hand, just like straight men and women, would often really prefer to have sex without a condom. The threat of AIDS is a pretty big disincentive to unprotected sex. The threat of HIV is a lesser disincentive. The uptick among heterosexuals has been less pronounced than among gay men simply because in Scotland, prevalence is far lower among heterosexuals. So any drop in condom use in sex between men and women will result in relatively fewer new infections.

Does that make me homophobic? Not unless someone’s been giving out the black-and-white glasses. In the same way as saying that more treatment means more people living longer with HIV does not make me anti-treatment. No-one who has seen friends die because they live in a place where they couldn’t get treatment could possibly be anti-treatment. We should be expanding treatment for its own sake. We also know that treatment reduces viral load among those who take it regularly, and who don’t have other STIs (athough any amount of viral load in someone who is kept alive through treatment is, whether you like it or not, higher than the viral load of someone who has died because they didn’t get treatment.) Treatment is GOOD, in its own right. We don’t need to build computer models based on entirely unrealistic assumptions in order to justify the need for more treatment. We DO, however, need to face the fact that until now, more treatment has been associated with more new infections. The world does not exist in black and white, in treatment OR prevention. The fact is, as we expand treatment, we need to expand other forms of effective prevention, too.

Can the wicked witch go back to her coven, now?

As promised, data on women, autonomy, partnerships and HIV. It’s quite true that I have not developed some magic indicator of “autonomy”. But the World Economic Forum has. Or at least its Gender Equality Index is as close as damnit. Let’s take the sub-Saharan African countries at either extreme, and set their equality index against their HIV rates:

On individual measures that are often indicators of women’s ability to make their own choices and decisions — educational level, for example, we see a strong correlation too, both at the national level:

and at the household level:

So, in countries where women are more equal to men on measures of workforce and political participation as well as education, there’s more HIV than in countries where women are more constrained. In countries where women are more educated, there’s more HIV. Within countries, more educated women are more likely to be infected with HIV.

Multiple concurrent partnerships: we’re crap at defining them, and therefore at measuring them. The imporant issue is simply: how likely is an infected person to be having sex with an uninfected person in the relatively short periods when viral load is high? These periods are more frequent where other STIs (and especially HSV2) are high. But the highest viraemia is right after someone first becomes infected. So anyone who has several partners in the two of three month window in which they themselves were infected are most likely to pass on the virus to others. If enough people (men AND women — it has to work on both sides of the equation in a heterosexual epidemic) have multiple partners in that time, you have the potential for a hyper-epidmic. Without it, you don’t.

Here are data from the first round of national surveys of HIV-related risk, way back in 1989-1991. The dark bars are people who reported that they had more than one REGULAR partner in the previous year. I.e. more than one person to whom they were married and with whom they had been having sex on an ongoing basis for a year or more. You can see that there’s something of a difference between countries in Africa and those elsewhere.

For your interest, I’ve also put in what people think their partners do. In almost every case, men report fewer partners than their wives think they have. I.e., women think men are pigs. And women report more partners than their husbands think they have. Men labour under the illusion that women are angels.

Ho hum.