The Wisdom of Whores

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.

Remember the fabulous singing Nobel prize winner? Now PCR ads are getting sexy again. Though I do have to wonder how may pints the founders of TwistDx had had when they registered their company name. Try saying it out loud even before a pint…

Thanks to Seif, who has yet to take me shoe shopping…

Who would have thought that showing your tits became a better strategy for pulling partners the older you get? Since I’ve never tried e-dating, it has never occured to me that it’s a spectacular source of data for epi-nerds interested in sexual networking. My eyes have been opened by OKCupid, whose data nerds have publish a wonderful analysis of what works and what doesn’t in on-line dating.

I found it slightly depressing that I’m out of the denominator (they only look at data from 18-32 year olds). But I was particularly delighted by this graph:

It looks at the effectiveness of showing clevage in your profile picture. The bad news is that all women’s pulling power falls over time. But Apparently, showing clevage bounces up your chances of getting a date more the older you get. Men, depressingly, don’t lose out on dates as they age. Unless they’re trying to show off their six-pack. Abs shots are less successful the older you get.

Now tell me data analysis is not sexy…

Thanks to Nico, who is definitely in the denominator, but has tragically stopped sharing his wisdom with us.

The other night, I was dining with someone who didn’t know their acronym from their elbow. I had to explain MSM (mice that have sex with mice; no, wait…) and had a special rant about LGBT. For the unitiated that’s Lesbian, Gay, Bisexual and Transgender. It just trips off the tongue, doesn’t it? And it is just about as elegant conceptually as it is linguistically. Those groups don’t actually want to hang out together very often (except, perhaps, where they’re bidding for HIV funding). It’s a bit like forming a trade association for Doctors, Actors, Farmers and Tailors — DAFT.

Inspired by Indonesian petrol stations, which sell “Elpiji” (LPG, liquified petroleum gas), I’ve started writing this most annoying acronym as “Eljibiti”. But The Onion has done it better, in this hilarious spoof report on Gay Pride. LAGALABATATA — the Los Angeles Gay And Lesbian And Bisexual And Transvestite And Transgender Alliance. Like so much else in The Onion, it is so funny because it is so close to the truth.

Thanks to Roger for the smile.

How ethical are HIV prevention trials? Every time we announce results of a trial that compares new HIV infections in a group with or without some new intervention (a microbicide for example, or a vaccine), some journalist or other jumps on the fact that researchers are just watching people get infected. Researchers then explain that everyone in the trial gets given the best possible existing prevention services — counselling, free condoms, treatment for other sexually transmitted infections. But is that really true?

The question was raised for me while I am here in Thailand by a comment on an earlier post. It pointed out that US taxpayers, through CDC, are funding a trial among drug injectors in Thailand that withholds the very thing we know will prevent most infections: sterile needles.

CDC, on its website, points out that withholding clean needles is “consistent with Thai government policy”. And yet the agency itself recognises that needle distribution programmes reduce HIV infections. The Helsinki declaration on medical research ethics says that if you’re trying out a new drug or procedure, you’ve got to try it against the best available alternative.
In the past, I’ve argued that it is reasonable for us to read that as “the best alternative feasibly available in the country where the study is being done”. There’s no point trying a drug designed for use in a developing country against a developed-country regimen which is likely to be better, but which couldn’t ever be offered in the study country because it requires too much money, technology or expertise to administer.

The “we’re using the Thai standard of care” argument is very convenient for CDC researchers. After all, they need quite a few people to get infected, so that they can see if significantly fewer people get infected if they’re using the trial drug, tenofivir.* CDC’s other tenofivir trial, among women in Botswana, has just been downgraded, because the research team has realised that it is not getting enough infections in either group for it to be able to measure a difference. That’s in part because of very high drop-out rates — already a red flag for a prevention method that obliges you to take a pill a day for as long as you’re at risk.

We know that an adequate supply of sterile needles, and the freedom to use them without fear of arrest, can cut HIV infections dramatically among injectors. If the CDC study in Thailand gave enough needles to injectors, they probably wouldn’t have enough infections to give them a trial result. And the tenofovir-based prevention method that’s being tried is a method that could be used by other groups too — gay men and sex workers and other heteros at high risk of exposure, for whom we don’t have such easy prevention options. So you can understand why researchers are reluctant to push the envelope on providing decent prevention to study participants. But in this case, the “local standard of care” argument really doesn’t wash. It would be perfectly feasible for Thailand to provide injectors with clean needles. The country has the technology, the money and the health systems to do that. The only block is a political one. It’s bad enough that Thai authorities live with this blind spot in their otherswise quite pragmatic HIV prevention programme. The US has been just as bad at home, although there’s now light at the end of the tunnel for safe injecting programmes in the US. All the more reason that US researchers (and taxpayers) should refuse to compound Thailand’s unethical policy with unethical research.

*Info on the trials: The Thai and Botswana trials aim to investigate whether uninfected people can take a daily dose of antiretroviral drugs to stop themselves getting infected with HIV if they are exposed to the virus through sex or needle-sharing with infected people. It’s know as Pre Exposure Prophylaxis or PrEP, and you can find our a lot more about it here.

Great news from Vancouver: the city’s safe injecting facility, Insite, is allowed to continue saving lives. For now. It’s the second time that Insite has won a case brought by the right-wing rottweilers of prime minister Stephen Harper. This victory was in the Supreme Court of British Columbia. But Harper may decide to put more taxpayers’ money into lawyers’ pockets by taking it to the nation’s supreme court.

An appeal would fly in the face of the data (which show that Insite reduces overdoses and many of the other frankly nasty things that happen to people who live with addiction to injectible drugs). It would fly in the face of pragmatism — up just one flight of stairs from the safe injecting room is a drug treatment centre which works to help people get off drugs when they’re ready to try. Detox is never an easy thing to achieve; our best bet is to have really strong links between services for current injectors and services that help them stop. But most of all it would fly in the face of any remaining self-respect that Canadians might have about their political system. Because although the newspapers talk of “the Harper government” doing this or that, Canada actually has no government right now, or at least none that answers to the normal description of parliamentary democracy. What right, then, does Harper have to be prosecuting court cases that waste tax dollars and lives?

Harper’s bully boy tactics may work for Insite in the end, though. HealthCanada is typically mealy-mouthed about an appeal, saying: “While the government respects the court’s decision, it is disappointed with the outcome. The government is reviewing the decision carefully. Until this review is complete, it would be inappropriate to speculate on future action on the part of the government of Canada.” But it’s very clear that a Liberal government would not keep banging its head against the wall of common sense that Insite represents. And by sending parliament packing until March, Harper may just have signed the death warrant for his own “government”. That would be good news for Insite users and other Canadians alike.

Thanks to Miriam for bringing this to my attention while I’m in distant Vietnam.

These gems from the delightful “blog” of “unecessary” quotation marks need no comment. Though the comments on “this post” are quite fun.

And from my best side:

Thanks to dkj for driving me to them.

For 20 years, American governments across the political spectrum have ignored a mountain of evidence showing that needle exchanges and other safe injecting programmes are the single most effective HIV prevention tool we have. But just before Christmas, with a minimum of fuss, Congress dropped the ban on federal funding for needle and syringe programmes.

The change, buried in a massive budget bill passed by Congress in mid December and and since signed into law by President Obama, passed with very little comment in the blogosphere. But it has the potential to revolutionise HIV prevention in many parts of the US as well as in other countries. US cities and states have been allowed to provide injectors with clean needles if they (the cities and states) paid for them themselves, but in conservative states it has often been hard to get local politicians to come up with the cash. Similarly, nothing is stopping countries outside the US funding their own harm reduction programmes, but the yeay or nay of the world’s largest funder of HIV programmes can have a huge effect on what local governments choose to do (and not to do!)

Perhaps people didn’t notice the good news about harm reduction because they were caught up in the histrionics of the Drug Warriors in New York City, who are apoplectic that the health department is handing out perfectly sensible advice on how to shoot up safely.

Dubbed “Smack for Dummies” by the New York Post, the pamphlet has the Warriors fretting that young mothers might come across it in a clinic waiting room, read the instructions on keeping your veins healthy, and think: “Hmm, that looks easy. Maybe I’ll try shooting up before I pick the kids up from playgroup this afternoon”.

I’m glad to say that Mayor Bloomberg and the NY health department are both standing firm.

Also in the deluge of good news from Washington — the omnibus spending bill does not earmark any money for abstinence-only sex ed programmes that we know don’t work.

While colleagues at USAID say they haven’t had any official word on the implications of the bill for HIV funding in other countries, everyone’s optimistic that the common sense, so late to arrive, will be quickly exported.

Though I work in a world of addictions, I try and keep mine in the closet. But with others springing out of the closet right left and centre, I’m going to come clean. I’m addicted to rugby. Rugby is said (largely by people who see no glory in the bad haircuts and hystrionic dives of diva soccer players) to be the inverse of soccer, a hooligans’ game played by gentlemen. Crusty gay crusader Peter Tachell, thrilled that Welsh rugby ledgend Gareth Thomas has come out as gay calls it a “very macho sport”. And yes, it’s tough. It pits several hundred kilos of testosterone fueled meat against another several hundred kilos at crotch level. Hands grab balls, though rarely the one in play. Shorts are used as weapons, and lose their coverage. There’s none of that pansy padding which distorts body and soul of American football players. Rugby is pure, hard muscle. Which is why I’ve always maintained it is the most homo-erotic sport on the planet. If you’re not convinced, another photo from the French national team’s iconic :

Homoerotic? Moi?

I don’t mean to belittle Gareth Thomas’s courage in coming out. It’s interesting that his coach’s first reaction was to advise the Lions captain tell his team members, because he guessed (rightly) that they’d provide really important support at a difficult time. He’s not the first player to come out, but it’s rare for guys to do it while they are in the prime of their careers. Hard on the heels of that revelation, former England player Brian Moore has spoken publicly about being sexually abused as a child. I don’t know why rugby players, who have a pretty small following compared to soccer players, have so much more courage than the divas with bad haircuts. When Brazilian superstar Ronaldo got caught with three transgender hookers more than a year ago, he pleaded ignorance, saying he thought they were just vanilla whores. I don’t know if that makes me more worried about homophobia in soccer, or more worried about that a player who earns squillions on the pitch has such a bad eye for a ball….

Christmas in London — what better way to celebrate than carol singing in the streets of Soho with singers from Westmister Abbey and the International Union of Sex Workers? The Rector of St Anne’s parish in Soho swished out in front in long robes and fuschia beret but it was this banner, carried by Nico and Thierry, that really led the way. Note the trick photography — by the time we got out on the streets it was dark and floating with magical snowflakes; the boys were definitely wearing more than body paint.

Soho was full of good cheer; lots of people joined in the carolling and a couple of crusty punks pulled out descant voices that rivalled the cathedral choir’s. There was much cheering for hookers; it made me wonder how many people knew that the jurassic feminists in this Nanny government had just the month before pushed through new legislation that will make it more dangerous for women (and men, and transgenders) to sell sex in the UK.

My challenge the evening of the carol singing was to tear myself away from the Glo-ooooo-ooooo-rias in time to heat up vast vats of mulled wine. I rose to that occasion ok. My challenge for the New Year is somewhat more daunting. TED has announced the programme for its next conference in California, and I’m hugely honoured to be speaking there, in some very great company.

TED talks are not very often about sex. But the best of them can even make statistics sexy. I leave you with this classic from Hans Rosling, an ally in the war on Data Hugging Disorder, but here popping some of the bubbles of the HIV narrative.