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The Business of AIDS

New America Media, Q & A, Sandip Roy Posted: Jul 20, 2008

Editor's Note: In southern Africa, the most dangerous thing an uninfected man can do is get married. Elizabeth Pisani explains why, and debunks other conventional wisdom about HIV and AIDS. Pisani is an epidemiologist and the author of The Wisdom of Whores: Bureaucrats, Brothels and the Business of AIDS. She spoke with New America Media editor and UpFront host Sandip Roy.

The numbers of reported AIDS patients were recently dramatically downsized for different countries. Why was this?

Downsizing the numbers was actually related to getting better data, particularly in India, the second most populous country. Small differences there can make very big differences in the numbers. The data is improving, and so theyre getting better estimates.

The World Health Organizations department of HIV/AIDS also said there would be no generalized epidemic of AIDS in the heterosexual population outside of Africa, so there wouldnt be a big, ticking time bomb in China.

We now know that HIV is not going to rage through the general populations of any continent outside of sub-Saharan Africa. Frankly, weve known that for 10 years or more, but we havent been able to say so because there are huge vested interests in keeping people worried. We have to face the fact that its essentially concentrated among men who have sex with one another, among people who buy and sell sex and among people who inject drugs.

None of which are popular government constituencies.

Exactly. Unless we can pretend its going to affect innocent women and babies, its very difficult to get governments to take an interest. Thats one side of the story. The other is that if its not everybodys problem, then UN agencies, NGOs or government agencies that dont want to deal with sex and drugs, cant get a crack at that huge and ballooning AIDS funding.

In cities like San Francisco and New York, activists, gay men mostly, really forced the establishment to pay attention to the disease. But youre suggesting that it has also created its own brand of orthodoxies that have been exported around the world and dont necessarily fit the way HIV is spreading in different parts of the world.

Thats exactly right. One of the things that activists did was they forced governments to take it seriously. They also turned it into an issue of individual rights, and the rights of people who may be in marginalized communities.

How was it different for someone getting diagnosed with HIV in the 1980s compared to today?

In the mid 1980s, an HIV diagnosis was like having wicked person branded across your forehead. It meant that you were quite likely to lose your insurance, your job, possibly be thrown out of your family, rejected by your friends and there was not a single thing we could for you, because there was no treatment.

Today, we have quite effective treatment in much of the world. So the idea that we shouldnt test people unless they specifically ask to be tested is one that we now call into question.

So what is the message we are giving people today?

Were really giving people mixed messages. Were saying, Dont worry, HIVs completely normal, you can live healthfully with it for many years. But on the other hand were saying, Dont worry, if we test you, you dont have to tell anyone, and it can be a big secret.

In many countries around the world, it is still a huge issue of stigma, right?

But stigma feeds on itself, so the more we say, We have to be scared of the stigma, the more the stigma grows.

I was working for the Ministry of Health in China a few years ago when the Chinese decided they were going to mass-test everyone they thought was at risk.

They started in Hunan, a province that had a big breakout in blood donors about 10 years ago. They went around the villages and tested 290,000 people. They said, Dont worry, if you test positive, you wont lose your job, you wont lose your housing, but you will get free health care and free schooling for your kids. But people were really suspicious, so a lot of them went into hiding.

But after they tested those 290,000 people, and found that about 8 percent were infected, and those people got free schooling for their kids and didnt lose their jobs, 7,000 people came out voluntarily for testing. And HIV infections was twice as high in that population. People were selectively hiding themselves because they were scared of the stigma.

Though there are treatments available, there is no cure. When more people do come forward to be tested, and governments provide services like free schooling, how long can it go on as a matter of public health?

If we dont start doing better on prevention, its not going to be able to go on for that long. We are talking about really scary levels of people on treatment, and the cost is coming down all the time, but its still very expensive. And the infrastructure that goes around providing that treatment is even more expensive. So if we dont stop people from becoming newly infected, were just going to get more and more people on treatment.

I find it absolutely astonishing that we are perfectly happy to pay to keep a drug injector on a lifetime of extremely expensive complex group of antiretroviral treatment, but were not prepared to pay a fraction of the cost to give them clean needles to stop them from getting infected in the first place.

Youve been quoted as saying, More treatment means more HIV. What do you mean by that?

I get a lot of hate mail about that. Treatments a great thing, but if people are on treatment, they live longer, and it increases the absolute number of people who have HIV. Thats not a controversial statement. Thats arithmetic!

You said that outside of sub-Saharan Africa, HIV/AIDS is not going to spread in the heterosexual population the way it has in China. What is different about sub-Saharan Africa?

The patterns of sexual networking. Weve been very reluctant to say people have sex in different patterns. But really, its related to the lifecycle of the HIV virus.

HIV is not very infectious, so when you become newly infected, before youve started making antibodies, its very easy to pass on. That phase only lasts a few months. After you start making antibodies, it calms down, and it can trot along at low levels for a long time. So what determines the likelihood that youll pass it on is, to a certain extent, how many people you have sex with in that very short window.

Traditional patterns of sexual networking in eastern, southern Africa are based on traditional patterns of polygamy. And its very common for people to have two or three ongoing regular partners at any given time. In my world, its very common for me to have lots more than two or three partners in my life but, sequentially.

I describe it as the difference between sex in strings and sex in nets. In eastern, southern Africa, people tend to have sex in nets: fewer partners, maybe, but more likely to have several partners simultaneously. And thats what spreads HIV.

You also write something that really startled me: In southern Africa, for example, the most dangerous thing an uninfected man can do is get married.

We have data for the general population for about 17 or 18 countries. And in all of the countries where we have data, girls are much more likely to be infected before marriage than boys. Women are much more likely to be infected while theyre still single than men, because younger women are more susceptible to infection, for reasons of body structure and the way the virus works.

A young man is more likely to have occasional relations with women of his own age, but not sufficiently frequently to become infected. Married, he has sex with the same woman over and over. If she was infected before she married, hes then more likely to become infected. Marriage is not a protective thing if youre a young guy.

What about Southeast Asia, where so much of your book is based, in Indonesia? What did you learn working with, for example, transgender sex workers there?

Actually I learned a lot about how science works from them. Before we really understood what was going on, we had to do research, and there was very little in those populations.

In one instance, I was talking to a transgender sex worker who was extraordinarily beautiful, and therefore rather well paid. She has extremely expensive tastes. She was sitting in my living room knocking back the expensive, single malt scotch and saying, You know I usually only drink Chivas. I was like, For someone whos got three clients a week, youve got really expensive taste. And she says, What do you mean three clients a week? I said, Well, thats what the studies show. And she said, Nah, thats nonsense. Youre talking to the wrong people.

I explained to her, Well, heres how we do the sampling. We take a random sample of the whole population. I gave her this little Epidemiology 101 lecture, and she just looks at me and said, No, youre not listening to me. Youre talking to all the dogs. Any sex worker whos talking to a research team is a sex worker whos not with a client. The ones who are not with a client are the dogs, and therefore youre getting low client numbers because youre talking to the ones who are not with clients! And I thought, shes right. We changed the way we did our research after that.

Related Articles:

Let's NOT Talk About Sex, Baby

Opium, Drug Use Drive Second Wave of AIDS Pandemic

In China, Kids with HIV Make Do with Adult Meds

Deal Struck for Cheaper Anti-HIV Drugs for Kids in 62 Countries

An Ironic Byproduct of Peace in Sudan: AIDS

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