By Lars Lofgren
After nearly a decade of conducting AIDS/HIV research in Southeast Asia, Elizabeth Pisani recants the lessons she has learned while helping governments and NGO’s reduce the spread of this disease. From stressing the importance of adequate disease surveillance to clearly outlining the ways that AIDS/HIV spreads throughout societies, Pisani clearly states the measures that must be taken in order to curtail the AIDS/HIV epidemic. In short, needle exchange programs as well as abundant access to condoms and lubricant for at-risk populations—mostly prostitutes, their customers, and drug injectors—offer the most potential for limiting the infection rate.
Pisani’s Take home Points:
- Policies that work in Africa will not work elsewhere. Additionally, effective HIV monitoring must include behavior, not just blood testing (37-38).
- The transmission rate of HIV through anal receptive sex is incredibly high. Therefore, any effective HIV prevention method must include male and transgender sex workers such as the waria in Indonesia (58).
- Within Asia, the majority of men that frequent prostitutes are married but this is because a majority of men in Asia are married. Single men have a slightly higher probability of visiting prostitutes (62).
- Soldiers and policemen are highly likely to visit prostitutes as well; Pisani has often classified them as a high-risk group for contracting HIV in her behavioral studies (64).
- A primary problem with condom promotion in Asia is that condom use falls dramatically when men have sex with a girl on a recurring basis. Even with prostitutes, condom use plummets when a male customer begins to visit the same prostitute and the relationship elevates even slightly above a formal business relationship (66).
- It has become far more socially acceptable to be openly gay within Asia, creating an environment similar to the US and British gay revolution during the 1970’s that saw the increased spread of HIV. There is no reason HIV cannot be controlled in a highly active gay scene as long as condom use is promoted and adopted (73-75).
- The correlation between risky sex and drug use is incredibly high because people frequently make poor decisions while using drugs (75-76).
- Drug injection, by far the riskiest behavior as a result of the prevalence of sharing needles, is the single greatest behavior in spreading HIV throughout the world, including the West (76).
- Pisani has learned several lessons and insights about quantitative behavioral research: though improvements have been made, researchers still don’t always know how the people they are talking to represent the larger population (91); research questions can be faulty (93-97); researchers sometimes attempt to “fix” data to account for faulty questions (97); people give different answers based on who they are talking to, neutral interviewers provide the most reliable data (104); mistakes are common throughout the data management process (106); biological testing has a host of logistical problems that distort data if not properly managed (118).
- Africa has been a complete failure for the HIV prevention industry (124).
- The dominant mantra maintains that poverty and gender inequality spread HIV. While a lack of development certainly does not help HIV prevention, it is not the primary influence in spreading HIV (127).
- HIV is not particularly infectious; certain behaviors transmit far more readily than others. Anal sex, forced sex, and having other STIs all increase the chance of transmission. Males can also more readily transmit HIV if they are uncircumcised (129-131).
- A person’s viral load will greatly influence whether or not they transmit HIV. People have high viral loads immediately after infection, after haveing any other infections, and shortly before death. Since those that have obvious signs of AIDS do not have much sex, the vast majority of transmissions occur immediately after the initial infection. Many HIV transmissions probably occur before a person would even test positive. (131-133).
- In regions where several sexual partners are common, men are uncircumcised, and STDIs go untreated, HIV will spread quickly (134).
- In Africa, there is a myth of the “innocent” wives being infected by their promiscuous husbands. This is not a correct depiction; many wives have sex with men other than their husband and often have had multiple sex partners before marriage. In every African country where data is available, unmarried women are more likely to be infected with HIV than unmarried men (137).
- HIV has become a development problem in much of Africa but the initial crisis was a result of a lack of effort in HIV prevention (144).
- The explosion of HIV in Africa is the result of people developing sexual relations in nets instead of strings -multiple partners at once instead of a string of partners—and untreated STDIs. Without the proliferation of circumcision and condom use to put a break on infection rates, HIV transmission has run rampant (156).
- In the rest of the world, HIV transmission is largely the result of drug injection, anal sex between men, and those that buy and sell sex (157).
- As HIV treatment becomes more effective with the widespread use of antivirals that keep HIV in check, HIV prevention must also escalate to counter the increased duration of the infection risks due to prolonged life expectancies of current HIV victims (164).
- Peer education to increase condom use does not work among sex workers because they are competitors in the market place. Peer education only works where there is an actual a sense of community (181-183).
- Within the US, people that pledge to abstain from sex until marriage do wait slightly longer to have sex than their peers. However, they do not have fewer partners than non-pledgers, are less likely to use condoms, and contract just as many STIs. 72 percent have sex before marriage (190-191).
- Abstinence promotion has been tagged to aid given by the United States, forcing many NGOs to recommend that prostitutes quit their jobs to avoid HIV. This policy fails measurably domestically and there is no evidence to indicate it fairs any better internationally (192-199).
- When sex workers do not use condoms, it is usually a result of intoxication instead of being able to charge for a higher fee (212-213).
- Contrary to the alarmism over human trafficking, Pisani has seen little evidence of it firsthand. In fact, she has only encountered one person that was obviously trafficked. Though she does not claim that human trafficking is nonexistent, Pisani suggests that its occurrence may not be has prevalent as many sources suggest (213-214).
- About 70% of injectors are not junkies; they are doctors or yoga instructors. To reduce HIV transmission, these users must have legal means to get clean needles (236).
- Many injectors do not use clean needles because it is illegal to carry them (238).
- Methadone is a oral drug that reduces the craving for heroin. Prescription methadone programs do reduce heroine and needle use, reducing the HIV transmission rate. However, care must be taken ensure the correct dosage. Otherwise the programs are ineffective (239-240).
- In Indonesia, heroin is often easier to obtain in prison. Needles are not. This turns prisons into HIV factories. Similar conditions exist in England, Russia, the United States, and elsewhere (243-245).
- Needle exchanges work especially well in prisons and methadone programs are also likely to be highly effective (246-247).
- Needle exchanges and other harm reduction programs do not promote drug use; they actually curtail it and assist people in quitting drugs (250).
- Not only do junkies have sex, contrary to popular myth, their partners often engage in risky behavior that is highly likely to further pass on HIV(276).
- In Southern Africa HIV is an extensive problem that requires a myriad of different approaches to reduce. For the rest of the world, programs that deal with how sex and drugs transmit HIV are the only programs that will work (271).
- International funds from the United States require that supplies and drugs be purchased from the United States. This creates a procurement nightmare that wastes a great deal of funding (283-284).
- HIV/AIDS programs are not required to show results, creating a highly inefficient NGO environment that poorly utilizes time and money on programs that have little or no impact (289-290).
- To reduce the prevalence of HIV/AIDS:  programs that aim to reduce sex frequency do not work,  places that people go to meet new sex partners should be “bombarded” with condoms and lubricant,  incentives should be in place to ensure condoms are used every time sex is bought or sold,  clean needles should be legally available at a subsidized price,  needles should be given to those in need especially in prisons,  though effectiveness is limited, methadone programs can work to a degree,  prevention services should be bundled with antiviral treatment,  other STIs should be treated in communities and screening processes should be employed on sex workers,  give infant formula to mothers that are infected,  circumcise men in communities with high rates of HIV, and  recognize that homosexuality is prevalent and provide programs for these communities as well (311-313).
- HIV programs will have to be tailored to specific localities (314-315).
This book is required reading for anyone involved with AIDS/HIV. Not only has Pisani presented a decades worth of work in an incredibly engaging book, her work has immediate implications for NGOs and governments worldwide. Highly accessible and deeply informative characterizes the entire book.
Overall, Pisani provides an insightful book. She responds to numerous counterarguments, provides a vast array of empirical evidence, as well as many personal anecdotes as case studies. Her passion and demand for policy clearly shows. She has avoided adopting any degree of ideology, developing policy recommendations that stem directly from evidence. Her work should be commended and utilized.
Pisani is a staunch advocate for HIV/AIDS prevention and her policies stem from that perspective. In other words, her analysis does not include other perspectives within social sciences. For example, Pisani argues that forcing NGOs to purchase supplies and materials from U.S. companies creates a highly inefficient system for providing AIDS/HIV prevention and treatment. However, she does not provide an economic analysis of this policy. In short, the added revenue to U.S. companies and subsequent boost to the American economy may outweigh the ineffectiveness within the HIV/AIDS prevention and treatment industry. Or it may not. Either way, Pisani neglects to provide analysis and her policies should be analyzed from several lenses before being adopted to avoid any unintended consequences.
Lastly, Pisani acknowledges the political dilemma for implementing her policy suggestion: people don’t like doing nice things for junkies like needle exchanges. She fails to provide any solutions to overcome this dilemma. Though creating awareness and understanding of the HIV epidemic is certainly one useful strategy (and one assumes this book is part of that strategy), Pisani never explains a framework for moving forward. Then again, Pisani is an epidemiologist and shouldn’t be faulted for not developing a strategy of policy advocation.
Pisani, Elizabeth. The Wisdom of Whores: Bureacrats, Brothels and the Business of Aids. New York: W. W. Norton & Company, 2008.
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