The naked truth HIV is a virus that spreads largely among people who have unprotected sex with several partners or share needles in any three-month period. Globally, those most likely to do that are: –Gay men –Men in jail –Drug injectors –People who sell and buy sex –East and Southern Africans Vote-loser No money Stigmatising Racist
We needed to “repackage” the problem The money argument: Spend now, save later The votes argument: Prevent HIV in “vulnerable populations” now, save “innocent women and children” later Subtext: it could happen to YOU!
If “everyone is at risk”… The AIDS mafia is happy (We get more money) Governments are happy (They don’t have to deal with “ick” groups) UN and NGOs are happy (They get cash regardless of mandate) Activists are happy (HIV is less stigmatised) HIV is happy (it can go on spreading)
Cambodia’s epidemic is “feminising” and “generalising”
Implying causality Half of all new infections are in young people, therefore we need HIV prevention programmes for young people African countries with the highest condom rates also have the highest HIV rates. Clearly condoms can’t be considered as the first line of defense against HIV –Bill Bennet, former US minister for education
Slide 17 Parts of the truth: HIV & GDP per capita—Global
Source: World Bank HIV IS a “development problem” In Africa, there’s more HIV in the richest countries Adult HIV prevalence by per capita GNP. The size of the circle represents absolute numbers of people infected
Unclear definitions Eight out of 10 Americans say AIDS is important. In India 2/3 say it is more important than other issues the world faces. In sub-Saharan Africa, 57% say it is just as important as other issues
Key questions: data Who is in the denominator (who does this sample represent?) –In Bali, an NGO says 21% of sex workers are infected with HIV. The Balinese government says it is 7%. Who is in the numerator (who meets the criteria for this measure?) –Seven out of 10 schoolgirls have boyfriends, and only 10% always use condoms Who is in the final analysis
Key questions: politics Who did this study? And who paid for it? Who am I talking to? Why are they telling me this? What are they not telling me? Who would disagree with them?
For all the “socio-economic determinants”, HIV is just a (not very) infectious disease For a new HIV infection you need: A person infected with HIV (and infectious) A person NOT infected with HIV (and susceptible) An exchange of body fluids
Who is HIV uninfected? Who is HIV infected? CONTACT Will they have sex or inject drugs together? HIV uninfected HIV infected EXPOSURE Will body fluids be exchanged? HIV uninfected HIV infected TRANSMISSION Is the HIV uninfected susceptible? Is the HIV infected infectious? NEW HIV INFECTION Abstinence Partner reduction Age and sero-sorting Condoms Sterile needles Blood screening Ceasarian Circumcision (Lubricant) (Microbicides/Vaccine) PMTCT/PEP/(PrEP) STI treatment ARVs STI treatment Testing Surveillance Source: Pisani, Back to Basics, 2006 Methadone
In the field of AIDS, treatment IS prevention -Senator Tom Coburn, June 2008