Hookers, gays, druggies, and death

Elizabeth Pisani is a smart lady: a journalist-turned-scientist with a PhD in epidemiology who's worked for the World Health Organization, the World Bank, and UNAIDS. She is also the author of the whistleblowing The Wisdom of Whores: Bureaucrats, Brothels and the Business of AIDS, an international bestseller that outlines the myriad ways in which governments, NGOs, and the United Nations has wasted billions of dollars trying to fight HIV and AIDS because they like to ignore that the disease is largely spread by prostitutes, gay men, and drug injecting folk. It’s because the uptight majority has to avoid these three groups so the general public doesn’t go crazy that HIV has become a huge global pandemic. But, setting aside the disaster of Old Testament proportions that is Sub-Saharan Africa, it seems that not all hope is lost: the new US administration has recently restructured its global AIDS policy along Dr. Pisani's book, and UNAIDS—the agency that Dr. Pisani herself worked in for 15 years—has finally embraced these concepts as an informal new “mission statement.” We decided to call Elizabeth in her London apartment and ask her a few questions about sex, drugs, and death.

Vice: Why did you write this book?
Elizabeth Pisani: To be honest, although the publishers like to say that this is a bomb-throwing, controversial book, it actually contains many things that people have been saying for quite a long time inside the AIDS industry. But you reach a point when you've been saying the same thing year after year, and everybody says you're right, but then nothing changes, so you start thinking that maybe you're just talking to the wrong audience.

So you popularized something that people within the community are well aware of.
People are aware of it, absolutely—but they have great difficulty acknowledging it, and working with it. The simple fact is that we still have a problem with doing nice things for junkies, gay men, and hookers.

We'll get to that later. The head of the US global HIV initiative was recently replaced. Do you think this was a good move?
To be completely honest with you, his predecessor was actually a pretty good guy. He was a guy who was trying to do the right thing in a politically impossible circumstance: working for an administration that thinks that the best way to prevent HIV is to cross your legs. Now, unfortunately, most of us fail to cross our legs, for all kinds of reasons. But, having chosen to take an appointment during the Bush administration, he was kind of doing the best that he could with what he had. But I think that the new administration thought he was too compromised by his association with those Bush administration rules: no clean needles for anyone, no constructive work with people who sell sex, no promotion of condoms unless we also promote abstinence, monogamy, and marriage, etc. The position of that program, which is by far the biggest funder of HIV programming around the world, was so associated with that failed approach that I think the Obama administration just thought they should get rid of him.

I ask this because, during the constant Bush-baiting in conversation with people in the last few years, something that always seemed to come up was, “At least he's spending a lot of money on AIDS in Africa.”
The Bush administration did up the ante for funding of HIV around the world…. It was really that administration that even made it possible to think in realistic terms about treating people in the poorest countries. To that extent, he is deserving of respect. Unfortunately, he was wrong in so many aspects of prevention.

In the last 15 years there's been a huge shift in perception of this virus, from one of “a disease of gay men and junkies who are looking to get AIDS” to the “women and children who get it for no fault of their own.”
Yes, gay men, drug injectors, and people who sell and buy sex, the three groups that are most likely to get HIV, are the so-called “wicked” people. At UNAIDS we had to find a way to turn it from a “disease of the wicked” into a “disease of the innocent.” What we were essentially trying to saying was, “If you don't invest in prevention for these high risk groups now, then you will have a bigger epidemic—i.e., innocent women and kids—later on.” What the politicians heard, however, was, “HIV prevention blah blah blah blah innocent women and children.” It's like talking to a dog who recognizes only its name and the name of the food.

Can you recollect a precise moment for this shift in perception?
It was when the African epidemic really hit people's radars. In Africa all of our data came from pregnant women, and you can't have a more touchy-feely innocent group than pregnant women and their unborn babies. That was the thing that really made people think it wasn't just a disease of “the wicked.” I remember how it began: it was really at the start of UNAIDS. There were all these different groups of numbers and we were trying to come up with good, well-calculated global figures. So we were getting in data from all of these countries, and one of the sets that the researcher I shared a desk with was analyzing came from Botswana. We thought the numbers were wrong: it said 28% of pregnant women were infected. We thought maybe they had forgot to put in a decimal point, or maybe they were the numbers from sex-workers, but clearly not pregnant women. So we went back and checked—Botswana is one of the wealthiest countries in Sub-Saharan Africa and they have well-resourced labs, so we had a tendency to believe their numbers—and it turned out that it was right. We were all walking around in shock, for weeks. And then we started looking much more carefully at data from other countries, much poorer than Botswana, and yes—it was happening all over southern Africa.

And that report pretty much became that famous front-page article of the New York Times.
Yes. And it came out just before one of the major biennial AIDS world conferences, in Geneva, and two years later they held the conference in Africa for the first time, in Durban, to really put a spotlight on what was happening over there. The level of sheer denial in Sub-Saharan Africa was absolutely extraordinary, and it remains extraordinary to this day. Shortly after this, I moved to Kenya. At that time we had estimated that there were three million people living with HIV in Kenya. And yet their national AIDS program basically only was one room next to the loo in the stairwell in the Ministry of Health, staffed by two people.

Insane. And up to two years ago the South African government officially denied that AIDS came from the HIV virus.
The only African country to have a success story in HIV prevention is Uganda and, basically, the difference was that the president, Yoweri Museveni, stood up and said, “HIV is a sexually transmitted infection, transmitted by having unprotected sex with several partners, and it leads to AIDS, and AIDS leads to death. And the high number of funerals of young adults that we're all going to in our country is a direct result of that.” He drew a straight line between risky sexual behavior, HIV infection, and death. It sounds so simple, but no other African leader did that for at least another decade.

Your book draws a very strong link between the way to control this epidemic and proper communication in the media, almost as if the best way to fight AIDS is to have people talk about it and write about it and read about it in the simplest, most factual terms possible.
Well, yes, but not only that. Certainly, not talking about it, not recognizing the facts, and not being absolutely clear about the scientific truths leads to pathetic failure. But—unfortunately—just recognizing the facts doesn't automatically lead to better policies, because you still have to do the right thing about those facts. So saying that, “In Eastern Europe and Asia, HIV is mainly driven by sharing needles between injection drug users,” doesn't lead to anything, unless we also say, “and we know that where you make clean syringes universally available people will use them,” and then go on to make them available. We tend to think that people are rational, sensible human beings who will make good decisions for their long-term health, if only they have the facts. It's silly. You know? I smoke cigarettes, for fuck's sake.

Yeah, I do too. I guess you'd hope that the facts reach the policy makers. And then you'd hope that they were rational people.
I think they are rational people. But what they're rational about is how to stay in power. So if there was any pressure on them to do the right thing, they would do the right thing. But HIV doesn't threaten all of us—realistically, HIV only threatens people who engage in behaviors which most of us don't engage in and don't approve of. So there's no pressure from the general public. Nobody is going to stand up and say, “Go spend my tax money giving clean needles to junkies because it's the right thing to do.”

So besides throwing up our hands and going “Oh well” some more, what do you think is to be done?
The AIDS industry itself, and people who are in the communities of highest risk, have actually bought into this whole “AIDS is everyone's problem” thing, because they don't want AIDS to be labeled as a gay disease or a sex-worker's disease. Particularly the gay community, which, in many countries, is very organized and very vocal, should say, “Hey, this is our disease, and we need more from you, we need more investment, more effective policies of treatment and prevention.” I think it's interesting that the countries who have best responded to HIV are essentially autocracies. Democracy isn't all that good at protecting the rights of minority groups who don't vote.

It's easier to make difficult political decisions in an autocracy. There's no risk of losing power, no popular unrest, no media on your ass. Dictators have it easy.
Yes, absolutely. The downside is that it's hard to convince the leaders of an autocracy to do the right thing. The best examples of effective prevention—such as the 100% condom use program in Thailand—were put in place by governments instituted by military coup.

I guess what you need is that medieval concept of the enlightened prince.
Yes! But when I say public health is a fascist discipline, I mean it, to a certain extent. If you look at what happened with swine flu or with SARS for example, to protect the majority, sometimes you have to curtail the rights of a minority. With avian influenza, SARS and swine flu, we've shut down entire cities or countries. This has never happened with HIV. HIV has such a legacy of the “rights-based approach” that most countries don't even do contact tracing. If you have a newly identified HIV case, nobody even asks them who they've had sex with in the last year, to try and go and save those people, and give them tests. We're not doing it because we're so uptight about privacy, confidentiality, and individual rights.

Wait, do you think the tests should be made compulsory?
No, I don't think so. But in England, of all the gay men coming in to STD clinics, 50% are leaving without an HIV test. I wouldn't make it compulsory, but I would make it routine, and I would want you to have a very good reason to not to have one.

What do you think of bug-chasers?
Ah. Well. I think it makes for a very good story, and therefore gets seized by the media and blown out of proportion. It does happen, but I don't think that it accounts for a substantial proportion of new infections. What does, on the other hand, is serosorting among gay men. That's the practice of selectively looking for partners of the same status as yourself—which is fine if you're both positive, but if you believe you're both negative it's one of the riskiest things you can do. If you're on gaydar.com three times a week looking for casual sex—you know, clean-to-clean only, or whatever the terminology on your site is—then the person you're selecting to have unprotected sex with is also doing that three times a week. And in a community with 3% incidence, you have a lot of people who have no idea that they're infected. So, actually, if you know you're negative and have recently had a test, you're safer to have unprotected sex with a positive guy who's on meds than with a negative guy who's untested.

OK, wait. Please explain that.
Well, if you're positive and on medication, and you're going for regular testing, and have had an undetectable viral load for six months and don't have any other STIs, then you're not very infectious. In fact, we have zero instances of transmission from people with undetectable viral load on treatment.

What's an undetectable viral load?
When you first get infected with HIV, the virus gets into your blood, and then it starts making copies of itself very, very quickly. Then, after two or three weeks, you start making antibodies to the virus. And that antibody forces the virus to go and hide inside healthy cells. When that happens, you're not very infectious. And that's why it’s safer to have sex with someone who is positive and on meds than with someone who thinks they're negative but has never been tested.

Is there a PC term for “people who think they're negative but have never been tested”?
We do spend a lot of time, and so much money, coming up with correct terminologies. It's such a waste.

Is this one of the biggest wastes of money in the UN with respect to AIDS?
Maybe. But the real winners are these programs for schoolkids, or migrants, or for integrating HIV programs into agricultural extension work, instead of just dealing with sex and drugs. We're still pouring money away to try to change the behavior of people who are at zero-risk in the first place, and we're not doing it for that minority of people who is at very, very high risk.

So your average, straight, middle-class, Western twenty- or thirty-something who doesn't inject drugs is actually at zero risk from fatal sexually transmitted diseases?
Yes, that's correct. And HIV is not even fatal anymore, either. People say it's like playing Russian roulette, but it's not. With Russian roulette there's a one-in-six chance of dying. But the scenario you described, there's around a 1-in-400 chance of being exposed to an infected partner, and then within that partnership it's another 1-in-300 chance of becoming infected.

So it's like playing Russian roulette with a revolver with 12,000 bullets.
Yeah, but I still think you should use condoms. Or just go for oral sex.

What are the chances there?
I'm not allowed to say zero—but there are about 70 million HIV infections in the world recorded today, and we know of 9 that have been transmitted orally. Unless you have really bad dental hygiene, the chances are infinitesimal. And if you're the “inserter” in oral sex, the risk is even closer to zero.

What about cunnilingus?
Ah, that's zero. You can put me on the record saying that there is absolutely no risk in cunnilingus.

Thank you, that is good to know.

(Portrait by Ben Rayner)