When Elizabeth Pisani began her career as an HIV epidemiologist, fewer than 1,5-million cases of HIV/Aids had been reported across the world. Within a year, by the end of 1997, 30-million people were estimated to be infected with HIV. As Pisani wrote in her first report for World Aids Day, that meant one in every 100 sexually active adults aged between 15 and 49 worldwide.
Today, just over a decade later, the global figure is estimated to be closer to 40-million, with more than 1,5-million new infections every year. Yet there is a widespread impression that the world is now winning the fight against the virus. The perception that it threatens only sex workers, heroin addicts and gay men has been replaced by the urgent consensus that this is a universal problem — backed by mind-boggling sums.
Ten years ago, the developing world received roughly $300-million a year from the west. By 2007, the figure was $10-billion. This year the United States alone has budgeted $5-billion for HIV in developing countries — and last month the US Congress voted to commit a further $50-billion over the next five years. The President’s Emergency Plan For Aids Relief (Pepfar), personally initiated by George Bush, has been described in Washington as the most successful foreign aid programme since the Marshall Plan, and ”the best thing that ever happened to the poor people I work with” by one HIV programme leader in Africa. On a recent visit to the continent, Bush was feted as the saviour who has put one and a half million Africans on life-saving drugs.
”We used to sit around fantasising about having unlimited resources,” Pisani recalls. ”Like winning the lottery.” Today, the HIV/Aids industry — ”or Aids mafia”, in her words — effectively has won the lottery. But Pisani is not celebrating. Her book, The Wisdom of Whores, published this week, condemns the global strategy for HIV/Aids as an ill-conceived waste of money which is not saving but costing lives.
”HIV is mostly about people doing stupid things in the pursuit of pleasure or money,” declares the cover on a proof copy of the book. ”We’re just not allowed to say so.” She suspects she will never work in the HIV/Aids industry again for saying so. ”But it’s true.”
Pisani (43) spent 10 years working in the field of HIV, first for UnAids and then for a non-governmental organisation (NGO) in Indonesia. As an epidemiologist, she quickly identified the risk of the virus spreading among drug injectors, gay men and the sex trade across Asia, Latin America and Eastern Europe — underdeveloped countries with inadequate resources to prevent an epidemic. That placed 100-million at risk in Asia alone — equivalent to a third of the population of the Africa. But the data was clear: ”HIV wasn’t going to rage through the billions in the ‘general population’. And we knew it.”
Like most of her colleagues, however, she also quickly realised that ”governments don’t like spending money on sex workers, gay men and drug addicts”. So she put her skills as a former journalist to work, and began producing the sort of reports that persuaded politicians in Washington and the West that it is not ”wicked people” but ”innocent wives” at risk. ”Aids couldn’t be about sex and drugs,” she explains. ”So suddenly it had to be about development, and gender, and blah blah blah.”
The strategy was more successful than she could ever have imagined. ”All these obsessively politically correct things started getting introduced.” HIV publications and conferences began devoting more time and attention to issues such as poverty, gender, development, vulnerability, leadership — what Pisani calls ”sacred cows” — than to condoms and clean needles. ”I’m just waiting for ‘climate change and Aids’,” she jokes sarcastically in her book — and sure enough, this week a headline appeared in an Australian newspaper: ”Global warming set to fan HIV.”
These were all far more palatable issues to politicians than sex and drugs, and the money began to roll in. But they are not, Pisani argues, what cause HIV/Aids. ”We have to stop this nonsense now. Talking about ‘vulnerability’ will not stop people getting infected.”
Pisani’s relief at being free now to ”tell it how it is” is palpable. After gaining a degree in classical Chinese, she joined Reuters as a reporter in the Far East, and then took a masters in medical demography in London in the early 1990s. She quit the field to write her book, and people are often surprised to discover she is an epidemiologist, because her charisma and sense of irony would be more familiar to a foreign correspondent’s club than an NGO. ”Basically,” she likes to say, ”my book is about sex, drugs and taxation.” It is easy to see why she grew exasperated with UN colleagues who would exchange tortuous memos agonising over the most sensitive wording of something as simple as ”men who have sex with men”. She wasn’t hostile to their liberal instincts — just impatient that semantics were wasting time, when people were dying.
There are two distinctly separate Aids epidemics, she says — one in Africa, and one in the rest of the world. In Africa, people are contracting the virus through heterosexual, non-commercial sex. But in most of the world, Pisani claims, the data clearly indicates that the risk is confined to drug users, sex workers and gay men — the very groups that Aids organisations have worked so hard to distance from the problem. Yet all the evidence of focused programmes which target these high-risk groups with effective preventative measures — condom use and clean needles — is that they work.
”We could knock this epidemic in the rest of the world on the head — just like we’ve knocked so many things on the head in the rest of the world — but we’re not doing it, largely because of the paradigm that we’re developing in Africa. The Aids industry has become an island unto itself, in a sea of common sense. That’s the tragedy of it. It’s unsayable.”
There is more than a touch of the maverick iconoclast about Pisani. The Wisdom of Whores is full of exotic anecdotes from the colourful world of transgender prostitutes, and the language — like her manner — is lively. But the book is built around a solid body of scientific evidence, and the blend of data analysis and straight talking makes a very persuasive argument. But if Pisani is right, why isn’t anyone else making it?
”If you are a data nerd, you spend your whole time looking at the numbers, and the conclusions are fairly inescapable. So a lot of the data nerds feel the same way as me. But at the NGO level, of UN organisations, we’ve been spouting all this stuff about development and poverty for so long that if you don’t look at the data, if you just listen to the rhetoric, you’d be completely forgiven for believing that stuff.”
Even if Pisani is right about the rest of the world, what can be wrong with a global strategy for Africa which has brought antiretroviral drugs (ARVs) to one and a half million of the poorest people in the world? It is easy to mock talk of ”gender and development and blah blah blah”, but it has persuaded a conservative president to fund HIV treatment on a previously unimaginable scale. Bush’s motive may be unconventional — he is said to see global HIV as a US national security risk — but surely, I suggest, if he throws enough money at the wall, some of it will stick.
”Not if you’re chucking it at the wrong wall.”
The problem, Pisani says, is that 80% of the Pepfar budget goes on treatment. ”Pepfar says great, we’ve got 1,8-million people in treatment. And next year it will be another 1,8-million! That will mean 3,6-million people. It’s exponential — and that’s the biggest question mark over the entire approach to Africa. The more treatment you have, the more infection you get.”
ARVs reduce people’s viral load, she agrees, making them less likely to infect someone else — as long as they don’t miss a single dose. ”But it also keeps them alive longer, and healthy enough to want to have sex. You only have to look at the experience of the UK or US gay communities where we’ve had more or less universal access to ARVs for at least eight or nine years, and the number of new infections are rising. More people are living longer with HIV, and there is what we call behavioural disinhibition: ‘Fuck the condoms, I don’t need them any more, because if he’s positive he’ll be on drugs, so he probably won’t infect me. And if I do get infected, it would be annoying, but not the end of the world.’
”But having Aids is not a picnic. Yes, it’s great that all this stuff on treatment is happening. But it becomes all the more urgent to have effective prevention. And that’s not happening.”
Even the 20 cents in every US dollar allowed to be spent on prevention is wasted, Pisani argues. A third of the prevention budget has to be allocated to faith-based organisations, which refuse to distribute condoms and will promote only abstinence before marriage. The failure rate of ”virginity pledge” programmes among young Americans in the US is about 75%; condoms’ failure rate is roughly 2%. Yet Pepfar, Pisani laughs, ”claims its policy decisions are ‘evidence based”’.
Pisani’s criticism of the treatment-and-abstinence approach in Africa has been echoed elsewhere. The director of America’s National Institute of Allergy and Infectious Diseases told an international conference last summer, ”For every person who gets life-saving drugs, six more are getting infected. Clearly, we’re losing that game.” Richard Holbrooke, the former US ambassador to the UN, agrees. ”Focusing primarily on treatment will never succeed.”
But if some in the Aids industry are willing to criticise the contradictions driven by rightwing ideology, Pisani finds them far less ready to admit the ideological motivation of their own ”Poverty causes Aids” agenda. They daren’t say the virus is usually transmitted by risky behaviour, she thinks, for fear of appearing ”judgmental” and confirming the old rightwing attitude that people with HIV don’t deserve to be cared for.
”A good friend of mine — he works in the industry and is a sensible guy — called me up and said, ‘You’ve got to change the blurb on the cover of your book. You can’t use the word stupid. You can’t call people stupid.’ I said, ‘I’m not calling people stupid, I’m saying they do stupid things. Not the same thing.’ But he said, ‘You will get absolutely crucified.’ So I’ve had to change it to ‘daft’.”
She half laughs, and rolls her eyes.
”You know, it’s one of the difficult things about arguing for a more targeted response. You’re basically saying, ‘Look, people are getting infected now because they’re doing dumb things.’ But people do dumb things all the time. I do. We all do. Why is it OK to be judgmental about people who smoke? But not to be judgmental about people who take crystal meth and fuck 16 guys in a weekend without condoms?”
Is Pisani judgmental?
”I don’t think it’s evil to have anal sex with 16 people in a weekend without condoms. I just think if you do that there’s a high likelihood you’re going to get infected. That’s all. It’s cause and effect. And I think if we can prevent a fatal disease, we should. I don’t get how it’s OK to keep someone alive once they’re sick — but not OK to stop them getting sick. I just don’t get that.” – guardian.co.uk Ã‚