The secret of HIV control can be found in the back streets

Abstract

An “entertaining rant” about the foibles of international aid for HIV prevention is underpinned by rigorous research, finds Joanna Busza

A major crackdown on prostitution is under way in Cambodia. Over the past few weeks police have been rounding up sex workers and closing down brothels. In response, 200 sex workers marched through Phnom Penh to protest against the human rights abuses—including extortion, intimidation, and rape—accompanying the mass arrests.^{1 2} Both sides have used the rhetoric of HIV prevention to support their cause: the police argue that commercial sex fuels the epidemic and thus should be abolished; the sex workers point out that forcing them into hiding limits their access to condoms and treatment for sexually transmitted infections.

This is the kind of scenario that makes the journalist turned epidemiologist Elizabeth Pisani’s blood boil, motivating her to write The Wisdom of Whores—an entertaining rant against the seemingly irreconcilable gap between what she calls Planet Epidemiology and Planet Politics. The book is full of similar examples, mainly from Asia, demonstrating how simple, effective HIV prevention measures that are based on sound evidence are routinely ignored in favour of ideological positions or are sidelined by those who seek to co-opt HIV funding for other aims.

Pisani takes aim at everyone guilty of “bad science”—not just the religious fanatics who have turned the Bush administration’s HIV and AIDS policy into a moralistic farce but also the “AIDS mafia,” those activists, consultants, and United Nations technocrats who talk about “poverty and gender inequality” instead of sex and drugs. The real problem with AIDS, she says, is that, except in a few hard hit countries in eastern and southern Africa, the virus is almost exclusively spread through shared syringes, anal sex between men, and commercial sex. So although the data indicate that “junkies,” “gays,” and “hookers” are the groups most in need of effective services, it is such groups that remain least likely to get them, as they lack political clout and because most policy makers are reluctant to take any action that could be seen as condoning or, worse, encouraging stigmatised behaviours.

The first part of the book sets out how data on HIV transmission have been gathered, analysed, used, and manipulated. Pisani is renowned for having developed among the best behavioural surveillance methods around, and she describes putting them into practice with poignancy and humour, relating anecdotes about getting stopped by the police with a cooler full of blood samples strapped to her motorbike or traipsing through muddy alleyways between karaoke bars with an army of clipboard wielding fieldworkers.

Pisani also talks a lot about journalistic “beat up”: exaggerating a story to increase sales. As an enthusiastic number cruncher for UNAIDS in the early 1990s, she applied this skill to reports with gusto, trying to portray a generalised epidemic around every corner. This was partly because advocating for services for the “dregs of society” is rarely successful and partly out of the naive hope that a big crisis would attract big money that could then be channelled into effective prevention. “We argued quite truthfully that men who inject, men who have sex with one another, and men who buy sex are likely to pass HIV on to their innocent wives,” Pisani writes. “And then came the sleight of hand. Once innocent wives were infected, we implied, HIV would blaze through the ‘general population’ . . . We weren’t making anything up. But once we got the numbers, we were certainly presenting them in their worst light.”

The book’s second part describes how cumulative “beat ups” backfired, leading to a bloated HIV and AIDS industry divorced from the realities of good public health. As AIDS programmes attracted greater funding, so too they attracted all manner of UN agencies, development institutions, and experts from a range of sectors, diluting focused efforts at prevention. Projects get double funded, organisations compete for the same territory, and there is no accountability regarding the effects of programmes on rates of transmission of HIV. “The result” states Pisani, “is a colossal waste of taxpayers’ money.”

In that respect the book continues a long tradition of exposés of the international aid sector, joining the ranks of Lords of Poverty: The Power, Prestige, and Corruption of the International Aid Business and subsequent accounts of misguided, disingenuous, or downright corrupt “humanitarian” endeavours. But what profession doesn’t have a skeleton or two in the closet for insiders to bring out for public scrutiny? Pisani paints herself as an iconoclast, someone who battled against the tide and is now airing the dirty linen in public at the expense of her future career in HIV prevention. This seems a bit of a “beat up” in itself: most of her criticisms are regularly heard at conferences and planning meetings and in friendly debates among colleagues at Pisani’s alma mater, the London School of Hygiene and Tropical Medicine.

Few other insiders will really be shocked or horrified by the book’s treatise, and many have similar tales from the frontlines. But Pisani deserves credit for setting forth those arguments in eloquent and accessible language, backed by rigorous research and a painstaking attention to detail. The Wisdom of Whores is a welcome addition to our library shelves, and trainee epidemiologists following in Pisani’s footsteps will appreciate finding a good dose of common sense and a lively romp through Asian red light districts, gay bars, and drug riddled nightclubs among their statistics texts and health promotion theory.

Cite this as: BMJ 2008;337:a800