One Unsupported Assumption Can Infect a Whole Body of Research

The author of a book on AIDS with one of the most stigmatizing titles possible, Elizabeth Pisani, is interviewed by IRIN about why HIV prevention efforts have failed to curb the spread of the pandemic. One of the answers she gives is that we started too late, which I guess suggests that she thinks we have started now.

She's right about missing an important opportunity by not implementing needle exchange programs in some countries where the bulk of HIV transmission continues to occur among injecting drug users. Russia and a lot of Central and Eastern Europe are still dithering about such programs and the US continues to deprecate them, though they have worked well in countries where they have been implemented.

She's a bit wide of the mark in claiming that not targeting sex workers to reduce sexually transmitted infections represents a missed opportunity, certainly in the case of developing countries, anyhow. Trials on the impact of such interventions showed that they had little effect in reducing HIV transmission and some of them may have even increased the risks of non-sexual transmission for participants.

Pisani is right about abstinence not working very well but she failed to influence attitudes towards that 'strategy' when she was working at UNAIDS. But now that she's a rebel, working at the London School of Hygiene and Tropical Medicine, that bastion of public health reaction, going along with the HIV industry line that almost all HIV transmission in African countries results from heterosexual sex is unlikely to change things much.

Again, Pisani is right that the 'all men are evil, all women are innocent' reflex is not helpful and never has been. But she fails to mention the extent to which women are affected by HIV in comparison to men. Overall in Africa, in excess of 60% of HIV positive people are women and among young people, the figure is in excess of 70%. HIV prevention activity has failed to address that and the industry seems oblivious to it.

Pisani still holds her stigmatizing view of HIV transmission as being a matter of promiscuity, which it is not, and never has been. Data about sexual behavior, such as it is, shows that those who are infected with HIV often faced lower sexual risk than many who were not infected and some who took precautions were even more likely to be infected than some who did not. The idea that HIV is mainly about sex is unsupported by evidence, but still the mainstream view.

Treatment as prevention, we are told, is not the answer to ending HIV transmission. But anyone who thinks the strategy will address the needs of any more than a small subset of people has been brainwashed, anyway. But this is not an argument against expanding the number of people receiving treatment. So far, so good.

The author of the Wisdom of Whores, surprisingly, admits that she doesn't know what is the best approach to HIV prevention in sub-Saharan Africa. And she seems to have some intuition that incidence, the yearly rate of new infections, might rise. Unfortunately, we are not told what is behind this intuition so it's hard to say if it's one of her good ones or one of her not so good ones.

Ultimately, Pisani doesn't touch on the great elephant in the UNAIDS room: why a virus that is difficult to transmit heterosexually is said to be almost always transmitted heterosexually, but only in Africa, where sexual behavior is little different from that in many other places. She has never justified the highly stigmatizing title of her book, nor the attitude towards Africans which has had, and continues to have, so much influence on HIV policy.

Indeed, Pisani is one of the people behind the kind of dubious research and mathematical modelling that so much current HIV thinking is based on. The claim that HIV is mainly transmitted sexually in African countries, and hardly ever transmitted through non-sexual modes, is supported by the flimisiest evidence, at best. Until this massive flaw in mainstream HIV thinking is revised, prevention efforts will continue to have little impact on epidemics.