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Elizabeth Pisani 談性、毒品及愛滋病--讓我們理性點吧!

Elizabeth Pisani: Sex, drugs and HIV -- let's get rational

 

Photo of three lions hunting on the Serengeti.

講者:Elizabeth Pisani

2010年2月演講,2010年4月在TED2010上線

 

翻譯:TED

編輯:朱學恆、洪曉慧

簡繁轉換:洪曉慧

後製:洪曉慧

字幕影片後制:謝旻均

 

影片請按此下載

MAC及手持裝置版本請按此下載

閱讀中文字幕純文字版本

 

關於這場演講

Elizabeth Pisani以極為有力的邏輯論點、智慧以及獨特的「公共衛生阿宅檢視鏡」,揭露了現今政治體系下產生的無數矛盾。這些政治決策使大眾的金錢無法有效運用在阻止愛滋病病毒的傳播上。她針對愛滋病高危險群做出了研究-從獄中的毒癮者到柬埔寨街上的性工作者-說明了有時和人們直覺大相逕庭的措施,反而能有效阻止可怕的愛滋病蔓延。

 

關於Elizabeth Pisani

Elizabeth Pisani使用非傳統領域的研究,瞭解在真實世界中,人們的行為如何影響愛滋病的傳播,並全面檢視過時而無效的預防策略。

 

為什麼要聽她演講

之前任職於多個政府衛生機構的Elizabeth Pisani,現在是一個打破假設的獨立研究者及分析師,對變性性工作者、吸毒者及其他族群進行調查,揭露令人驚訝(卻往往被人們忽略),且與傳統研究相牴觸的人口統計資料。

 

Pisani直言不諱地說,全球對於愛滋病的真實情況根本無法理解及進行有效管理,譴責在公共衛生領域中,金錢、投票及媒體扮演著糾纏不清的角色。她說明政治和所謂的「道德」如何使資金的用途處處受限,並主張將資金用於真正能使現況有所改變的地方。正如環球郵報所描述的:「Pisani是個頭腦清晰、活潑、有見地及缺乏耐心的人。」

 

「我們依然沒將我們的精力集中在人們真正需要的地方。」

-Elizabeth Pisani

 

Elizabeth Pisani的英語網上資料

Website: TheWisdomof Whores.com

 

[TED科技‧娛樂‧設計]

已有中譯字幕的TED影片目錄(繁體)(簡體)。請注意繁簡目錄是不一樣的。

 

Elizabeth Pisani 談性、毒品及愛滋病--讓我們理性點吧!

「人們會做蠢事,這就是愛滋病傳播的原因。」這是不久前英國《衛報》的頭條標題。我很好奇,有誰同意這句話?舉個手吧!嗯,有一兩位勇敢的聽眾。

 

這句話事實上出自一位流行病學家,她研究愛滋病已有15年,足跡遍及四大洲,這個人就是我。

 

我想說的是,這句話只有一半是真的。有些人的確是因為做了蠢事而感染愛滋病,但其中大部分人做出這些蠢事有完全理性的原因。現在,「理性」在公共衛生上是首要的準則。如果你戴上公共衛生阿宅眼鏡,你會看到若我們提供人們所需的資訊,告訴他們什麼對他們是好的,什麼是不好的,或我們提供服務,讓他們可以根據所得的資訊來行動,加上一點點動機,人們將可以做出理性的決定,並過著健康長壽的生活。棒極了!

 

這對我來說是有點問題的,因為我在愛滋病領域工作。雖然我很確定你們都知道,愛滋病與貧窮及性別不平等有關,如果你有參加2007年的TED,就會知道愛滋病也與咖啡的價格息息相關。事實上愛滋病和性交、毒品脫不了關係。若有兩樣東西能讓人類喪失理智,那就是勃起跟上癮。

 

(笑聲)

 

我們先看看,對於一個癮君子來說什麼是不理性的。我記得我跟一個印尼朋友Frankie聊天,我們當時正在吃午餐,他跟我分享在巴里島獄中注射毒品的經驗。那一天是某個人的生日,他們很體貼地走私了一些海洛因到獄中,他非常大方地跟獄中好友分享這些海洛因。於是,每個人排成一排,所有癮君子排成一排,過生日的壽星把注射器裝滿海洛因,然後走過來開始為大家注射。他替第一個傢伙注射,接著他將針頭往襯衫上一擦,繼續幫下一個傢伙注射。Frankie說,「我排在第22個,我可以看到朝著我前進的針頭,到處都有血跡,針頭變得越來越鈍。然後我大腦的一部分開始思考,『這真令人作嘔,真的很危險』,但我大部份腦子想的卻是,『輪到我的時候,請留一點給我,拜託留下一些海洛因給我。』」接著,故事說完後,Frankie說,「天啊!你知道嗎?毒品真的會讓你變得很蠢。」

 

你也知道,你無法反駁他說的。但事實上,那時的Frankie是個海洛因成癮者,而且他被關在監獄裡,所以他只能選擇接受骯髒的針頭或是不要吸毒。如果有個地方會讓你超想吸毒,那就是在監獄了。

 

但我是個科學家,我不願意將八卦軼聞當數據,所以讓我們來看看以下的數據吧!我們訪談了印尼三大城市中600個毒癮者,我們問,「你知道愛滋病是如何感染的嗎?」「噢!當然!透過共用針頭。」幾乎全部的人都說,沒錯,是透過共用針頭感染的。「你知道可以在哪裡取得乾淨且負擔得起的針頭,來避免感染愛滋病呢?」「喔!當然!」全部的人都知道。「我們是吸毒的人,當然知道去哪裡弄到乾淨的針頭。」「那你會隨身攜帶針頭嗎?」我們真的就在街頭採訪這些人,在他們出沒和買賣毒品的地方。「你會隨身攜帶乾淨的針頭嗎?」最多四個人中會有一個帶著。這也難怪他們上週注射毒品時,每次均使用乾淨針頭的比例只有十分之一,其他十分之九都是共用針頭。

 

你看這是多麼地矛盾。大家都知道,如果他們共用針頭就會感染愛滋病,但他們還是會共用針頭。到底為什麼?是不是共用針頭會感到比較過癮之類的?我們對這些吸毒者這麼問。他們說,「你瘋了不成?你當然不會想跟別人共用一個針頭,就像你不想跟別人共用牙刷,就算是枕邊人也一樣,會共用針頭只有一個令人討厭的原因;不,不,我們共用針頭是因為我們不想進監獄。」所以,目前在印尼,如果你隨身帶著針頭,警察就會把你抓起來,然後丟到牢裡。這有點改變了整件事,對吧?因為當下你的選擇是,我可以用自己的針頭,不然就是共用針頭,然後染上愛滋病,很可能在十年後就因此死掉;或是現在用我自己的針頭,然後明天進監牢。雖然毒蟲們覺得把自己暴露在愛滋病病毒下是個極糟的主意,但他們深信在牢裡度過一年是個更糟的決定。他們可能在牢裡面臨Frankie遇到的狀況,無論如何還是暴露在愛滋病的威脅下。突然間,共用針頭似乎變成一個相當理性的決定。

 

現在讓我們從決策者的角度來看這個問題。這是個相當簡單的問題,就這麼一次,雙方的動機一致。我們已經知道就公共衛生而言何謂理性;政府想要人們使用乾淨的針頭,毒癮者也想要使用乾淨的針頭。所以我們很簡單就可以解決這個問題,就是讓大家廣泛地拿到乾淨的針頭,也不用擔心被捕的問題。第一個想出這個方法,並把它做全國性推廣的,就是眾所皆知、心地善良的民主主義者柴契爾夫人。她實施世界上第一個全國性針頭交換計畫,其他的國家也跟進,包括澳洲、紐西蘭及一些其他國家。在這些國家中,你可以看到,注射者中感染愛滋病的不超過4%。

 

目前,沒有實施這項政策的地方,像是紐約、莫斯科、雅加達,我們講的是高峰期;每兩個注射者就有一個感染這個致命的疾病。柴契爾夫人並不是出自於對毒癮者的愛而實施這個政策,她這麼做是因為她治理著一個實施全國性健康福利的國家,所以,如果她不先投資來做有效的預防,就得為後來的治療付出昂貴的代價。很明顯,後者的代價高多了,所以她做了一個很理性的政治決定。現在,如果我拿出公共衛生阿宅眼鏡,再看看這些數據,這一切看起來顯而易見,不是嗎?但在這個國家,很明顯,政府覺得沒有這樣的迫切性為大眾提供健康醫療,於是我們採取一個非常不同的解決方法。我們在美國一直做的事就是驗證這些數據,不停地驗證。你看到的是數百篇研究的驗證,由美國頂尖科學界中的菁英科學家們整理出來的。這裡是一些研究,指出針頭交換計畫是有效的,絕大部分都有效;這些是顯示針頭交換計畫沒有成效的研究。你們可能會認為這是一堆煩人幻燈片其中的一張,接著我會按下控制鍵,然後其他幻燈片會接著播放。不過,並沒有,這就是全部了。

 

(笑聲)

 

另一邊沒有任何資料,所以這是非常不理性的;你會想,甚至期待政客也是有理性的,他們會回應他們認為選民想要的,所以我們看到,選民會很樂於回應像這樣的情況:(為孩童創造美好世界),而不願意看到這樣的狀況:(為毒蟲創造美好世界)。

 

(笑聲)

 

所以拒絕提供針頭給成癮者變得相當有道理。現在讓我們來談談性。我們面對性會更有理性嗎?好的,我甚至不打算談論那些天主教教會完全不合邏輯的論點,他們認為如果你發送保險套,大家就會跑出去性交。我不知道教皇Benedict會不會在線上看TEDTalks,但如果Benedict有收看,我有話想對你說:我隨身帶著保險套,卻從來沒機會使用過。(笑聲)這沒那麼容易,也許你們運氣會好些。

 

(掌聲)

 

好的,嚴格來說,愛滋病不是這麼容易透過性交傳染的,是否會傳染要看你血液和體液裡含有多少愛滋病病毒。感染最初期,就在一開始,我們身體內會有非常高量的病毒數,然後你會開始製造抗體。之後很長的時間內,10年或12年,病毒數量都維持在相當低的數目。如果你又因性交而受到感染,病毒數量會再向上衝,但基本上來說,身體並不會產生變化,直到你開始有愛滋病的症狀。到了這個階段,就在這,你看起來狀況不會太好,你也會覺得不舒服,你不會像以往般性交的那麼頻繁。

 

所以因性交而傳染的愛滋病,基本上是取決於這為期相當短的階段中,你有多少個性伴侶,這時你體內的病毒量正值高峰期。現在,這就會讓大家抓狂了,因為這意味著,你必須討論有些人會在較短的時間內,比其他人擁有更多性伴侶,這被認為是很污名化的。我一直很好奇,因為我覺得污名化是件不好的事,而頻繁的性交是相當好的一件事,不過我們姑且先不討論這個吧!事實是,耗時20年的詳盡研究告訴我們,有一群人會更傾向於在短時間內換大量的性伴侶,這些人基本上來說是賣春者,他們的性伴侶,及大多派對場合中的同性戀者,這些人平均而言有著比異性戀者多上三倍的性伴侶。感染愛滋病的異性戀者,多半來自有多配偶制傳統的國家,以及相對有較高女性自主權的國家,幾乎所有這些國家都在非洲東部及南非。這都反映在我們今天面對的傳染病上。

 

你可以看到這些從非洲得到的可怕數據,這些都是在南非的國家,這裡的成年人有三分之一到七分之一感染愛滋病。目前世界上其他國家基本上感染人口沒有太大變化,變動的比例相當相當低,但在高危險群中卻有相當大比例的人感染愛滋病,像是毒品注射者、性工作者及男同性戀者。你會看到洛杉磯的數據中,男同性戀者中有25%的人感染愛滋病。當然,你不會只因為不安全的性交而感染愛滋病,只有跟一位陽性愛滋病患者有不安全的性交才會使你感染愛滋病。

 

在世界上大部分地方,這些少數的預防措施失效而未成功,但針對性交易中的預防措施,我們這些日子以來其實做得還不錯。在大部分國家的性交易中,保險套的使用率介於80%~100%。同樣的,這是因為動機上的一致性。對公共衛生而言這是理智的,對個人性工作者也是理性的選擇,因為染上性病對生意很不好,沒人想要這樣;而且,事實上顧客也不想染病回家。所以本質上在性交易行業中可以達到相當高的保險套使用率。

 

但在「親密」關係中就困難多了。因為你的太太或你的男友,或那些你希望成為伴侶的人,我們都有著對浪漫的幻想、信任及親密感,而沒有什麼會比「親愛的,要用誰的保險套呢?」這類問題更不羅曼蒂克了。所以,面對這樣的問題,你真的需要相當大的誘因來使用保險套。

 

我們舉個例子,這位男士名叫Joseph,他來自海地,患有愛滋病,他現在大概也沒有活躍的性生活,但他對大眾需要使用保險套的原因起了提醒作用。這也是在海地,提醒大家為何想性交的原因,也許吧!現在,有趣的是,這也是Joseph,接受抗逆轉錄病毒藥物治療六個月後,這就是我們所謂的Lazarus效應。但這改變了在性交方面做怎樣的決定才算理智的因素,所以我們得到這樣的回應。有些人會說,「喔,這不太重要,因為事實上治療也是很有效的預防措施,因為治療會降低你體內的病毒量,因此也比較不容易傳染愛滋病。」如果大家再看看這些病毒報告,如果在染病時確實開始接受治療,那麼,然後呢?你的病毒攜帶量會下降。但這是跟什麼數據相比?如果你沒有接受治療呢?那麼你會死亡,所以你的病毒量會降到零,所有這些綠色部分,包含這些數量衝高的峰值,都是因為你無法就診或藥吃完了,或是你去派對狂歡了三天根本忘了吃藥,又或因為你開始有抗藥性,不管怎樣,事實是,愛滋病病毒是不會消失不見的,除非你接受治療。

 

難道我是在說,喔,好吧,預防策略很棒,我們乾脆停止治療吧?當然不是,當然不是這樣,我們當然需要盡可能地擴展抗逆轉錄病毒的治療,但我要做的是,質疑那些說治療勝於預防的人,這根本不是真相,我認為我們可以從男同性戀者的經驗中學到很多。他們身處的國家都有著更普及的治療,也已施行15年了。我們看到的是,事實上,保險套的使用率相當地高,同性戀群對愛滋病的反應也很快,幾乎不太需要公共衛生人員的協助,我會這麼說。自從接受治療後,保險套的使用率明顯驟降,主要有兩個原因。其中一個假設是,「喔,如果他已感染愛滋,可能在服藥了,那他所攜帶的病毒量一定較低,所以我還蠻安全的。」

 

另一個就是,人們根本不像懼怕愛滋病那樣懼怕愛滋病病毒,的確如此。愛滋病是會致死的疾病,而HIV是看不見的病毒,就只是讓你每天吃顆藥。這蠻煩人的,但這比每次性交都使用保險套來得煩人嗎?不管你喝得多醉,不管你喝了多少杯?如果我們看看數據,可以發現問題的答案就是…嗯。

 

這些是來自蘇格蘭的數據。你可以看到,在他們開始推行全國性針頭交換計畫之前毒品注射者染病的高峰期,然後數據一路下滑。在異性戀中也是一樣,大部分是性工作者或毒品施打者。在治療開始後,其實不會有太多狀況發生,這是因為我先前提到的動機一致的措施。但在男同性戀中,數值急遽上升,就在治療開始變得普及的三四年間。這是新的感染案例。

 

這意味著什麼?這意味著人們變得較不擔心,及這個族群中有更多病毒傳播的聯合效應。更多人活得更久、更健康、更可能帶著愛滋病病毒與別人性交,這遠大於較低病毒攜帶量所帶來的影響,非常值得我們擔心。這意味著什麼?這說明當我們有更好的治療時,也需要做更多的預防措施。

 

這是實際情況嗎?不,而且我稱這個現象為同情迷思。我們過去幾天中談了很多關於同情的話題,實際情況是,人們無法產生提供良好性交及生育健康服務給性工作者的意願,也無法產生發放針頭給毒癮者的意願,但一旦他們不再是我們不願饒恕的毒蟲或賣春者,而是愛滋病受害者時,我們就能產生同情心,來為他們一輩子購買這些極為昂貴的藥物。從公共衛生的角度來看,這一點道理都沒有。

 

我想跟Ines說些話,這幾乎是最後所說的話了。Ines是個變性人,在雅加達街頭從事妓女行業,她是個有小雞雞的女生。她為什麼要做妓女?當然,因為她迫於無奈,因為她沒有較好的選擇,等等等等。如果我們可以教她縫紉,幫她在工廠找到工作,這一切都會好轉。這是印尼的工廠員工一小時所得,平均20美分,會因所在省份而稍有不同。我跟15000個性工作者訪談後,得到這張幻燈片上的數據。這是這些性工作者所說他們一小時的所得。所以,這不是件好差事,但對很多人來說,這確實是相當理性的選擇。好的,Ines。

 

我們有工具,知識,也有現金,也有預防愛滋病病毒的決心。

 

Ines:那為何愛滋病患者的數目還在上升?這都是政治問題。當牽扯到政治時,一切都毫無道理了。

 

Elizabeth Pisani:「當牽扯到政治時,一切都毫無道理了。」所以,從性工作者的角度來看,政客讓這一切變得毫無道理;從公共衛生學者的角度看,毒癮者只是在做蠢事。我的意思是,事實是,每個人對理性都有不同的解釋,這個星球上有多少人,就會有同樣多的各種理性決定,這也是人類存在的光輝之一。但這些不同的理性決定並不是完全彼此不相干,因此對一個毒品注射者來說,共享針頭是理智的,這是因為政治家所做的一個愚蠢決定;對一個政治家而言,做出這個愚蠢決定也是理智的,因為他們必須對他們所認為的選民需求做出回應。但重點是,我們就是選民,我們當然不是全部的選民,但TED是個思想領導者的群體,在這房間中的每一個人,還有在線上收看的每一個人,我想我們都有責任,要求這些政治家根據科學證據和常識來做出決策。對我們來說,單獨影響世界各地像Frankie、Ines這些人的理性想法確實很困難,但你至少可以用你的選票,來阻止政治家做出傳播愛滋病這樣的蠢事。

 

謝謝

 

(掌聲)

 

以下為系統擷取之英文原文

About this Talk

Armed with bracing logic, wit and her "public-health nerd" glasses, Elizabeth Pisani reveals the myriad of inconsistencies in today's political systems that prevent our dollars from effectively fighting the spread of HIV. Her research with at-risk populations -- from junkies in prison to sex workers on the street in Cambodia -- demonstrates the sometimes counter-intuitive measures that could stall the spread of this devastating disease.

About the Speaker

Elizabeth Pisani uses unconventional field research to understand how real-world behaviors influence AIDS transmission -- and to overhaul antiquated, ineffective prevention strategies. Full bio and more links

Transcript

"People do stupid things. That's what spreads HIV." This was a headline in a U.K. newspaper, The Guardian, not that long ago. I'm curious -- show of hands -- who agrees with it? Well, one or two brave souls.

This is actually a direct quote from an epidemiologist who's been in field of HIV for 15 years, worked on four continents, and you're looking at her.

And I am now going to argue that this is only half true. People do get HIV because they do stupid things, but most of them are doing stupid things for perfectly rational reasons. Now, "rational" is the dominant paradigm in public health. And if you put your public health nerd glasses on, you'll see that if we give people the information that they need about what's good for them and what's bad for them, if you give them the services that they can use to act on that information, and a little bit of motivation, people will make rational decisions and live long and healthy lives. Wonderful.

That's slightly problematic for me because I work in HIV, and though I'm sure you all know that HIV is about poverty and gender inequality, and if you were at TED '07, it's about coffee prices; actually, HIV's about sex and drugs. And if there are two things that make human beings a little bit irrational, they are erections and addiction.

(Laughter)

So, let's start with what's rational for an addict. Now, I remember speaking to an Indonesian friend of mine, Frankie. We were having lunch, and he was telling me about when he was in jail in Bali for a drug injection. And it was someone's birthday, and they had very kindly smuggled some heroin in to the jail, and he was very generously sharing it out with all of his colleagues. And so everyone lined up, all the smackheads in a row. And the guy whose birthday it was filled up the fit, and he went down and started injecting people. So he injects the first guy, and then he's wiping the needle on his shirt, and he injects the next guy. And Frankie said, "I'm number 22 in line, and I can see the needle coming down towards me, and there is blood all over the place. It's getting blunter and blunter. And a small part of my brain is thinking, 'That is so gross and really dangerous,' but most of my brain is thinking, 'Please let there be some smack left by the time it gets to me. Please let there be some left.'" And then, telling me this story, Frankie said, "You know, god, drugs really make you stupid."

And, you know, you can't fault him for accuracy, but, actually, Frankie, at that time, was a heroin addict, and he was in jail. So his choice was either to accept that dirty needle or not to get high. And if there's one place you really want to get high, it's when you're in jail.

But I'm a scientist, and I don't like to make data out of anecdotes, so let's look at some data. We talked to 600 drug addicts in three cities in Indonesia, and we said, "Well, do you know how you get HIV?" "Oh yeah. By sharing needles." I mean, nearly 100 percent. Yeah, by sharing needles. And, "Do you know where you can get a clean needle at a price you can afford to avoid that?" "Oh yeah." 100 percent. "We're smackheads; we know where to get clean needles." "So are you carrying a needle?" We're actually interviewing people on the street, in the places where they're hanging out and taking drugs. "Are you carrying clean needles?" One in four, maximum. So no surprises then that the proportion that actually used clean needles every time they injected in the last week is just about one in 10, and the other nine in 10 are sharing.

So you've got this massive mismatch. Everyone knows that if they share they're going to get HIV, but they're all sharing anyway. So what's that about? Is it like you get a better high if you share or something? We asked that to a junkie and they're like, "Are you nuts? You don't want to share a needle anymore than you want to share a toothbrush even with someone you're sleeping with. There's just an ick factor there. No, no. We share needles because we don't want to go to jail." So, in Indonesia at this time, if you were carrying a needle, and the cops rounded you up, they could put you into jail. And that changes the equation slightly, doesn't it. Because your choice now is either, I use my own needle now, or I could share a needle now and get a disease that's going to possibly kill me 10 years from now, or I could use my own needle now and go to jail tomorrow. And while junkies think that it's a really bad idea to expose themselves to HIV, they think it's a much worse idea to spend the next year in jail, where they'll probably end up in Frankie's situation and expose themselves to HIV anyway. So suddenly, it becomes perfectly rational to share needles.

Now, let's look at it from a policy maker's point of view. This is a really easy problem. For once, your incentives are aligned. We've got what's rational for public health. You want people to use clean needles, and junkies want to use clean needles. So we could make this problem go away simply by making clean needles universally available and taking away the fear of arrest. Now, the first person to figure that out and do something about it on a national scale was that well-known, bleeding heart liberal Margaret Thatcher. And she put in the world's first national needle exchange program and other countries followed suit, Australia, The Netherlands and few others, and in all of those countries, you can see, not more than four percent ever became infected with HIV, of injectors.

In places that didn't do this, New York City for example, Moscow, Jakarta, we're talking, at its peak, one in two injectors infected with this fatal disease. Now, Margaret Thatcher didn't do this because she has any great love for junkies. She did it because she ran a country that had a national health service. So, if she didn't invest in effective prevention, she was going to have pick up the costs of treatment later on, and obviously those are much higher. So she was making a politically rational decision. Now, if I take out my public health nerd glasses here, and look at these data, it seems like a no-brainer, doesn't it. But in this country, where the government apparently does not feel compelled to provide health care for citizens, we've taken a very different approach. So what we've been doing in the United States is reviewing the data, endlessly reviewing the data. So these are reviews of hundreds of studies by all the big muckety-mucks of the scientific pantheon in the United States, and these are the studies that show needle programs are effective, quite a lot of them. Now, the ones that show that needle programs aren't effective -- you think that's one of these annoying dynamic slides, and I'm going to press my dongle and the rest of it's going to come up, but no, that's the whole slide.

(Laughter)

There is nothing on the other side. So, completely irrational, you would think, except that, wait a minute, politicians are rational too, and they're responding to what they think the votes want. So what we see is that voters respond very well to things like this and not quite so well to things like this.

(Laughter)

So it becomes quite rational to deny services to injectors. Now let's talk about sex. Are we any more rational about sex? Well, I'm not even going to address the clearly irrational positions of people like the Catholic Church, who think somehow that if you give out condoms, everyone's going to run out and have sex. I don't know if Pope Benedict watches TEDTalks online, but if you do, I've got news for you Benedict. I carry condoms all the time, and I never get laid. (Laughter) It's not that easy. Here, maybe you'll have better luck.

(Applause)

Okay, seriously, HIV is actually not that easy to transmit sexually. So, it depends on how much virus there is in your blood and in your body fluids. And what we've got is a very, very high level of virus, right at the beginning, when you're first infected, then you start making antibodies, and then it bumps along at quite low levels for a long time, 10 or 12 years, you have spikes if you get another sexually transmitted infection, but basically, nothing much is going on until you start to get symptomatic AIDS. And by that stage, over here, you're not looking great, you're not feeling great, you're not having that much sex.

So the sexual transmission of HIV is essentially determined by how many partners you have in these very short spaces of time when you have peak viremia. Now, this makes people crazy because it means that you have to talk about some groups having more sexual partners in shorter spaces of time than other groups, and that's considered stigmatizing. I've always been a bit curious about that because I think stigma is a bad thing, whereas lots of sex is quite a good thing, but we'll leave that be. The truth is that 20 years of very good research have shown us that there are groups that are more likely to turn over large numbers of partners in a short space of time, and those groups are, globally, people who sell sex and their more regular partners, they are gay men on the party scene who have, on average, three times more partners than straight people on the party scene, and they are heterosexuals who come from countries that have traditions of polygamy and relatively high levels of female autonomy, and almost all of those countries are in east or southern Africa. And that is reflected in the epidemic that we have today.

So you can see these horrifying figures from Africa. These are all countries in southern Africa where between one in seven and one in three of all adults are infected with HIV. Now, in the rest of the world, we've got basically nothing going on in the general population, very, very low levels, but we have extraordinarily high levels of HIV in these other populations who are at highest risk, so drug injectors, sex workers, and gay men. And you'll note that's the local data from Los Angeles. 25 percent prevalence among gay men. Of course, you can't get HIV just by having unprotected sex. You can only HIV by having unprotected sex with a positive person.

In most of the world, these few prevention failures not withstanding, we are actually doing quite well these days in commercial sex. Condom use rates are between 80 and 100 percent in commercial sex in most countries. And, again, it's because of an alignment of the incentives. What's rational for public health is also rational for individual sex workers because it's really bad for business to have another STI. No one wants it. And, actually, clients don't want to go home with a drip either. So, essentially, you're able to achieve quite high rates of condom use in commercial sex.

But in "intimate" relations, it's much more difficult because, with your wife or your boyfriend, or someone that you hope might turn into one of those things, we have this illusion of romance and trust and intimacy, and nothing is quite so unromantic as the, "my condom or yours, darling?" question. So, in the face of that, you really need quite a strong incentive to use condoms.

This, for example. This gentleman's called Joseph. He's from Haiti, and he has AIDS, and he's probably not having a lot of sex right now, but he is a reminder in the population, of why you might want to be using condoms. This is also in Haiti and is a reminder of why you might want to be having sex, perhaps. Now, funnily enough, this is also Joseph after six months on antiretroviral treatment. Not for nothing do we call it the Lazarus Effect. But it is changing the equation of what's rational in sexual decision making. So, what we've got -- some people say, "Oh, it doesn't matter very much because, actually, treatment is effective prevention because it lowers your viral load and therefore makes it more difficult to transmit HIV." So, if you look at the viremia thing again, if you do start treatment when you're sick, well, what happens? Your viral load comes down. But compared to what? What happens if you're not on treatment? Well, you die, so your viral load goes to zero. And all of this green stuff here, including the spikes, which are because you couldn't get to the pharmacy or you ran out of drugs, or you went on a three day party binge and forgot to take your drugs, or because you've started to get resistance, or whatever, all of that is virus that wouldn't be out there, except for treatment.

Now, am I saying, oh, well, great prevention strategy, let's just stop treating people? Of course not. Of course not, we need to expand antiretroviral treatment as much as we can. But what I am doing is calling into question those people who say that more treatment is all the prevention we need. That's simply not necessarily true, and I think we can learn a lot from the experience of gay men in rich countries where treatment has been widely available for going on 15 years now, and what we've seen is that, actually, condom use rates, which were very, very high -- the gay community responded very rapidly to HIV, with extremely little help from public health nerds, I would say -- that condom use rate has come down dramatically since treatment for two reasons really. One is the assumption of, "Oh well, if he's infected, he's probably on meds, and his viral load's going to be low, so I'm pretty safe."

And the other thing is that people are simply not as scared of HIV as they were of AIDS, and rightly so. AIDS was a disfiguring disease that killed you, and HIV is an invisible virus that makes you take a pill every day. And that's boring, but is it as boring as having to use a condom every time you have sex, no matter how drunk you are, no matter how many poppers you've taken, whatever? If we look at the data, we can see that the answer to that question is mhmm.

So these are data from Scotland. You see the peak in drug injectors before they started the national needle exchange program. Then it came way down and both in heterosexuals, mostly in commercial sex and in drug users, you've really got nothing much going on after treatment begins, and that's because of that alignment of incentives that I talked about earlier. But in gay men, you've got quite a dramatic rise starting three or four years after treatment became widely available. This is of new infections.

What does that mean? It means that the combined effect of being less worried and having more virus out there in the population, more people living longer, healthier lives, more likely to be getting laid with HIV, is outweighing the effects of lower viral load, and that's a very worrisome thing. What does it mean? It means we need to be doing more prevention, the more treatment we have.

Is that what's happening? No, and I call it the compassion conundrum. We've talked a lot about compassion the last couple of days. And what's happening really is that people are unable quite to bring themselves to put in good sexual and reproductive health services for sex workers, unable quite to be giving out needles to junkies, but once they've gone from being transgressive people, whose behaviors we don't want to condone, to being AIDS victims, we come over all compassionate and buy them incredibly expensive drugs for the rest of their lives. It doesn't make any sense from a public health point of view.

I want to give, what's very nearly the last word, to Ines. Ines is a a transgender hooker on the streets of Jakarta. She's a chick with a dick. Why does she do that job? Well, of course, because she's forced into it because she doesn't have a better option, et cetera, et cetera, and if we could just teach her to sew and get her a nice job in a factory, all would be well. This is what factory workers earn in an hour in Indonesia, on average, 20 cents. It varies a bit province to province. I do speak to sex workers, 15,000 of them for this particular slide. And this is what sex workers say they earn in an hour. So, it's not a great job, but for a lot of people it really is quite a rational choice. Okay, Ines.

We've got the tools, the knowledge and the cash, and commitment to preventing HIV too.

Ines: So why is prevalence still rising? It's all politics. When you get to politics, nothing makes sense.

Elizabeth Pisani: "When you get to politics, nothing makes sense." So, from the point of view of a sex worker, politicians are making no sense. From the point of view of a public health nerd, junkies are doing dumb things. I mean the truth is that everyone has a different rationale. There are as many different ways of being rational as there are human beings on the planet, and that's one of the glories of human existence. But those ways of being rational are not independent of one another. So it's rational for a drug injector to share needles because of a stupid decision that's made by a politician, and it's rational for a politician to make that stupid decision because they're responding to what they think the voters want. But here's the thing: We are the voters. We're not all of them, of course, but TED is a community of opinion leaders, and everyone who's in this room, and everyone who's watching this out there on the web, I think has a duty to demand of their politicians that we make policy based on scientific evidence and on common sense. It's going to be really hard for us to individually affect what's rational for every Frankie and every Ines out there. But you can at least use your vote to stop politicians doing stupid things that spread HIV.

Thank you.

(Applause)
 

 


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