PC Book Club: The Wisdom of Whores

Thanks to PEPFAR, a huge chunk of PC Peru volunteers are finding themselves knee-deep in HIV prevention. It's no surprise that, as a result, books discussing the AIDS pandemic are now appearing on the Peace Corps Book Club list.

In The Wisdom of Whores: Brothels, Bureaucrats and the Business of AIDS, epidemiologist Elizabeth Pisani tears apart the current ideology driving AIDS work worldwide.

Africa is leading the world in HIV-infection rates, and rightfully so much of HIV prevention and funding is going to this part of the world. However, Pisani argues, what's happening in South and East Africa is NOT what is happening everywhere else. And while these parts of Africa have HIV infection in the general population, the rest of the world is discovering the highest risk of HIV infection isn't. In fact, the epidemic is concentrated in pretty condensed at-risk populations: sex workers, males who have sex with males and drug injectors.

An overwhelming amount of AIDS funding, however, is not funneled toward these groups, but toward the general population, where the risk is much lower. Instead of focusing funding for providing and promoting the use of clean needles, condoms and lubricant, money is being spent on development projects, life skills for teens and encouraging abstinence.

Not to say that these programs aren't useful. But as Pisani points out, economic development and individual empowerment are all well and good, but what will really stop the spread of HIV are condoms and clean needles.

I've spent the past year working on HIV prevention projects in my site. We've trained 60 teachers, 40 youth health promoters and over 200 teenagers in HIV prevention. We've shown movies, done marches, and recorded radio spots. We've organized community meetings to educate house wives and conducted condom relays in classrooms.

But has it really made a difference in curbing the spread of HIV?

According to Pisani, it most likely hasn't. And from the data I've seen, she's probably right. HIV infection rates in Tumbes ARE high, but really only in males who have sex with males, and sex workers. In the general population – where all our work is conducted – the rates are actually quite low.

This is kind of disheartening for a girl who has spent a lot of time waving bananas in the air with one hand and condoms with the other.

Perhaps our resources would be better utilized if we focused our energy in the at-risk populations. But in a culture with such fierce machismo, where prejudice and hostility might lurk around any professed outsider, how can we seek them out without putting them at risk?

Our solution so far has been to blanket the entire community with information in hopes of reaching those who are truly at risk, which – let's face it – is a little like throwing seeds across an open field in hopes that a few will start to grow.

As Pisani mentioned, a positive byproduct of our project might be a reduction in teen pregnancy and STIs. Some youth might not cave to growing delinquency because they're kept busy with sessions and project activities. And we're certainly doing a lot to open up lines of communication concerning sex and condom usage.

But what's more, the community is stepping up, working together – getting excited about something.

Call me naive, but I think that's a pretty good step. And even though we're not where we need to be, we're at least moving forward. Hopefully in the right direction.

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Pisani's evaluation of the problems guiding the HIV pandemic and her solutions (pulled directly from her book):

The Problem (on Planet Epidemiology)

The overwhelming majority of HIV-infected adults get HIV by having unprotected sex with an infected person, or by sharing needles with them while injecting drugs.

People pass the virus most easily when they have lots of it in their blood (i.e. when they are newly infected).

HIV is transmitted most easily when it comes into contact with sores, lesions or foreskin.


The Solution (On Planet Epidemiology)

Cut the exchange of body fluids between infected and uninfected people.

Getting people to give up sex doesn't work very well, so in terms of sexual transmission, our best bet is to persuade uninfected people to use condoms with any partner likely to be infected with HIV. In East and Southern Africa and in many gay communities that means any new sex partner. Bombard the places people go to meet new partners with condoms and lube. Remember that men have sex with another in prison.

For heterosexuals in most of the world, the highest-risk sex is paid for. Create incentives to use condoms every time sex is bought or sold.

Methadone and other oral drugs can help people stop injecting, so make them widely available but recognize that they don't always work. Make it easy as possible for people who are still injecting to do it safely. Make clean needles available, make them free or dirt cheap. Give them to people in prison if they need them. Make sure no one winds up in prison just because they're carrying needles.

Don't forget to make sure that all injecting equipment used in health services is sterile. Screen all blood for HIV before transfusion.

Cut the amount of virus in the blood of people who are infected. The most obvious way to do this is to provide people who need it with antiretroviral treatment. Test for infection where you're most likely to find it. Bundle prevention services with AIDS drugs at every opportunity. Treating other infections (such as sexual transmitted infections) promptly will reduce spikes in the amount of virus, even among people who are not on anti-HIV drugs.

Close all the potential "open doors," so the virus can't get into the uninfected person.

In communities where there is lots of HIV, circumcise men. Screen for sexually transmitted infections and treat them among women, men and transgenders who sell sex, and among their clients and regular partners. Make sure you use drugs that work. Promote the use of lubricant in all anal sex and for female sex works, too, to minimize tears and lesions. Package it with condoms. Get it into gay bars.