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Except in southern and east Africa, plus the Ivory Coast, most HIV infections are concentrated among people who inject drugs, are prostitutes or clients of prostitutes, or gay men. One of the things Pisani learned upon leaving a job writing training manuals for HIV surveillance in Geneva and going to Indonesia to help run a surveillance program is that people unhelpfully don't fall neatly into one of these categories, but can fall into several. For example, a man may work part-time as a prostitute, and buy sex from anatomically male prostitutes who consider themselves women, and use drugs, and not consider himself gay because he'd rather have sex with his girlfriend who it turns out supports herself as a prostitute. After Pisani learned about this complications by talking to prostitutes, their clients and drug users, the nice neat survey forms she had written had to be rewritten to account for this variety. HIV, outside of southern and east Africa, generally spreads very slowly beyond prostitutes, their clients, gay men, or those who inject drugs, contrary to the insinuations of the 1990s era UN reports which tried to suggest that a pandemic among the general population would result if nothing was done.
Just because HIV isn't likely to cause a pandemic in the general population, outside of southern and east Africa where it already has, doesn't mean that only a small number of people are infected. A good proportion, something on the order of 10-25%, of the young men in east Asia buy sex. They can spread it to their wives (married men buy sex less often then single men, but they still buy sex), but if their wives are faithful it won't spread much further.
Unfortunately, much of the general public doesn't like these people and would be happy to see them die; even those who occasionally buy sex or have tried heroin don't see themselves as belonging to one of those nasty groups. As a result, when HIV funding increased greatly in the early 2000s, much of it was spend on largely irrelevant programs for the general population, such as HIV presentations to women in prenatal clinics who were highly unlikely to get the disease. Governments which are secure in their power, including such unlikely bedfellows as the Thatcher government in Britain and the Chinese communist government in the early 2000s, are ironically the ones more likely to treat those populations who actually need it.
Providing condoms and lubricant (mainly for anal sex) for prostitutes and their clients is very helpful. Providing clean needles to drug users is also very helpful; providing bleach to sterilize those needles isn't (that works fine the lab but not with actual users). Aside from the case of Vancouver, where an increase in the popularity of injecting cocaine rather than heroin caught the program by surprise, providing clean needles has been very successful for those actually addicted. One problem is that most people who have tried heroin don't become addicted, so don't see themselves as junkies and don't go to needle exchange programs. Prostitutes can get their clients to use condoms, as the clients are generally too impatient to argue and they seem to pay the same either way, and where prostitutes work in brothels the government can lean on the brothel owners and test the prostitutes for HIV to insure compliance. People who sell or buy sex and also use drugs (not just inject drugs, but more broadly) are a problem, because being in altered mental state makes you less inclined to use condoms.
What doesn't work are peer to peer support groups, as prostitutes see their fellow prostitutes as competitors and not as allies, and the drug users mainly want to get high.
Prostitution is not the dream job of most prostitutes; they do it for the money. In the sense that prostitution pays about 3 times as much as other work, even after subtracting payments to pimps or brothel owners, they are coerced into it. If by coercion you mean that the prostitutes were kidnapped or lead on by false promises of another job, well Pisani could only find a handful of the hundreds she talked to who had that experience. Of the tiny proportion of prostitutes "freed" from prostitution by a raid sponsored by an anti-trafficking western-based NGO, most of those freed quickly returned to prostitution, as the cake-baking or sewing classes offered by the local partner of the NGO didn't pay enough to live on and often cost the prostitutes money to boot.
What seems to be different in southern and east Africa is more the temporal pattern of having heterosexual sex with different partners than the number of partners per se. Also, a fair proportion, perhaps 20-30%, of women (I mean those outside the sex trade) as well as men in these areas have multiple partners. The crucial difference is that in these areas the persons involved are likely to have several partners in a single year, as opposed to be serially monogamous. As HIV is most easily spread shortly after a person becomes infected, because then they have the most viral particles in their body, seeing several lovers within a short time is an opportunity for the virus to find multiple new hosts. Unfortunately, it has been difficult for leaders to bring this unfortunate consequence up, both to the general and universal squeamishness among politicians about having to talk about sex, and because such statements could be interpreted as a racial slur about black people being over-sexed. In fact, the people in these areas probably have fewer sex partners over their lifetimes than does the average westerner. Because no one wants to talk about it, HIV in southern and east Africa has been recast as a development problem, meaning we have to wait until the countries get richer and women's earnings catch up to those of men. Unfortunately for this hypothesis, the richest countries in the area, like South Africa, have some of the highest infection rates.
Pisani has more to say than I can include in this review. Other topics she discusses are the relative effectiveness of NGOs and government bureaucracies, the constantly changing official euphemisms to avoid talking about peoples drug and sex habits, the unfortunate way aid programs tend to be judged in terms of effort expended rather than results accomplished, and the way a big pot of money can attract people with little expertise in the field. I found the book well-written and enjoyable, despite the sometimes grisly topic. Learning about the variety of human behaviors in these aspects of life was enlightening.
I first posted this review on goodreads.com
"Whores" is one of a rare species of book such as Upton Sinclair's The Jungle (Enriched Classics) or Jessica Mitford's " The American Way of Death Revisited " that has the power to reform an industry. In this case, the author exposes the AIDS prevention industry that sprang up when First World governments started to shovel money into the vital struggle against HIV retrovirus. Or at least, that's where they should have shoveled it. If you think that the U.S. Government's emphasis on chastity over latex is a great way to spend your tax dollars, you definitely need to read this book.
I was particularly interested in learning why the AIDS epidemic in Asia has not taken off with the same alacrity as it did in South and East Africa.
Elizabeth Pisani may resemble one of Dante Gabriel Rossetti's ethereal Pre-Raphaelite models, but she talks about sex, drugs, and AIDS in the language of her subjects: the sex workers of Indonesia, China, East Timor, and Africa (foreskin soup, anyone?). She describes how governments are wasting billions of AIDS dollars on "schoolgirls and housewives and Boy Scouts" when they should be concentrating on preventive measures for the people who are actually at risk for this deadly disease: "junkies and gay guys and the people who buy and sell sex."
If you are someone who believes that "junkies and gay guys and the people who buy and sell sex" are getting what they deserve, this author has a message for you, too: remember who is infecting the housewives, Boy Scouts, and even the unborn children. The HIV-positive carrier could be your boyfriend, your sister, or your grandchild. Is there anyone in this 21st century without a friend or relative who is infected with this deadly retrovirus?
Some people may object to the frank language of `Whores.' Others may object to its message that condoms will do more to limit the spread of AIDS than misguided attempts at abolishing the sex trade. Most of us will have our eyes opened on what really needs to be done with our tax dollars in order to mitigate the worldwide AIDS crisis.
Review copy supplied by author