Elizabeth Pisani

Pisani has been working in AIDS research pretty much since its inception, at all the big organizations: UNAIDS, WHO, CDC, World Bank, Ministries of Health in China, Indonesia, East Timor, and the Philippines. She tells the story of the evolution of AIDS programs, which started out as shamefully poorly funded and are now overwhelmed with badly managed donor money. Personal and political ideologies have blocked the most effective programs, channeled money toward populations that don't need it, show more used resources in the most inefficient ways possible (for example, when she wrote this book most US aid was tied up so that a program in Asia would have to buy condoms made in the US and ship them across the world, as opposed to just buying the much cheaper condoms made locally. Same problem but on a grander scale with drugs, which pharma companies made a mint off of, even after Brazil and India rebelled against their patents and started making their own generics)...Pisani has a light, cheeky tone for most of this book, but hints of righteous anger filter through, mostly in the form of bitingly sarcastic footnotes. God, I love sarcastic footnotes.

Definitely worth a read if one is interested in donor aid, AIDS, or the research of infectious diseases. show less

Elizabeth Pisani is an epidemiologist and public health worker specialising in AIDS prevention. In this book, she is writing about something she feels strongly about - the fact that huge amounts of money spent on tackling AIDS will do nothing at all to prevent further cases.

One of the reasons for this is that when AIDS first started to kill a lot of people in the West it was something which was ignored and misunderstood. Early AIDS campaigners had to fight for the disease to be taken show more seriously; for the rights of those infected (to dignity, confidentiality, continued access to jobs and services). They often knew more about the disease and the treatments than the majority of the medical profession. Their campaigning had positive results, including focusing people’s attention on the rights of the people living with an infectious disease. But even now the approach to AIDS prevention is influenced by this beginning, in ways that don't always apply. For example, the principle of peer education works best among gay men: but "Being infected with HIV does not glue people together if their backgrounds are too disparate. Mony said that support groups for HIV positive women in Cambodia often broke down because infected housewives didn’t want to talk to infected prostitutes. ‘If a woman starts telling her story and it is clear she was a sex worker, you can see the faces of the others change. They blame {the sex workers} for infecting their husbands. So they think: I’m infected because of her,’ she told me." Similarly, sex workers that Pisani worked with in Indonesia saw each other as competition and were less inclined to listen to or give advice.

Similarly, to reduce the stigma around AIDS and to get more money from squeamish donors, a narrative has grown up that AIDS is a development issue.

If HIV is spread by ‘poverty and gender inequality’, how come countries that have plenty of both, such as Bangladesh, have virtually no HIV? How come South Africa and Botswana, which have the highest female literacy and per capita incomes in Africa, are awash in HIV, while countries that score low on both – such as Guinea, Somalia, Mali and Sierra Leone – have epidemics that are negligible by comparison?

The idea that AIDS is 'about' development has led to huge amounts of the money available for AIDS prevention being spent on education programmes for the general population. In the countries where HIV has jumped from high-risk groups into the general population, this makes sense. But there are relatively few countries where this is the case.

For the same amount of sleeping around, you now have a greater risk of getting infected with HIV if you use a condom every single time you have sex in Swaziland than you do if you never use a condom at all in China ... The likelihood of a condom bursting is tiny, but where close to one in two of your potential lovers is infected with HIV, as in Swaziland, the combined probability of burst condom plus infected partner is still higher than the likelihood of chancing upon an HIV positive heterosexual partner in China. In fact, it is higher than chancing upon an HIV positive prostitute in China.

So that's a chunk of cash wasted. Pisani's organisation was once given a huge sum for AIDS prevention in East Timor, a country with a tiny incidence of HIV. She jokes that it's enough money to send every prostitute in the country to Harvard.

And why has HIV jumped into the general population in certain countries? It's all to do with with the predominant sexual practices. Take three men who have all had five sexual partners in the last year. One has had five girlfriends, one after the other, and been faithful to each one while they were together. One is married, regularly sleeps with one of the women who works at his favourite bar and has the occasional trip to a brothel. The third has a wife and four regular girlfriends who he sees from time to time. Only the last is seriously likely to spread HIV - because you are at your most infectious when newly infected yourself; and because his girlfriends have other boyfriends who they sleep with often enough to infect them. Some countries where this sexual pattern is common have managed to tackle AIDS, by being very frank about what is causing the disease to spread. But orthodoxies of all kinds can stop this from happening:

‘OK honey, you have a good time at the conference in Durban,’ says a cartoon businessman, before texting his secretary: ‘The wife has gone to Durban. Come over tonight and roll in the sack with me.’ His secretary texts back to reject him: ‘I am no longer your rollover.’ Pretty tame. But within weeks, the Swaziland National Network of People Living with HIV and AIDS had organized a march on parliament and got the campaign, called ‘Secret Lover’, taken off the air. According to a press release issued by the International Community of Women Living with HIV/AIDS: ‘A new government-sponsored HIV prevention campaign in Swaziland uses insulting language to target HIV-positive women and suggests that they are the cause of the spread of HIV.’

There is plenty more of this but I am too depressed to go on. In the end the book becomes something of a howl of anguish. The problem seems so insurmountable, and there is no reason to think it is getting better. Some countries have successfully reduced HIV - but many more are at the early stages of an epidemic and are making all the same mistakes again.

Pisani writes well. She is passionate, no-nonsense, and doesn't over-generalise. There is some great gonzo stuff at the beginning when she arrives in Indonesia to do field research for the first time, and all her easy assumptions collapse. And above all, she is sympathetic to the lives of the people in high-risk groups that she is working with - their decisions might be stupid, but they are stupid in a way that is human and understandable.

Leticia was infected with HIV by her pimp. ‘And then I buried him.’ She now works as an HIV prevention counsellor, but she is not optimistic about persuading sex workers to use condoms with their intimate partners. ‘Everyone’s got to make a difference between work and home life.’

But overall reading this book left me feeling powerless, frustrated and angry.

If the topic sounds interesting you might like Pisani's TED talk - it was this that made me want to read the book in the first place. show less

Epidemiologist Elizabeth Pisani's book on 'sex, drugs and HIV' is both really informative and powerfully written, in terms simple enough for readers who don't have a background in medicine or number crunching, like myself. She has really opened my eyes on the subject, from how HIV is transmitted to how badly those afflicted are still being treated worldwide, because 'governments 'don't like spending money on sex workers, gay men or drug addicts' - those most often infected with the show more disease.

Like Caitlin Doughty in her book on death and the funeral industry, Pisani is forthright and refreshingly open, but also engaging and quite funny, considering the topic. She challenges what we think they know of HIV/AIDS - 'in rich countries, AIDS was a disease of gays and junkies, of prostitutes and their clients' and 'If you talk about AIDS these days, most people think of Africa' - while bringing readers up to date (or relatively so - 2009) with how many people are infected in which African, Asian and South American countries, and the amount of money and practical care and treatment (or lack thereof) they are receiving. She also talks about prevention vs treatment, and the puritanical attitude of the US during the Bush administration - 'Anyone taking money from the US government to do AIDS work has to sign a statement saying that they oppose the practice of prostitution'.

Neither does Pisani shy away from discussing 'sex and drugs', from prostitution and the waria (transgender people) of Indonesia to shooting drugs in prisons and needle exchanges (another taboo concept in the US). I have to admit that this book really highlighted my ignorance, about issues I didn't even know I should know about! The treatment of HIV with antiretroviral drugs has diminished the threat of AIDS in the Western world to the point where men and women are 'bored of being "good" and starting to take risks again - not using condoms, which are not always promoted by religious communities (moral purity and denial ranking higher than staying healthy and alive), and sharing needles.

An absolutely fascinating book, which I only wish was more up to date - how do AIDS infection rates and research stand today? show less

This is quite possibly the best book for anyone studying public health, international development, or who ponders the issues of sex work and HIV/AIDS. Her book brings to life what the dry epidemiology textbooks seem to kill off: the the dynamic interplay of money, disease, desire, choice, and -- of course -- the US political-ideological-theological agenda. Get to it! Borrow mine!