Sex, drugs and death

As the treatment of HIV and Aids becomes a multi-million dollar industry, questions must be asked about how the money is being spent, says the author of a new book

‘OBVIOUSLY IT IS a great challenge to try and write a general interest book about a disease that is killing so many people. But I think a lot of people are interested in sex and drugs, and are quite interested in the sex trade and how that works,” author and former scientist specialising in HIV policy, Elizabeth Pisani, announces brightly. She is referring to her just-published book about the HIV surveillance and policy work in Asia she did over a decade, and which has the provocative title of The Wisdom of Whores; Bureaucrats, Brothels, and the Business of AIDS.

“I think people are quite concerned about HIV, not least because it such an enormous drain on our tax resources,” Pisani continues. “Ireland, for instance, spends more per capita on HIV in the developing world than any other country bar two . A lot of people in this country, whether they know it or not, are investing an awful lot of money in this, and I think people have a right to know where all the money is going.”

Brought up in Spain, France, Germany and England, Pisani has spent the greatest part of a peripatetic life in Indonesia. There has been a lifetime base at a family home in Castletownshend, Co Cork, where she wrote most of her book. She studied classic Chinese at college, an unusual choice for the time. “I can give you a sensible answer as to why, or do you want the truth?”

The truth proves to be that she was “16 and drunk” in a nightclub in New York, when a friend bet her that she would not study classical Chinese at college – something she had never before considered. She won the bet. “Life is full of accidents like that.” Her language skills drew her to Hong Kong, and a stint as a foreign correspondent for Reuters. Later, she decided to train in London as an epidemiologist – a specialist in diseases – Pisani focused her scientific work and research very early on the HIV virus. For 10 years, she worked for ministries of health in China, Indonesia, East Timor and the Philippines, as well as conducting HIV policy research for the World Health Organisation and UNAIDS (the joint UN programme on HIV and Aids).

IT IS SOME WAY into the interview, and Pisani is explaining in an assured, confident voice about the short-term relaxant effect of amyl nitrate for men who are having recipient anal sex. We are sitting in the foyer of a central Dublin hotel, and are not the only people there. It is unclear which part of Pisani’s sentence has caught the attention of the man who has been bent over a newspaper on a nearby couch, but when it has been delivered, he snaps up his head and stares around at us. Pisani, both elegant and distinctive in blue and green silk, can’t see him from where she is sitting. I can. The expression on his face is part disgust, part amazement and part curiosity.

This man’s instinctive reaction probably sums up the general response American-born Pisani has had from strangers to the work she has been involved in for the last 13 years, 10 of those in Asia. When people asked her in those years what she did for a living, her stock reply was “sex and drugs”.

A lot of the work that Pisani did in South East Asia was HIV surveillance among high-risk sectors. This included extensive work with the transgender sex scene in Indonesia, which is culturally very different from other more traditional forms of prostitution, and was thus difficult to assess for risk. Pisani’s website and blog, www.wisdomofwhores.com, includes several video clips with people she interviewed in this and other communities, which make for enlightening viewing, and are a lively complement to the text.

To date, 25 million people have died of Aids worldwide. It is estimated that there are 33 million people who currently have the HIV virus. For a disease that was unheard of until the 1970s, these are staggering statistics under any circumstances. As are the figures which governments around the world have since spent on trying to manage the epidemic.

“When I started working in HIV, the HIV budget for the developing world was $250 million . This year it is $15 billion .” Pisani shakes her head and laughs without mirth. One of the points she makes in her book is that there is too much ideology and too much money in what she refers to as “the Aids industry”, and how easy it is for this money to be misdirected as a result.

“WHEN IT WAS a very small pie, most organisations weren’t that interested in HIV, but the minute it became the leader in the development world spending hitlist parade, everyone wanted to do something. As long as there was not really that much money around, the only organisations who were prepared to deal with that money were those who dealt with sex and drugs.

“But then it became a ‘development problem’, a ‘problem with poverty’, a ‘problem with gender’, blah blah blah. It makes it very easy for everyone, because people say, ‘Oh, poverty, I do poverty, I want some Aids money.’ In some parts of the world, particularly sub-Saharan Africa, it is true that Aids is so bad there that it is now a development problem, since prevention was so bad. In the rest of the world, that is absolutely not true.”

As an example of misdirected and wasted funding, Pisani cites the $2 million the US allocated in 2002 for a HIV programme in East Timor – a country where only seven people had ever tested positive for HIV. “East Timor did not have a HIV problem,” she hisses, perched right on the edge of the sofa, still clearly furious six years later. “We spent the $2 million proving that there was no problem.”

The Aids industry is full of myth-making. The biggest myth which continues to be perpetuated in certain parts of the world, according to Pisani, is that everyone is at risk from Aids.

“This is not true! It is confined to sections of society where there are clearly defined risk factors. But governments generally aren’t that keen to be seen to be spending tax money on drug injectors and sex workers and gay guys – these aren’t hugely politically popular. So it’s much easier to peddle the myth that everybody is at risk and that way, you can spend money on pregnant women and schoolchildren and other more popular groups and feel like you are addressing the problem, when in fact you are not.”

According to Pisani, there is no mystery about who is at risk from contracting the HIV virus, no matter what certain governments and religions would like to make people believe. At risk are people who have unprotected sex with an infected person, and by sharing needles when injecting drugs. Condom use helps enormously in prevention.

This is not, however, what the Tanzanian government, to take one example, would have its citizens believe. One of the photographs posted on Pisani’s website is an image of a skeleton, with the slogan ‘Faithful Condom User’. These billboards were displayed publicly in Tanzania by the government; the juxtaposition of image and words giving a hugely misleading message, and one which Pisani is unprintable on.

Pisani’s views, which she was not slow to vocalise when she was actively working in the field, did not make her popular at the time with some of her less conservative colleagues and employers.

She thinks she will be even less popular now when they read her book, with its sharp criticism of how governments and organisations have managed the Aids epidemic since its start. She’s probably right.

The Wisdom of Whores; Bureaucrats, Brothels, and the Business of AIDS by Elizabeth Pisani, is published by Granta at £12.99.