Epidreamiology

The Guardian is having a bit of fun at the expense of Tony Blair, following this interview with him and Liberian President (and Nobel Laureate) Ellen Johnson Sirleaf, during which he sidesteps the issue of gay rights and refuses to answer the question when asked whether governance and human rights go hand in hand.

On one point I think they are both right: that Tony Blair's presence in Liberia is restricted to a few specific development issues.  He is not in Liberia as a senior global statesman promoting peace and love: he is there as a hired contractor to the Liberian government, who have hired his Africa Governance Initiative to advise them on delivering in some key policy areas.  Criticising him for not pushing gay rights in this context is kind of missing the point: if Sirleaf had thought he was out to make trouble for her in a sensitive policy area, she would never have awarded the contract.  Besides - and I think he missed a trick by not pointing this out - the work he does with the Liberian government probably does advance human rights, just not the ones the journalist is asking about.  In my work on HIV I work on rights, including gay rights, but I would find it pretty absurd if a journalist criticised me for having had no impact on access to education or on extrajudicial arrests.  It's a shame that the journalist in this case fell into the common trap of reducing all African human rights issues to gay rights.

Nonetheless the interview is embarrassing.  It is profoundly depressing that a Nobel Peace Laureate should have the attitudes Sirleaf has.  Blair's discomfort is palpable.  Given his record on gay rights in the UK though, I suspect it is partly his embarrassment at the things Sirleaf was saying.  But I really don't see what the problem would have been with Blair giving a straight answer to the question of whether governance and human rights go hand in hand.  Given his championing of interventionist foreign policy in the cause of advancing human rights when he was Prime Minister, it would be nice to see him nail his colours to the mast.  It is certainly nonsense to hide behind the notion that this episode is an example of "country ownership" and that no-one outside Liberia has the right to comment.  It reminds me of that silly statement a Foreign Office minister made a few months ago which seemed to imply homophobia is OK if it is "traditional".  If human rights isn't an issue that transcends borders I don't know what is, and I would have thought no-one knows that better than Blair.  

It isn't every day that the UNAIDS website carries a feature story about African sex workers fighting for their rights.  The feature in question was published shortly after March 3rd, which is International Sex Worker Rights Day, and described initiatives supported by UNAIDS in two countries: Kenya and Namibia.  It is great that the story is featured so prominently.

I was quite involved in the Namibia work, as I've explained here and here.  As a result I read the UNAIDS story very closely after seeing it on Twitter.  And then I wrote to UNAIDS: 

I also sent an email.  It's been a couple of days since I contacted them so I think it is fair to explain here which parts of the story I take issue with.

Firstly, this sentence:

The publications noted that sex workers are disproportionately affected by HIV due to the nature of their work—most of the time they can not negotiate the use [sic] condoms with their clients.

(Emphasis added).

I've read every piece of research conducted with sex workers in Namibia, dating back to 2000. The quality of the research is, on the whole, very poor, based on unspecified methods and non-representative samples.  Nonetheless none of the studies says that most sex workers cannot negotiate condom use.  The participants in the community assessment research we set up in October didn't say this was the case either.  To be sure, condom use is not systematic.  This may have something to do with negotiation skills, but as the assessment showed it is also affected by lots of other things, such as the attitudes of clients, with the fact that police officers use posession of condoms by sex workers as evidence of criminal activity, and lack of supply. It is inaccurate and stigmatising to imply the problem is just about sex workers.

Secondly, this:

The reports include recommendations for action by national and local stakeholders to address these challenges and protect the human rights of sex workers. Such recommendations include addressing violence, abuse and stigma towards sex workers as well as reducing legal and policy barriers that block their access to HIV services.

(Emphasis added).

When sex workers involved in the work asked for changes to laws and policies, they were not doing so on the grounds that it would help them get access to HIV services.  They were doing so because the laws and policies as they stand are one of the main reasons they are so vulnerable to violence, abuse and stigma.  Yes, HIV is a big issue for sex workers in Namibia.  But it is one of many issues.  That much was clear from what sex workers said throughout this project and during their interviews with several Namibian newspapers.  Indeed the quotes from sex workers that UNAIDS uses in its feature more accurately reflect the reality.

The reason I think this is important is because the whole idea behind the work we did in Namibia was to move away from the standard survey approaches which ask sex workers the same standard questions about condom use and access to services, and to give sex workers space to talk, among other things, about the issues that HIV programmes aren't helping them with and maybe even won't help them with.  We achieved this to an extent, so it is frustrating to see this message get homogenised into the same old narratives that we normally hear.  I've written before about the need HIV policy wonks have to only discuss things that have categorically been shown to have an epidemiological association with HIV.  That's fine up to a point, but if we're really committed to listening to communities, we've got to take what they are saying at face value.

Yesterday I shared some media coverage of international sex worker rights day events in Namibia, as well as reports of some work I was involved in last year that were launched on the same day.

I want to draw attention to one of the reports in particular.  Because there has been very little research on sex work in Namibia, and because most of the programmes designed to support sex workers are framed around a very narrow HIV focus (information, condoms, cajoling or even coercing people to get tested and have STI check ups; and no attention to issues like violence, discrimination and insecurity), UNFPA and UNAIDS wanted to do a bit of qualitative research to look in more detail at what was going on.  

Although I'm a big fan of epidemiological research (quantitative and qualitative), and I use the results of research all the time, it seemed in this context that it wasn't particularly feasible (given the resources available) or appropriate to see this as a classic research project, with publication in a peer-reviewed journal or changing national policies as the ultimate goal.  What seemed more important, given that a major new HIV programme aimed at sex workers was about to be launched, was to document some of the specific situations in the towns that the programme was going to target, to help influence the sorts of things that get addressed, and to identify and point out any gaps in the programme.  Moreover, there are quite a few sex workers in Namibia who are very involved in community work, whether in relation to HIV or more broadly, and we wanted to help them get even more involved.  

So we decided to provide some introductory training on one qualitative method - focus group discussions - and got them to think through what sorts of issues their colleagues might want to discuss.  We used those suggestions to develop a guide, and sent them out to conduct their own research.

The report describes the results in detail.  It also describes the limitations, of which there are many.  Although I remain adamant that the purpose of this activity was never to extract data that will tell the whole story and represent the realities of sex workers throughout Namibia, some common themes come out of each of the five towns.  But there are also differences.  It's the differences that interest me.  I wanted to give people an opportunity to discuss and think about what was going on in their own towns, and what, practically, immediately, might be done to fix some of the problems in each town.  And to an extent, I think that's what we got.  It's not generalisable; in fact the results from each town are probably very biased.  We know, for instance, that in most of the towns, we failed to talk to any male or transgender sex workers.  But if we recognise the biases and their relevance to each town, but use the information to get positive change in each town, then that's OK.

We've also got a team with a new set of skills, who can do the same thing again, or can replicate it in other towns, or - why not - help other marginalised groups like men who have sex with men, migrants, or people living in slums do the same thing.

Maybe "research" is the wrong term to describe using research techniques in creative ways.  This participatory approach isn't new to community development work: far from it.  It isn't new to public health researchers either.  Practitioners have been advocating it for decades.  But it remains a marginal rather than a maintream practice.  So that's why I'm making it a big deal.

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Update: The Namibian Sun carried a feature describing the assessments on 7th March 2012. The article is a good reflection of the findings, although some of the stock sex worker library pictures they've used as illustrations are a little unfortunate.

The 3rd of March was International Sex Worker Rights day, marked by sex worker rights activists and defenders across the world.  Although sex workers have been campaigning for rights in Namibia for years, the movement is still very much "emerging" since, until the last 3 years or so, they have received very little support.  

In Namibia, as in many other countries, sex workers have limited opportunities to be heard when they want to talk about human rights, and as a result, the discussions are often constrained by the need to relate them to issues like HIV (as I discussed here) or trafficking.

In this context it is heartening to see not only that news outlets in Namibia gave significant coverage to the events organised by local sex worker organisations (front page of The Namibian; articles in New Era and Republiklein), but that the coverage didn't focus just on the HIV angle, and acknowledged the broader issues.  Since the event took place, some of those involved have told me that the feedback from different decision-makers has been very positive, and they are optimistic that we are now seeing a step-change in how some of the media and decision-makers are approaching sex worker rights.

I'm particularly proud to have played a role in supporting some of the work that went into these events, with the support of UNFPA and UNAIDS: this review of the literature on sex work and HIV in Namibia:

Click here to download:

Literature_Review.pdf (1.04 MB)

(download)

Click here to download:

Literature_Review.pdf (1.04 MB)

This report of a series of local assessments done by sex workers to investigate human rights, health and HIV in five towns:

Click here to download:

Community_Assessment.pdf (1.8 MB)

(download)

Click here to download:

Community_Assessment.pdf (1.8 MB)

Click here to download:

National_Meeting.pdf (1.67 MB)

(download)

Click here to download:

National_Meeting.pdf (1.67 MB)

The job isn't done of course: it has barely started.  But many of the partners in Namibia have committed to following up on this work, so things are looking positive.

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For more of a discussion on the aims of the local assessments, click here.

Since then I have slept in a number of Salvation Army shelters, and found that, though the different houses vary a little, this semi-military discipline is the same in all of them. They are certainly cheap, but they are too like workhouses for my taste. In some of them there is even a compulsory religious service once or twice a week, which the lodgers must attend or leave the house. The fact is that the Salvation Army are so in the habit of thinking themselves a charitable body that they cannot even run a lodging-house without making it stink of charity.

George Orwell, Down and Out in Paris and London, 1933.

Update. The Orwell quote was posted on 20 February, but today (21st) I was pointed to another quite remarkable piece of writing from even longer ago, this time from Oscar Wilde.  It resonates with some of what I've been thinking recently, about activism on HIV and rebelliousness.

The virtues of the poor may be readily admitted, and are much to be regretted. We are often told that the poor are grateful for charity. Some of them are, no doubt, but the best amongst the poor are never grateful. They are ungrateful, discontented, disobedient, and rebellious. They are quite right to be so. Charity they feel to be a ridiculously inadequate mode of partial restitution, or a sentimental dole, usually accompanied by some impertinent attempt on the part of the sentimentalist to tyrannise over their private lives. Why should they be grateful for the crumbs that fall from the rich man’s table? They should be seated at the board, and are beginning to know it. As for being discontented, a man who would not be discontented with such surroundings and such a low mode of life would be a perfect brute. Disobedience, in the eyes of any one who has read history, is man’s original virtue. It is through disobedience that progress has been made, through disobedience and through rebellion. Sometimes the poor are praised for being thrifty. But to recommend thrift to the poor is both grotesque and insulting. It is like advising a man who is starving to eat less. For a town or country labourer to practise thrift would be absolutely immoral. Man should not be ready to show that he can live like a badly-fed animal. He should decline to live like that, and should either steal or go on the rates, which is considered by many to be a form of stealing. As for begging, it is safer to beg than to take, but it is finer to take than to beg. No; a poor man who is ungrateful, unthrifty, discontented, and rebellious is probably a real personality, and has much in him. He is at any rate a healthy protest. As for the virtuous poor, one can pity them, of course, but one cannot possibly admire them. They have made private terms with the enemy and sold their birthright for very bad pottage. They must also be extraordinarily stupid. I can quite understand a man accepting laws that protect private property, and admit of its accumulation, as long as he himself is able under these conditions to realise some form of beautiful and intellectual life. But it is almost incredible to me how a man whose life is marred and made hideous by such laws can possibly acquiesce in their continuance.

The proper aim is to try and reconstruct society on such a basis that poverty will be impossible.

Oscar Wilde, The soul of man under socialism, 1891.

In Carl Sagan's Contact, an alien civilisation discovers Earth, and sends a blueprint for a machine that will transport just five earthlings to another world.  To build the machine, humans have to develop entire new industries and technologies. Once the construction is complete, the human race has to decide which five people can represent them - a delicate exercise that balances the interests of financial clout, geopolitical representation and gender. 

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The world of national and global responses to AIDS often acts a bit like an alien, in its attempts to make good on the principle of actively involving communities and people who are affected in the response.  The reason this principle is so embedded is that those communities spent years being the only ones doing anything about the epidemic, and kicking doors down to get politicians and donors to do something about it.  They had strength in numbers, and millions owe their lives to them. (And I’d estimate that tens if not hundreds of thousands of people, including me, owe their jobs to them).

As the principle has become central to the response to AIDS, the various movers and shakers have looked for ways to enshrine it in policy, to systematize it.  Local, provincial, national AIDS coordination committees are all supposed to have community members on them.  Donors like the Global Fund to fight AIDS, TB and Malaria want to know that various categories of people affected have played a role in designing any projects they fund.  Governments and international advisors, have created space, often because they know that’s where the smart money is.

But the thing is, it’s so damn hard for those who are in charge to make this work - given their assumptions, that is.  As one senior government official said to me last year, “we’re happy to involve the [insert category of marginalized population here], but they need to pick the right representative”.  The right representative.  Right presumably meaning those who will stay broadly on-message, and who understand the ins and outs of epidemiology, evidence-based policy making and global financing.  Good luck with that. 

There is also an expectation that whoever the representatives are, they should represent and reflect the views of their communities.  But these aren’t homogenous communities.  Often their main shared characteristic in common is being HIV-positive or selling sex for a living, or something along those lines.  While people within these categories may well have shared experiences, this doesn’t mean they all want the same things or that they cope in the same way.  People within them often fundamentally disagree with each other in many ways.  The structured, formalised systems for community involvement that are increasingly the norm do have some value, but they cannot resolve conflict or create compliance.  Another UN official once told me she had arranged over 20 meetings with sex workers to "try and get them on common ground".  I would have thought that after 2 or 3 meetings she might have realised she was doing something wrong.

Just like the aliens who may one day come and ask to be taken to our leader, the handful of national policy makers who insist on being accountable to just one or two interlocutors when they are supposed to meet the needs of thousands, are living on another planet.  

Some history

I've been wanting to use this headline for a very long time.  Some years ago the World Bank's Global HIV/AIDS Programme published an operations manual, designed to help governments design and manage "multisectoral" AIDS programmes financed by World Bank grants or loans.  The manual, which ran to several hundred pages, was called "Turning Bureaucrats into Warriors".  A pretty good title actually, emphasising the extraordinary efforts needed to effectively combat AIDS, and hanging on the public health industry's penchant for militaristic terms ("attack rate", "intervention", "target"...). A call to arms.

Around the time Turning Bureaucrats into Warriors was published, I was involved in an advisory capacity - and a little later as a paid consultant - in the implementation of the "civil society" component of a large World Bank AIDS programme in one country.  The primary approach was to provide small grants (around $500-$1000) to hundreds, even thousands of small community groups, to fund them to carry out short-term, small-scale, focussed actions primarily on HIV prevention.  They could pick from a menu of five standardised activities, which included community awareness raising and advocacy with local leaders to speak out about AIDS.  In terms of getting community groups to talk about AIDS for the first time I'd say it was a success, but several years on hardly any of us thinks short term awareness raising projects are of much value.  

Moreover, the quality of what they did was often limited.  I spoke to a number of grant recipients: they received little training to carry out their projects, often waited months for the first disbursement of cash, and sometimes never received the final "tranche" - the 10% they were entitled to on approval of their final report.  The civil servants and NGO workers managing the programme, approving proposals, disbursing funds, and checking reports, were for their part often unimpressed with what community groups did.  Reports wouldn't get approved because they didn't meet the exacting standards, according to which every last penny or cent had to be accounted for and documented with receipts.  Even the half-litres of petrol from the informal market, even the bananas bought from street vendors to demonstrate condom use.  (Previous readers may notice I've used the banana before. Apologies).  

Community groups, many of which desperately wanted to do something, were being constrained in terms of what to do, how long to do it for, and forced to manage their finances as if they were standard players in the market economy.  I couldn't help feeling that what the programme was actually doing was turning warriors into bureaucrats.  Some learned to play the game, others just gave it up altogether.  What was particularly frustrating for me, was that as I worked on the initiative I discovered that the World Bank doesn't require grantees or borrowers to apply this type of financial monitoring to community based projects.  My suggestion to the government warriors running the programme that they adopt the Bank's Community Driven Development approach, which drops the spreadsheets and instead encourages local groups to have their work appraised and monitored by the community they are serving - in other words the community signs off if it is happy that a decent job has been done - met with a stony silence.

Back to the present day

I've been thinking about this experience in the light of what is going on now at the Global Fund to fight AIDS, TB and Malaria.  Just recently, Aidspan published an article that described the double standards the Global Fund operates when giving grants to different types of organisations.  To cut a long story short, International NGOs who receive grants as "Principal Recipients" are allowed to charge an indirect "overhead" based on a percentage of the grant total.  But national NGOs aren't - they are expected to itemise and charge every single head office expenditure if they want the Global Fund to pay for it. Itemising and charging every single item is complicated and quite inefficient, and arguably, on the whole national NGOs have less capacity to do this than international ones.

Whatever happens, it is unlikely that the situation is going to change much for the organisations working under the Principal Recipients: the subrecipients, the sub-sub recipients, the sub-sub-subs... the local community groups.  In other words the same types of organisations that were being funded through World Bank programmes a few years ago.  These small, local organisations: the ones staffed by volunteers, with no computers and often little training, are still expected to account for everything.  And it's not just the bananas and the petrol.  If community groups want funding to do outreach, you can be pretty sure they will be asked to get a list of the names, genders, national ID numbers and signatures of everyone they talk to as "proof" that they actually did the work.  Think about what that means when, for instance, you are trying to build trust with stigmatised groups.  Sign right here to confirm you're a sex worker or homosexual please!  What do you mean you're a woman, your ID card says you're a man!

Community "systems"

It's a topic I keep returning to but, if we're really serious about the idea that community groups and organisations have a major role to play in things like health promotion, and health care, we need another approach.  I suspect government-employed health workers, and local community health centres, aren't expected to jump through the hoops that community groups have to in order to run their services.  The World Bank's "standardised activities" have been superseded by much better evidence of what works, and as I've argued before I think that it isn't unreasonable to ask community groups to stick to certain norms and ethical guidelines when delivery services.  That's not bureaucracy, it is common sense, and moreover these guidelines can be designed in a way that allows groups to adapt them to their contexts.  But we really need to move on from the bean-counting approach.  We need to revisit some of the ideas from the World Bank's community driven development model.  We need to move toward some of the smart ideas coming up in the literature about involving communities themselves in monitoring, and using that mechanism as an incentive to improve services and to make sure money gets spent in a worthwhile way and to keep providers accountable locally, not just accountable to lists of names, activities, and folder-fulls of receipts.  And we need to put in place mechanisms to ensure that community groups get stable, predictable funding, training, and advice, to help them meet the expectations of the people they are working for.  In short, the question of whether NGOs getting grants from the Global Fund get overheads or not is relatively insignificant.

But I'm worried that donors' growing apathy with HIV and civil society, and the Global Fund's increasing risk aversion and attention to strict financial procedures, the emphasis on things that can be counted (and therefore described as "performance") mean that things are about to get much harder for community groups. We shall see.  

Diane Abbott is on the warpath. The shadow health minister responded to the findings of the latest Health Survey for England (HSE), which show that 27% of women aged 16-24 reported having had sex before they reached the age of consent (16 years old). Says Abbott, in an interview with the Guardian:

"The underlying cause must be the 'pornification' of the culture and the increasing sexualisation of pre-adolescent girls. Too many young girls are absorbing from the popular culture around them that they only have value as sex objects. Inevitably, they act this notion out.

"The government needs to respond to spiralling underage sex, not with pointless schemes to teach abstinence, but with better PSHE [personal, social, health and economic] teaching in schools for both girls and boys."

In so doing she rehearses an increasingly popular and nuance-free moral panic about sexualisation and underage sex, which the findings of the research really don't support.  Abbott also perpetuates a damaging perception that in matters of sex, girls and women are always the victims, with boys and men at best invisible and at worst the perpetrators of abuse.  

The problems around how the media and politicians deal with underage sex are explored in this blog post by Petra Boynton.  Elsewhere, Petra also provides a critical take on contemporary discussions of sexualisation (also here) and pornification.

The more you look into this story, however, the more the plot thickens.  Abbott was interviewed by Sarah Boseley, the Guardian's health correspondent.  Her article begins:

More than a quarter of young women today say that they first had sex when they were below the age of 16, a greater proportion than in any previous generation asked about underage sex in an official annual health survey.

Around 27% of women aged between 16 and 24 said they had sex before they reached 16, according to the Health Survey for England. Fewer men in the same age bracket – 22% – said they were under 16 when they first had sex.

"A greater proportion than in any previous generation asked about underage sex in an official annual health survey".  I'm pretty sure there is only one way to interpret this: the implication is that the 27% in the 2010 HSE is higher than in any previous survey.  Now that is odd, since the seminal survey on sexual behaviour was the NATSAL (National Survey of Sexual Attitudes and Lifestyles) which, in 2000, showed that something in the range of 27.2% of girls aged 16-24 reported having initiated sex before the age of 16*.  For boys, the result was around 27.8%, pretty much the same as it was for girls.

(*I say something in the range of because the table reports the results for 16-19 year olds and 20-24 year olds separately, so I've had to go back and work out the percentage for both groups).

To be sure, the NATSAL was sampled in a different way and it covered the whole of Britain (as opposed to just England), but nonetheless how can the 2010 HSE results for girls be reported as being higher than any other national survey?  Especially given that each of these estimates comes with a degree of uncertainty - the NATSAL estimate for girls, for instance, has a 95% confidence interval of (again, roughly) 24.9%-27.2%.  Given that the sample size for the HSE was smaller, the uncertainty of the HSE estimate is likely to be greater.

It's not ideal, then, that the news article doesn't explore the context of the figures.  Perhaps, though, the press release for the HSE was misleading? Here's how it starts:

Some 27 per cent of women aged between 16 and 24 reported having sex when they were below 16 – a greater proportion than women in any previous generation covered by the survey.

Now that's different from the Guardian article, in an interesting way. What does "any previous generation covered by the survey" mean? It could mean any generation covered in a previous HSE survey, but from what I can tell previous HSEs have not systematically asked the same question.  I can't find them in the trend tables that compare HSE results year on year.  In any case if they had, the press office - and the Guardian article - ought to have reported these previous figures.  Note that just like the Guardian and Diane Abbott, the press release focuses on women and girls.  

The press release can be interpreted in another way: what it means is that the proportion of women aged 16-24 reporting having started sex before the age of 16 in the 2010 HSE is greater than the proportion of women in any other age group in the 2010 HSE.  In other words the comparison that is being made is between cohorts of different age groups within the same study.  This is fair enough, providing the risk of response and recall biases for the older cohorts is acknowledged.  I thought it would be interesting to check the proportion among women in the 2010 HSE report who would have been 16-24 at the time of the NATSAL (2000): the 25-34 year olds.  In this group, 18% of the women reported having had sex before the age of 16, and 25% of the men.  Even accounting for confidence intervals, the discrepancy between the 18% of women reported by HSE respondents casting their minds back to what they got up to in the 1990s, and the 27% of women reported by what ought to have been respondents of a similar profile back in 2000, is large.  It's also strange that the NATSAL found similar proportions for boys and girls, but the HSE results, for 25-34 year olds, finds a much higher proportion of boys reporting having had sex before the age of 16.  The studies can't both be right.  Moreover, one might ask: if girls are starting to have sex earlier but boys are increasingly waiting, does that mean girls are increasingly having sex with older men?  That seems to be the implication but where are the data to back that up?  The press release, the Guardian article, and by association Diane Abbott's comments are all misleading.

What of the HSE survey itself?  The report (sexual health section) and the methods can be viewed and deserve to be examined closely.  One or two things immediately leap out, however: the report states that people were asked at what age they had first "had sex".  If President Clinton taught us anything it is that not everyone means the same thing by "had sex".  The question that participants were actually asked was more nuanced, fortunately: "How old were you when you first had sexual intercourse?", but even then I'm not sure how clear it is.  What is harder to understand is that when this question was put to women, they were asked specifically about intercourse with a man; and men were asked about intercourse with women.  So the figures for first sexual intercourse below the age of 16 only relate to sex with someone of the opposite sex.  This leaves no room for different identities or even ambiguities about gender, and while relationships with people of the same sex is explored later in the survey, it seems odd that it is left out here. 

So, we end up with a story that is very hard to interpret: uncertainty about the survey approach, the press release, the media coverage and the political opportunism that it has generates. A perfect storm of poor.

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There are many good sources of information on young people and sexual health in the UK.  If you wish to investigate further, look at the links provided on the blogs of sexedukation and Brook, and the resources that the amazing Bish Training produces, including his resource on porn and young people.

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H/T Petra Boynton for the subject matter of this post, and also for the title.

Earlier this year I went to a meeting on sex work in the global AIDS epidemic. The purpose was to look at the current information on HIV in populations and among sex workers and assess the relationship, and to look at how effective different types of intervention and programme in reducing the risk of HIV among sex workers. Most of the best quality evidence comes from a fairly narrow set of interventions, that have been shown (or not, as the case may be) to have a direct impact on HIV transmission or acquisition. Things like vaginal microbicides, presumptive STI testing and treatment, HIV testing, peer education, and condom distribution and counselling.  Things that, to all intents and purposes, "look" like HIV interventions.

Of course, for an intervention to be discussed as part of the evidence base, there has to be decent evidence - whether it is evidence of positive effects or of negative ones.  So some things didn't come up in the discussion, despite being widely implemented in the context of HIV programmes, because there is no evidence of their impact. Things like microfinance and income generating projects aimed at reducing numbers of sex workers, which I began to review a few years ago and never properly finished... but take my word for it, there isn't much in the way of quality research or good theory for this approach. Although the approach does not feature prominently in the current UNAIDS guidance on sex work and HIV, it remains a central pillar of the US government's strategy on HIV and sex work.

Untested approaches are at best a waste of money and at worst actually harmful.  It is certainly the case that economic programmes such as these only reach a fraction of the numbers reached by "classic" HIV programmes, for the same amount of money.

But what is more alarming is the things that don't come up in the discussion of the programme evidence base, despite there being a pretty strong association between them and HIV.  On Saturday December 17th, it is the International Day to End Violence Against Sex Workers, and I am talking about violence.  Time and again, sex workers tell us that the criminalised nature of sex work, and in particular the role played by law enforcement agents and health care workers in committing violence and in failing to address it properly, mean that violence is one of the biggest risks they face, and is a far more immediate threat than HIV.  The epidemiological association between violence and HIV has also been documented in a number of observational studies: in Bangladesh, in Cambodia, in India and in Kenya, for instance.  Other reviews can be found here (disclosure: I wrote that one), and here.

But as with income generation strategies, because hardly any well designed intervention studies have looked at how best to tackle violence, fighting violence against sex workers as a means of tackling HIV doesn't come up in many systematic reviews on HIV prevention with sex workers.  To be sure, many HIV programmes acknowledge that it is an issue but they generally don't do much to tackle it - and of course there is hardly any commitment to tackling the laws and attitudes that make it so easy for the perpetrators of violence to get away with it.  When tackling violence does appear in programme plans, it is often something along the lines of "training police officers to refrain from violence".  Or, as Cheryl Overs would put it, sending them to workshops with a nice buffet lunch and a perdiem for the purpose of telling them something they already know, rather than handing them a ticket to a jail cell. "Sure, there is a role for the carrot, but justice demands some stick too sometimes".

Funding proposals that do attempt to tackle violence are required to demonstrate and justify how their efforts will directly impact HIV transmission.  When it comes to sex workers, violence is not seen as something worth tackling in its own right.  

Sure enough, during the meeting I talked about at the top, someone pointed out that tackling violence against sex workers was unlikely to appear in any evidence-based guidelines on how to design HIV programmes for sex workers because the evidence base is so weak.  But the thing is, when the discussion is about young women, or men who have sex with men, or children, building efforts that tackle violence into HIV programmes irrespective of the evidence for a link between violence and HIV is a no-brainer; and rightly so.

Which explains the angrily scrawled note which I passed to the person sat next to me and which you saw at the start of this post.

Another World AIDS Day comes round, and while the main players can't seem to decide what the theme is for 2011 ("be an activist" according to UNAIDS; "getting to zero" according to the World AIDS Campaign; "leading with science, uniting for action" according to the US government), it is clear that there are two issues that are dominating all of the current discussions about the fight against the pandemic: the major advances in the technologies used to fight HIV transmission, and the abrupt and significant decrease in the funding being made available to pay for them.  

Secretaty Clinton talked, a few weeks ago, about the US government's commitment to a "combination" approach to HIV prevention based on proven technologies to prevent mother-to-child transmission, on male circumcision, and on making the most of the now-proven fact that putting people on treatment significantly reduces the chances they will transmit the virus onwards.  In her speech she stated that creating an AIDS-free generation was now official US policy.

More recently still the Global Fund to fight AIDS, TB and Malaria, set up only ten years ago to channel funding to efforts to fight these three diseases, announced that because most of its donors have failed to commit enough funding, and indeed because many haven't even paid what they promised, it is suspending funding for new grants and proposing a new model which will take account of the reduction in funds available.

Much of the commentary on World AIDS Day 2011 is likely to focus on the disconnect between the optimism of knowing "what works" and the failure of donor governments to keep their promises.  I think this article from the Instute of Development Studies sums up the ambivalence very well.  But it also talks about some of the other challenges: the challenges of implementation.

I've been trying to sum up how I think my year as a freelancer working to support AIDS programmes has gone.  Earlier today I sent a few tweets:

World AIDS Day, I met a MSM* peer educator in Madagascar in March; he died of AIDS 2 weeks after I met him because docs didn't want to know.

("men who have sex with men" - actually, he identified as gay but its hard to explain this in 140 characters)

World AIDS Day, also thinking about many people with HIV in Benin who said they often default on treatment bcs drugs don't arrive on time.

World AIDS Day, also thinking abt sex workers in Namibia, struggling to convince donors that they need more than just condoms and HIV tests.

World AIDS Day, also thinking of the month I wasted helping an NGO write proposal it was incapable of implementing. Luckily it wasn't funded.

I wasn't going to say anything else, but then it occurred to me that, with the exception of the last one, none of these issues has much to do with either the lack of money or the existence of new technologies. These problems were happening irrespective of whether men have foreskins or not, and irrespective of the preventive effect of ARV treatment.  Madagascar has plenty of money for ARVs and only has to keep a few hundred people on treatment, and yet there are failures when it comes to stigmatised populations.  Benin is a small country, with reasonable grants for HIV treatment, but somehow many people with HIV still face problems getting their drugs regularly.  The situation faced by sex workers in Namibia is faced by sex workers around the world. Despite explaining how badly they get treated by health care workers, or how often they get beaten up and extorted by cops, the default mode for HIV programmes seems to be to give them leaflets and condoms.

As for the last tweet... well, that is about the money, and about what happens when big institutions end up searching high and low for ways of justifying their existence.

As we move into the fourth decade of the fight against HIV and AIDS, promoting the amazing new tools at our disposal and demanding the funds to pay for them, I hope we won't lose sight of the fact that there's an awful lot of other stuff the AIDS response needs to start fixing and doing better if the technology and the money is going to make a difference.