Sex, Drugs and HIV — Let’s get rational by Elizabeth Pisani (Transcript)

Transcript – Elizabeth Pisani on Sex, Drugs and HIV — Let’s get rational at TED 2010

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Elizabeth Pisani – Author

“People do stupid things. That’s what spreads HIV.” This was a headline in a UK newspaper, The Guardian, not that long ago. I’m curious, show of hands, who agrees with it? Well, one or two brave souls.

This is actually a direct quote from an epidemiologist who’s been in field of HIV for 15 years, worked on four continents, and you’re looking at her.

And I am now going to argue that this is only half true. People do get HIV because they do stupid things, but most of them are doing stupid things for perfectly rational reasons.

Now, rational is the dominant paradigm in public health, and if you put your public health nerd glasses on, you’ll see that if we give people the information that they need about what’s good for them and what’s bad for them, if you give them the services that they can use to act on that information, and a little bit of motivation, people will make rational decisions and live long and healthy lives. Wonderful.

That’s slightly problematic for me because I work in HIV, and although I’m sure that you all know that HIV is about poverty and gender inequality, and if you were at TED ’07 it’s about coffee prices… Actually, HIV is about sex and drugs, and if there are two things that make human beings a little bit irrational, they are erections and addiction.

So, let’s start with what’s rational for an addict.

Now, I remember speaking to an Indonesian friend of mine, Frankie. We were having lunch and he was telling me about when he was in jail in Bali for a drug injection. It was someone’s birthday, and they had very kindly smuggled some heroin into jail, and he was very generously sharing it out with all of his colleagues. And so everyone lined up, all the smackheads in a row, and the guy whose birthday it was filled up the fit, and he went down and started injecting people.

So he injects the first guy, and then he’s wiping the needle on his shirt, and he injects the next guy. And Frankie says, “I’m number 22 in line, and I can see the needle coming down towards me, and there is blood all over the place. It’s getting blunter and blunter. And a small part of my brain is thinking, ‘That is so gross and really dangerous,’ but most of my brain is thinking, ‘Please let there be some smack left by the time it gets to me. Please let there be some left.'” And then, telling me this story, Frankie said, “You know … God, drugs really make you stupid.”

And, you know, you can’t fault him for accuracy. But, actually, Frankie, at that time, was a heroin addict and he was in jail. So his choice was either to accept that dirty needle or not to get high. And if there’s one place you really want to get high, it’s when you’re in jail.

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But I’m a scientist and I don’t like to make data out of anecdotes, so let’s look at some data.

We talked to 600 drug addicts in three cities in Indonesia, and we said, “Well, do you know how you get HIV?”

“Oh yeah, by sharing needles.” I mean, nearly 100%. Yeah, by sharing needles.

And, “Do you know where you can get a clean needle at a price you can afford to avoid that?”

“Oh yeah.” Hundred percent. “We’re smackheads; we know where to get clean needles.”

“So are you carrying a needle?” We’re actually interviewing people on the street, in the places where they’re hanging out and taking drugs. “Are you carrying clean needles?” One in four, maximum.

So no surprises then that the proportion that actually used clean needles every time they injected in the last week is just about one in 10, and the other nine in 10 are sharing.

So you’ve got this massive mismatch; everyone knows that if they share they’re going to get HIV, but they’re all sharing anyway.

So what’s that about? Is it like you get a better high if you share or something? We asked that to a junkie and they’re like, “Are you nuts?” You don’t want to share a needle anymore than you want to share a toothbrush even with someone you’re sleeping with. There’s just kind of an ick factor there. “No, no. We share needles because we don’t want to go to jail.”

So, in Indonesia at this time, if you were carrying a needle and the cops rounded you up, they could put you into jail. And that changes the equation slightly, doesn’t it? Because your choice now is either I use my own needle now, or I could share a needle now and get a disease that’s going to possibly kill me 10 years from now, or I could use my own needle now and go to jail tomorrow.

And while junkies think that it’s a really bad idea to expose themselves to HIV, they think it’s a much worse idea to spend the next year in jail where they’ll probably end up in Frankie’s situation and expose themselves to HIV anyway. So, suddenly it becomes perfectly rational to share needles.

Now, let’s look at it from a policy maker’s point of view. This is a really easy problem. For once, your incentives are aligned. We’ve got what’s rational for public health. You want people to use clean needles — and junkies want to use clean needles. So we could make this problem go away simply by making clean needles universally available and taking away the fear of arrest.

Now, the first person to figure that out and do something about it on a national scale was that well-known, bleeding heart liberal Margaret Thatcher. And she put in the world’s first national needle exchange program, and other countries followed suit: Australia, The Netherlands and few others. And in all of those countries, you can see, not more than 4% ever became infected with HIV of injectors.

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Now, places that didn’t do this — New York City for example, Moscow, Jakarta — we’re talking, at its peak, of one in two injectors infected with this fatal disease.

Now, Margaret Thatcher didn’t do this because she has any great love for junkies. She did it because she ran a country that had a national health service. So, if she didn’t invest in effective prevention, she was going to have to pick up the costs of treatment later on, and obviously those are much higher. So she was making a politically rational decision.

Now, if I take out my public health nerd glasses here and look at these data, it seems like a no-brainer, doesn’t it? But in this country, where the government apparently does not feel compelled to provide health care for citizens, we’ve taken a very different approach.

So what we’ve been doing in the United States is reviewing the data — endlessly reviewing the data. So, these are reviews of hundreds of studies by all the big muckety-mucks of the scientific pantheon in the United States, and these are the studies that show needle programs are effective — quite a lot of them.

Now, the ones that show that needle programs aren’t effective — you think that’s one of these annoying dynamic slides and I’m going to press my dongle and the rest of it’s going to come up, but no — that’s the whole slide.

There is nothing on the other side. So, completely irrational, you would think. Except that, wait a minute, politicians are rational too, and they’re responding to what they think the voters want. So what we see is that voters respond very well to things like this and not quite so well to things like this.

So it becomes quite rational to deny services to injectors.

Now let’s talk about sex. Are we any more rational about sex?

Well, I’m not even going to address the clearly irrational positions of people like the Catholic Church, who think somehow that if you give out condoms, everyone’s going to run out and have sex. I don’t know if Pope Benedict watches TEDTalks online, but if you do, I’ve got news for you Benedict — I carry condoms all the time and I never get laid. It’s not that easy! Here, maybe you’ll have better luck.

Okay, seriously, HIV is actually not that easy to transmit sexually. So, it depends on how much virus there is in your blood and in your body fluids. And what we’ve got is a very, very high level of virus right at the beginning when you’re first infected, then you start making antibodies, and then it bumps along at quite low levels for a long time — 10 or 12 years — you have spikes if you get another sexually transmitted infection. But basically, nothing much is going on until you start to get symptomatic AIDS, and by that stage, you’re not looking great, you’re not feeling great, you’re not having that much sex.

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