"People do stupid things. That's what spreads HIV." This was a headline in a U.K. newspaper, The Guardian, not that long ago. I'm curious, show of hands, who agrees with it? Well, one or two brave souls.
"Ljudi rade glupe stvari. Zbog toga se širi HIV." To je bio naslov u novinama u Velikoj Britaniji, u Guardianu, ne tako davno. Zanima me, dignite ruke, tko se slaže s tim? Pa, jedna ili dvije hrabre duše.
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.
To je u stvari stvarni citat epidemiologa koji se bavi HIV-om već 15 godina, radio je na četiri kontinenta, i upravo je gledate.
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.
Sada cu pokušati obraniti tezu kako je to tek napola istina. Ljudi doista dobiju HIV zato što rade glupe stvari, ali mnogi od njih rade glupe stvari zbog potpuno razumnih razloga. Dakle, "razumno" je dominantna paradigma u javnom zdravstvu, i ako stavite javnozdravstvene štreberske naočale, vidjet ćete da ako damo ljudima informacije koje su im potrebne, o tome što je dobro za njih, a što loše, ako im pružite usluge koje mogu koristiti da iskoriste te informacije, i nešto motivacije, ljudi će donijeti racionalne odluke i imat će duge i zdrave živote. Predivno.
That's slightly problematic for me because I work in HIV, and although I'm sure 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's about sex and drugs, and if there are two things that make human beings a little bit irrational, they are erections and addiction.
To je pomalo problematično za mene, jer radim sa HIV-om i premda sam sigurna da svi vi znate kako je HIV povezan sa siromaštvom i nejednakosti spolova, a ako ste bili na TED-u 2007. znate da je povezan i s cijenama kave... No, HIV je povezan sa seksom i drogom, i ako postoje dvije stvari koje čine ljude pomalo nerazumnima, to su erekcija i ovisnost.
(Laughter)
(Smijeh)
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."
Hajmo razmisliti što je razumno za ovisnika. Sjećam se kad sam razgovarala sa svojim prijateljem iz Indonezije, Frankiejem. Ručali smo i pričao mi je o vremenu kada je bio u zatvoru na Baliju zbog korištenja droge. Netko je slavio rođendan, i vrlo ljubazno je prokrijumčario nešto heroina u zatvor, i bio je vrlo velikodušan u dijeljenju sa svim svojim kolegama. I tako su se svi poredali, svi narkići u nizu, i tip koji je slavio rodendan je napunio špricu, išao je i uštrcavao je heroin. Tako je uštrcao prvom tipu, onda je obrisao iglu o svoju košulju, pa je uštrcao heroin drugom tipu. I Frankie je rekao, "Ja sam 22. po redu, i vidim iglu kako se mi se približava, i krv je posvuda. Postaje sve tuplja. I mali dio moga mozga razmišlja, 'Ovo je tako odvratno i stvarno opasno', ali veći dio moga mozga razmišlja 'Molim te, neka ostane barem malo kad dođe do mene. Molim te neka ostane barem malo.'" I onda, dok mi je pričao ovu priču, Frankie je rekao, "Znas... pobogu, droga te stvarno učini glupim."
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.
I znate, ne možete reći kako nema pravo. Ali, u stvari, Frankie je u to vrijeme bio ovisnik o heroinu i bio je u zatvoru. Znači njegov izbor je bio ili prihvatiti to prljavu iglu ili ne doživjeti taj vrhunac. I ako postoji ijedno mjesto gdje se želite ušlagirati, to je zatvor.
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 percent. 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.
Ali ja sam znanstvenica i ne želim izvlačiti podatke iz anegdota, pa pogledajmo neke podatke. Razgovarali smo sa 600 ovisnika u tri indonezijska grada, i rekli smo, "Pa, znate li kako se dobije HIV?" "O da, dijeljenjem igala." Mislim, skoro 100 posto. Da, dijeljenjem igala. I, "Znate li gdje možete dobiti čistu iglu po pristupačnoj cijeni, da izbjegnete to?" "O, da!" 100 posto. "Narkići smo, znamo gdje možemo dobiti čiste igle." "Dobro, imate li sada iglu kod sebe?" Intervjuirali smo ljude na ulici, na mjestima gdje se druže i uzimaju drogu. "Imate li čiste igle?" Jedan od četiri, najviše. Stoga nije bilo iznenađujuće da udio ljudi koji je stvarno koristio čiste igle svaki put kada su si davali drogu prošli tjedan bio oko jedan od deset, dok su ostalih devetoro dijelili igle.
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.
Tako da imate ovaj veliki nesrazmjer. Svi znaju da će dobiti HIV ako dijele igle, ali svi ih svejedno dijele. Što je s tim? Je li vrhunac bolji kada dijelite igle ili što? Pitali smo to narkiće i rekli su, "Jesi ti luda?" Ne želiš dijeliti igle isto kao što ne želiš dijeliti četkicu za zube, čak ni s nekim s kim spavaš. To je kao neki "fuj" čimbenik u cijeloj priči. "Ne, ne. Dijelimo igle zato što ne želimo ići u zatvor." Trenutačno u Indoneziji ako nosite iglu i policija vas privede mogu vas smjestiti u zatvor. I to blago mijenja računicu, zar ne? Zato što je sada vaš izbor ili koristiti svoju vlastitu iglu sada, ili dijeliti iglu sada i dobiti bolest koja će me možda ubiti za 10 godina, ili mogu koristiti svoju iglu sada i otići u zatvor sutra. I dok narkići misle kako je jako loše izložiti se HIV-u, misle da je ipak mnogo gora ideja provesti sljedeću godinu u zatvoru, gdje će vjerojatno završiti u Frankievoj situaciji i svejedno se izložiti HIV-u. Tako da odjedamput postaje savršeno razumno dijeliti igle.
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 four percent of injectors ever became infected with HIV.
Pogledajmo to sada sa stajališta ljudi koji stvaraju politiku. To je stvarno jednostavan problem. Odjedamput, vaši poticaji su usklađeni. Imamo ono što je razumno za javno zdravstvo. Želite da ljudi koriste čiste igle – i narkići žele koristiti čiste igle. Tako da jedostavno možemo riješiti ovaj problem tako da učinimo igle dostupnima svima i uklonimo strah od uhićenja. Naime, prva osoba koja je shvatila to i učinila nešto na državnoj razini je bila dobro poznata, iskrena liberalka, Margaret Thatcher. Pokrenula je prvi svjetski program razmjene igala. I ostale su zemlje pratile: Australija, Nizozemska i nekolicina ostalih. I, kao što vidite, u svim tim zemljama manje od četiri posto ljudi koji si ubrizgavaju heroin postanu inficirani HIV-om.
Now, places that didn't do this -- New York City for example, Moscow, Jakarta -- we're talking, at its peak, 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 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, (Laughter) 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.
Sada, u mjestima koja to nisu to ucinila, New York primjerice, Moskva, Jakarta, govorimo u vrijeme vrhunca, jedan od dva korisnika je inficirana ovom smrtonosnom bolesti. Margaret Thatcher nije ovo napravila zato što obožava narkiće. Napravila je to zato što je vodila državu koja je imala socijalnu zdravstvenu zaštitu. Da nije uložila u učinkovitu prevenciju, morala bi kasnije platiti troškove liječenja, koji su očito višestruko veći. Tako da je donijela politički racionalnu odluku. Ako sada izvadim svoje naočale javnozdravstvenog štrebera i pogledam ove podatke, čini se kako ne moramo puno razmišljati, zar ne? Ali u ovoj zemlji, u kojoj se vlada ne osjeća pozvanom da pruži zdravstvenu skrb svojim građanima, (Smijeh) krenuli smo s drugim pristupom. Dakle, ono što smo radili u Sjedinjenim Američkim Državama je pregledavanje podataka – beskrajno pregledavanje podataka. Ovo je, dakle, pregled stotina studija svih glavonja znanstvenog panteona SAD-a, i ovo su studije koje pokazuju da su programi zamjene igala učinkoviti – mnogo njih. Sada studije koje pokazuju da ti programi nisu učinkoviti -- sigurno mislite kako je ovo jedan on onih iritantnih dijapozitiva s animacijom i da ću stisnuti gumbić i da će se pojaviti ostatak, ali ne, ovo je cijeli dijapozitiv.
(Laughter)
(Smijeh)
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.
Nema ništa na drugoj strani. Dakle, pomislili biste, potpuno nerazumno. Ali, pričekajte trenutak, političari su također razumni, i ponašaju se onako kako misle da bi glasači htjeli. I vidimo da ono na što glasači pozitivno reagiraju su stvari poput ove i ne tako pozitivno na stvari poput ove.
(Laughter)
(Smijeh)
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. (Laughter) (Applause) It's not that easy! Here, maybe you'll have better luck.
Tako da postaje prilično razumno uskratiti usluge korisnicima droga. Hajdemo razgovarati o seksu. Jesmo li iole razumniji kada je u pitanju seks? Neću niti komentirati očito nerazumna stajališta ljudi poput Katoličke crkve, koja misli kako ćete dijeljenjem kondoma potaknuti ljude da spavaju zajedno. Ne znam gleda li papa Benedikt TEDTalks na netu, ali ako gledate, imam novosti za Vas, ja uvijek imam kondome sa sobom i nikad se ne ševim. (Smijeh) (Pljesak) Nije to tako jednostavno! Evo, možda ćete vi biti bolje sreće.
(Applause)
(Pljesak)
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.
U redu, ali ozbiljno, HIV se u stvari ne može prenijeti tako lako spolnim putem. Dakle, ovisi o tome koliko je virusa prisutno u vašoj krvi i tjelesnim tekućinama. I ono što imamo je izrazito visoka razina virusa točno na početku, kada postanete zaraženi, onda počnete proizvoditi protutijela, i onda se održava na dosta niskim razinama dugo vremena, 10 ili 12 godina, imate povišenja ako dobijete drugu spolno prenosivu bolest. Ali, u osnovi se ne događa mnogo toga sve dok ne počnete dobivati simptome AIDS-a, a u tom stadiju ne izgledate bajno, ne osjećate se odlično, ne seksate se toliko puno.
So the sexual transmission of HIV is essentially determined by how many partners you have in these very short spaces of time when you have peak viremia. Now, this makes people crazy because it means that you have to talk about some groups having more sexual partners in shorter spaces of time than other groups, and that's considered stigmatizing. I've always been a bit curious about that because I think stigma is a bad thing, whereas lots of sex is quite a good thing, but we'll leave that be. The truth is that 20 years of very good research have shown us that there are groups that are more likely to turnover large numbers of partners in a short space of time. And those groups are, globally, people who sell sex and their more regular partners. They are gay men on the party scene who have, on average, three times more partners than straight people on the party scene. And they are heterosexuals who come from countries that have traditions of polygamy and relatively high levels of female autonomy, and almost all of those countries are in east or southern Africa. And that is reflected in the epidemic that we have today.
Tako da spolno prenošenje HIV-a je u stvari određeno s brojem partnera koji imate u ovim kratkim vremenskim razmacima kada imate vršnu viremiju. E pa, ovo izluđuje ljude zato što morate razgovarati o tome da neke skupine imaju više spolnih partnera u kraćem vremenskom periodu od drugih skupina, a to se smatra stigmatizacijom. Uvijek bi mi to bilo zanimljivo jer mislim kako je stigma loša stvar, dok je mnogo seksa prilično dobra stvar, ali pustit ćemo to na miru. Istina je kako je 20 godina vrlo dobrog istraživanja pokazalo da postoje skupine koje imaju veću vjerojatnost da će imati veliki broj partnera u kratkom vremenskom periodu. A, globalno, te su skupine ljudi koji prodaju seks i njihovi učestaliji partneri. Potom, homoseksualci na noćnoj sceni koji u prosjeku imaju tri puta više partnera od heteroseksualaca na noćnoj sceni Potom heteroseksualci iz zemalja koje imaju tradiciju poligamije i relativno visoku razinu autonomije žena, i skoro sve te zemlje se nalaze u istočnoj i južnoj Africi. I to se očituje u epidemiji koju imamo danas.
You can see these horrifying figures from Africa. These are all countries in southern Africa where between one in seven, and one in three of all adults, are infected with HIV. Now, in the rest of the world, we've got basically nothing going on in the general population -- very, very low levels -- but we have extraordinarily high levels of HIV in these other populations who are at highest risk: drug injectors, sex workers and gay men. And you'll note, that's the local data from Los Angeles: 25 percent prevalence among gay men. Of course, you can't get HIV just by having unprotected sex. You can only HIV by having unprotected sex with a positive person.
Možete vidjeti ove zastrašujuće brojke iz Afrike. Ovo su sve zemlje južne Afrike, gdje je između jednog od sedam i jednog od troje svih odraslih ljudi inficirano HIV-om. U ostatku svijeta se praktički ništa ne događa u općoj populaciji, vrlo, vrlo niske razine, ali imamo iznimno visoku razinu HIV-a u ovim drugim poplacijama koji imaju veći rizik: narkomani, prostitutke i homoseksualci. I primjetit ćete, ovo su lokalni podaci iz Los Angelesa: 25 postotna prevalencija medu homoseksualcima. Dakako, ne možete dobiti HIV samo zato što imate nezaštićeni spolni odnos. Možete dobiti HIV samo ako imate nezaštićeni odnos s HIV pozitivnom osobom.
In most of the world, these few prevention failures notwithstanding, we are actually doing quite well these days in commercial sex: condom use rates are between 80 and 100 percent in commercial sex in most countries. And, again, it's because of an alignment of the incentives. What's rational for public health is also rational for individual sex workers because it's really bad for business to have another STI. No one wants it. And, actually, clients don't want to go home with a drip either. So essentially, you're able to achieve quite high rates of condom use in commercial sex.
U većem dijelu svijeta, bez obzira na manjkavost prevencije, dosta se dobro držimo ovih dana u komercijalnom seksu: postotak upotrebe kondoma je između 80 i 100 posto u komercijalnom seksu u većini zemalja. I, opet, to je zbog usklađivanja inicijativa. Što je razumno za javno zdravstvo je isto tako razumno i za pojedine seksualne radnike, zato što je jako loše za posao ako imate još jednu spolno prenosivu infekciju. Nitko je ne želi. I, u stvari, ni mušterije ne žele doći kući s kapavcem. Tako da u biti, možete postići vrlo visoke razine upotrebe kondoma u komercijalnom seksu.
But in "intimate" relations it's much more difficult because, with your wife or your boyfriend or someone that you hope might turn into one of those things, we have this illusion of romance and trust and intimacy, and nothing is quite so unromantic as the, "My condom or yours, darling?" question. So in the face of that, you really need quite a strong incentive to use condoms.
Ali u "intimnim" odnosima mnogo je teže, jer s vašom ženom ili dečkom ili s nekim za koga se nadate da će postati nešto od tog dvoje, imamo tu iluziju romantike i povjerenja i intimnosti, i ništa nije toliko neromantično kao pitanje "Moj ili tvoj kondom, draga?" Dakle, suočeni s time morate imati dosta jaki poticaj za korištenje kondoma.
This, for example, this gentleman is called Joseph. He's from Haiti and he has AIDS. And he's probably not having a lot of sex right now, but he is a reminder in the population, of why you might want to be using condoms. This is also in Haiti and is a reminder of why you might want to be having sex, perhaps. Now, funnily enough, this is also Joseph after six months on antiretroviral treatment. Not for nothing do we call it the Lazarus Effect. But it is changing the equation of what's rational in sexual decision-making. So, what we've got -- some people say, "Oh, it doesn't matter very much because, actually, treatment is effective prevention because it lowers your viral load and therefore makes it more difficult to transmit HIV." So, if you look at the viremia thing again, if you do start treatment when you're sick, well, what happens? Your viral load comes down. But compared to what? What happens if you're not on treatment? Well, you die, so your viral load goes to zero. And all of this green stuff here, including the spikes -- which are because you couldn't get to the pharmacy, or you ran out of drugs, or you went on a three day party binge and forgot to take your drugs, or because you've started to get resistance, or whatever -- all of that is virus that wouldn't be out there, except for treatment.
Primjerice, ovo je gospodin koji se zove Joseph. Sa Haitija je i ima AIDS. I vjerojatno se u ovom trenutku puno ne seksa, ali je podsjetnik u populaciji zašto biste htjeli koristiti kondome. Ovo je isto snimljeno na Haitiju i podsjetnik je zašto biste se možda htjeli seksati. No, zanimljivo je da je ovo isto Joseph nakon šest mjeseci antiretrovirusne terapije. Ne zovemo ovo Lazarov učinak bez razloga. Ali ovo mijenja računicu o tome što je razumno u donošenju odluka o spolnom odnosu. Dakle, ono što imamo... Neki ljudi govore "To i nije toliko važno, jer je liječenje u stvari učinkovita prevencija, jer smanjuje vašu razinu virusa u krvi i zbog toga je teže prenijeti HIV." I ako opet pogledate graf viremije, ako počnete liječenje kad ste bolesni, što se dogodi? Vaša razina virusa u krvi padne. Ali u usporebi s čim? Što se dogodi ako se ne liječite? Pa, umrete, i vaša razina virusa padne na nulu. I ovo zeleno na grafu, uključujući vrškove, koji se javljaju zato što niste uspjeli doći do ljekarne, ili im je ponestalo lijekova, ili ste tri dana partijali i zaboravili ste uzeti lijekove, ili ste počeli razvijati otpornost, ili štogod, sve to znači kako je virus prisutan, samo zbog liječenja.
Now, am I saying, "Oh, well, great prevention strategy. Let's just stop treating people." Of course not, of course not. We need to expand antiretroviral treatment as much as we can. But what I am doing is calling into question those people who say that more treatment is all the prevention we need. That's simply not necessarily true, and I think we can learn a lot from the experience of gay men in rich countries where treatment has been widely available for going on 15 years now. And what we've seen is that, actually, condom use rates, which were very, very high -- the gay community responded very rapidly to HIV, with extremely little help from public health nerds, I would say -- that condom use rate has come down dramatically since treatment for two reasons really: One is the assumption of, "Oh well, if he's infected, he's probably on meds, and his viral load's going to be low, so I'm pretty safe."
Govorim li "Oh, odlična strategija prevencije. Hajdemo prestati liječiti ljude." Naravno da ne, naravno da ne. Moramo proširiti liječenje antiretrovirusnim lijekovima što više možemo. Ali dovodim u pitanje tvrdnje ljudi koji kažu kako je više liječenja sva prevencija koju trebamo. To jednostavno nije nužno tako, i mislim da možemo mnogo naučiti iz iskustva homoseksualaca bogatih zemalja, gdje je liječenje široko dostupno zadnjih 15 godina. I ono što smo vidjeli da se razina korištenja kondoma, koja je bila vrlo visoka, i homoseksualna zajednica se vrlo brzo prilagodila na HIV, uz vrlo malo pomoći javnozdravstvenih štrebera, rekla bih, no razina korištenja kondoma je dramatično pala otkako je počelo liječenje zbog dva razloga. Jedan je pretpostavka, "Pa dobro, ako je inficiran, vjerojatno pije lijekove, i njegova razina virusa je niska, pa sam prilično siguran."
And the other thing is that people are simply not as scared of HIV as they were of AIDS, and rightly so. AIDS was a disfiguring disease that killed you, and HIV is an invisible virus that makes you take a pill every day. And that's boring, but is it as boring as having to use a condom every time you have sex, no matter how drunk you are, no matter how many poppers you've taken, whatever? If we look at the data, we can see that the answer to that question is, mmm.
A druga stvar je da se ljudi jednostavno ne boje HIV-a toliko koliko su se bojali AIDS-a, i s razlogom. AIDS je bila bolest koja vas je unakazila i ubila, a HIV je nevidljivi virus zbog kojeg uzmeš tabletu svaki dan. I to je zamorno, ali je li jednako zamorno kao korištenje kondoma svaki put kad se seksaš, bez obzira koliko si pijan, bez obzira na to koliko si poppera uzeo, štogod? Ako pogledamo podatke, možemo vidjeti da je odgovor na to pitanje mmmm...
So these are data from Scotland. You see the peak in drug injectors before they started the national needle exchange program. Then it came way down. And both in heterosexuals -- mostly in commercial sex -- and in drug users, you've really got nothing much going on after treatment begins, and that's because of that alignment of incentives that I talked about earlier. But in gay men, you've got quite a dramatic rise starting three or four years after treatment became widely available. This is of new infections.
Ovo su podaci iz Škotske. Vidite vrh kod intravenskih korisnika prije nego je počeo nacionalni program zamjene igala. I od tada je jako pao. I kod heteroseksualaca, većinom u komercionalnom seksu, i kod ovisnika o drogama, ne događa se mnogo toga nakon početka liječenja, i to je zbog onog usklađivanja inicijativa o kojem sam ranije govorila. Ali kod homoseksualaca, imate dramatičan porast koji počinje tri-četiri godine nakon što je liječenje postalo široko dostupno. Ovo su nove infekcije.
What does that mean? It means that the combined effect of being less worried and having more virus out there in the population -- more people living longer, healthier lives, more likely to be getting laid with HIV -- is outweighing the effects of lower viral load, and that's a very worrisome thing. What does it mean? It means we need to be doing more prevention the more treatment we have.
Što to znači? To znači da združeni učinak manje zabrinutosti i veće prisutnosti virusa u populaciji, više ljudi koji žive duže, zdravije, koji imaju veću vjerojatnost da će spavati s nekim s HIV-om, prevaguje učinak nižih razina virusa u krvi, a to je vrlo zabrinjavajuća stvar. Što to znači? To znači da moramo vršiti više prevencije što imamo više liječenja.
Is that what's happening? No, and I call it the "compassion conundrum." We've talked a lot about compassion the last couple of days, and what's happening really is that people are unable quite to bring themselves to put in good sexual and reproductive health services for sex workers, unable quite to be giving out needles to junkies. But once they've gone from being transgressive people whose behaviors we don't want to condone to being AIDS victims, we come over all compassionate and buy them incredibly expensive drugs for the rest of their lives. It doesn't make any sense from a public health point of view.
Događa li se to? Ne, i ja to nazivam "zagonetkom suosjećanja". Puno smo pričali o suosjećanju zadnjih nekoliko dana, a ono što se stvarno događa je da se ljudi ne mogu natjerati da osposobe dobru zdravstvenu spolnu i reproduktivnu skrb za seksualne radnike, i da dijele igle narkićima. Ali kada oni prestanu biti prekršitelji, čije ponašanje ne želimo odobravati i postanu žrtve AIDS-a, postanemo suosjećajni i kupujemo im neopisivo skupe lijekove ostatak njihova života. Nema nikakvog smisla sa stajališta javnog zdravstva.
I want to give what's very nearly the last word to Ines. Ines is a a transgender hooker on the streets of Jakarta; she's a chick with a dick. Why does she do that job? Well, of course, because she's forced into it because she doesn't have any better option, etc., etc. And if we could just teach her to sew and get her a nice job in a factory, all would be well. This is what factory workers earn in an hour in Indonesia: on average, 20 cents. It varies a bit province to province. I do speak to sex workers, 15,000 of them for this particular slide, and this is what sex workers say they earn in an hour. So it's not a great job, but for a lot of people it really is quite a rational choice. Okay, Ines.
Želim dati posljednju riječ Ines. Ines je transrodna prostitutka na ulicama Jakarte. Ona je ženska s pimpekom. Zašto se bavi tim poslom? Naravno, zato što je prisiljena da to radi, zato što nema boljih opcija, itd., itd. I kad bismo je samo naučili šivati i našli joj dobar posao u tvornici, bila bi dobro. I ovoliko radnici u tvornici zarade na sat u Indoneziji: u prosjeku, 20 centi. Malo varira od provincije do provincije. Razgovarala sam sa radnicama u seksualnoj industriji, njih 15.000 za ovaj dijapozitiv i kažu kako toliko zarade na sat. Dakle to nije odličan posao, ali za mnoge ljude stvarno je razuman odabir. U redu, Ines.
We've got the tools, the knowledge and the cash, and commitment to preventing HIV too.
Imamo mnogo oruđa, znanja i love, i predanosti za prevenciju HIV-a.
Ines: So why is prevalence still rising? It's all politics. When you get to politics, nothing makes sense.
Ines: I zašto prevalencija jos uvijek raste? To je politika. Kada dođete do politike, više ništa nema smisla.
Elizabeth Pisani: "When you get to politics, nothing makes sense." So, from the point of view of a sex worker, politicians are making no sense. From the point of view of a public health nerd, junkies are doing dumb things. The truth is that everyone has a different rationale. There are as many different ways of being rational as there are human beings on the planet, and that's one of the glories of human existence. But those ways of being rational are not independent of one another, so it's rational for a drug injector to share needles because of a stupid decision that's made by a politician, and it's rational for a politician to make that stupid decision because they're responding to what they think the voters want. But here's the thing: we are the voters. We're not all of them, of course, but TED is a community of opinion leaders. And everyone who's in this room, and everyone who's watching this out there on the web, I think, has a duty to demand of their politicians that we make policy based on scientific evidence and on common sense. It's going to be really hard for us to individually affect what's rational for every Frankie and every Ines out there, but you can at least use your vote to stop politicians doing stupid things that spread HIV.
Elizabeth Pisani: "Kada dođete do politike, više ništa nema smisla." Dakle, sa stajališta seksualne radnice političari nemaju smisla. Sa stajališta javnozdravstvenog štrebera, narkići rade glupe stvari. Istina je da svatko ima drugačiju logičku podlogu. Postoji toliko različitih načina da budete razumni koliko ima ljudi na zemlji, i to je jedna od predivnih stvari ljudskog postojanja. Ali ti načini da budemo razumni nisu međusobno nezavisni, tako da je razumno za intravenskog korisnika dijeliti igle zbog glupe odluke koju je donio političar, i razumno je da političar donese tu glupu odluku jer odgovaraju na ono što misle da glasači žele. Ali u ovome je stvar: mi jesmo glasači. Naravno, nismo svi, ali TED jest zajednica ljudi koji oblikuju mišljenja. I svatko tko je u ovoj prostoriji i svatko tko ovo gleda na netu, mislim kako ima dužnost zahtjevati od svojih političara da donose odluke temeljene na znanstvenim dokazima i zdravom razumu. Bit će nam teško da pojedinačno utječemo na ono što je razumno za svakog Frankieja i svaku Ines, ali možete barem iskoristiti svoj glas da zaustavite političare da rade glupe stvari koji šire HIV.
Thank you.
Hvala.
(Applause)
(Pljesak)