As I approached this work in South Africa, I did some statistical analyses, and I mainly used the gender inequality index. And that is a number that's derived by the UNDP, or the United Nations Development Program, and it takes into account a couple of things. Women, and how many complete secondary education, it looks at the maternal mortality ratio, or how many women die in childbirth per 100,000, it looks at an adolescent fertility ratio, how many teenagers are getting pregnant. It also looks at labor, how many women are involved in the labor force. And it takes all these statistics and it combines them into one number, and that number is the Gender and Equality Index, and it goes from zero to one, zero being perfect gender parody which no country has, all the way up to, I think one of the highest is 0.75 and that would be Yemen. And so I traced the gender inequality index with the prevalence of HIV around the world, and although there's a smattering of data on the plot, there is a trend so that the worse the gender inequality, the higher the prevalence of HIV. One notable exception is that most of the Muslim countries do not have a high HIV even though they have high gender inequality, and it's theorized that there's something protective about the Islamic religion in HIV acquisition. I then took the analysis one step further and [COUGH] divided countries into whether their epidemics were predominantly heterosexual or predominately non-heterosexual, and by non-heterosexual I mean men who have sex with men or IV drug users. I also looked at those and compared them to the gender and inequality index, and basically found that all countries with a heterosexual epidemic have a high gender inequality index, or conversely, there are no countries with a low gender inequality index that have a heterosexual epidemic. All countries, though, have a small pool of IV drug users and then websites with men that have HIV. And so even though this is an ecological study and there are some problems with that, and these are only associations, you could interpret this as gender inequality being the catalyst that drives HIV out of the higher risk pool of IV drug users and men who have sex with men, and creates the high prevalence heterosexual epidemics that we have today. And if that is the case then it means we should be focusing more on structural interventions, things like reducing gender inequality, because it may be that, if we look at somewhere like in Zimbabwe that has a high gender inequality, high prevalence, what if we really were to reduce the gender inequality index to levels in Finland or Iceland where it's very good? Would we see a very sharp decrease in the HIV prevalence, or, should we follow the paradigm that's being followed today, which is we'll treat ourselves out of the epidemic. Let's give pills to everybody who has HIV, and now let's start giving the pills to people who don't have HIV, the high risk women so that they can be protected from acquiring HIV. And interestingly they've recently done three trials, more, but three big trials, on pre-exposure prophylaxis in high risk HIV women. >> Where? Where is this? >> In Southern Africa. >> And pre-exposure prophylaxis refers to giving instead of, usually people with HIV have a three medicine cocktail to treat their HIV. These studies gave a two medicine HIV cocktail to high-risk women, so they weren't infected at all but they were at high risk, and the idea was if they had drug on board, if they were ever in a situation where they are infected, they could eliminate that infection before it setup. And trials like this actually worked int he US, there was a trial with men who have sex with men, and they took the drug and there was something like 70% to 80% protection for people that had high levels of the drug in their bodies. So they decided to replicate this in southern Africa, and I think the main problem with it was they didn't take into mind that gay men in the US have much more agency than women in southern Africa. They have the ability to understand, decide their risk, and implement interventions if they choose to, on the other hand women in Southern Africa, all the trials failed at least in the women's groups. There was one that was somewhat successful in couples that were discordant, but just in the high risk women the trials failed and they were cancelled early. And when they looked at the data they found that the drug levels were not high in the women, even though the women reported taking them 100%, and so they thought to themselves, okay, why are the women laying to us. They almost blamed the women for being non adherent, and they said okay, well now it's time to bring the social scientists on board to understand why the women aren't taking the drugs. And when I heard them saying that, this was actually one of the researchers said that at one of the recent HIV meetings, I thought to myself you know what? I think the, it's actually the biomedical researchers that could use some social science research, to understand why it is they feel that there must be a biomedical solution for every problem. And I think It reminded me of an experiment that Thomas Kuhn, the famous historian of science, was fond of recollecting, and it goes something like this. They brought participants into a room and they showed them a deck of cards, and they showed them the cards that some of them were mismatched according to suit, so they might have a queen of spades but the spades were red. And they flipped through and they showed them that, and people would be a little bit confused but nobody would, not everyone would identify it right off the bat. And finally, after a little bit of consternation, they would realize that, this was a queen of hearts, even though it was a queen of spades, even though they were calling it a queen of hearts because they saw the red, and it was just the red that made them say that it was a heart. And what this experiment told Thomas Kuhn is that we approach sets of problems with a lens on. When you look at a deck of cards you always expect it to be black spades, red hearts, that's just the way you see the world, and to see it differently takes a bit of a shock to the system. And so analogously, we are in a world where we've come to expect biomedical solutions to every problem, and when you have those lenses on, you look at HIV and prevention and you say okay, there must be a shot, there must be a microbicide, there must be pills that we can take to prevent this. And we don't say to ourselves, maybe if we reduced gender inequality, there wouldn't be this problem in the first place. And so I'll bring this up at meetings and they'll say, you know what it's not either or, we can actually do the pills and we can do the gender and equality, and the gender and equality interventions. And what I've come to find though, and this is I guess my personal evaluation of the situation, is that the authority accorded to biomedical solutions, I really do believe undermines structural intervention. So that when someone with an idea to give pills to the women to prevent HIV comes in the room and presents that, it sucks all of the air out of the room, and the social scientists are not left with much leverage to say, no, no, no, no, no, you know what? If you take the time to really put all the resources we have into abolishing the school fees, and helping girls stay in school until they finish secondary school, and creating situations where women can negotiate condom use, creating situations where women can enter into the labor force easier, that you actually get better prevention than you will by prescribing the pre-exposure prophylaxis. And so that brings me to my current research projects, which are just getting off the ground, I'm slowly getting funding trickling in to fund this. And the idea is to rerun the trial, to give women the pill, the pre exposure prophylaxis, because I need to compare structural intervention with the biomedical intervention. So, one arm of high risk women would have the cocktail, one woman would have the cocktail and the amount of money that it takes to pay for the cocktail, which is usually about $50 per month,as an incentive to take the cocktail, and then the other arm would just have the $50, which is the cost of that intervention. And the $50 would be conditional upon remaining HIV-free with the goal, just saying to them, use this money in any way you want, but do your best to remain HIV-free, and we're going to talk about the ways you can do that. You can either use this to negotiate condom use, you can use it to ask your partner to get tested, you can leave your partner, you can share it with your partner, and yeah, like I said, with the understanding of using more condoms. You can stay with one partner and maybe there's a sugar daddy that you don't need, I mean, there's a variety of mechanisms where they could reduce their risk, and we're not going to tell them which one to do, but we will interview them monthly. And if at the end of a year or two, there is reduced incidence in that arm, I think by exploring with the women how they were able to negotiate their structural risk, we can then focus on those as structural interventions. And so the goal would not be to say okay, we want to just give women money around the world so that they can reduce their risk, it would be to find out how they are negotiating their risk with that empowerment.
