Perhaps Americans should rewrite the tax code and restrict the ability of charities to set their own private foreign policy. However, I think the externalities these charities can create for America, such as positive feelings about the United States should be included in the calculations.

Also, don’t discount the ability of private firms in the United States to use government agencies to push an agenda overseas. I remember a friend who was working in East Africa telling me about the anger directed toward United States relief efforts. I was, at first, surprised that locals had very mixed feelings about receiving excess American grain. Until he explained that local farmers complained that they could not make a living farming when the United States was giving away grain (which did not always go to the most needy, but just entered the general market for grain because of government corruption etc.) Some of the more strident farmers claimed that it was a plot by the United States (and corporate interests) to encourage dependency.

On the Aids issue: A possible solution, devoid of moral restrictions, but still following Judge Posner’s logic, might suggest that the Gates Foundation should be running whorehouses in Africa.

The Gates could recruit prostitutes, raise salaries, and require that they keep clean houses (no unsafe sex, regular check-ups, etc.). Increased incomes and status for female prostitutes made possible from a Gates (or other foundation grant) could have, if you will pardon the phrase, the biggest bang for your charity buck.

Pay a premium for uncircumcised females, a discount to circumscribed males, fire prostitutes who don’t practice safer sex, etc. and you might create real social change. Not all positive changes, but if you want to concentrate on reducing Aids it may get you much closer to your goal.

I don’t think any current African governments are doing much to help female prostitutes, or females generally, so the crowding out issue becomes mute.

In combination with strict laws against freelance prostitutes, the government could grant (or sell) cathouse licenses to a private foundation, or have them government run, and have a real impact on Aids infections in Africa.

Rather then claim that private charity money is by nature largely wasteful, we should concentrate on new creative enterprises that generate the enthusiastic support of local politicians. What African despot could resist the profits from monopolistic bordellos that come with international subsidizes.

Heck, while I am going crazy, why not tax the whorehouses and use the revenue to finance the purchase of Aids medications.

Of course, the Gates would not, I think, enjoy being depicted as a pimp and madam in the international press. So the desire to look good is more important then to do good, so perhaps we should get rid of the tax advantages for these private foundations.

I leave the relative merits to others.

Sorry
a discount to circumcised males

not

a discount to circumscribed males

The whole logical underpinning of the African AIDS Epidemic makes little or no sense to me. Poverty and disease are rampant in sub-Saharan Africa and I don't understand how anything approaching meaningful statistical reporting and testing can be done. People are dying there certainly, but the WHO definition of AIDS is so vague that if you or I went to Africa and caught a flu bug we'd be classified as an AIDS patient. I sense that much of the AIDS hysteria in Africa and the subsequent tacit acceptance of it in the US media is a way of "getting the message out" (and therefore perhaps expiating some guilt) about African misery by connecting it to a disease that has a place in the US consciousness.

Am I wrong? Most of the studies and numbers I've seen are fairy tales made by interested parties.
Who can impartially answer these questions?

Judge Posner or anyone else:

I wish you would explain why you think sexual abstinence won't work, but that promotion of condom use can prevent spread of disease?

It seems pretty simple to avoid HIV/AIDS: Wait till you're married before having sex and don't share needles.

I am one with Alvin: why not support abstinence, which is the only 100% effective way?

Alvin/Joel
Because sadly, it doesn't work. In the long run, advocating abstinence is a viable strategy. But in the short run [like, a generation], it doesn't work. Abstinence is essentially a values issue - most people won't abstain if the choice is abstinence or safe sex, unless they value abstinence for another reason. An alternative to abstinence is necessary at least during a transitional period, in which the value of abstinence is instilled.

"The causes include profound ignorance about the disease (due in part to superstition)..."

Due in far larger part to the Roman Catholic Church, which continues to insist that using a condom is a sin.

KipEsquire,
I'd argue that the Roman Catholic Church has less to do with the lack of condom use in Africa as does superstition, and African tribal religions.

After all, just 7% of South Africans are Roman Catholics, with an unknown but certainly higher percentage (I am guessing about 20%) being atheistic or subscribing to some form of tribal religion or superstition.

To Alvin:

95% of the American population engages in premarital sex, and has for generations. If the abstinence message doesn't work here, why should it work in sub-Saharan Africa? Condoms /are/ effective-- if they're used. Increasing the social and economic status of women would be a significant step in combating AIDS, as it would allow women greater power in insisting on the use of safer sex practices.

On average, Americans are more promiscuous than the citizens of African countries with even the worst rates of HIV infection. The difference is that Americans are far more likely to use protection than are their African counterparts.

The kind of promiscuity you are talking about seems a little incredibles, in that it would have to involve an unenending string of serial partners of both sexes. I can understand different moral standards or norms, but is there some big sex party in Africa none of us know about? The numbers and sexual practices don't differ significantly from the US where AIDS is virtually exclusive to the gay community. As I said earlier, none of this makes any sense.

The total amount of money spent fighting AIDS in other than the wealthy countries has been estimated at $8.3 billion a year,...

On the subject of inefficiency, the USA spends more in a month on the war in Iraq than the rest of the world spends in a year on the problem of AIDS in developing countries.

A few random comments:

The stats for sexual activity among youth who've taken a vow of abstinence til marriage are virtually identical to the rates for the general population.

While the rate of AIDS is higher for gay males the number of cases are about equal with heteros. Sadly one vector we have in common with Africa is that of traveling truckers or conventioneers getting it from drug using prostitutes and bringing it home to wife and perhaps new borns. (Here our health care techs would, mostly, prevent passage to infants but not so in most of Africa)

Did you know that in Canada's large cities there are health workers who actually go to the streets seeking out needle using drug addicts and give them clean needles along with a pamphlet on where to get treatment on demand when they are ready?

A big and important contrast from the US where "conservatives" from the Reagan era, policies of AIDS epidemic neglect, to the present have foolishly, but energetically opposed needle exchange programs.

Randall.... why so cynical? An AIDS test is now a simple and quick process. Just as with political polling statisticians can extrapolate from a small sample. For a nation or country they'd select geographic sampling areas to avoid applying a city or rural rate to the entire country.

BTW where'd you get this idea: "Most of the studies and numbers I've seen are fairy tales made by interested parties."

Who are the tellers? and who are the "interested parties?" Jack

Judge Posner is consistent in his views about what the problems in Africa and maintains that about the HIV epidemic. For once, I think that he ought to take cognizance of certain facts.

For instance, the comparison of the HIV /AIDs trajectory between Uganda and South Africa strikes me as very casual and inappropriate. The former was among the first countries in Africa to have a full blown AIDs epidemic which was also driven by the long civil war in that country. I think this factor is material for any dispassionate analysis because all interventions aside, the infection rates reached its peak much earlier than it would have in Southern Africa.

Secondly, granted that substantial portions of sub-Saharan African populations are uneducated, it is an overstatement to claim that there is widespread ignorance of the dynamics of HIV infection in that continent. Related to this is the very real question of female genital mutilation. While it is a repugnant and violent practice, I have never encountered evidence that it is a driver of the HIV epidemic.

Thirdly, if judge Posner's thesis is that Africa's institutional infrastructure is a signifcant part of the problem, then one would expect that countries that score higher in that regard would have a better handle on the prevention and treatment of HIV and AIDs. Botswana is one of Sub-Saharan Africa's better governed economies. In spite of its relatively good economic and political stability, the infection rates are virtually the highest in the continent.

Preliminary reports of a study concentrated in east Africa have established that malaria infection triples the likelihood of infection upon contact with HIV.

In sum, most sub-Saharan African countries are governed by undeniably incompetent fashion but for HIV, it appears that the institutional quality thesis does not explain it all.

I posted this on my blog... I agree generally with Posner's point...but the language used is priceless:
"effective bargaining" for safe sex - only a member of the Ivory Tower

Just what would effective bargaining for condoms etc entail?:

guy: oh that's so hot, keep doing it
girl: you like it?
guy: wait what are you doing, I don't wanna use that
girl: I just wanna be safe sweety
guy: but it feels weird
girl: I'll rub your feet later?
guy: Hmm, that's a decent proposition, but I'm not completely sold
girl: I could also go to that football game like you've been asking me to
guy: What about the foot rub, the game, and maybe we get to have sex later this afternoon
girl: I'm afraid the costs of all that exceed the benefit of using a condom - my utility preferences at this point is to not have intercourse with you at all
guy: That seems sub-optimal. Alright, you don't have to go to the game or give me a foot rub -
just some marginal sex this afternoon
...
girl: I dunno babe, we've been bargaining so long now that it's already dinner time.

An in-depth report from the LA Times today outlines how the
Gates Foundation's investments in oil companies and polluters undermine its work on AIDS and malaria. It dovetails nicely on this week's and last week's topics (maybe they've been reading the blog!).

http://www.latimes.com/news/la-na-gatesx07jan07,1,6935188.story

I don't know if "the rate of AIDS is higher for gay males the number of cases are about equal with heteros" counts as a lie, a damn lie or statistics. Male homosexual and homosexual/intravenous drug use infections account for over half of the US' HIV+ cases, but you're talking about only 5% of the US population (probably much smaller if you limit it to homosexuals who regularly engage in high-risk practices).

As far as meaningful statistical analysis, how can this can be realistically achieved when you have African nations clamoring for foreign capital, The WHO and CDC which have included any poverty-related illness as part of the AIDS diagnosis without any HIV test been given, mind you), testing in Africa which is only done in pre-natal clinics (where pregnancy can create a false positive) and extrapolated to the general population, and finally US Gay and AIDS organizations looking for a bully pulpit to retain public interest and Federal funding?

Randall Re: "I don't know if "the rate of AIDS is higher for gay males the number of cases are about equal with heteros"counts as a lie, a damn lie or statistics."" ??????? This is what I found to corroborate what I posted with a single click. You may want to answer your question for yourself with a few other clicks.

* An estimated one million people are currently living with HIV in the United States, with approximately 40,000 new infections occurring each year.
* 70 percent of these new infections occur in men and 30 percent occur in women.
* By race, 54 percent of the new infections in the United States occur among African Americans, and 64 percent of the new infections in women occur in African American women.
* 75 percent of the new infections in women are heterosexually transmitted.
* Half of all new infections in the United States occur in people 25 years of age or younger.

JK.... I've an "absolutist" approach to the AIDS epidemic.... that is that and AIDS case is an AIDS case regardless. And with the cases being about 50-50 between hetros and gays we'd be fools to target eradication among only one group, especially at the fastest growing group are young hetros.

Your second paragraphs reads like the "stuff" of "talk radio" and "faith-based" ideologues. Is that the case?

Garth! good chuckles!

Dan: Perhaps we should have a thread here as to whether it does any good in an age of nationless international corporate activity, for large investors, or anyone else, to redline the, subjective, worst of them from their portfolios. I'd suggest it doesn't.

For example if Gates and any number of "good folk" withheld investment enough to have any effect at all on the stock price the resulting bargains will be attractive to someone willing to scoop up the "poor corporate citizen" premium so their stock would tend to revert to the norm. ie no effect.

I suspect the case is a bit different though on the positive action side of investing in companies one believes are trying to do well by doing good, such as companies that focus on conserving oil as compared to making their money by drilling for more in countries with little respect for civil rights and human dignity. Confusing? Yep! But I think investors can help the do-gooder company by making it easier and cheaper to raise capital but can not hurt a BP or Exxon.

Jack:
I don't want the tenor of this debate to degenerate, but the CDC has 70% of the total new AIDS cases (this was for 2004) occurring among homosexuals (65 for male-to-male contact, another 5% with intravenous drug use). The chance of a non-male, non-homosexual American contracting AIDS is miniscule, and if you further protect yourself by not injecting controlled substances into your body your chance of contracting AIDS is around 1 in 30,000 (about 30 times less likely than a gay male). The dire predictions of a US where AIDS "is not a gay disease anymore" have never materialized, which is why the claims of an African epidemic make no sense. AIDS is (physically) much harder to transmit heterosexually. I'm assuming you're taking offense to the tone of my second paragraph, but there is nothing undocumented or crazy in what I'm saying: there is no credible epidemiological data coming out of Africa that I know of regarding AIDS. The presence of dozens of poverty-based illnesses, including TB, are now cause to label any African an AIDS sufferer - an HIV test (even if one could be had) is not required. The population of Africa is not shrinking. The coffin stores are not swamped. Africa suffers mightily from ignorance, poverty, greed, the specter of colonial misrule and a thousand other things. But AIDS is not one of them.

I don't know what else to say.

Ben: First off I'd like to reiterate that I consider and AIDS case to be an AIDS case and that in combatting the epidemic it would be wise to work just as hard in lowering the absolute number of cases.... regardless.

But.... as you brought up the slippery nature of stats let's take a look at them in light of your post and your seeming approach of deciding some cases are more important that others:

As you point out the new cases among those engaging in homosexual activity (which goes well beyond just that subset identifying themselves as "gay".) are 65% plus 5% for IV drug users a total of 70%

Despite "AIDS is (physically) much harder to transmit heterosexually" (to which I'll agree) your CDC pie chart shows a 78% hetero contact as the source of infection for women along with a 16% for hetero males.

And can we agree that we're not doing too well at containing the epidemic? While the 42,500 new cases in 04 is not a lot higher than the 39,500 new cases of 000, it's not less either and we're still adding over 40,000 new cases each year to a base of 415,000, each of which is a potential vector for further spreading of the disease to both the smaller "gay" community and the much larger hetero community.

Given that IV drug use accounts for 20% of both male and female it would seem that the lowest cost "no brainer" would be that of free needle exchange, and because it would attack several very costly birds with one stone, a much higher committment to treatment on demand for those addicted to drugs.

Perhaps effective needle exchange alone could cut IV transmission in half? which would be a ten percent reduction in new infectees which I assume would compound downward as those 4,000 not infected in any given year would not be vectors for transmission in any subsequent year.

One thing you could NOT say might be that of retracting that "AIDS is not one of the major problems of Africa" as it's a bit on par with denial of the holocaust, except for there being many more victims; both those who are dead and dying and a generation of impoverished orphans left behind. Jack

What is all this talk that AIDS is not an epidemic in Africa???

I suppose you believe the holocaust didn't happen either?

From wikipedia - Inhabited by just over 12% of the world's population, Africa is estimated to have more than 60% of the AIDS-infected population.

...yeah, I'm sure it's a mass conspiracy.

And I find the quote: "AIDS is (physically) much harder to transmit heterosexually" to be at least misleading and at most wildly innacurate. What's so much "harder" about it. HIV is transmitted via seminal fluid. Condom use among heteros in Africa is virtually non-existant.

...Maybe I'm missing something. If so, please tell me.

According to the Kaiser foundation:

In the United States, in 1985 women represented 8% of new Aids diagnoses. In 2005, women are 27%. As of 2005, 1.2 million people live with HIV/AIDS in the United States with about 300,000 of them women.

Black women in the United States account for 67 % of AIDS cases (for women over age 13). The rate in Black women is 24 times higher then for white women. In 2002, HIV was the leading cause of death for Black women aged 25-34.

In the United States, in 2005, 71% of women are infected through heterosexual sex, 27% percent from injection drug use. Having another STD increases risk of infection during heterosexual sex.

Cervical barriers and new microbicides are being researched as a way to prevent STDs in general and HIV.

Black Americans (male and female) account for 50% of the Aids cases diagnosed in 2005.

In 2005 the AIDS case rate per 100,000 for Black men is 103.6, black women, 49.9, white men 13.1. In 1985 Blacks were 25% of new AIDS diagnoses, in 2005 they are 50%.

The Kaiser study says that white men are much more likely to be infected through homosexual sex, but for some reason does not give data. But in a study of 5 major cities, 46% of black men who have sex with other men were infected: 21% for white men, 17% for Latino men.

Black teens (13-19) accounted for 73% of new AIDS cases reported among teens in 2004.

Accurate data from Africa seems to be difficult to acquire. There may be incentives to over count the number of AIDS cases. Since, I am told, diagnosis is often based on symptoms not test results, data can be easily distorted. Some data is based on pregnant women going to clinics, which is hardly a random sample of the general population.

Still, what is the root cause of the problem in Africa? If stories are to be believed, African men who engage in heterosexual sex are far more likely to acquire HIV/AIDS. Why? Perhaps they have untreated STD’s that make transmission easier. Perhaps prostitutes in Africa work until they die and have higher viral loads. Perhaps Blacks are more prone to the disease, for some reason (thus the higher infection rate in Black Americans and Africans.).

So what is the root cause? Since HIV/AIDS is transmitted by sex or injection drug use, reducing HIV/Aids means changing sexual activity. Treating STD’s in general may reduce the infection rate. Giving prostitutes, or others, microbicides to reduce the risk of transmission.

I do wonder about studies that claim that sexual activity in the United States and Africa are similar. While the frequency may be close, I doubt that Americans go to prostitutes at the same rate as Africans (labor patterns contribute to this). If Americans were somewhat randomly having sex with each other, you would expect lower infection rates then in Africa where some males are regularly going to prostitutes. The number of sexual encounters may be the same, but they are of a very different nature.

Perhaps, too many Africans do see the marginal benefit of a few more healthy years in the future as too low to compensate for the cost of safe sex today. But what is the cost of safe sex? Minimal. Perhaps the current emphasis on the orphans of AIDS will generate greater maternal instincts and encourage women to engage in safer sex, if not to protect them, then to protect their children.

The problem with trying to solve any societal problem lies with controlling the Devils Handmaidens; corruption, ignorance, and poverty. All readily apparent on the Dark Continentand in Asia. Perhaps, these should be dealt with first before venturing into the "Heart of Darkness". Ahh, Kurz! Here we come for better for worse! At least it would make each dollar spent more effective.

It's truly amazing how most Americans and Europeans are ignorant in the ways of most of the world.

I'd like to dispel the notion that my comments somehow imply that the suffering of Gays or Africans merits any less attention or compassion than the suffering of your average over-privileged US White Male. Africans are dying in droves, as they always have, from the crushing weight of poverty, greed, political corruption, poor sanitation, internal warfare, vestiges of colonial mismanagement and a host of other problems.
I have only two points to make, which I believe are well documented for anyone with eyes to see, are

1. All objective evidence points to the conclusion that the African AIDS epidemic is a sham. People are dying in Africa, but from what they have always died of. The African AIDS Epidemic is a well-intentioned but logically vacuous fabrication meant to direct attention to the continually suffering but long-neglected peoples of Africa. It is perpetuated in this country because

2. the dire predictions of AIDS as "a disease that strikes everyone" have not materialized and the AIDS industry in this country, sensibly equating the loss of public attention in AIDS to a loss of their own funding has sought another arena to further their cause. I am not say that this is some sort of evil conspiracy, only the confluence of many of the baser elements of human nature.

Does this mean we should ignore the suffering of Sub-Saharan Africa? By no means! It just means that we should do the right things for the right reasons.

Thank you for reading.

Randall
Even if AIDS cases in Africa were overstated by 500% it would still be a terrible health crisis. While accurate data on AIDS in Africa may be hard to obtain, I see no reason to believe that it is a fabrication.

If you had data from some village that showed that HIV deaths were really TB or something else, I might agree with you. But it is hard to believe that AIDS in Africa is some sort of myth. Why would so many create this grand conspiracy or - even harder to believe - independently create such a myth?

In any case, Posner's point is that external attempts to combat disease in Sub-Saharan Africa may be a waste of money. For Judge Posner a more cost effective course would be for these countries to take a rather low-tech approach - to educate people on the dangers of disease. Much as basic improvements in sanitation in previous generations had a huge impact on health outcomes, - simple preventative measures in Africa can reap large rewards.

I find a few problems with Judge Posner's approach. One, absent the political will in many African countries, I can support funding by foreign agencies to educate the population on the causes of diseases. Is it cost effective? While his approach may be more cost effective other approaches can still have a positive NPV - depends on how you value each year of life you safe.

Next, while I understand that the goal should be prevention, I am more optimistic that micro biotic research can find a way to block the virus from infecting. However, the African market for such a drug may not be profitable without the promise of payments by third parties, private or public.

With a smaller, but still serious, AIDS problem in the United States the market for such drugs is shrinking. Plus, the political pressure on drug companies to lower prices only serves to reduce research in such drugs. Absent a possibility of payment by a credible source (which eliminates most African leaders), who will take on the task?

Judge Posner can argue that simple steps will get us most of the way to the goal, less disease, if the African leaders have the will power. African leaders are the best change agents in their respective countries. I think medical research can take us farther but it requires outside assistance.

Hatfield: Thanks for the helpful Kaiser info. As for waiting until corruption is conquered or even "minimized" we here in the US would get little done were we to do such waiting. No, the running of a country is that of dealing with many issues at once and realizing that finding an equilibrium of getting the priorities right is an ongoing quest and one that is never achieved and even the best of democracies "muddles through".

Many of the posts here seem to indicate a complacent belief that we in the US have the AIDS epidemic under control or that it is a ho-hum/yawn "gay" or "black" problem of little risk to our "white" or should I say middle and upper income group as the "black" problem is largely one of poverty, prostitution and drug use.

But the US numbers are hardly encouraging: The new cases are increasing and keeping up with adding 10% per year to the 2004 base of 415,000. Though most of the new cases are among an age group perhaps centered around 25-30 let's assume that 30% of the new cases die within a year or so.

That still leaves a growth rate of 7% which gives us a doubling time of 10 years, (Rule of 72) that far outstrips the growth of our population. Perhaps the fairly young group, assisted by new medications, will live long enough (30 years) for three doubles before death from natural, or advanced AIDS causes, has much effect.

So, unless we find more effective means of lowering the infection rate we'd have perhaps 3.3 million by 2035. Today we've an infected rate of perhaps .2% of 200 million adults. The 2035 rate may be 1% of say 300 million adults or five times today's percentage. But, as the ratio of those infected to non-infected rises we'd expect the rate of of new infections to rise as well.

Much of the problem in Africa, Randall's unsupported claims aside, is that a sort of critical mass has been reached where a very high percentage of any sexual activity or birth-giving events carries a tremendous rate of risk and a nuclear expansion of new cases that will be very difficult to reverse. That's the reason CDC tries to nip epidemics in the bud.

The US would do WELL to redouble our own efforts to avoid the scenario my envelope scratchings above would indicate and in terms of cost alone an aggressive needle exchange program and treatment on demand for those addicted to drugs will seem a very good investment as compared to the costs of caring for three million or more AIDS patients in the near future.

I'm not leaving out hopes of changes in behavior, it's just that I know how to distribute clean needles and other than educational efforts I don't know how to change behavior in others. Treatment on demand is something we should have been doing for a whole host of reasons, not the least of which would lowering our crime and incarceration rates; the spread of AIDS is just one more compelling reason to get serious about it today.

Uganda uses an abstinence element in its educational program. Why the reluctance to concede that it has some utility?

About 40,000 new cases a year are diagnosed in the United States. This has remained steady for a decade, down from 150,000 cases in the 1980's.

About 17,000 people a year die of aids. Age adjusted HIV death rate has declined more then 70% since a the peak in 94-95. The decline is in part from the decline in new cases (since the 80's) and the success of new medications.

Populations being infected have changed. Heterosexual transmission was 3% of new cases in 1985. It grew to 31% of all new cases in 2005. During the same period homosexual transmission dropped from 65 to 43%. As mentioned earlier, most of the growth in AIDS is in the Black community.

The above is from the Kaiser Foundation.

I have little faith in needle exchange efforts. I have yet to see a drug addict who will faithfully keep clean needles. As long as they remain an addict, they will continue to take unsafe risks.

Blacks still consider AIDS one of the top health issues. It has become less of an issue for others racial groups.

Homosexual sex is still the easiest way to transmit the disease with 58% of all new cases.

AIDS is still a very real problem but compared to what it looked like in the 1980's it is less of a problem for most groups.

So increasingly HIV/AIDS is becoming a Black problem in the United States. That is still an American problem.

Perhaps of interest: A compilation of needle exchange studies.

http://www.ucdmc.ucdavis.edu/news/syringe_exchange.html

"Injection drug use now accounts for nearly one-third of new AIDS cases in this country. When drug users' sexual partners are included, injection drug use accounts for up to three-quarters of new HIV infections. The infection spreads via shared use of injection equipment and other drug paraphernalia, as well as through unprotected vaginal and anal intercourse."

...... it's of interest that in other countries a drug user has the option of purchasing needles at any pharmacy, while the US bans such sale. What choice does that leave those who are addicted?

The summary of studies turns up some interesting info. Jack

Correction
Should read:

Homosexual sex is still the easiest way to transmit the disease with 58% of all new cases in males.

This is getting off topic, but needle studies are very mixed. In my opinion, where they are used they have some impact but minimal. I believe that tracking studies will show that most addicts may exchange needles from time to time, if they can, but to expect this group to do it all the time is wishful thinking. The longer they remain an addict, the more likely they will slip into risky acts.

I could support paying addicts for turning in used needles to keep them from injurying sanitation workers and losing them near school yards.

But the way to save an addict is to end the addiction.

What if the Gates Foundation (or someone rich) invested in R&D to develop a fantastic condom that men want to use? A condom that actually *improves* sexual pleasure, distributed freely or cheaply, would be used more frequently and reduce AIDS transmission. If we can put a man on the moon, why can't we build a condom that feels great?

KippEsquire:

Due in far larger part to the Roman Catholic Church, which continues to insist that using a condom is a sin.

There is a rational, empirically based argument that condoms do NOT reduce AIDS in Sub-Saharan Africa but, paradoxically, increase disease rates.

The theory is that condom campaigns encourage adults to have more sex, and more risky sex, than they otherwise would engage in, and that, given the failure rates of condoms for disease protection, the campaigns actually increase disease rates.

The intuitively appealing response (give condoms) may not always be the best one in some areas.

It is a very weak argument that which blames the teachings of the Catholic Church for the spread of AIDS.

Yes, she morally condemns the use of condoms. However, at the same time, she condemns sexual relations outside the bonds of marriage.

What a strange new breed of pious Catholics! So mindful of Church teaching when it comes to condoms, but who disregard entirely her teachings on chastity and marital fidelity, of which the prohibition of contraception is a consequence.

Dan? I'm wondering if you read the summary of needle exchange studies I posted? You're welcome, of course, to your opinion but it seems counter to what the studies showed.

Here's a simply question that may shed light on the subject in the US. As the US, unlike many other "advanced" countries bans over the counter sales of needles; what option does the addict have here? Why would we leave addicts cornered in such a manner? My bias leans heavily toward universal, free and easily available needle exchange over selling them over the counter to the general public.

The study summary went on to discuss, precisely, your concern of how long needles are out there and the percentage returned that are infected with AIDS.

Your concept of paying to get needles returned seems positive, but I guess exchanging clean for dirty would be payment enough and about all that could be hoped for in our current political climate/bankruptcy.

"But the way to save an addict is to end the addiction."

I too favor far more pro-active programs to treat and hopefully cure higher percentages of addicts for all the social and humanitarian reasons there are. But, for the purposes here of trying to prevent the further expansion of the AIDs epidemic, I have to assume the current addict population as a "given" and focus my attentions on how to mimimize them as the strong vector they are in spreading AIDS and creating a doubling rate of ten years those infected.

NRWO?
"There is a rational, empirically based argument that condoms do NOT reduce AIDS in Sub-Saharan Africa but, paradoxically, increase disease rates."

Ha! I can't help but ask if NRWO stands for New Right Wing Organization? But say you lost your spot as armchair empiricist and theoretician and instead were forced by extreme poverty to work as an African prostitute servicing 20 truck drivers per shift; are the tools of your trade going to include a very large box of condoms? Or, you later marry a truck driver, given what you know of Africa and truck drivers, might you feel unduly at risk having unprotected sex? Also, after he arrives home from a long trip what do you suggest as a tactic for having less sex?

"What a strange new breed of pious Catholics! So mindful of Church teaching when it comes to condoms, but who disregard entirely her teachings on chastity and marital fidelity,"

The problem is that the Catholic Church retains a great amount of power as an institution, (through it's hospitals, charitable organizations, politicians) yet as is the case around the world it can no longer persuade the masses to obey its dictates about sex.

One thing that's rarely mentioned in the debate about Aids in Africa is the striking difference between infection rates in Christian nations as opposed to Muslim nations. I assumed that this was because there is greater piety, and more draconian punishments for violating vice laws. But it's also true that some of these nations have been more receptive to distributing condoms than their Catholic neighbors.

Joel: As a matter of theology some guy once invited "he who is w/o sin to cast the first stone". Shall we follow His advice?

As a matter of history guiding us in public health perhaps we'll recall how syphillis ripped through the world before there was a cure, despite the death sentence risk.

It would be good for the Catholic Church and others to come to grips with their god having created creatures in which the sex urge trumps all else so frequently. In Africa they should square their position on unprotected sex with their positions on suicide and opposition to the death penalty. Fortunately, as posted here, they're only 7% of Africa.

This is off topic but

The average injecting drug user injects themselves 1,000 a year. Do you think these people, even when clean needles are avaiable, are going to be that careful. I will argue that tracking studies will show, the longer you are an addict, the closer you are to AIDS. You stay using, needle exchanges will not safe you for long.

A study at Yale last year I think argued in favor of needle exchange programs but the real source of benefit is that the exchange process is done with attempts to counsel and test for HIV.

Also with more communities offering needle exchange programs, why are more drug users being infected with HIV.

BTW

Sorry for typing errors, I'm tired.

But 40,000 new cases a year, 17,000 deaths a year. Net increase of 23,000 cases a year. It will take over 50 years to double the current HIV population. New cases are constant for the last decade, deaths may decline, but I don't see how you get twice the HIV/AIDS cases in the United States in ten years

Jack:

Ha! I can't help but ask if NRWO stands for New Right Wing Organization?

No, it stands for Nothing Rhymes with Orange. I got tired of writing the full name, so I began using NRWO. I am a classic liberal.

I am not so sure that your (prostitution) example works: Giving condoms to prostitutes might encourage prostitutes to take on more and more risky sexual partners, and might encourage other poor women to enter prostitution under the (mistaken) presumption that condoms eliminate disease risk. This could very well increase disease rates. Indeed, there may be a parallel to regulations requiring seat belt use in cars. I believe that time series studies have shown that enactment of seat belt laws are typically followed by increased car accidents and bodily injury (but lower fatalities?). The theory: Once people wear seatbelts they are more prone to engage in risky driving, which increases accident rates. The general principle is that people are more prone to engage in reckless behavior when they believe that behavioral countermeasures (wearing seatbelts or condoms) minimizes it consequences. That’s probably true for individual events (individual sexual encounters or individual driving episodes) but the cumulative effect of engaging in repeated reckless behavior (which is encouraged by condom or seatbelt use) may, paradoxically, increase bad consequences.

To Judge Posner: I saw your piece on Second Life. Very cool.

No comments in two days. That must mean we solved AIDS in Africa, right? Good work everyone.

Bush is going crazy. He is shooting down any way out of the mess. Meanwhile, the US and the dollar are ready to collapse. The fight is to persuade the US Congress to adopt a real capital budget, and get out of the Thirty Years War in Iraq, Iran, etc.

The idea of an expanded war is the option of "stabilization" of the financial bubble. Look at the US bombing of Somalia, this is part of it. Force panic stricken people to do anything for a so-called "war economy".

Meanwhile, the widespread fraud of not reporting the true state of the Housing Market, is seen in the NY Times, Jan. 7th. Also see Moody's economy.com . The US Comerce Dept figures reported for new home sales both 1. significantly overstate the level of new home sales, and 2. understate the number of new homes listed for sale- inventory of homes for sale- due to Commerce's not taking account of people cancelling their contracts to buy new homes. For more at
real crash

NRWO:

hmmm, is there a site where you can collect these, seeming, 180 degree canards? We've recently discussed drunk driving and auto "safety" and counter to your "beliefs" as safety belt usage has climbed to 80% or so US auto deaths have stayed flat in absolute terms but have dropped dramatically in terms of deaths per mile driven.

I hope you're no activist and that we'll be saved having to counter any campaign of yours for prostitutes to "go bare" and especially NOT in Africa where her odds of servicing HIV positives are likely one in two....... or worse.

BTW do you figure those tooling around in newer Volvos or other rigs with side air bags and all the safety stuff are the most reckless of drivers?

Howie: You've at least two truths going in your post. Observation of Bush does give one the feeling the Secret Service should have restraining gear close by. His announcement of the "surge" (escalation) and "new strategy" (your guess as good as mine) was flat and had none of the confidence or rallying effect of Churchhill's "we'll fight on the beaches.." speech and would have seemed even sillier if it did as this is NOT "America's finest hour" or anything even remotely in the neighborhood, but simply proof positive that he and his fellow, aging neo-cons, never learned any of the myriad lessons of Vietnam.

You're also right on housing, the Pollyanna's are "forgetting??" that while housing itself is but 6% of our economy the declines will be magnified by our multiplier rate that is about 4 times the primary economic activity.

Among the "smoked" numbers are some 10% of housing that has been "sold" but to "investors" (speculators) and they too are empty and on the market. As you mention some "solds" contracts are being canceled, and there'll be many who'll have to walk away from underwater values, ARMS and a host of other "deals" used to take a sale in the last couple of years. With the appreciation game being changed how many boomer couples say "Well this is it....... time to unload the family home? the speculative second home or condo?"

Dan I'll repost the summary of studies:

http://www.ucdmc.ucdavis.edu/news/syringe_exchange.html

????????? I asked the board what choice they have in a nation which A. does not SELL needles over the counter, B. has a sketchy programs of needle exchange? Let's take a look at your theory which I assume? you post in opposition to either A or B??

The average injecting drug user injects themselves 1,000 a year.

........ and were he, or more worrisomely she, the active drug using prostitute, to at least have one needle for themselves...... they can not infect themselves. It is the sharing of scarce needles that is the problem.

Do you think these people, even when clean needles are available, are going to be that careful.

......... often when folks say "these people" it's as though "they" have left the human race, have NO sense of self-preservation and have gone daft besides. This despite observing on nearly a daily basis what an otherwise sane, nicotine addict will go through or endure to feed his addiction. But why DO all this just to avoid making sure needles ARE readily available and offer an easy option of using one's own needle?

I will argue that tracking studies will show, the longer you are an addict, the closer you are to AIDS. You stay using, needle exchanges will not safe you for long.

........ no disagreement here. IV drug addiction is not life enhancing in the least, but ever were we a callous people unconcerned with "their" early deaths, we'd still be far better off lengthening that time.

...... Here's my path to a ten year doubling, using your numbers (despite my belief that life spans for HIV/AIDS is climbing rapidly)

OK 23,000 net new AIDS cases to be added to a base of 415,000 per year. Say, 5.5% increase. So, using "Rule of 72" for the increase of compounded interest we've a 14 year doubling rate. Rough envelope scratching to be sure as I don't know how many of the 415,000 base will die off in 13 years but we've already counted 17,000 AIDS deaths per year prior to compounding the additional percentages added to the base.

Why do I compound? Well, I figure that if the base "recruits" 5.5% new members, the next 23,000 will do the same.

What we need to see.... and why I'd sign on for a universal Federal needle exchange program in a heartbeat, would be a GROSS new infection rate of half what it is today. Subtract out the death rate and that base of 415,000 would be flat or begin its downward spiral. When, we, or even Africa turns the corner and the base begins shrinking by even 5% per year we're in a downward spiral of fewer to infect others and with a boost from natural lifespans ending for aging base members; the US problem could be near zero in that same 15 year period.

What tools do we have to fight with to cut the rate of new infections in half? "Behavior changes?" "Abstinence??" And needle exchange. Take your best shot? Jack