Elizabeth Pisani: Sex, drugs and HIV -- let's get rational

Translator: Maria Liivak Reviewer: Triin Sinissaar

"People do stupid things.

"Inimesed teevad rumalusi.

That's what spreads HIV."

See on HIV leviku põhjus."

This was a headline in a U.K. newspaper,

Selline pealkiri oli ühes UK ajalehes,

The Guardian, not that long ago.

"The Guardianis", mitte just ammu.

I'm curious, show of hands, who agrees with it?

Huvitav - tõstke käsi - kes sellega nõustub?

Well, one or two brave souls.

Üks-kaks vaprat hinge.

This is actually a direct quote from an epidemiologist

Tegelikult on see otsene tsitaat ühelt epidemioloogilt,

who's been in field of HIV for 15 years,

kes on HIV vallas tegutsenud viisteist aastat,

worked on four continents,

töötanud neljal kontinendil,

and you're looking at her.

ja ta seisab praegu teie ees.

And I am now going to argue

Nüüd kavatsen ma väita,

that this is only half true.

et see on ainult pooleldi tõsi.

People do get HIV because they do stupid things,

Inimesed tõesti saavad HIV sellepärast, et nad teevad rumalusi,

but most of them are doing stupid things

aga enamik neist teeb rumalusi

for perfectly rational reasons.

täiesti ratsionaalsetel põhjustel.

Now, "rational" is the dominant paradigm

"Ratsionaalne" on rahva tervishoius

in public health,

peamine paradigma.

and if you put your public health nerd glasses on,

Ja kui te vaatate läbi tervishoiunohiku prillide,

you'll see that if we give people the information that they need

siis näete: kui anda inimestele infot, mida nad vajavad,

about what's good for them and what's bad for them,

selle kohta, mis on neile hea ja mis halb;

if you give them the services

kui võimaldada neile teenuseid,

that they can use to act on that information,

mida nad saavad sellest infost lähtudes kasutada,

and a little bit of motivation,

ja anda neile pisut motivatsiooni,

people will make rational decisions

siis hakkavad nad langetama ratsionaalseid otsuseid

and live long and healthy lives.

ning elavad kaua ja tervislikult.

Wonderful.

Imevahva.

That's slightly problematic for me because I work in HIV,

Minu jaoks on see pisut probleemne, sest ma töötan HIV vallas,

and although I'm sure you all know

ja kuigi ma usun, et te kõik teate,

that HIV is about poverty and gender inequality,

et HIV on vaesuse ja soolise ebavõrdsuse teema,

and if you were at TED '07

ning kui te osalesite TEDil 2007,

it's about coffee prices ...

siis ka kohvihindade teema;

Actually, HIV's about sex and drugs,

tegelikult on HIV seksi ja narkootikumide teema.

and if there are two things that make

Ja kui on kaks asja, mis panevad

human beings a little bit irrational,

inimesed veidi irratsionaalselt käituma,

they are erections and addiction.

siis need on erektsioon ja sõltuvus.

(Laughter)

(Naer)

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

Alustame sellega, mis tundub mõistlik sõltlasele.

Now, I remember speaking to an Indonesian friend of mine, Frankie.

Ma mäletan vestlust ühe oma indoneesia sõbraga, Frankie'ga.

We were having lunch and he was telling me

Me lõunastasime ja ta jutustas ajast,

about when he was in jail in Bali for a drug injection.

mil ta kandis Balil süstimise eest vanglakaristust.

It was someone's birthday, and they had very kindly

Parajasti oli kellelgi sünnipäev, ning too oli väga lahkelt

smuggled some heroin into jail,

vanglasse veidi heroiini sisse smugeldanud

and he was very generously sharing it out

ja jagas seda heldelt laiali

with all of his colleagues.

kõigile oma kolleegidele.

And so everyone lined up,

Kõik võtsid järjekorda,

all the smackheads in a row,

kamp sõltlasi rivis.

and the guy whose birthday it was

Kutt, kelle sünnipäev oli,

filled up the fit,

täitis süstla

and he went down and started injecting people.

ja hakkas rivi algusest teisi süstima.

So he injects the first guy,

Ta süstib esimest tüüpi,

and then he's wiping the needle on his shirt,

siis pühib nõela oma särgi vastu puhtaks

and he injects the next guy.

ja süstib järgmist tüüpi.

And Frankie says, "I'm number 22 in line,

Frankie ütles: "Ma olen järjekorras 22. kohal

and I can see the needle coming down towards me,

ja näen süstalt enda poole liikumas,

and there is blood all over the place.

see on verine,

It's getting blunter and blunter.

nõel jääb aina nürimaks.

And a small part of my brain is thinking,

Väike osa mu ajust mõtleb:

'That is so gross

"See on nii rõve

and really dangerous,'

ja tõeliselt ohtlik,"

but most of my brain is thinking,

aga suurem osa mu ajust mõtleb:

'Please let there be some smack left

"Palun tee nii, et seal oleks veidi herot alles,

by the time it gets to me.

kui süstal minuni jõuab.

Please let there be some left.'"

Palun, et natukenegi oleks alles."

And then, telling me this story,

Mulle seda lugu rääkides

Frankie said,

ütles Frankie:

"You know ... God,

"Tead, jumal hoidku,

drugs really make you stupid."

narko teeb tõesti rumalaks."

And, you know, you can't fault him for accuracy.

Ja noh, mitte, et see laias laastus tõsi poleks,

But, actually, Frankie, at that time,

aga tegelikult oli Frankie samal ajal

was a heroin addict and he was in jail.

heroiinisõltlane ja ta oli vanglas.

So his choice was either

Nii et tema valik oli

to accept that dirty needle or not to get high.

kas võtta vastu räpane nõel või mitte olla pilves.

And if there's one place you really want to get high,

Ja kui on mõni koht, kus sa tõesti tahad olla pilves,

it's when you're in jail.

siis on see vangla.

But I'm a scientist

Aga mina olen teadlane

and I don't like to make data out of anecdotes,

ja mulle ei meeldi luua fakte anekdootidest,

so let's look at some data.

nii et vaatame hoopis fakte.

We talked to 600 drug addicts

Me rääkisime 600 narkosõltlasega

in three cities in Indonesia,

kolmes Indoneesia linnas

and we said, "Well, do you know how you get HIV?"

ja küsisime: "Kas te teate, kuidas te nakatute HIV-st?"

"Oh yeah, by sharing needles."

"Jah, muidugi, süstlaid jagades."

I mean, nearly 100 percent. Yeah, by sharing needles.

Peaaegu 100%. Jah, muidugi, süstlaid jagades.

And, "Do you know where you can get a clean needle

Ja: "Kas te teate, kust te saate puhta süstla

at a price you can afford to avoid that?"

soodsa hinnaga, et haigestumist vältida?"

"Oh yeah." Hundred percent.

"Jah, muidugi." 100%.

"We're smackheads; we know where to get clean needles."

"Me oleme sõltlased, me teame, kust saada puhtaid süstlaid."

"So are you carrying a needle?"

"Nii et kas teil on puhas süstal praegu kaasas?"

We're actually interviewing people on the street,

Me küsime inimestelt tänaval,

in the places where they're hanging out and taking drugs.

kohtades, kuhu nad kogunevad ja narkot teevad.

"Are you carrying clean needles?"

"Kas teil on puhtaid süstlaid kaasas?"

One in four, maximum.

Ühel neljast, maksimaalselt.

So no surprises then that

Niisiis pole mõtet üllatuda,

the proportion that actually used clean needles

et inimesi, kes kasutasid puhtaid nõelu

every time they injected in the last week

igal korral, kui nad end eelmisel nädalal süstisid,

is just about one in 10,

oli ainult umbes üks kümnest.

and the other nine in 10 are sharing.

Ülejäänud üheksa kümnest jagavad nõela.

So you've got this massive mismatch;

Absoluutselt ei klapi.

everyone knows that

Kõik teavad, et

if they share they're going to get HIV,

kui nad nõela jagavad, saavad nad HIV,

but they're all sharing anyway.

aga nad jagavad ikkagi.

So what's that about? Is it like you get a better high if you share or something?

Mis toimub? Kas on siis nii, et kui jagad nõela, siis saad parema kaifi?

We asked that to a junkie and they're like, "Are you nuts?"

Me küsisime seda ja nad vastasid: "Hullud olete või?

You don't want to share a needle anymore than you want

Sa ei taha jagada süstalt sugugi rohkem kui

to share a toothbrush even with someone you're sleeping with.

oma hambaharja isegi inimesega, kellega sa magad.

There's just kind of an ick factor there.

See on lihtsalt vastik.

"No, no. We share needles because we don't want to go to jail."

Ei, ei. Me jagame süstlaid, sest me ei taha vangi minna."

So, in Indonesia at this time,

Nii et Indoneesias on praegu nõnda,

if you were carrying a needle and the cops rounded you up,

et kui sul on kaasas süstal ja politsei võtab su vahele,

they could put you into jail.

siis nad võivad su panna vangi.

And that changes the equation slightly, doesn't it?

See muudab võrrandit veidi, eks ole.

Because your choice now is either

Sest nüüd on su valik, et kas

I use my own needle now,

ma kasutan praegu omaenda süstalt

or I could share a needle now

või ma jagan praegu süstalt

and get a disease that's going to

ja saan haiguse, mis tõenäoliselt

possibly kill me 10 years from now,

tapab mu kümne aasta pärast,

or I could use my own needle now

või ma kasutan praegu omaenda süstalt

and go to jail tomorrow.

ja lähen homme vangi.

And while junkies think that

Ja kuigi narkomaanide meelest on väga halb mõte

it's a really bad idea to expose themselves to HIV,

end HIV ohtu seada,

they think it's a much worse idea

on nende arust palju halvem mõte

to spend the next year in jail

järgmine aasta vanglas veeta,

where they'll probably end up in Frankie's situation

kus nad tõenäoliselt satuvad Frankie' olukorda

and expose themselves to HIV anyway.

ja satuvad HIV ohtu niikuinii.

So, suddenly it becomes perfectly rational

Nii et järsku muutub täiesti ratsionaalselt mõistetavaks

to share needles.

jagada kellegagi süstalt.

Now, let's look at it from a policy maker's point of view.

Vaatame olukorda seadustetegija seisukohast.

This is a really easy problem.

Tõeliselt lihtne probleem.

For once, your incentives are aligned.

Ometi kord on kõik stiimulid üksteisega vastavuses.

We've got what's rational for public health.

Rahva tervishoiu seisukohast on ratsionaalne,

You want people to use clean needles --

et inimesed kasutaksid puhtaid süstlanõelu

and junkies want to use clean needles.

ja narkomaanid tahavadki kasutada puhtaid süstlaid.

So we could make this problem go away

Nii et me võiksime selle probleemi lahendada

simply by making clean needles universally available

lihtsalt muutes puhtad süstlad igal pool kättesaadavaks

and taking away the fear of arrest.

ja võttes ära hirmu arreteerimise ees.

Now, the first person to figure that out

Esimene inimene, kes sellele viitas

and do something about it on a national scale

ja selle suhtes midagi rahvuslikul tasandil tegi,

was that well-known, bleeding heart liberal

oli too hästituntud liberaal, kelle süda jooksis verd,

Margaret Thatcher.

Margaret Thatcher.

And she put in the world's first

Tema teostas maailma esimese

national needle exchange program,

rahvusliku süstlavahetuseprogrammi

and other countries followed suit: Australia, The Netherlands and few others.

ja teised riigid järgisid tema eeskuju: Austraalias, Hollandis

And in all of those countries, you can see,

ja kõikides nendes riikides, mida näete,

not more than four percent of injectors

nakatus HIV-sse mitte rohkem

ever became infected with HIV.

kui 4% süstijatest.

Now, places that didn't do this -- New York City for example,

Kohtades, mis samamoodi ei talitanud, näiteks New Yorgis,

Moscow, Jakarta --

Moskvas, Jakartas,

we're talking, at its peak,

nakatus tipphetkedel

one in two injectors

üks süstija kahest

infected with this fatal disease.

sellesse saatuslikku haigusesse.

Now, Margaret Thatcher didn't do this

Margaret Thatcher ei teinud seda sellepärast,

because she has any great love for junkies.

et ta tunneb suurt poolehoidu narkomaanide suhtes,

She did it because she ran a country

vaid sellepärast, et ta juhtis riiki,

that had a national health service.

millel oli riiklik tervishoiusüsteem.

So, if she didn't invest in effective prevention,

Kui ta poleks investeerinud efektiivsesse preventsiooni,

she was going to have pick up the costs

oleks ta pidanud hakkama maksma

of treatment later on,

hilisema ravi eest,

and obviously those are much higher.

mis on arusaadavalt palju kallim.

So she was making a politically rational decision.

Nii et ta langetas poliitiliselt ratsionaalseid otsuseid.

Now, if I take out my

Kui ma võtan nüüd välja oma

public health nerd glasses here

tervishoiunohiku prillid

and look at these data,

ja vaatan neid fakte,

it seems like a no-brainer, doesn't it?

siis tundub kõik väga lihtne, eks ole.

But in this country,

Aga meie riigis,

where the government apparently does not feel compelled

kus valitsus nähtavasti ei tunne kohustust

to provide health care for citizens, (Laughter)

tagada kodanikele tervishoiusüsteemi,

we've taken a very different approach.

on võetud hoopis teistsugune lähenemine.

So what we've been doing in the United States

Nii et mida me USA-s teinud oleme?

is reviewing the data -- endlessly reviewing the data.

Lõputult andmeid läbi töötanud.

So, these are reviews of hundreds of studies

Need on tulemused sadadest uurimustest,

by all the big muckety-mucks

mille autorid on kõik need tähtsad kujud

of the scientific pantheon in the United States,

USA teaduste panteonist,

and these are the studies that show

ja päris paljud neist uuringutest näitavad,

needle programs are effective -- quite a lot of them.

et süstlavahetusprogrammid on tõhusad.

Now, the ones that show that needle programs aren't effective --

Need, mis näitavad, et süstlavahetusprogrammid ei ole tõhusad...

you think that's one of these annoying dynamic slides

Küllap arvate, et see on üks neist tüütutest dünaamilistest slaididest,

and I'm going to press my dongle and the rest of it's going to come up,

et ma vajutan nuppu ja ekraanile tekib ülejäänud info,

but no -- that's the whole slide.

aga ei, see ongi kogu slaid.

(Laughter)

(Naer)

There is nothing on the other side.

Vastuargumentide poolel pole mitte midagi.

So, completely irrational,

Niisiis on see täiesti irratsionaalne,

you would think.

mõtleksite te,

Except that, wait a minute, politicians are rational, too,

ainult et poliitikud on samuti ratsionaalsed

and they're responding to what they think the voters want.

ja toimivad vastavalt sellele, mida valijad nende arust tahavad.

So what we see is that voters respond

Nähtavasti reageerivad valijad

very well to things like this

väga positiivselt loosungile "parem maailm lastele"

and not quite so well to things like this.

ja mitte nii positiivselt loosungile "parem maailm narkaritele".

(Laughter)

(Naer)

So it becomes quite rational

Nii et ses suhtes on üsna ratsionaalne

to deny services to injectors.

keelata teeneid süstijatele.

Now let's talk about sex.

Räägime nüüd seksist.

Are we any more rational about sex?

Kas me oleme seksi osas kuidagi ratsionaalsemad?

Well, I'm not even going to address

Ma ei hakka isegi puudutama

the clearly irrational positions

ilmselgelt irratsionaalseid seisukohti,

of people like the Catholic Church,

mida esindab näiteks katoliku kirik,

who think somehow that if you give out condoms,

kelle meelest on kuidagi nii, et kui sa jagad laiali kondoome,

everyone's going to run out and have sex.

siis kõik tormavad kohe välja ja hakkavad seksima.

I don't know if Pope Benedict

Ma ei tea, kas paavst Benedictus

watches TEDTalks online,

jälgib TEDi kõnesid internetis,

but if you do, I've got news for you Benedict --

aga kui te praegu vaatate, Benedictus, siis mul on teile uudiseid.

I carry condoms all the time

Mul on kondoomid kogu aeg kaasas,

and I never get laid.

aga mitte keegi ei seksi minuga.

(Laughter) (Applause)

(Naer)

It's not that easy!

Asi pole nii lihtne.

Here, maybe you'll have better luck.

Võtke, võib-olla on teil rohkem õnne.

(Applause)

(Aplaus)

Okay, seriously,

Aga tõsiselt,

HIV is actually not that easy

HIV ei ole tegelikult nii hõlpsasti

to transmit sexually.

seksuaalsel teel ülekanduv.

So, it depends on how much virus there is

See sõltub sellest, kui palju viirust

in your blood and in your body fluids.

on su veres ja kehavedelikes.

And what we've got is a very, very high level of virus

Väga-väga kõrge viirusetase on alguses,

right at the beginning when you're first infected,

kui sa oled alles äsja nakatunud,

then you start making antibodies,

siis hakkad sa tootma antikehasid

and then it bumps along at quite low levels

ja edasi jääb viirus küllaltki madalale tasemele

for a long time -- 10 or 12 years --

pikaks ajaks, 10 või 12 aastaks.

you have spikes if you get another sexually transmitted infection.

Sellised jõnksud tekivad, kui nakatud uuesti seksuaalsel teel,

But basically, nothing much is going on

aga suuremalt jaolt ei toimu eriti midagi

until you start to get symptomatic AIDS,

kuni sa hakkad haigestuma sümptomaatilisse AIDSi.

and by that stage,

Ja selleks ajaks

you're not looking great, you're not feeling great,

ei näe sa eriti hea välja, ei tunne end eriti hästi

you're not having that much sex.

ja ei seksi niikuinii teab kui palju.

So the sexual transmission of HIV

Nii et HIV ülekandumine seksuaalsel teel

is essentially determined by how many partners you have

sõltub peaasjalikult sellest, kui palju partnereid sul on

in these very short spaces of time

nendel väga lühikestel ajavahemikel,

when you have peak viremia.

mil vireemia on kõige kõrgem.

Now, this makes people crazy

See ajab inimesed hulluks,

because it means that you have to talk about

sest see tähendab, et tuleb rääkida sellest,

some groups having more sexual partners

et mõnel grupil on rohkem seksuaalpartnereid

in shorter spaces of time than other groups,

lühemate ajavahemike jooksul kui mõnel teisel grupil,

and that's considered stigmatizing.

ja seda peetakse häbimärgistamiseks.

I've always been a bit curious about that

Ma olen seda alati veidi imeks pannud,

because I think stigma is a bad thing,

sest ma arvan, et häbimärgistamine on halb asi,

whereas lots of sex is quite a good thing,

aga palju seksi on üsna hea asi,

but we'll leave that be.

aga jätame selle.

The truth is that 20 years

Tõde on, et 20 aastat

of very good research

väga tõhusaid uurimusi

have shown us that

on meile näidanud,

there are groups that are more likely to turnover

et on inimgruppe, mis tõenäolisemalt vahetavad

large numbers of partners in a short space of time.

palju partnereid lühikese aja jooksul

And those groups are, globally,

ja ülemaailmselt on need grupid:

people who sell sex and their more regular partners.

inimesed, kes müüvad seksi, ja nende regulaarsemad partnerid;

They are gay men on the party scene

homoseksuaalsed mehed, kes käivad pidudel,

who have, on average, three times more partners

kellel on keskmiselt kolm korda rohkem partnereid

than straight people on the party scene.

kui on heterodel, kes käivad pidudel;

And they are heterosexuals

ja kolmas grupp on heteroseksuaalid

who come from countries that have

riikides, kus traditsiooniliselt on

traditions of polygamy

levinud polügaamia

and relatively high levels of female autonomy,

ja suhteliselt kõrge naiste autonoomia tase,

and almost all of those countries are in east or southern Africa.

ning peaaegu kõik need riigid asuvad Ida- või Lõuna-Aafrikas.

And that is reflected in the epidemic that we have today.

See paistab silma ka epideemias, mis meil täna on.

You can see these horrifying figures from Africa.

Siin näete neid kohutavaid numbreid Aafrikast.

These are all countries in southern Africa

Kõigis neis Lõuna-Aafrika riikides on

where between one in seven,

alates ühest seitsmendikust

and one in three

kuni ühe kolmandikuni

of all adults,

täiskasvanutest

are infected with HIV.

nakatunud HIV-ga.

Now, in the rest of the world,

Ülejäänud maailmas

we've got basically nothing going on in the general population --

ei toimu meil suurt midagi üldise rahvastiku seas,

very, very low levels --

kus tase on väga-väga madal.

but we have extraordinarily high levels of HIV

Aga ebatavaliselt kõrge HIV-tase

in these other populations who are at highest risk:

on väiksemates gruppides, kellel on kõige suurem risk,

drug injectors, sex workers

s.t. süstijad, sekstöötajad

and gay men.

ja homoseksuaalsed mehed.

And you'll note, that's the local data from Los Angeles:

Pange tähele, see on kohalik info Los Angelesest.

25 percent prevalence among gay men.

25%-line levik homoseksuaalsete meeste hulgas.

Of course, you can't get HIV just by having unprotected sex.

Muidugi ei saa nakatuda HIV-sse lihtsalt kaitsmata seksi teel,

You can only HIV by having unprotected sex

vaid kaitsmata seksi teel inimesega,

with a positive person.

kes on HIV-positiivne.

In most of the world,

Suuremas osas maailmast,

these few prevention failures

vaatamata nendele vähestele

notwithstanding,

ebaõnnestumistele preventsioonis,

we are actually doing quite well these days

läheb meil tegelikult praegu päris hästi

in commercial sex:

kommertsseksi osas.

condom use rates are between 80 and 100 percent

Kondoomikasutus kõigub enamikus riikidest

in commercial sex in most countries.

müüdava seksi puhul 80% ja 100% vahel.

And, again, it's because of an alignment of the incentives.

Ja jällegi on see seotud sellega, et stiimulid on teineteisega vastavuses.

What's rational for public health

See, mis on rahva tervishoiu jaoks ratsionaalne,

is also rational for individual sex workers

on ühtlasi ratsionaalne igale sekstöötajale individuaalselt,

because it's really bad for business to have another STI.

sest ärile mõjub järjekordne suguhaigus väga halvasti.

No one wants it.

Seda ei taha keegi.

And, actually, clients don't want to go home with a drip either.

Ka klient ei taha koju naasta suguhaigusega,

So essentially, you're able to achieve

nii et põhimõtteliselt on võimalik saavutada

quite high rates of condom use in commercial sex.

kommertsseksis üpris kõrget kondoomikasutuse protsenti.

But in "intimate" relations

Aga "intiimsetes" suhetes

it's much more difficult because,

on olukord palju keerulisem, sest

with your wife or your boyfriend

oma naise või poiss-sõbraga

or someone that you hope might turn into one of those things,

või kellegagi, kelle suhtes sa loodad, et ta võib selleks saada,

we have this illusion of romance

on meil illusioon romantikast,

and trust and intimacy,

usaldusest ja lähedusest,

and nothing is quite so unromantic

ja pole midagi ebaromantilisemat kui

as the, "My condom or yours, darling?" question.

küsimus "kas minu või sinu kondoom?"

So in the face of that,

Nii et selles valguses

you really need quite a strong incentive

peab sul tõesti olema tugev stiimul

to use condoms.

kaitsevahendi kasutamiseks.

This, for example, this gentleman is called Joseph.

Näiteks see. Selle härra nimi on Joseph.

He's from Haiti and he has AIDS.

Ta on pärit Haitilt ja tal on AIDS

And he's probably not having a lot of sex right now,

ja tõenäoliselt ei ta seksi praegu väga palju,

but he is a reminder in the population,

aga ta meenutab sulle,

of why you might want to be

miks sa peaksid tahtma

using condoms.

kasutada kondoome.

This is also in Haiti and is a reminder

See foto on samuti Haitilt ja võib-olla

of why you might want to be having sex, perhaps.

meenutab see sulle hoopis, miks sa tahaksid seksida.

Now, funnily enough, this is also Joseph

Veidral kombel on see mees samuti Joseph,

after six months on antiretroviral treatment.

kuus kuud pärast antiretroviirusravi algust.

Not for nothing do we call it the Lazarus Effect.

Me ei kutsu seda ilmaasjata "Laatsaruse efektiks."

But it is changing the equation

Aga see muudab võrrandit seoses sellega,

of what's rational

mis on ratsionaalne

in sexual decision-making.

seksiga seotud otsuste langetamisel.

So, what we've got --

Lood on nii...

some people say, "Oh, it doesn't matter very much

mõned ütlevad: "See ei loe eriti,

because, actually, treatment is effective prevention

sest tegelikult on ravi küllalt tõhus preventsioon,

because it lowers your viral load and therefore

sest see vähendab viiruse hulka veres ja seega

makes it more difficult to transmit HIV."

muudab haiguse edasiandmise raskemaks."

So, if you look at the viremia thing again,

Vaadake nüüd uuesti seda vireemia-skeemi.

if you do start treatment when you're sick,

Kui sa haigena alustad ravi, mis juhtub?

well, what happens? Your viral load comes down.

Viiruse hulk väheneb.

But compared to what? What happens if you're not on treatment?

Aga võrreldes millega? Mis juhtub, kui sind ei ravita?

Well, you die,

Sa sured,

so your viral load goes to zero.

nii et viiruse hulk alaneb nullini.

And all of this green stuff here, including the spikes --

Ja see roheline ala siin, s.h. need jõnksud,

which are because you couldn't get to the pharmacy,

mis tulenevad sellest, et sa ei jõudnud apteeki

or you ran out of drugs, or you went on a three day party binge

või sul said rohud otsa või sa pidutsesid kolm päeva järjest

and forgot to take your drugs,

ja unustasid rohtu võtta

or because you've started to get resistance, or whatever --

või et sa oled ravimitele immuunseks muutumas või mis iganes -

all of that is virus

see kõik on viirus,

that wouldn't be out there, except for treatment.

mida ei oleks, kui poleks ravi.

Now, am I saying, "Oh, well, great prevention strategy.

Kas see tähendab, et ma ütlen: suurepärane preventsioonistrateegia

Let's just stop treating people."

on lihtsalt lõpetada inimeste ravimine?

Of course not, of course not.

Muidugi mitte, muidugi ma ei ütle seda.

We need to expand antiretroviral treatment as much as we can.

Me peame antiretroviirusravi laiendama nii palju kui saame.

But what I am doing is calling into question

Küll aga avaldan ma umbusku inimeste suhtes,

those people who say that more treatment

kes väidavad, et suurem hulk ravi

is all the prevention we need.

lahendab kõik preventsioonimured.

That's simply not necessarily true,

See lihtsalt ei ole tingimata õige

and I think we can learn a lot from the experience of gay men

ja me saame palju õppida homomeeste kogemusest

in rich countries where treatment has been widely available

rikastes riikides, kus ravi on olnud laialdaselt kättesaadav

for going on 15 years now.

juba 15 aastat

And what we've seen is

ja sellest nähtub, et

that, actually, condom use rates,

kondoomikasutamine,

which were very, very high --

mis oli väga, väga kõrge -

the gay community responded very rapidly to HIV,

gay-kogukond reageeris HIV-le väga aktiivselt,

with extremely little help

kusjuures ilma olulise abita

from public health nerds, I would say --

tervishoiunohikute poolt -

that condom use rate has come down dramatically since treatment

et kondoomi kasutamine on ravi tekkimisest alates dramaatiliselt vähenenud

for two reasons really:

peamiselt kahel põhjusel.

One is the assumption of, "Oh well,

Üks oletus on selline:

if he's infected, he's probably on meds,

"Kui ta on nakatunud, siis ta võtab ilmselt ravimeid

and his viral load's going to be low, so I'm pretty safe."

ja ta viirusetase on madal, nii et mind ei ähvarda suur oht."

And the other thing is that people are simply

Teine on see, et inimesed lihtsalt

not as scared of HIV

ei karda HIV-d sama palju,

as they were of AIDS, and rightly so.

kui nad kardsid AIDS-i, ja õigusega.

AIDS was a disfiguring disease that killed you,

AIDS oli moonutav haigus, mis su tappis,

and HIV is an invisible virus

ja HIV on nähtamatu viirus,

that makes you take a pill every day.

mille pärast sa pead iga päev tabletti võtma.

And that's boring,

See on tüütu,

but is it as boring as

aga kas see on sama tüütu

having to use a condom every time you have sex,

kui kohustus kasutada kondoomi igal korral, kui seksid,

no matter how drunk you are,

ükskõik kui purjus sa ka poleks,

no matter how many poppers you've taken, whatever?

ükskõik kui palju sa poppersit oled teinud või mis iganes?

If we look at the data, we can see that

Kui me vaatame andmeid, näeme,

the answer to that question

et vastus sellele küsimusele on

is, mmm.

"mhm".

So these are data from Scotland.

Need on andmed Šotimaalt.

You see the peak in drug injectors

Näete väga kõrget taset narkosüstijatel

before they started the national needle exchange program.

enne rahvusliku süstlavahetusprogrammi algatamist.

Then it came way down.

Seejärel haigus vähenes tunduvalt

And both in heterosexuals -- mostly in commercial sex --

ja nii heteroseksuaalide puhul, eeskätt kommertsseksis,

and in drug users,

kui ka narkomaanide puhul

you've really got nothing much going on after treatment begins,

ei toimu pärast ravi algust suurt midagi,

and that's because of that alignment of incentives

kuna stiimulid on üksteisega vastavuses,

that I talked about earlier.

nagu ma enne rääkisin.

But in gay men,

Aga homoseksuaalsete meeste puhul

you've got quite a dramatic rise

näete üsna dramaatilist kasvu,

starting three or four years

mis algas kolm-neli aastat

after treatment became widely available.

pärast seda, kui ravi muutus kättesaadavaks.

This is of new infections.

See tuleb uutest nakatumistest.

What does that mean?

Mida see tähendab?

It means that the combined effect of being less worried

See, et ühtaegu muretsetakse vähem

and having more virus out there in the population --

ja et rahva seas on rohkem viirusekandjaid,

more people living longer, healthier lives,

rohkem inimesi, kes elavad kauem ja tervemalt,

more likely to be getting laid

suurema tõenäosuse ja võimalusega seksida

with HIV --

vaatamata sellele, et neil on HIV,

is outweighing the effects of lower viral load,

kaalub üles väiksema viirusetaseme veres

and that's a very worrisome thing.

ja see on väga murettekitav asi.

What does it mean?

Mida see tähendab?

It means we need to be doing more prevention the more treatment we have.

Seda, et mida rohkem me ravime, seda enam peame haiguse levikut takistama.

Is that what's happening?

Kas see nii toimubki?

No, and I call it the "compassion conundrum."

Ei, ja ma nimetan seda kaastunde keerdküsimuseks.

We've talked a lot about compassion the last couple of days,

Me oleme viimastel päevadel rääkinud palju kaastundest.

and what's happening really is that people are

Tegelikult toimub see, et inimesed

unable quite to bring themselves to put in

miskipärast ei raatsi võimaldada

good sexual and reproductive health services for sex workers,

head günekoloogilist raviteenust sekstöötajatele,

unable quite to be giving out needles to junkies.

ei suuda jagada süstlaid narkomaanidele,

But once they've gone from being

aga siis, kui need pole enam

transgressive people whose behaviors we don't want to condone

mitte patustajad, kellele me ei suuda andestada,

to being AIDS victims,

vaid on muutunud AIDSi-ohvriteks,

we come over all compassionate

muutume me kaastundlikuks ja ostame neile

and buy them incredibly expensive drugs for the rest of their lives.

uskumatult kalleid ravimeid terve nende ülejäänud elu.

It doesn't make any sense

Rahvastiku tervise seisukohast

from a public health point of view.

on see täiesti ebaloogiline.

I want to give what's very nearly the last word to Ines.

Ma tahan lõpuks anda sõna Inesele.

Ines is a a transgender hooker on the streets of Jakarta;

Ines on transvestiidist prostituut Jakarta tänavatel.

she's a chick with a dick.

Tüdruk riistaga.

Why does she do that job?

Miks ta sellist tööd teeb?

Well, of course, because she's forced into it

Muidugi sellepärast, et ta on selleks sunnitud,

because she doesn't have any better option, etc., etc.

sest tal ei ole paremat võimalust, jne, jne,

And if we could just teach her to sew

ja kui me saaksime õpetada talle õmblemist

and get her a nice job in a factory, all would be well.

ja leida talle kena töö vabrikus, oleks kõik hästi.

This is what factory workers earn in an hour in Indonesia:

Vabrikutöölised teenivad Indoneesias tunni ajaga

on average, 20 cents.

keskmiselt 20 senti.

It varies a bit province to province.

See on provintsiti pisut erinev.

I do speak to sex workers, 15,000 of them

Ma rääkisin 15 000 sekstöötajaga

for this particular slide,

selle konkreetse slaidi jaoks.

and this is what sex workers

Ja nad väidavad, et sellise summa

say they earn in an hour.

teenivad nad tunni ajaga.

So it's not a great job, but for a lot of people

See pole tore töö, aga väga paljudele

it really is quite a rational choice.

on see üsna ratsionaalne valik.

Okay, Ines.

Hea küll, Ines.

We've got the tools, the knowledge and the cash,

Meil on vahendid, teadmised ja raha

and commitment to preventing HIV too.

ja pühendumine HIV leviku takistamisele.

Ines: So why is prevalence still rising?

INES: Nii et miks levik ikka suureneb?

It's all politics.

See on kõik poliitika.

When you get to politics, nothing makes sense.

Kui sa jõuad poliitikani, ei ole miski loogiline.

Elizabeth Pisani: "When you get to politics, nothing makes sense."

ELIZABETH PISANI: "Kui sa jõuad poliitikani, ei ole miski loogiline."

So, from the point of view of a sex worker,

Sekstöötaja seisukohast

politicians are making no sense.

ei ole poliitikute tegudes mingit loogikat.

From the point of view of a public health nerd,

Tervishoiuametniku-nohiku seisukohast

junkies are doing dumb things.

teevad narkomaanid rumalusi.

The truth is that everyone has a different rationale.

Tõde on, et igaühel on erinevad aluspõhimõtted.

There are as many different ways of being rational

Ratsionaalne saab olla nii paljudel eri viisidel

as there are human beings on the planet,

kui palju on inimesi meie planeedil

and that's one of the glories of human existence.

ja see on üks inimeksistentsi võludest.

But those ways of being rational

Aga need eri viisid ratsionaalne olla

are not independent of one another,

ei ole üksteisest sõltumatumad.

so it's rational for

Nii et ühest küljest on ratsionaalne

a drug injector to share needles

narkosüstija jaoks jagada musta süstalt

because of a stupid decision that's made by a politician,

mõne poliitiku rumala otsuse tõttu,

and it's rational for a politician

ja poliitiku jaoks on ratsionaalne

to make that stupid decision

teha see rumal otsus,

because they're responding to

sest ta toimib nii,

what they think the voters want.

nagu ta arvab, et valijad tahavad.

But here's the thing:

Asi ongi selles:

we are the voters.

meie oleme valijad.

We're not all of them, of course, but TED is a community of opinion leaders.

Peale meie on neid muidugi veel, aga TED on arvamusliidrite kogukond

And everyone who's in this room,

ja kõigil, kes siin ruumis viibivad,

and everyone who's watching this out there on the web,

ja kõigil, kes vaatavad meid internetist,

I think, has a duty to demand of their politicians

on minu meelest kohustus nõuda oma poliitikutelt,

that we make policy based on scientific evidence

et me teeksime seadusi, lähtudes teaduslikest faktidest

and on common sense.

ja tervest mõistusest.

It's going to be really hard for us

Tõeliselt raskeks osutub

to individually affect what's rational

mõjutada individuaalselt seda, mis on ratsionaalne

for every Frankie and every Ines out there,

iga Frankie' ja iga Inese jaoks,

but you can at least use your vote

aga te saate vähemasti kasutada oma valijahäält

to stop politicians doing stupid things

selleks, et poliitikud lõpetaksid tobedused,

that spread HIV.

mis aitavad HIV levikule kaasa.

Thank you.

Aitäh.

(Applause)

(Aplaus)