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

Translator: Inés Rodríguez Reviewer: Noelia Bernárdez Alonso

«A xente fai parvadas.

Iso é o que propaga o VIH.»

Foi titular nun xornal do Reino Unido,

The Guardian, non hai moito tempo.

Teño curiosidade. Levantade a man, quen está de acordo con el?

Ben, un ou dous valentes.

"People do stupid things.

De feito, é a cita dunha epidemióloga

That's what spreads HIV."

que leva 15 anos no campo do VIH,

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

traballou en catro continentes

The Guardian, not that long ago.

e estades a mirar para ela.

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

E agora vou razoar

por que isto é unha media verdade.

Well, one or two brave souls.

As persoas pillan VIH porque fan parvadas,

This is actually a direct quote from an epidemiologist

pero a maioría delas fan parvadas

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

por razóns perfectamente racionais.

worked on four continents,

O «racional» é o paradigma principal

and you're looking at her.

en saúde pública.

And I am now going to argue

Se poñede os lentes de friki da saúde pública, veredes

that this is only half true.

People do get HIV because they do stupid things,

que se se lle dá ás persoas a información que necesitan

but most of them are doing stupid things

para saber o que é bo ou malo para elas,

for perfectly rational reasons.

se se lles dan os servizos

Now, "rational" is the dominant paradigm

para actuar en consecuencia

e un pouco de motivación,

in public health,

tomarán decisións racionais

and if you put your public health nerd glasses on,

e vivirán vidas longas e saudables.

Marabilloso.

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

Isto é un pouquiño problemático para min porque traballo co VIH

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

e, aínda que seguro que todos sabedes

if you give them the services

que o VIH ten que ver coa pobreza e a desigualdade de xénero,

that they can use to act on that information,

and a little bit of motivation,

e se estivestes na TED′07

people will make rational decisions

tenq ue ver cos prezos do café...

and live long and healthy lives.

En realidade, o VIH ten que ver co sexo e as drogas

Wonderful.

e, se hai dúas cousas que fan

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

aos seres humanos un chisco irracionais,

and although I'm sure you all know

son as ereccións e as adiccións.

that HIV is about poverty and gender inequality,

(Risas)

and if you were at TED '07

Así que imos comezar por ver que é racional para un adicto.

it's about coffee prices ...

Actually, HIV's about sex and drugs,

Recordo unha conversa co meu amigo indonesio Frankie.

Estabamos a xantar mentres me falaba

and if there are two things that make

de cando estivo no cárcere en Bali por consumo de drogas.

human beings a little bit irrational,

they are erections and addiction.

Era o aniversario de alguén e, moi amablemente,

(Laughter)

meteran unha pouca heroína no cárcere

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

e estaba a repartila xenerosamente

con todos os seus colegas,

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

así que fixeron unha fila,

We were having lunch and he was telling me

todos os xonquis en liña,

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

e o rapaz que estaba de aniversario

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

encheu a xiringa

smuggled some heroin into jail,

e empezou a inxectar a xente.

and he was very generously sharing it out

Inxecta o primeiro rapaz,

with all of his colleagues.

limpa a agulla coa camisa

And so everyone lined up,

e inxecta o seguinte.

all the smackheads in a row,

E Frankie di: «Son o número 22 na fila

and the guy whose birthday it was

filled up the fit,

e podo ver a xiringa vindo cara a min,

and he went down and started injecting people.

e hai sangue por todas partes.

So he injects the first guy,

A agulla estase desafiando

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

e unha pequena parte do meu cerebro pensa:

and he injects the next guy.

“Isto é noxento e moi perigoso”.

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

Pero a maior parte do meu cerebro di:

and I can see the needle coming down towards me,

“por favor, deixade algo de cabalo

para cando chegue a miña vez.

and there is blood all over the place.

Por favor, deixade un pouco”».

It's getting blunter and blunter.

And a small part of my brain is thinking,

E entón, contándome esta historia,

Frankie dixo:

'That is so gross

«Xa sabes... Meu deus, as drogas fante moi estúpido».

and really dangerous,'

but most of my brain is thinking,

'Please let there be some smack left

E tiña toda a razón.

by the time it gets to me.

Pero o certo é que, nese momento, Frankie

Please let there be some left.'"

And then, telling me this story,

era heroinómano e estaba no cárcere,

Frankie said,

así que a súa elección estaba entre

"You know ... God,

aceptar esa xiringa ou non colocarse

drugs really make you stupid."

e, se hai un sitio onde queres colocarte,

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

é no cárcere.

Porén, son científica

But, actually, Frankie, at that time,

e non me gusta obter datos a partir de anécdotas,

así que vexamos algúns datos.

was a heroin addict and he was in jail.

So his choice was either

Falamos con 600 drogadictos

to accept that dirty needle or not to get high.

en tres cidades de Indonesia

e dixemos: «Sabedes onde pillastes o VIH?».

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

«Ah, si, compartindo xiringas».

it's when you're in jail.

Case o 100 %. «Si, compartindo xiringas».

But I'm a scientist

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

«Sabedes onde conseguir xiringas limpas

so let's look at some data.

a un prezo alcanzable para evitar iso?»

We talked to 600 drug addicts

«Ah, si». O 100 %.

«Somos xonquis; sabemos onde conseguir xiringas limpas».

in three cities in Indonesia,

«Entón, levades con vós unha xiringa?»

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

Estamos a entrevistar a xente na rúa,

"Oh yeah, by sharing needles."

en lugares onde quedan para drogarse.

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

«Tedes xiringas limpas?»

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

Un de cada catro, máximo.

at a price you can afford to avoid that?"

"Oh yeah." Hundred percent.

Non foi unha sorpresa descubrir

que a proporción que usara agullas limpas

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

"So are you carrying a needle?"

cada vez que se inxectara na última semana

We're actually interviewing people on the street,

era de un de cada 10,

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

e que os outros nove estaban a compartilas.

"Are you carrying clean needles?"

Daquela, existe esta tremenda discordancia;

One in four, maximum.

todo o mundo sabe

So no surprises then that

que se comparte xiringas vai pillar VIH,

the proportion that actually used clean needles

pero, aínda así, compárteas.

every time they injected in the last week

De que vai isto? Cren que ao compartir colócanse máis?

is just about one in 10,

Preguntámosllo a un xonqui. Respondeu: «Estades tolos?».

and the other nine in 10 are sharing.

Non queres compartir xiringa igual que non compartirías cepillo de dentes

So you've got this massive mismatch;

everyone knows that

nin coa persoa coa que te estás deitando.

if they share they're going to get HIV,

Dá noxo.

«Non, non. Compartimos xiringas porque non queremos acabar no cárcere».

but they're all sharing anyway.

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

En Indonesia, nese momento,

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

se levabas enriba unha xiringa e a poli te cachaba,

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

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

podían meterte no cárcere.

E iso cambia un chisco a ecuación,

There's just kind of an ick factor there.

porque agora tes dúas opcións:

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

comparto unha xiringa agora e pillo unha enfermidade

So, in Indonesia at this time,

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

que posiblemente me mate dentro de 10 anos

they could put you into jail.

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

ou podo usar a miña propia xiringa hoxe

Because your choice now is either

e ir ao cárcere mañá mesmo.

I use my own needle now,

Aínda que os xonquis pensan que

é malísima idea exporse ao VIH,

or I could share a needle now

cren que é unha idea moito peor

and get a disease that's going to

pasar o próximo ano no cárcere,

possibly kill me 10 years from now,

onde probablemente acaben coma Frankie

or I could use my own needle now

e se expoñan ao VIH de todas maneiras.

and go to jail tomorrow.

De súpeto, compartir xiringas

And while junkies think that

convértese en algo totalmente racional.

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

Agora, mirémolo dende o punto de vista de quen fan as leis.

they think it's a much worse idea

É un problema fácil de resolver.

to spend the next year in jail

Por unha vez, os teus incentivos coinciden.

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

Por unha banda, temos o que é racional para a saúde pública.

and expose themselves to HIV anyway.

Queremos que a xente use xiringas limpas

So, suddenly it becomes perfectly rational

e os xonquis queren usar agullas limpas,

to share needles.

así que poderíamos desfacernos deste problema

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

facendo que as xiringas limpas estean dispoñibles universalmente

This is a really easy problem.

For once, your incentives are aligned.

e eliminando o medo ao arresto.

A primeira persoa en darse de conta disto

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

e facer algo a escala nacional

foi a célebre e tan compasiva política liberal

You want people to use clean needles --

and junkies want to use clean needles.

Margaret Thatcher.

So we could make this problem go away

Puxo en marcha o primeiro sistema nacional de troco de xiringas

simply by making clean needles universally available

do mundo,

e outros países foron detrás:

and taking away the fear of arrest.

Australia, os Países Baixos e algún máis.

Now, the first person to figure that out

En todos eses países, podemos ver

and do something about it on a national scale

que só o 4 % dos adictos

was that well-known, bleeding heart liberal

contraeron o VIH nalgún momento.

Margaret Thatcher.

En lugares onde non se levou a cabo

And she put in the world's first

(Nova York, Moscova, Iacarta),

national needle exchange program,

nos peores momentos

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

un de cada dous inxectores

And in all of those countries, you can see,

infectábanse desta letal enfermidade.

not more than four percent of injectors

ever became infected with HIV.

Margaret Thatcher non fixo isto

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

polo seu amor aos xonquis;

Moscow, Jakarta --

fíxoo porque gobernaba un país

we're talking, at its peak,

que tiña un sistema nacional de saúde,

one in two injectors

así que, se non investía nunha prevención efectiva,

infected with this fatal disease.

ía ter que pagar os custos do tratamento

Now, Margaret Thatcher didn't do this

máis adiante

e, obviamente, sairía moito máis caro.

because she has any great love for junkies.

Estaba a tomar unha decisión politicamente racional.

She did it because she ran a country

Se collo

that had a national health service.

os meus lentes de friki da saúde pública

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

e miro para estes datos...

she was going to have pick up the costs

Penso que, máis claro, auga, non?

of treatment later on,

and obviously those are much higher.

Pero neste país,

onde aparentemente o goberno non se sente obrigado

So she was making a politically rational decision.

a dar atención sanitaria aos cidadáns,

Now, if I take out my

[Risas] abordamos o problema dun xeito diferente.

public health nerd glasses here

and look at these data,

Así que o que estamos a facer nos Estados Unidos

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

é revisar os datos sen parar.

Esta é a análise de centos de estudos

But in this country,

where the government apparently does not feel compelled

realizados polos máis ilustres científicos dos Estados Unidos

to provide health care for citizens, (Laughter)

e estes son os moitísimos estudos que amosan

we've taken a very different approach.

que os programas de troco de xiringas son efectivos.

So what we've been doing in the United States

is reviewing the data -- endlessly reviewing the data.

Os que conclúen que os programas non son efectivos...

Pensaredes que estarán nunha desas diapositivas dinámicas insufribles

So, these are reviews of hundreds of studies

by all the big muckety-mucks

e que vou premer no botón e van aparecer,

of the scientific pantheon in the United States,

pero non: esta é a diapositiva completa.

(Risas)

and these are the studies that show

Non hai nada ao outro lado.

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

Así que pensaredes:

«totalmente irracional».

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

Pero os políticos tamén son racionais

but no -- that's the whole slide.

e responden ao que cren que queren os seus votantes.

(Laughter)

There is nothing on the other side.

Así que o que vemos é

que os votantes responden moi ben a cousas así,

pero non tan ben a cousas así.

So, completely irrational,

(Risas)

you would think.

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

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

Rexeitar dar servizos aos heroinómanos

So what we see is that voters respond

convértese en algo bastante racional.

very well to things like this

and not quite so well to things like this.

Agora falemos sobre sexo.

Somos máis racionais co tema do sexo?

(Laughter)

Nin sequera vou mencionar

a postura claramente irracional

de colectivos coma a Igrexa Católica,

So it becomes quite rational

que pensa que, se alguén reparte condóns,

to deny services to injectors.

todo o mundo liscará a ter sexo.

Now let's talk about sex.

Are we any more rational about sex?

Non sei se o papa Bieito

ve TEDTalks en liña,

Well, I'm not even going to address

pero, se o fas, teño boas novas para ti, Bieito:

the clearly irrational positions

of people like the Catholic Church,

sempre levo condóns enriba

who think somehow that if you give out condoms,

e nunca consigo botar un foguete.

everyone's going to run out and have sex.

(Risas) (Aplausos)

Non é tan doado!

I don't know if Pope Benedict

Ao mellor vós tedes máis sorte ca min.

watches TEDTalks online,

(Aplausos)

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

I carry condoms all the time

Non, en serio.

and I never get laid.

Transmitir o VIH por vía sexual,

(Laughter) (Applause)

realmente, non é tan sinxelo.

It's not that easy!

Depende de canto virus haxa no teu sangue

Here, maybe you'll have better luck.

e nos teus fluídos corporais.

(Applause)

Temos niveis altísimos de virus

nada máis ser infectados por primeira vez,

Okay, seriously,

logo comezas a producir anticorpos

HIV is actually not that easy

e van tirando cara niveis bastante baixos

durante moito tempo (10 ou 12 anos)

to transmit sexually.

con picos se te volves contaxiar por vía sexual.

So, it depends on how much virus there is

in your blood and in your body fluids.

Pero en xeral, non pasa nada

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

ata que aparecen os síntomas da sida,

pero, nesa etapa,

right at the beginning when you're first infected,

non es atractivo, non te atopas ben,

then you start making antibodies,

e non tes moito sexo.

and then it bumps along at quite low levels

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

Así que a transmisión sexual do VIH

you have spikes if you get another sexually transmitted infection.

está fundamentalmente determinada por cantas parellas tes

But basically, nothing much is going on

neste curto espazo de tempo

until you start to get symptomatic AIDS,

cando a viremia acada o seu pico.

and by that stage,

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

Isto tolea á xente,

porque implica ter que falar

you're not having that much sex.

So the sexual transmission of HIV

de que algúns grupos teñen máis parellas sexuais en pouco tempo

is essentially determined by how many partners you have

ca outros,

e iso causa estigma.

in these very short spaces of time

Sempre tiven moita curiosidade sobre iso

when you have peak viremia.

porque penso que o estigma é malo,

Now, this makes people crazy

mentres que ter moito sexo é boa cousa,

pero deixémolo estar.

because it means that you have to talk about

A verdade é que 20 anos

some groups having more sexual partners

de moi boa investigación amosaron que

in shorter spaces of time than other groups,

and that's considered stigmatizing.

hai grupos que tenden a cambiar moitas veces de parella

I've always been a bit curious about that

because I think stigma is a bad thing,

nun curto espazo de tempo.

whereas lots of sex is quite a good thing,

A nivel mundial, eses grupos son

but we'll leave that be.

as traballadoras sexuais e as súas parellas máis frecuentes.

The truth is that 20 years

Tamén aparecen os homes gais de esmorga,

of very good research

que, de media, teñen 3 veces máis parellas

have shown us that

que as persoas heterosexuais de esmorga.

there are groups that are more likely to turnover

E hai heterosexuais que proceden de países

large numbers of partners in a short space of time.

con tradición de poligamia

And those groups are, globally,

e bastante liberdade das mulleres,

people who sell sex and their more regular partners.

e case todos eses países están no leste ou no sur de África.

They are gay men on the party scene

who have, on average, three times more partners

E iso vese reflectido na epidemia actual.

than straight people on the party scene.

Podedes ver estas cifras terroríficas de África.

And they are heterosexuals

who come from countries that have

Todos estes son países do sur de África

traditions of polygamy

onde entre un de cada sete,

and relatively high levels of female autonomy,

e un de cada tres adultos,

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

están infectados co VIH.

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

No resto do mundo,

apenas aparecen casos na poboación xeral

You can see these horrifying figures from Africa.

(son niveis moi baixiños),

These are all countries in southern Africa

pero temos niveis altísimos de VIH

where between one in seven,

and one in three

nestas outras poboacións de maior risco:

of all adults,

inxectores de droga, traballadoras sexuais

are infected with HIV.

e homes gais.

Now, in the rest of the world,

Estes son os datos locais dos Ánxeles:

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

25 % de prevalencia nos homes gais.

very, very low levels --

but we have extraordinarily high levels of HIV

Por suposto, non pillas o VIH só por ter sexo sen protección.

in these other populations who are at highest risk:

Só podes pillar o VIH tendo sexo sen protección

drug injectors, sex workers

cunha persoa positiva.

and gay men.

Na maior parte do mundo,

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

esta prevención fracasa,

25 percent prevalence among gay men.

aínda que, en realidade

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

estamos a facelo bastante ben no ambito d prostitución:

You can only HIV by having unprotected sex

os índices de uso de condón están entre o 80 e o 100 %

with a positive person.

na prostitución na maioría dos países.

Outra vez, é grazas ao aliñamento de incentivos.

In most of the world,

these few prevention failures

O que é racional para a saúde pública,

notwithstanding,

tamén é racional para as prostitutas,

we are actually doing quite well these days

porque é moi malo para o negocio ter outra ITS.

in commercial sex:

condom use rates are between 80 and 100 percent

Ninguén o quere.

E os clientes tampouco queren volver a casa cunha vía posta.

in commercial sex in most countries.

Así que na prostitución é sinxelo acadar

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

altas taxas de uso de condón.

What's rational for public health

Pero nas relacións «íntimas»

is also rational for individual sex workers

é moito máis difícil porque

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

coa túa muller ou co teu mozo

No one wants it.

ou con quen che gustaría que se convertera niso,

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

So essentially, you're able to achieve

temos ese delirio de romance,

confianza e intimidade,

quite high rates of condom use in commercial sex.

e non hai nada menos romántico que a pregunta de:

But in "intimate" relations

it's much more difficult because,

«O teu condón ou o meu, querido?»

with your wife or your boyfriend

Fronte a iso,

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

necesitas un incentivo moi forte

we have this illusion of romance

para usar condón.

and trust and intimacy,

and nothing is quite so unromantic

Este é un señor chamado Joseph.

É de Haití e ten a sida.

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

Probablemente non estea a ter moito sexo agora mesmo,

So in the face of that,

pero é un recordatorio para a poboación

you really need quite a strong incentive

de que hai que usar condón.

to use condoms.

Isto tamén é en Haití e, se cadra,

This, for example, this gentleman is called Joseph.

é un recordatorio de por que quererías ter sexo.

He's from Haiti and he has AIDS.

(Risas)

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

Sorprendentemente, este tamén é Joseph

but he is a reminder in the population,

logo de 6 meses con tratamento antirretroviral.

of why you might want to be

using condoms.

Con razón se lle chama Efecto Lázaro.

This is also in Haiti and is a reminder

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

Pero está a mudar a ecuación

do que é racional

Now, funnily enough, this is also Joseph

ao tomar decisións sexuais.

after six months on antiretroviral treatment.

Achamos que algunha xente di:

Not for nothing do we call it the Lazarus Effect.

«Non importa moito porque

o tratamento é unha prevención efectiva,

porque baixa a carga viral e, por tanto,

But it is changing the equation

fai máis difícil que se transmita o VIH».

of what's rational

Miremos a gráfica da viremia outra vez.

in sexual decision-making.

Se comezas o tratamento ao enfermar,

So, what we've got --

que acontece? A túa carga viral diminúe.

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

because, actually, treatment is effective prevention

Pero comparado con que? Que ocorre se non te tratas?

because it lowers your viral load and therefore

Morres,

makes it more difficult to transmit HIV."

así que a carga viral baixa a cero.

So, if you look at the viremia thing again,

E isto en verde, incluíndo os picos,

if you do start treatment when you're sick,

que ocorren porque non puideches ir á farmacia,

well, what happens? Your viral load comes down.

quedaches sen menciñas ou fuches de troula tres días seguidos

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

e esqueciches tomar os medicamentos

Well, you die,

ou porque están xurdindo resistencias ou o que sexa,

so your viral load goes to zero.

todo iso son virus que non estarían por aí

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

se non fose polo tratamento.

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

Estou dicindo

«boa estratexia de prevención. Deixemos de tratar á xente».

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

Claro que non.

and forgot to take your drugs,

Hai que espallar os antirretrovirais todo o que poidamos.

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

Pero o que estou a facer é pór en dúbida

all of that is virus

a aqueles que din que máis tratamento

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

é toda a prevención que necesitamos.

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

Isto non é necesariamente verdade

Let's just stop treating people."

e podemos aprender moito da experiencia dos homes gais

Of course not, of course not.

nos países ricos,

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

onde o tratamento leva estando dispoñible

dende hai 15 anos

But what I am doing is calling into question

e o que estamos vendo é que

those people who say that more treatment

os índices de uso de condón,

is all the prevention we need.

That's simply not necessarily true,

que foron moi altos

(a comunidade gai respondeu rapidísimo ao VIH

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

con moi pouquiña axuda

in rich countries where treatment has been widely available

dos frikis da Saúde Pública),

o uso de condón diminuíu moitísimo desde que existe tratamento

for going on 15 years now.

And what we've seen is

por dúas razóns:

that, actually, condom use rates,

unha é asumir que,

which were very, very high --

se alguén está infectado, tomará medicamentos

the gay community responded very rapidly to HIV,

e a súa carga viral será baixa, así que estamos a salvo.

with extremely little help

A outra razón é que a xente

from public health nerds, I would say --

non lle ten tanto medo ao VIH

that condom use rate has come down dramatically since treatment

coma lle tiña á sida, e con razón.

for two reasons really:

A sida era unha enfermidade desfiguradora que adoitaba matarte

One is the assumption of, "Oh well,

e o VIH é un virus invisible

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

que che fai tomar unha pastilla cada día.

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

E iso é aburrido,

And the other thing is that people are simply

pero tan aburrido coma

not as scared of HIV

ter que usar condón cada vez que tes sexo,

as they were of AIDS, and rightly so.

sen importar o bébedo que esteas

AIDS was a disfiguring disease that killed you,

ou a cantidade de popper que tomaras?

and HIV is an invisible virus

Se miramos os datos, podemos ver que

that makes you take a pill every day.

a resposta a esta pregunta é «mmm...».

And that's boring,

but is it as boring as

Estes datos son de Escocia.

Podedes ver o pico de inxectores de droga

having to use a condom every time you have sex,

antes de existir o programa nacional de troco de xiringas.

no matter how drunk you are,

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

Logo baixou.

E tanto en heterosexuais (sobre todo na prostitución)

If we look at the data, we can see that

coma en drogadictos

the answer to that question

non cambia moito logo de que empece o tratamento.

is, mmm.

Isto débese

So these are data from Scotland.

ao aliñamento de incentivos do que falei anteriormente.

You see the peak in drug injectors

before they started the national needle exchange program.

Pero nos homes gais

houbo un enorme aumento tres ou catro anos

Then it came way down.

despois de que o tratamento

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

comezara a estar dispoñible.

and in drug users,

Isto son as novas infeccións.

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

Que significa isto?

and that's because of that alignment of incentives

Que a combinación dunha menor preocupación

that I talked about earlier.

e a maior presenza do virus na poboación

But in gay men,

you've got quite a dramatic rise

(hai máis xente vivindo vidas máis longas e sas,

starting three or four years

con maior probabilidade

after treatment became widely available.

de foder, aínda tendo VIH)

This is of new infections.

está a superar os efectos da baixa carga viral,

What does that mean?

It means that the combined effect of being less worried

e é un feito moi preocupante.

Isto que significa?

and having more virus out there in the population --

Que necesitamos facer máis prevención canto máis tratamento temos.

more people living longer, healthier lives,

É iso o que está a acontecer?

more likely to be getting laid

Non, e eu chámoo o «enigma da compaixón».

with HIV --

Estivemos falando moito de compaixón nestes últimos días,

is outweighing the effects of lower viral load,

e o que en realidade acontece é que a xente é incapaz de esforzarse

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.

en crear bos servizos de saúde sexual e reprodutiva

para traballadores sexuais,

Is that what's happening?

incapaz de repartir xiringas aos xonquis.

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

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

Pero cando pasan de ser

persoas transgresoras cuxas condutas non queremos consentir

and what's happening really is that people are

a ser vítimas da sida,

unable quite to bring themselves to put in

de súpeto somos compasivos

good sexual and reproductive health services for sex workers,

e mercámoslles fármacos carísimos durante o resto da súa vida.

unable quite to be giving out needles to junkies.

Non ten sentido

dende o punto de vista da saúde pública.

But once they've gone from being

Por último, quero cederlle a palabra a Ines.

transgressive people whose behaviors we don't want to condone

Ines é puta transxénero nas rúas de Iacarta;

to being AIDS victims,

é unha moza con pito.

we come over all compassionate

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

Por que fai ese traballo?

Por suposto, porque se ve obrigada,

It doesn't make any sense

from a public health point of view.

porque non ten outra opción mellor etc.

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

Se puidésemos aprenderlle a coser

e darlle un bo traballo nunha fábrica, todo estaría ben.

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

Isto gañan por hora os traballadores dunha factoría en Indonesia:

she's a chick with a dick.

Vinte céntimos, de media.

Why does she do that job?

Varía un chisco entre provincias.

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

Falei con 15.000 traballadoras sexuais

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

para esta diapositiva en concreto

And if we could just teach her to sew

e isto é o que afirman gañar por hora.

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

Non é un gran traballo, pero para moita xente

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

on average, 20 cents.

é unha elección bastante racional.

It varies a bit province to province.

De acordo, Ines.

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

for this particular slide,

Temos as ferramentas, os coñecementos,

and this is what sex workers

say they earn in an hour.

diñeiro e o compromiso para previr o VIH.

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

it really is quite a rational choice.

Ines: Entón por que a prevalencia segue a aumentar?

Okay, Ines.

É todo cuestión de política.

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

Cando se trata de política, nada ten sentido.

and commitment to preventing HIV too.

«Cando se trata de política, nada ten sentido».

Ines: So why is prevalence still rising?

Dende o punto de vista dunha prostituta,

os políticos non teñen sentido.

Dende o punto de vista dunha friki da saúde pública,

It's all politics.

os xonquis fan parvadas.

When you get to politics, nothing makes sense.

A verdade é que todos teñen unha lóxica diferente.

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

Hai tantas formas de ser racional

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

coma seres humanos hai no planeta,

e esa é unha das marabillas da existencia humana.

politicians are making no sense.

From the point of view of a public health nerd,

Pero esas formas de ser racional

non son independentes entre si,

junkies are doing dumb things.

así que é racional para un drogadicto

The truth is that everyone has a different rationale.

compartir xiringas

grazas a unha decisión estúpida tomada por un político,

There are as many different ways of being rational

as there are human beings on the planet,

e é racional para o político

tomar esa decisión estúpida

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

But those ways of being rational

porque está respondendo ao que cre

are not independent of one another,

que os seus votantes queren.

so it's rational for

Pero aquí está a cousa:

a drug injector to share needles

nós somos os votantes.

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

Non todos: TED é unha comunidade de líderes de opinión,

and it's rational for a politician

e todo aquel que está nesta sala

to make that stupid decision

e todo aquel que está vendo isto na rede

because they're responding to

penso que ten o deber de esixirlles aos seus políticos

what they think the voters want.

que fagan políticas baseadas

But here's the thing:

na evidencia científica e no sentido común.

we are the voters.

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

Vai ser moi complicado para nós

influír de forma individual no que é racional

And everyone who's in this room,

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

por todos os Frankies e Ines que están aí,

pero, cando menos, podedes empregar o voso voto

I think, has a duty to demand of their politicians

para impedir que os políticos

that we make policy based on scientific evidence

fagan parvadas que propaguen o VIH.

and on common sense.

Grazas.

It's going to be really hard for us

(Aplausos)

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.

Thank you.

(Applause)