When Elizabeth Pisani writes about AIDS, she wants people to know the unvarnished details. Her data on prevalence is gathered in nightclubs where researchers ask patrons about their sexual habits. She talks to women across Asia who have chosen prostitution because it pays better than factory work. And she studies the impact of specific sexual activities, explaining scientifically why, say, anal sex is so much riskier than vaginal sex. The Wisdom of Whores: Bureaucrats, Brothels, and the Business of AIDS is, in other words, unlike most books on HIV policy, which shroud arguments about sex and drugs in abstract, uncontroversial terms. Pisani prefers to hit the controversy head on, writing about AIDS as it affects those who are most likely to spread it. As a result, her impassioned critique of failed prevention programs and distorted aid spending is never dull, and rarely feels preachy.
The Wisdom of Whores is Pisani's story of more than a decade spent working in HIV prevention. She starts with her decision in 1994 to give up journalism and study epidemiology "Sex, drugs and plenty of squeamish politicians. AIDS was the disease for me," she writes and ends after she quit her job in 2005, following a meeting of epidemiologists in Bangkok that left her doubting the impact of science on real-world AIDS policy. Along the way, Pisani draws on anecdotes from her time chatting with transvestite hookers, rich-kid junkies, epidemiologists and policymakers in Indonesia, where she spent a few years developing HIV surveillance systems.
These people give Pisani powerful evidence that we must first accept an obvious truth: HIV is not spread by poverty or underdevelopment, as aid workers sometimes suggest, but by the specific usually avoidable actions of human beings. Mali is poorer than South Africa, and Bangladesh is poorer than Kenya; yet Mali and Bangladesh have low HIV rates. Fighting AIDS through poverty alleviation has so far had little impact on disease spread, Pisani argues. But targeted distribution of condoms and needles to sex workers and addicts, she says, has been proved to save lives and prevent epidemics at low cost.
Ironically, Pisani, now 43 and living in London, was one of the experts who helped brand AIDS as a disease of poverty in the first place. In the late 1990s, she was in Geneva writing U.N. reports and begging for more AIDS funding. She tried to sell donor governments on the idea that smart prevention policies could stop other regions from falling into the kind of intractable crisis that unchecked AIDS had wrought in Africa. It worked, Pisani tells TIME, but not the way she intended: "We thought naively that if you said, 'If you don't do something for junkies, then women and children will get infected,' governments would do something for junkies." They didn't. Instead, donors and field workers were more interested in helping women and children, even in countries where they weren't yet at risk.
Today, Pisani finds that fund raisers, donors and government officials remain hesitant to discuss the nitty-gritty details of AIDS transmission details of sharing needles, gay cruising and the sex trade. Pisani's book lays out the relevant science. It explains, for example, why regular sex with the same five partners is riskier than 10 successive monogamous relationships, and why sharing needles is more dangerous than almost any kind of sexual activity.
In Pisani's eyes, squeamishness and silence are killers. When money finally poured into AIDS programming early this decade, very little cash got to the marginalized groups who really were high-risk. In Ghana, three-quarters of new HIV infections occur in the sex trade, according to the World Bank, but 99% of the HIV funding goes to general-population programs like microcredit schemes. The same pattern of ignoring high-risk, low-status people is found in countries like Nigeria, Cambodia and Thailand, says Pisani: "It's very strong to say it's deliberate neglect, but we are deliberately choosing not to do things that we know work well in reducing the spread of an infectious disease because we don't like doing nice things for junkies."
Few of the arguments in The Wisdom of Whores are new. But it's rare to see them expressed with such frank simplicity. Pisani is never one to mince words. "In the AIDS business we're all whores," she says. Given how aid groups seek out donors' money, "We're all selling ourselves to the highest bidder." As with the prostitutes, their actions follow a certain logic and it could be deadly.