The campaign to provide cheap drugs for Africa's fight against Aids has lately been on something of a roll. It shared top billing, for example, at last month's World Social Forum, the shadow anti-globalisation conference held in Brazil. One campaigner, Ben Jackson of Action for South Africa, summed up the campaign's case in the Observer when he denounced the west for "witnessing a devastating plague and sitting on a cure".
There is just one problem with this analysis: that there is a plague is without doubt, but there remains no cure for Aids. Instead, there is merely a partial, imperfect treatment. What's worse, a raft of new evidence suggests that, far from having Aids on the run, the west is encountering more problems with the disease than has been let on.
Not that you would know this from the attitude of the drug companies, which, although they disagree with the Africa campaigners on almost everything else, appear to share their belief that the west, in effect, has Aids licked. A new ad from Merck Sharp & Dohme features a couple in soft focus pointing a huge gun, under the headline: "Aids, your days are numbered!" Presumably this is news to the retrovirus: as of late, the creature has actually been on a little roll of its own.
Last month, the Public Health Laboratory Service announced that the number of people in Britain testing positive for HIV is at a record high. The spin put on this sudden and unexpected event by the government's health spokespeople is that the figures are rising because people are more willing to come forward, now that they realise they can benefit from the effective treatments that have become available. By this reckoning, the previous ten years of decline, which everyone celebrated as a huge victory, were really a disaster and a sign of scepticism in the medical profession. That this rise has been accompanied by an explosion in other sexually transmitted diseases, not least among gay men, does not exactly support the government's case.
In fact, it is much more probable that, as people have begun to think Aids has been conquered, fear of the disease has declined. One obvious sign of this is the growing acceptance of unsafe sex. Whereas ten years ago, porn that had been made before the age of HIV was often banned from gay cinemas or clubs, risky sexual behaviour has now become just another lifestyle option. The new ad for safe sex by the Terrence Higgins Trust, Britain's premier Aids organisation, takes a nicely non-committal line. A pleasant-looking, besuited, professional and positive gay man is pictured tussling with the appeal of fucking without a condom. His groin emits a thought bubble, urging him to take the risk, but his head is all in a quandary, as he reminds himself that "I'll get a hard time if he finds out I've got HIV".
The strap line under the man manages to issue this feeble declamation: "Weighing up the pleasure against the hassle you might get can help you decide if it's really worth it." Hassle? A hard time? The language is that of teenage comics, and more appropriate to the perils of two-timing than transmitting a terminal disease. The trust argues that these ads have been tested on its target audience, who no longer like to be hectored about condoms, thus confirming that (among gay men at least) the decade-long assumption that unsafe sex was simply a no-no has crumbled.
Further proof of this shift comes from the internet, where there is an increasing number of chatlines for gay men who are interested in "barebacking" (fucking without a condom). Gay.com's London barebacking site sits unobtrusively between "Asians" and "Bisexuals", and seemed to be doing a roaring trade when I peeked in.
Another British site with details of e-groups, where people place mail messages, rejoices in the name "Knocked Up". It's for men who wish to exchange and explore fantasies about infecting others or being infected. Prospective members are warned that no "flaming" or criticism will be permitted. There is also a specific warning that any member who discusses the need for safe sex will be barred from the group. These guys definitely need to get out more often. Or, on the other hand, maybe not.
It's not just the internet. In clubs, the safe sex message has powerful competition. It is hard to make rational risk assessments after getting "loved up" on E. Ecstasy is what the people in white coats call a disinhibitor, and, along with Viagra, in the form of Sextasy, the inhibitions it undermines are often sexual. The same goes for the increasingly common drug GHB, some users of which report a sense of euphoria and a surge of horniness. As for specifically gay clubs, the horse tranquilliser ketamine is a big hit both for dancing and, increasingly, for sex. The term disinhibitor doesn't really do it justice, apparently. In the United States, crystal meths, a mega-amphetamine, is also being blamed for the sudden enthusiasm for barebacking. Clearly, the days are long gone when all safe sex advocates had to worry about was people having the odd spliff.
No one denies that, after a decade and a half of tired messages about condoms, it is hard to maintain a sense of crisis. There are undeniable attractions in unsafe sex, not least the intimacy. There's also the thrill of transgression. If sex always stuck to the rules, the missionary position would not have become a byword for a lack of imagination.
Above all, however, the allure of risky behaviour used to be counterbalanced by fear, and it is that which has dwindled. Aids has lost the power to terrify, now that the disease no longer seems to be a death sentence. The irony is that, just as the numbers testing positive begin to rise again, there comes new evidence that the doctors may have claimed victory too soon.
The orthodox treatment for HIV in the west, which is known as HAART (highly active anti-retroviral therapy), consists of various drugs taken in combinations. Originally it was hoped - admittedly, rather wishfully - that HAART might, if applied for long enough, actually clear the body completely of HIV. But in recent studies, when patients have stopped taking even the most powerful and apparently effective combinations, the retrovirus has crept back, usually from hiding places where the drugs cannot as yet reach. That, if it really needs pointing out, is not the definition of a cure.
Even when the drugs aren't stopped, most doctors accept that HIV eventually comes back. It develops resistance to even the most complex pharmaceutical combinations. The drugs therefore have to be shuffled each time resistance emerges. A recent US army survey showed that one in every four people infected in the past three years has been infected with a retrovirus that exhibits at least one type of drug resistance. In other words, HIV in the west is getting stronger. So much for its days being numbered.
All this might not matter if the drugs could just be shuffled ad infinitum, expensive though this would be. So expensive, by the way, that no one has explained adequately how most African countries could ever afford it. Testing for resistance requires hi-tech equipment and specialist staff, not just cheap drugs.
An even bigger problem was raised at the last International Aids Conference in Durban, South Africa, when Anthony Fauci, the high priest of the battle against Aids, admitted: "Prolonged use of HAART for more that ten years is fast becoming realised as not a viable option."
The reason is that anti-HIV drugs often have powerful side effects. Sometimes they are little things like rashes and nausea - small prices to pay, most victims have concluded. But, as new drugs have been added to the combinations, the side effects have got stranger. On a recent trip to Los Angeles, I saw some for myself. A friend who has been on "combinations" for almost a decade now has a lattice of engorged cables around his body where once veins used to be. He is one of a growing number of people who have begun to react to drugs after being on them for years. Even when people change their drugs or come off them, effects such as the cables can remain. But it doesn't stop there.
In California, there is no ill wind that does not bring someone a healthy living. In the gay magazines handed out free in West Hollywood, the usual assortment of cosmetic surgeons' ads now routinely offer a new service. Amid the discount offers for orthodontics and blepharoplasty (eye-bag removal sounds so much less enticing in English) are an increasing number that claim to specialise in treating something called lipodystrophy.
Some anti-HIV cocktails cause fat within the body to run riot. No one really knows why, but the effects are unmistakable. Fat drains from the face, causing an effect known as facial wasting. In the gyms, guys are still busy pumping their biceps and calves. But the face is beyond salvation, and their hollow cheeks and stretched skin require the expensive and rather unconvincing assistance of plastic surgeons.
Luckily, sufferers usually have plenty of fat elsewhere to harvest. For the other main effect of lipodystrophy is its accumulation of fat in unpredictable places. Often, it's on the stomach, and it is not always content to stop growing. My friend introduced me to Phil, an otherwise lean African American whose distended gut he has named "Sakwina" (a little African baby), in honour of the protease inhibitor saquinavir, which he blames for the condition. It made him look as if he were six months pregnant.
Quite how this would play in a Tanzanian village, I do not know. In the most optimistic scenario, maybe the lumps of fat and the fake pregnancies among men might not cause understandable scepticism that the west was poisoning Africans. Stranger things have happened. In fact, in Los Angeles, I saw one. Hunchback lumps of fat on the back are the most dreaded of all the effects of lipodystrophy, precisely because they mark out the person as HIV-positive in a way that cannot be disguised - that and the nodules which speckle some people's bodies and, in certain cases, become cancerous. Maybe the campaign to spread the benefits of this new western technology will include the cost of counselling.
In future, the downside of long-term use of combination therapies might be eradicated. It may be possible to maintain patients on drugs for their whole lives. But, in the end, it may not be. It may also never be possible to find a way around the dilemma that every time doctors make advances in HIV care, the fear of Aids retreats - and so the infection rate rises. Until they find a real cure, the pharmaceutical companies cannot claim to have found the answer to HIV. Not yet. If anything, they have a whole new set of problems on their hands (resistance and side effects) that is all of their own doing. They are in the midst of a vast and hugely expensive experiment that may or may not prove successful. The question is whether, along with the cheap drugs, Africa wants to be part of that experiment.