NO ONE CAN accuse the small organisation that has set up shop in Washington DC near to the Anacostia River and a couple of miles from the White House of being unclear about its objectives. With total frankness they proclaim their name – Help Individual Prostitutes Survive – and for the last twenty years that is exactly what they have done. They are there to help sex workers live a life free of infection, intimidation and violence. Their cavernous office is down a steep stairway in the basement of an unprepossessing office building next to a liquor store. A notice inside warns: ‘Caution. Rat Traps Active Throughout’. They fight for funds to survive but this mixture of ex-sex workers – men, women and transgender – together with about fifty active volunteers run a service that, in one respect at least, does more for the public good than is achieved by quite a number of congressmen in their comfortable offices on Capitol Hill.

HIPS, as everyone calls it, is one of the main sources of clean needles for injecting drug users in the city. When I visited in June 2013, they told me that in the last twelve months they had distributed around 200,000 clean needles, often from a van that trundles the streets of Districts Seven and Eight between 8.00 at night and 5.00 the next morning – their hours follow the working hours of their clients. In the same twelve months they provided around a million condoms.

The United States is a nation of contradictions. Internationally they have brought massive help to countries who otherwise would not have been able to cope. Their aid has saved the lives of millions of men, women and children who a few years ago would have certainly died, and has stemmed the flow of the Aids orphans and the babies born with HIV. The money that they still devote to research holds out the greatest hope for the future. Their policies, for all the warts, are immeasurably superior to those of their old Communist foes. Their generosity is in an entirely different league. These are noble achievements, but the great irony is that America itself suffers from some of the same deficiencies that they spend billions of dollars trying to put right in other lands. Their present health insurance system is simply not fit for the purpose of tackling a public health epidemic like HIV and Aids. Some of their policies put political populism in front of what is necessary. Their general failure to engage with sex workers means that an obvious method of transmission remains open.

Prostitution remains a criminal offence in Washington, as it does in most of the United States, and the exploitation and persecution of sex workers has often characterised relations between police and sex workers in American cities. A 2012 report by Human Rights Watch on the position in New York, Los Angeles, San Francisco and Washington revealed widespread abuse. Many sex workers, particularly members of the transgender community, said that they had been stopped and searched for condoms while walking home or even waiting for a bus. As in Russia, possession of condoms was treated as an admission of guilt and the public health interest of reducing infection was utterly ignored. That is why a recent agreement between HIPS and the police in Washington DC that possession of a condom by itself would not be regarded as proof of prostitution is seen as such a step forward.

Cyndee Clay, the vivacious executive director of HIPS, has worked in Anacostia for the last seventeen years. She told me, ‘We want sex workers to be safe, healthy and free of coercion and violence. The policy of criminalising sex work and drug-taking exacerbates the problem not reduces it. Across the board sex workers face discrimination and a lot of violence.’ The criminal law, she added, does not help: ‘You can get five months in gaol for a five-dollar sex act.’ Their basement office is a place of refuge and advice without the formality and deterrence of official form-filling.

What makes the success of HIPS remarkable is that much of their work appears to directly contradict the position of Congress itself. Take drugs as an example. In 1988, just as Britain and a number of other countries were introducing clean needles, the United States decided to go in an entirely different direction. No federal funds would be made available for needle and syringe schemes – overseas or at home. The usual argument was put forward that it would only condone and encourage crime. And then, in 2009, as the ban became more and more indefensible and when the Democrats took control of both the Senate and the House of Representatives, policy changed. Federal funds became available, much to the delight of activists and the satisfaction of the Obama administration. But almost before the ink had dried on the new agreement, the ban was restored.

The elections of 2010 (confirmed in 2012) saw the Republicans take control of the House of Representatives – and a new breed of Republicans at that. The traditional and pragmatic old guard gave way to a new Tea Party intake, some of whom opposed virtually any spending of taxpayer funds. Money for an organisation called Help Individual Prostitutes Survive, one which dealt with both drug taking and sex work, was definitely not on their agenda. In this kind of political climate there was no way that the funding of schemes to enable drug users to contain, but continue, their habit would survive. In the negotiations to get through the budget of 2011, funds for clean-needle schemes perished and the ban was restored. One Democrat insider (with unusual party political honesty) explained the position to me.

He could, of course, have been describing the official view in Moscow.

The change was watched with dismay by many public health campaigners. Insults flew. The mildest was that Congress with a Democratic Senate and a Republican House of Representatives was ‘dysfunctional’ and was peopled by congressmen who were ‘off the wall’. Since the almost catastrophic breakdown of the talks with President Obama in the autumn of 2013 over the budget, such criticism, of course, has become commonplace.

The saving grace is that the United States has a federal system and, in spite of all the stones thrown at it, a flourishing democracy. States can – and do – do their own thing. ‘You can’t just press a switch and everyone will fall into line’, one federal health official told me. States like California and New York, and over two dozen others, finance their own needle schemes or at least allow them to be privately financed. They are not going to take orders from Washington, particularly when all the evidence points the other way. ‘If you don’t have policies that target drug users and sex workers are you really serious?’ one campaigner I spoke to demanded to know. Of course the other side of the coin is that states that do not support needle schemes – notably states in the south like Texas and Tennessee – can never be forced to run them.

The kind of mess you can get into by going the opposite route is amply illustrated over the border in Canada, where there is conflict between the provincial government in Vancouver and the national government in Ottawa. In the early 1990s Vancouver saw an explosive increase in drug use and by 1996 almost a third of injecting drug users were infected with HIV and 90 per cent with Hepatitis C. This was swiftly followed by what Dr Julio Montaner, the director of the British Columbia HIV Centre, calls ‘an epidemic in overdose deaths’. One part of Vancouver’s response was to set up a needle exchange scheme on a supervised site where users could bring in their own drugs and inject them in a safe environment. The scheme succeeded to such an extent that the local police brought drug users to the site and overdosing was virtually eliminated. It was not enough, however, to persuade the federal government, which objected – again on the grounds that it was condoning illegality – and then pursued Dr Montaner and his colleagues in the courts, to the extent of taking the battle to the Supreme Court. The government case was unanimously rejected in September 2011, but no one thinks that even now Ottawa has given up the battle.

In the shadow of the White House, Washington DC has been spared Vancouver’s kind of power struggle and not even the new generation of Republicans look set to seek one. Washington is in fact a constitutional anomaly: it is not a state, and locals sometimes complain vociferously that they live in a kind of limbo under the control of Congress itself. Vehicle licence plates proclaim ‘no taxation without representation’ and residents lament that as they have no congressmen of their own (only a delegate) they are run by ‘senators from Kansas’. To be fair, and luckily for HIPS, when it comes to clean needles, local decision-making prevails. Policy is the responsibility of the city council and the mayor. They set out the policy and approve the funds to be devoted to it. Of course this does not do away with the argument that the federal ban itself is utterly regressive and puts political gut feeling ahead of evidence and the overwhelming view of the American medical and public health professions. Domestically the practical effect has been to deprive dozens of schemes of much needed resources, leaving them with no other option but to try to raise the money locally.

Shortly after the ban was reinstated, the 2012 International Aids Conference was held in Washington DC and there the Secretary of State, Hillary Clinton, declared her ambition for the future of HIV/Aids prevention. The International Aids Conference is a unique occasion that brings together directors of foundations, workers on the ground in different countries, and government ministers from around the globe (although for some reason in 2012 British ministers decided to miss out on the most important conference in the HIV calendar – a discussion for a later chapter). In putting together the conference, one barrier had already been torn down. Many of the men and women who attended were living with HIV themselves and for over twenty years US policy had been to prevent such people from coming into the country. At long last the restriction was lifted. The delegates were rewarded with an array of star speakers from Elton John to Bill Gates but, in policy terms, the most important speaker by a mile was the Secretary of State herself. But she did not mention the change of policy. At the very least a word or two of explanation might have been expected. But there was nothing. Not a word. It was the elephant inside the conference hall.

Instead, Mrs Clinton’s message was deliberately up-beat, designed to inspire the 20,000 delegates who had streamed into the vast convention centre and to catch the attention of the world’s media. She told us she looked forward to the historic goal of ‘creating an Aids-free generation’: a generation in which virtually no child anywhere will be born with HIV; in which adults will be ‘at significantly lower risk’ of becoming infected, irrespective of where they lived; a generation in which ‘if someone does acquire HIV’ they will have access to treatment to prevent them developing Aids and passing on the virus. If you looked at the small print it was something less than a pledge to eliminate HIV and Aids, but it was a barn-storming performance all the same and one which brought the audience to its feet.

So just how near are we to attaining Mrs Clinton’s declared goal of an Aids-free generation? Let us test that rhetoric, not in some far off country, but in Mrs Clinton’s own Washington backyard in the District of Columbia. On the face of it the Washington position does not look so bad. There are certainly parts of the United States which appear to have far bigger problems. In New York, 130,000 live with HIV and in California and Florida the figures are just above and just below the 100,000 mark. The comparable figure for Washington DC is a mere 15,000. But then Washington is a tightly confined city with a total population of only 600,000. Once population size is compared with infections, the true position is revealed. The adult HIV prevalence rate of just under 3 per cent puts the capital of the richest country in the world on a par with sub-Saharan countries like Nigeria and Rwanda. It’s fair to say that comparison is overdone to the extent that it is hardly sensible to compare prevalence in one relatively small city with whole countries, where the peaks of urban areas tend to be evened out by the troughs of the suburbs and the countryside. Nevertheless, no one would deny that over the years the city has faced a major public health crisis. As Mrs Clinton herself says, ‘Washington today has the worst problem of any comparable city in the United States.’

There has never been any secret about where the epidemic is concentrated. It is not in the smart streets of Georgetown but in Districts Seven and Eight where HIPS is centred. It is an area which is literally off the tourist map and, in spirit if not geographical distance, a thousand miles from the tourist buses and the bookshops and cafés around Dupont Circle. Poverty is endemic, unemployment runs at almost 20 per cent and housing is poor and overcrowded. I remember years ago a Washington journalist referring to it deprecatingly as the ‘Gold Coast’ to mark out the high number of African Americans living there.

A more sympathetic portrait was painted by the journalist Ewen MacAskill in The Guardian. In July 2011 he wrote:

Throughout the 1990s and the first years of the twenty-first century, the HIV position in Washington steadily deteriorated and the mayor and the council did all too little to combat the rise. It was not until 2005 that the full scandal was properly revealed. An independent watchdog organisation, the DC Appleseed Center for Law and Justice, reported that the annual rate of new Aids cases in Washington was believed to be ten times the national average. One estimate was that one out of every twenty residents was infected. The report charged that frequent changes in HIV leadership in the council’s health department prevented consistent policy making, that testing and condom distribution were utterly insufficient, that both prevention and needle exchange programmes were dangerously weak and that the surveillance system providing information for the policy makers was not fit for purpose.

The Appleseed report was entirely damning but had one beneficial effect: the then mayor, Tony Williams, declared HIV to be his ‘number one priority’. The uphill struggle to recovery slowly began. The Aids section of the health department was put under the direction of determined reformer Marsha Martin after a whole series of her predecessors came and went. When she took over in September 2005 there was no real data on the size of the epidemic and no proper figures had ever been collected about new infections. When I spoke with her in July 2013 she told me her guiding principle had been that ‘if we communicated to the public that this was a serious problem then the public would respond’. And so it proved.

The new management launched a city-wide testing campaign: ‘Come together DC – Get screened for HIV’. By 2008 the District was providing 73,000 tests – an increase of 70 per cent on the year before. Better surveillance revealed a population where over half of new infections occurred in gay and bisexual men, with African American men and women most highly affected. What also became clear was that (as in so many countries) about a fifth of those with HIV were undiagnosed, did not know their condition and, other things being equal, would continue to spread the disease.

The latest figures show that the figure for public-supported HIV tests has now climbed to around 125,000 a year. Tests are made available in pharmacies and even when renewing a driver’s licence. As drivers wait to take their eye tests they are offered the HIV check as a matter of routine. This success has been achieved in spite of the predictable reluctance of some private general practitioners, in a dispute over fees, to carry out this essentially simple task – which in any event could be done at home. At the same time as increased testing, the American capital also experienced ‘the rubber revolution’, with the District distributing an ever-increasing number of condoms – male and female. Around 115,000 were given away in 2006, 1.5 million in 2008 and today the District distributes over 4.5 million a year.

The result is that, in the latest of their periodic reports, DC Appleseed holds up Washington as an example of what can be achieved. HIV surveillance has now become ‘a national model’, testing and condom distribution are both rated today as A minus, while a straight A goes to prison work where tests are offered to all inmates as they enter with only a 10 per cent refusal rate – offering a guide to the British prison authorities who are now belatedly following suit. So it would be good to report that the position on the ground in Washington has been transformed. And yet in one respect the position seems hardly to have moved at all. The prevalence of HIV in DC is marginally up on the position back in 2005 and is the rate which has led to all the African comparisons. But that figure comes with a massive health warning. The prevalence rate (the number living with HIV compared to population) is valuable for showing the number of people who need treatment, but in substantial part it is a retrospective picture.

The much more worrying position is the trend in new infections – the incidence rate – and the number of deaths from Aids. In 2012 in Washington there were over 800 people newly diagnosed – down on the 1,300 peak of a few years ago but stubbornly stuck at this level. The equivalent national figures for the whole of the United States show some 50,000 people newly diagnosed each year – similarly stuck after the initial fall. As for deaths, the latest figures show that in Washington there are now around 200 deaths a year from Aids while nationally the figure is 15,500 a year – bringing the number of people who have died from Aids since the epidemic began to almost 650,000. Some find that a surprise: a few weeks before my visit to Washington in 2013 I was at Westminster, and was asked by a well-known and bright peer: ‘Do people in the West still die from Aids?’ He knew they died in Africa but could not conceive that it could still be the case in a rich country like the United States with all the modern drugs at their disposal.

For all the success that testing programmes have had in Washington it remains the case that thousands of men and women will still not come forward, with the result that much HIV remains undiagnosed. The stigma around HIV remains strong – particularly in the African American community. As Greg Pappas, who acquired a wealth of experience in his time at the District of Columbia health department told me, ‘People die rather than face up to the fact that they are HIV positive.’ Others simply do not want to reveal that they are gay and fear that the news could reach their family or neighbourhood. So to persuade more to test remains a difficult challenge – but there is another issue which raises just as many problems.

The comforting assumption is that if only you can get people to test then all problems are solved. It is assumed that if found positive they will automatically go onto treatment and just as automatically they will follow the regime and ensure a stable life. Sadly that is not remotely the case. Public health officials in Washington love to illustrate the issue with a ‘cascade’ chart which shows not only the difficulties of getting people into treatment but, once there, retaining them. The goal is full adherence to the treatment schedule and the achievement of minimal activity of the virus. This is termed an ‘undetectable viral load’ – which in plain English means more or less total suppression of the virus for the individual, which reduces infectiousness and the risks of HIV being passed on to other people.

That is the goal, but the official health figures tell a very different story. Out of almost 1.2 million people in the United States living with HIV, the figures cascade downwards to show little more than a quarter of that number with an undetectable viral load. A fifth are undiagnosed and live in ignorance of their condition. The cascade continues downwards with about 420,000 on antiretroviral treatment and, in the end, only 330,000 fully adhere to the treatment and have an undetectable viral load. The cascade is illustrated in the chart below:

In Washington the figures show the same trend. The figures of course are an average and in San Francisco, for example, the claim is that the drop-out rate is much less among men who have sex with men. But their achievement entails twenty-five years of fairly relentless publicity and (perhaps above all) an acceptance of gay sex which is not shared in much of the United States, let alone in very many other countries around the world.

The more general truth is that ensuring that patients adhere to the treatment is often every bit as difficult as persuading them into testing and treatment in the first place. Yet unless that is achieved a whole fresh set of complications arise. People risk death if they abandon treatment altogether, but more commonly they dip in and dip out. The problem for them is that they risk becoming drug resistant to the basic antiretroviral drugs and need more complex treatment which may or may not be available. The problem for the public is that the people who have dropped out of treatment become infectious again and can then spread the virus.

The American position pinpoints a major under-reported global issue. It shows what happens if access and adherence to treatment breaks down. If this happens in the richest of rich countries, what happens in the poorer countries of the world where health systems are under-developed and where there can be substantial difficulty for the patient in making the journey to the hospital in the first place? In the United States, apart from some remote areas, there are no physical obstacles in reaching medical care. Rather, the obstacles appear to be principally financial. Health care in the United States relies on private insurance but that leaves substantial numbers of uninsured or partially insured people who drop out of HIV care because they cannot afford to continue. This, after all, is why President Obama has expended so much political capital trying to reform health care with the Affordable Care Act. Men and women with HIV figure prominently among the uninsured and are potential beneficiaries. Or at least that is the hope. The latest study conducted at the beginning of 2014 by the Kaiser Family Foundation shows that the new act is unlikely to transform the position on HIV and Aids. Around 70,000 people with HIV could gain new coverage but that number will be reduced when the many states that do not plan to expand their Medicaid programmes are taken into account.

In contrast (as the table below shows) almost 60 per cent of those living with HIV across the Atlantic in Britain stick with their treatment and do not drop out. Britain runs the much maligned free-at-the-point-of-use National Health Service, which is attacked in the United States as a peculiarly socialist measure and sniped at in Britain for its well-reported failures. The central principle of the British health service is that no one is turned away from treatment for lack of funds. In public health, all logic tells you that should be the guiding principle. In the same way, France runs a much-admired health system which again produces a much wider coverage of antiretroviral therapy than anything reached in the United States. I should add a rider. The European figures are undoubtedly better, but they still show that 40 per cent of those with HIV (including the undiagnosed) have not achieved the goal of an undetectable viral load.

So where does all this leave the United States in achieving Mrs Clinton’s Aids-free generation? Some considerable way off I fear. Of course it is the case that the most massive progress has been made. We are light years from the position I saw in 1987 when young men were dying and the politicians were looking the other way. The position was turned around by men like the former surgeon general Everett Koop who came to Washington with a reputation as an unyielding moral conservative much loved by President Reagan and the White House and left as one of the most effective Aids campaigners the United States has ever known, much to the delight of the liberals who had vociferously opposed his appointment. In Washington DC enormous credit goes to Marsha Martin who, by reorganising the city’s public health response, did so much to stem the tide in the capital itself and who now seeks to assist other cities in taking charge of their own epidemics. In addition there is an array of private foundations and civil society organisations which have been giving help ever since Washington’s dark days; organisations like N Street Village and Whitman-Walker Health, which I will come to shortly, and of course HIPS. As Marsha Martin herself told me, ‘If we did not have the private sector response it would be a nightmare. You cannot rely on government to provide the resources.’

Nevertheless the problems of reaching the Aids-free goal are formidable. Habits are slow to change and the impact of health promotion can wear off as the years go by. Most high-school-aged young people and a large number of children in middle school are sexually active. In Washington, over 13 per cent report having had sexual intercourse before the age of thirteen – over double the national average – and many have a number of partners. The use of condoms drops from 79 per cent for 14–17-year-olds to 45 per cent for 18–24-year-olds and the trend continues into middle age with inevitable results. In the US generally most new infections are among men and women in their twenties (15,500 per year) but they remain high with people in their thirties (11,500) and their forties (11,300) – those who have lived through at least a decade of prevention publicity. The US national figures show that of those people diagnosed 30,573 were infected from male to male sexual contact, about 3,600 from injecting drugs and 13,300 through heterosexual contacts – and in Washington the proportion of infections through heterosexual sex is higher than the national average. As one worker told me, ‘The woman may be in a monogamous relationship but that does not mean the partner is doing the same.’

And there is one further overarching problem – deprivation. The head of one civil society organisation told me, ‘The greatest barrier to preventing HIV is poverty. The next greatest is not to have medical insurance.’ A local health official added ‘We are not dealing with the educated middle class. We are dealing with people with a whole range of other issues like unemployment and homelessness.’ Only a handful of those entitled to housing assistance in Washington receive it. According to a Washington Post report in April 2013, the average public housing wait for a one-bedroom apartment was twenty-eight years. Homelessness has been long associated with increased risky behaviour and poor health, while housing instability means simply communicating with people moving from one poor address to another is difficult and is an obvious barrier to both testing and treatment.

One significant effort to make progress is made by a private charity called N Street Village which cares for homeless women. Their origins go back almost twenty years to a time when they were the first to give care to homeless women in Washington who were dying from Aids. The director Schroeder Stribling told me, ‘They faced terrible prejudice. Other women in a homeless hostel would say, “We don’t want you here. We don’t want to eat with you. We don’t want to share your laundry.” We said to the women: “You can stay here. You can die here.”’ Since then, with the new drugs, the position has changed radically, and inside the buildings of N Street Village much wider care is now provided. ‘We didn’t need full time nurses any more’, she continued.

The effects of homelessness and poverty in Washington go wide. Young gay black men face the prospect of being thrown out of their family home if their sexual orientation is revealed. They then need a roof over their head and it is at that point that they can get together with an older man and become infected. According to Don Blanchon, the head of Whitman-Walker Health, housed in the Elizabeth Taylor Medical Center (so called not because she started it, but because the original benefactor admired her as an actor), they do not have the power to insist on the use of a condom. In spite of all the efforts, the goal of a sensible standard of living and individual and family stability in Washington is still a long way off in Districts Seven and Eight. As Schroeder Stribling remarked, ‘We are the nation’s capital. We have all this power, all this money. And even then we don’t get it done.’ To put the point in the terms of this book: if it cannot be achieved in the capital of the richest nation on earth what chance is there in a slum in India, a township in South Africa, or a grindingly poor village in Ukraine? The answer is that the chances would be even less without American help.

For Washington does have another vastly important role. It is the political home for the biggest givers of international aid in the world. Washington funds the President’s Emergency Plan for Aids Relief, known everywhere as PEPFAR, and USAID, which implements much of the work overseas. In the five years from 2009 to 2013 Congress authorised $48 billion of US taxpayers’ money for the President’s fund and, in addition, each year (and here they have to date proved entirely constructive) provide about a third of the revenue which enables the Global Fund to Fight Aids, Tuberculosis and Malaria to function. In both Washington and New York there is again an array of civil society organisations ranging from the International Aids Vaccine Initiative to the private foundations of Bill and Melinda Gates and of George Soros. But it is PEPFAR that is the most striking achievement. Countering HIV has never been the most popular cause among politicians and yet since 2003 the United States has sustained a vastly expensive programme giving help to people who, if the truth is known, are strongly disapproved of by many of the citizens of middle America. What is more it was a programme introduced by a Republican President.

PEPFAR was not the brain child of Hillary Clinton’s husband when he was the United States President at the end of the 1990s. Bill Clinton did relatively little in the international field when he was actually in the White House. His daughter Chelsea is said to have asked him after he had left, ‘Why didn’t you do anything about global HIV?’ Whether this is true or not, what is certain is that Bill Clinton’s major contribution came – like President Mandela in South Africa – after he had left office, with the Clinton Foundation and his formidable success in bringing down the price of drugs. Nevertheless, the author of the emergency fund which has saved countless lives was his Republican successor George W. Bush. Much reviled for the ‘War on Terror’ and the invasion of Iraq, it is probably his greatest legacy. As Jason Wright, the head of International HIV/Aids Alliance in Washington, told me, ‘It was a sort of Nixon goes to China thing. It was crucial that it was a Republican President doing this. The Republicans supported their President.’

The figures spelling out the achievements since then are by any standards impressive. The United States, through PEPFAR, now supports over six million people around the world on antiretroviral treatment – up from 1.7 million in 2008 – and each year provides drugs to prevent mother-to-child transmission for around 1.5 million pregnant women. The goal is to reach a position where the numbers put onto treatment in individual nations each year at least exceed the new HIV infections. That process has still a long way to go. In countries like Botswana and Kenya treatment is ahead of new infections but in others, like Nigeria and Uganda, it is vastly behind.

Some critics say that although the US spends a vast amount on countering Aids, its total spend on overseas aid is still only 0.2 per cent of GDP, compared with the 0.7 per cent which is the United Nations’ goal and which countries like Britain make a particular effort to meet. But as a former British Chancellor of the Exchequer, Nigel Lawson, was apt to say, ‘cash is cash’ and for the last fifteen years American cash has kept poor nations supported and international organisations financed. A more fundamental criticism is that some of the conditions laid down over the years for the receipt of funds have been unnecessarily and damagingly restrictive.

One rule laid down is that PEPFAR must report to Congress if a country fails to spend sufficient of its prevention funding to ‘promote abstinence, delay of sexual debut, monogamy, fidelity and partner reduction’. Reports still faithfully record the number of abstinence messages that are distributed. When I was in Kenya just after the New Year in 2013, I was handed a report that said around 720,000 people were reached with ‘abstinence and faithfulness messages’ in 2011. The suspicion is that, although sincere, these efforts are no more successful than the efforts of the British and Canadian armies in the First World War that exhorted soldiers to ‘do your duty, fear God and honour the King’. As many workers point out, abstinence for women is little use if the men they eventually team up with are HIV positive. Nevertheless the ‘no grazing’, ‘keep to one partner’ messages which aim to break the habit of multiple partners can be useful – provided they are seen to come from national politicians and health officials rather than from overseas.

An undoubtedly damaging PEPFAR rule concerns sex workers. Historically grants have always come with two conditions. First funds cannot be used to ‘promote or advocate’ the legalisation of prostitution and second grants can only go to groups with a policy which ‘explicitly’ opposes prostitution. There has then been a policy requirement that organisations tackling HIV must refrain from any speech or activity that the government deems ‘inconsistent’ with the anti-prostitution pledge. That has extended to what a recipient says or does not only with PEPFAR funds but even with its own private funds.

Not surprisingly these rules have put successive administrations under fire from civil society organisations and, at last, in June 2013 that flak led to a successful legal challenge. The Supreme Court ruled that the First Amendment to the Constitution precluded the government not only from censoring speech but also from ‘telling people what they must say’. However, whether the Supreme Court decision has settled the issue is quite another matter. The ruling applies only to United States organisations and not to foreign-based ones, and there still remains the power of any government to choose to fund some activities and not others.

And so we return to the elephant in the room at the International Aids Conference in 2012. Perhaps the Secretary of State failed to mention the renewed ban on using federal funds for needle schemes because overseas, where alternative funding is not easy to come by, the impact of the government’s backflip will be much more severe. With casualties from injecting drugs still rising in Eastern Europe and Central Asia and with drugs now making an unwelcome appearance in Africa, it is a decision that goes smack against all the good work that the United States has done internationally over the last years.

They gave Mrs Clinton a standing ovation that day because everyone in that vast Washington hall believed that in terms of HIV and Aids the United States had saved the world and that without their effort a whole range of countries would be in an utterly desperate plight today. They also wanted to believe that the historic goal of an Aids-free generation was near but – uneasily – they recalled the world as they knew it: the vast distance there was still to travel in Africa; the deteriorating position in Russia and Eastern Europe; the sheer numbers infected in India and China; the ominous signs of new epidemics in the Middle East and North Africa; and the depressing statistic that, even today, for every new person put on treatment many more are infected. Some thought that she was being optimistic, others that she was falsely raising expectations – rather like the periodic newspaper headline promising ‘a cure to Aids’.

The obstinate refusal of too many American politicians to help drug users means that dirty needles still spread the epidemic not only at home but in other countries of the world. None of this is the fault of the clinicians, the local health workers, or the volunteers. The fault lies fairly and squarely with the politicians. It is political action which is required: political action in Washington. If the politicians were to look again at just the ban on supporting clean-needle schemes that would help not only the American public but also send a clear message around the world. As it is, Russian officials now claim that the United States has been converted to their harsh and balefully unsuccessful policies. Can Republican congressmen (together with some Democrats) be happy that they are now portrayed in the world as arm in arm with Russian officials, following the old Communist ways? Are they content to bring up the rear in this particular conga of death?