NOVEMBER, AND THE jacaranda trees are in full purple and in the city’s gardens the canna shine out a fresh, bright scarlet. On the quay crowds gather around the signature sails of the Opera House and if you look up to the iron girders of the massive Harbour Bridge you can see a small line of tiny specks being led in a human chain across the top span. In the harbour ferry boats criss-cross the water and a group of white sailing yachts change tack to catch the wind. This is Sydney, New South Wales. It is home to about a quarter of Australia’s twenty-two million population, and it has prospered and has survived better than most during the international financial crisis. It is a city of business with a skyline dominated by the tall, oblongs of concrete and glass which house the banks and the insurance companies. It is also a city of galleries, music and theatre. But for our purposes, it is a city where some say policies towards HIV are the best in the world. So is this the promised land?

A few miles from the centre of Sydney there is a small block of offices by the side of a quiet square with a war memorial to the dozens of young men from Redfern who perished in two world wars. The well-kept building contains the smart offices of the Scarlet Alliance, which represents Australian sex workers. The alliance was formed back in 1989 in an effort to afford some protection against exploitation. Today, after a remarkable set of reforms, sex work in New South Wales is entirely legal and basically run just like any other business. Brothels must meet normal business requirements but here there is no question of them or the sex workers being specially licensed. The protection comes from standard occupational health and safety laws. Brothels, strip clubs, massage parlours, escort services and street prostitution are all now within the law. Street workers in Sydney can take their clients to ‘safe houses’ – with security on the gate – and so avoid the violence which is the occupational hazard of the sex worker’s life. There is none of the hypocrisy of so many nations that prostitutes should be allowed but not seen.

Janelle Fawkes, the chief executive of the alliance, is a softly spoken woman who, like all her executive committee, was once a sex worker herself. She says the effect of the new laws, which were introduced in the mid-1990s, has been entirely beneficial both to sex workers and to the public generally. There is not the corruption that typified the previous free-for-all. Although it would be an exaggeration to say there are no complaints, they mainly come today not on moral grounds but on planning grounds from people who do not want to live next door to a brothel. Most crucial in the terms of this book, Janelle Fawkes claims that the record in public health terms is outstanding. HIV rates among sex workers are less than 1 per cent. Rates of sexually transmitted infections are also very low. There is no recent case of HIV being passed on by a sex worker and the use of condoms is virtually 100 per cent. It seems to be the kind of outcome that nations around the world have been seeking.

So how was this deeply pragmatic policy, which seems to ride roughshod over the usual opposition of politicians and Church, introduced? It goes back to the Royal Commission on the Police which between 1995 and 1997 examined corruption inside the New South Wales force to devastating effect. In page after page it exposed an almost incredibly long list of abuses, including police perjury, the planting of evidence, theft and extortion, interference with internal investigations, the police code of silence – and police protection of club and vice operators. They found that brothel managers were paying protection money to the police and that, in one area, local brothels were providing police with free alcohol and sexual services. The commission’s investigation was so detailed and comprehensive that it could not be ignored. Dozens of police left the service. They took advantage of an amnesty against prosecution, were dismissed or retired. Others were prosecuted and several committed suicide once the extent of the corruption was revealed.

The New South Wales government had a choice – the kind of choice which other countries throughout the world have faced and still face. They could have denounced the sex work and tried to legislate it out of existence, or they could have tried to brush it under the carpet and hope it could be kept out of sight. In the event they faced up to the issue and, in the words of the commission, they allowed well-run brothels to operate on the basis that ‘a potential opportunity for corrupt conduct on the part of the police was closed off’. There was a lengthy and fierce debate in both houses of the New South Wales Parliament but, in the end, the legislation was passed as a bipartisan measure.

So just how well has this radically reformed system worked out? In 2012 the Kirby Institute at the University of New South Wales, in cooperation with Melbourne University, published a study of the position in three Australian cities: Sydney, where sex work has been largely decriminalised; Melbourne, where brothels or individual sex workers must be licensed; and Perth where most forms of commercial sex are illegal but where there is a limited licensing scheme. There was no question which city came out best. They found that New South Wales had ‘one of the healthiest sex industries ever documented’.

The report confirmed the claims of the Scarlet Alliance. Condom use in Sydney brothels was virtually 100 per cent and the prevalence of other sexually transmitted diseases was at least as good as the general population and probably better. Contrary to original fears, decriminalisation had not led to an increase in numbers of sex workers. The number of sex workers in Sydney brothels was similar to twenty years previously, when the new system was introduced.

As for the alternative models found in Melbourne and Perth, the report was damning. Licensing, which on the face of it sounds an attractive halfway house, came in for particular criticism. Professor Basil Donovan from the Kirby Institute said, ‘Jurisdictions that try to ban or license sex work always lose track as most of the industry slides into the shadows.’ In Queensland, 90 per cent of the sex industry was operating illegally and in Victoria the figure was 50 per cent. The report said, ‘Licensing systems are expensive and difficult to administer and they always generate an unlicensed underclass. That underclass is wary of and avoids surveillance systems and public health services … licensing is a threat to public health.’ In Sydney there are also some sex workers operating outside the regulations, but the problem is not remotely on the same scale as with licensing.

The report also provided a sketch of the sex workers and their clients. Compared to their counterparts in Perth and Melbourne, the brothel-based sex workers in Sydney were better educated and, although they were more likely to have been born in an Asian or other non-English-speaking country, there was virtually no evidence of trafficking or coercion. Indeed, the position was a substantial improvement on the pre-reform position when sex workers in brothels were typically poorly educated women from Thailand, with false passports and visas, and usually in debt to the agents who had organised their travel to Australia. As for men, only 2.3 per cent of men in New South Wales purchased sexual services in any one year.

The finding of the report was that reform in Sydney had ‘improved human rights; removed police corruption; netted savings for the criminal justice system; and enhanced the surveillance, health promotion, and safety of the New South Wales sex industry’. To which I would add that the sex workers I met in Delhi, Kiev and Washington would all have dearly loved such a system.

None of this of course will still the international debate. Everyone has a view and politicians are likely to head for what they see as the popular ground. The absolutist position is that selling sex is just wrong and therefore sex work should be banned altogether. The trouble with this argument is that over the ages it has failed as a practical solution. Sex work has continued but it has simply gone underground, with the obvious effects that proper health checks have been ignored and criminality encouraged. That is why in most nations we have reached not prohibition but a no man’s land of disapproving acceptance. There is no great morality in allowing the resulting exploitation and corruption, but that is what most of the world prefers to do. As is the case in India, we allow the pimps to prosper at the expense of the sex workers and the gangsters to grease the palms of the police while we look the other way.

A variation on prohibition is to make it illegal for clients to buy sex, but to abolish the crime of soliciting and, at the same time, to set up schemes to help sex workers leave the trade. In February 2014 the Times columnist Janice Turner came out in support of such schemes, saying that ‘across Europe the mood has changed’ and pointing to efforts in France and the European Parliament to go down this road. The article produced a swift rejoinder from some of those working in the area. Further criminalising sex work, they argued, would have serious adverse effects whether or not it was focused on the buyer or the seller. It would not stop people selling sex but would drive sex work underground. The group added, ‘It would also enforce stigma through legislation and this will make it far less likely for sex workers to engage with sexual health and social care services and report to the police if they are attacked.’

If I were a citizen of Sydney in this debate I would say that here we have a system which works. We have reduced sexual disease and virtually eliminated sex workers passing on HIV. Sensible precautions like the use of condoms are very widely followed and police corruption has been eliminated. Violence against sex workers has been substantially reduced and the amount of sex work outside the law is limited. If I lived in Sydney I would also say, ‘You show me how any new system would improve on that and, also incidentally, if this is to be a worldwide policy, just how you intend to help sex workers find alternative work in Africa and India.’ Treating sex work as a normal business may not be the perfect solution. Different surveys in different countries show that many sex workers feel exploited and would like to leave the occupation. The trouble is that driving sex work underground does not prevent exploitation – it encourages it – and at the same time endangers both public health and the health of the sex worker. Sensible control may be as far as we can get today and for the foreseeable future. As for criminalisation, the internet and mobile phones make the law extremely difficult to enforce and mean that predominantly it is the street workers who are prosecuted. Business controls at least hold out the prospect for sex workers that they escape the miserable subservience and violence that characterises their lives in so many countries today, while also providing a substantial step forward in public health.

When the New South Wales Royal Commission presented its final report in 1997, sex work was not the only activity that came under scrutiny. Their most critical findings centred on the police and illegal drugs, particularly in the Kings Cross area, which has always been the centre of the drugs trade in Sydney. The commission found that there was:

In Kings Cross itself there were ‘shooting galleries’ permitted by the police on the basis that medical assistance would be on hand for those who overdosed. The trouble was that supervision was left in the hands of people who lacked any medical training, had criminal records, and were closely involved in the supply of drugs. The arrangements placed no emphasis on rehabilitation, and referral to the public health system was clearly against the interests of those running the ‘galleries’.

Today the position is very different. Standing on the outskirts of Kings Cross, a short taxi ride from the sex workers’ headquarters in Redfern, is the old Darlinghurst fire station. Today it houses the Kirketon Road Centre where drug users can come to collect their methadone and clean needles and where there is a room where injecting can be medically supervised. To reach it you pass two vending machines at the building’s entrance offering a clean needle and syringe for two Australian dollars and follow an uncovered, narrow staircase up to the crowded waiting room.

The director of the centre, whom I met on my visit in November 2012, is the vivacious Dr Ingrid van Beek who also works in under-developed countries overseas with the Global Fund. She told me that the result of adopting a clean-needle policy is that today the number of injecting drug users who contract HIV is ‘minuscule’. ‘The time for governments who have not yet introduced the policy to talk of pilot schemes is past,’ she added. ‘We know what works.’ She readily concedes, however, that it is easier to do in countries with developed health care systems than it is in countries which do not even have the facilities for prenatal work.

Today there are around 1,000 needle and syringe outlets in New South Wales including pharmacies, and automatic machines which dispense boxes of six needles. The centre runs a bus that takes the harm-reduction message (together with needles, condoms and testing kits) throughout the Kings Cross district. Everyone is refreshingly open about the problem. In the 1990s used needles and syringes littered the streets. Today there are collecting bins – even on the ferry to the popular beach at Manly.

Reviewing the success of the clean-needle policy Dr van Beek shares the views of clinicians and police in other countries – that there is absolutely no evidence of increased criminality as a result of this policy. She says that the evidence is not of more crime, but of drug users being reached by the health service for the first time: ‘Thirty years ago people who injected would not have been anywhere near the health service.’ Her personal view is that, as a general policy, the use of drugs should be decriminalised but the efforts should be maintained to counter the importers and the pushers.

As for methadone, she says: ‘Methadone produces a transformation in a user’s lifestyle and that is obviously good. But down the track you face problems of quality of life. Your life is limited by when you can get your methadone. So if you can come off it altogether then that is obviously good.’ But she warns that compulsory targets will not work. Each case needs to be managed – one to one. It is the antidote to the view of some politicians that users can be forced off methadone in a set time and easy public spending savings achieved. If only it were so.

Sydney still remains a centre for drugs, although drug use itself has changed. In the 1990s there was a glut of cheap heroin imported from the golden triangle of Thailand, Burma and Laos with the result that the number of users injecting drugs increased. Then in 2001 there was a dramatic reduction in supply. No one quite knows why, but the most popular theory is that the suppliers found easier markets at home and in China and Indonesia. The price was not so high but it was easier to distribute and there was a much bigger market. One result in Sydney has been that as supply has decreased, the price of heroin has increased and the number of injectors has reduced. One doctor told me, ‘The average age of injectors is around thirty. Young people are not taking it up. It is too expensive.’

So both in sex work and drug taking there has been a substantial revolution in Sydney, much of which can be put down to the work and revelations of the 1997 Royal Commission. It is perhaps here that there is a lesson for the rest of the world. The inquiries revealed precisely the problems that New South Wales faced. The corruption which they established was of long standing, but it was only when it was exposed in detail that politicians took the kind of measures that were necessary. It was the catalyst for change. The approach was broadly bipartisan and based on evidence. Many of the old prejudices were forgotten in the name of better public health and the end of corruption. What would be the effect if similar commissions of inquiry were to look at the position in Moscow or Delhi – or for that matter Washington or London?

Sydney has not always been so advanced. Back in the 1980s Bill Bowtell was chief adviser to the federal health minister, Neal Blewett, in the very early days of the HIV epidemic in Australia. ‘It was a horrible period,’ he told me. ‘People were scared. Some said it was the judgement of God and that Aids was something that killed sinners.’ Cars were burnt because people who had been in them had HIV. Nurses pushed food under the door to Aids patients. Sitting in a small café in the shadow of Sydney’s St Vincent’s Hospital, he also remembers that clean-needle exchanges were opposed by many, including doctors, on the grounds that it would lead to more crime. ‘If crime goes up we will come after you,’ the Australian Medical Association told him encouragingly. Are doctors’ unions the same the world over?

This was of course the time when there were no antiretroviral drugs and public education was the only option. Blewett and the Hawke government decided on a very similar approach to what we were doing in Britain. Indeed Sammy Harari, who oversaw much of the British advertising, also worked in Australia. In the resulting campaign, rather than being presented with gravestones and white lilies, the public in Australia were warned by the grim reaper, scythe in hand, ready to cut down anyone who did not take sensible precautions. Today when journalists look back at these campaigns they tend to refer to both Britain’s tombstone and Australia’s grim reaper as ‘notorious’, ignoring the fact that in both countries HIV and other sexual diseases fell sharply. As Bowtell says, ‘It was the only weapon we had. People were dying.’ Today such a campaign would be strangled by a focus group but, of course, the difference is that we now have the drugs to preserve life. The real criticism is that no one has had the wit (or the money) to develop an effective campaign for the second decade of the twenty-first century.

New South Wales, if not the rest of the nation, has travelled a vast distance since those early days. Politicians and health professionals in Sydney take a pride in the city’s reputation. The approach has been bipartisan, pragmatic and down to earth. The guiding principle is: ‘We do what it takes.’ Successive ministers of health in New South Wales have shown a commitment to HIV absent in other countries and have not been afraid of challenging the orthodox. Sydney has led the way, but there are others who are not afraid of new ideas. When I was there in 2012, the prison authorities in Canberra were exploring the idea of a clean-needle scheme in prison on the basis that everything should be done to avoid prisoners sharing. The argument was that, as everyone knew that drugs were used in prisons the world over, you could provide clean needles in just the same way as condoms were provided for protection in prisoner sex.

Another feature of the Australian approach at its best is how public health authorities have worked in partnership with the organisations representing the people who have contracted HIV. One official told me:

So is this as good as it gets? It may well be that it is, but that does not mean that the position either in Sydney or in Australia generally is ideal. In Australia there are about 32,000 people living with HIV with around 8,000 unaware of their condition and undiagnosed. What gives most cause for concern – and the charge that Australia has lost momentum – is the relentless rise in the number of new infections. These are tracked by the Kirby Institute in Sydney and the latest figures show that nationally in 2012 there was a 10 per cent increase in cases to 1,253 – the biggest rise in the annual figures for two decades. Back in 1999 the total was 724 new diagnoses. The New South Wales figures are the worst in the whole country.

As in virtually every country I have visited around the world, all the public health officials say the urgent need is for more testing. But here there is a failure in the Australian system. To take a test is a cumbersome process. You go in, wait and pay but it is not until a week later that you get the result – and then you are invited to come in again, wait and pay. The doctors and the laboratories stand in the way of speeding up the process and home testing seems a long way distant. It is a system-wide failure according to an editor based in Sydney:

The HIV position in both Australia and New South Wales is dominated by men having sex with men. Around two-thirds of new diagnoses nationally are of gay men and the reasons for the rise in infections are not too difficult to find. About a third of gay men admit to having unprotected sex. Many will never have even seen the ‘grim reaper’ advertisements of the 1980s but, even more ominously, according to Professor Andrew Grulich of the Kirby Institute, ‘the fear has fallen away even among those who remember the early days’. There is now a false complacence typical of many other countries where there is easy access to antiretroviral drugs. There may not be a cure, they seem to think, but surely all that is needed is a pill a day. It is the other side of the treatment coin and ignores all the problems – mental as well as physical – that go with HIV. Personally, I have never met anyone with HIV who laughs it off as a trivial inconvenience. A useful part of public education would be to spell out the consequences.

Better sex education in schools would also help. In Sydney it is left to the principals of the schools to determine. Some do it well, including some (but not all) Catholic schools. Others are seriously wanting. One local health worker told me that ‘In many schools it is not addressed at all – or if addressed it is guided by the moral view of the teacher or the school. It is not objective health advice. Yet if you ask parents if they favour sex and relationship lessons there is overwhelming support.’

Sadly there seems a real risk that rather than improving the position, it may become worse. In January 2014 a two-man team was appointed to review the national school curriculum. One of the two, Kevin Donnelly, has decided views on what relationship and sex education in schools should contain. In a book he wrote in 2004, he argued that many parents believed that the sex education in schools should be strictly limited. He wrote: ‘Many parents would consider the sexual practices of gays, lesbians and transgender individuals decidedly unnatural and that such groups have a greater risk in terms of transmitting sexual diseases and Aids.’

You could of course argue that the lack of good sex education lies behind the big increases in other sexually transmitted diseases, particularly among younger people. New notifications of chlamydia in 2011 reached almost 80,000; the numbers have tripled over the last decade. The most affected were women between fifteen and twenty-four. Gonorrhoea has also increased sharply in the last ten years with almost 12,000 new cases a year mainly affecting young men. The public health message is failing to get through to young people.

And what about the prejudice against gay people so prevalent in many other countries and which has such a devastating impact on the willingness to test? I have yet to come across a country where there is no prejudice. Not one. We should remember also that Australia was one of the last major countries to decriminalise homosexuality. Ending the British colonial laws established after 1788 was a long, tortuous business. New South Wales did not get around to it until 1989 and the very last state to decriminalise was Tasmania in 1997. We should not assume that even today acceptance is enthusiastically embraced by everyone, even in a liberal city like Sydney. As it happens, Australia has now been presented with what many gay people would regard as a test case, although others would regard it as more a test of religious belief.

In October 2013 the legislative assembly of the Australian Capital Territory (ACT), with a population of almost 400,000, passed a law which made equal marriage legal in Canberra – or so they thought. The effect was that for five days same-sex couples could get married in Australia’s capital city and twenty-seven couples did just that. However, in mid-December 2013, the Australian High Court intervened and ruled that the Federal Marriage Act, which was amended by Prime Minister John Howard in 2004 to stipulate that marriage could only be between a man and a woman, took precedence over any state and territory legislation. The only way that the law could be changed was (as we saw in India with the legalisation of homosexuality itself) by an act of federal parliament.

The question now is whether the Conservative Australian Prime Minister Tony Abbott, who came to office in September 2013, will follow David Cameron, the Conservative Prime Minister in London, and change the national law. The prospect does not look promising. It was after all the federal government that successfully challenged the ruling of the ACT court but, more importantly, Abbott himself is a stern opponent of same-sex marriage. He also realises the political implication of any move to reform the position. No more than in Britain is it a vote winning issue for a Conservative leader with his own party. The only reason to legislate in London in 2013 was because it was right – and that was the view of both Houses of Parliament on a free vote. The solution in Australia could be to follow that example and allow a free vote if ever an equal marriage bill is introduced. My own view is that in the end the reformers will win here and the question is not whether but when. It will be a vast pity if a country like Australia, which has set the pace in so many ways, failed this test.

To my mind Sydney is at the same time the most relaxed and the most sensible city I visited. In dealing with HIV the leaders here have been both pragmatic and successful. But those working in the field are slightly aghast at the prospect of Sydney being set up as the promised land. ‘It is at that point that complacency sets in,’ one doctor said to me. Nevertheless, in terms of prevention and treatment there are few cities that can match it. Certainly Sydney can teach the cities of Europe and the Old World a few lessons.