Monday 26 March 2012

Some brief reflections on PSF 2012

L-R: Rob Lake (AFAO Executive
director) and Michael Hurley
(PSF facillitator)

Michael Hurley (Adjunct Assoc. Professor, ARCSHS) who facilitated the Positive Services Forum concluded the forum proceedings by providing his reflections on some of the overriding themes that emerged across the two days.

He challenged us to consider how HIV is perceived within the context of public health. With the rapid decline in mortality directly related to HIV, the development of co-morbidities, and the increasing life-expectancy, he said that the story of HIV in Australia is “not a straight-forward story to tell”.

Michael observed that there were a number of dualities in the current response to HIV. For example: the existence of ‘old epidemics’ and ‘new epidemics’ in Australia generates tensions for service providers and require new approaches; the cultural versus the biomedical (eg. safe sex practices versus treatment as prevention); the public health and the counter-public health approach (public health versus criminalisation).

Michael spoke of the centrality in the response of treatment as prevention, and the need to increase rates of testing. This prioritises the biomedical approach to prevention, in which people living with HIV (PLHIV) are at the centre. He noted the distinction between two terms: scientific efficacy and practical effectiveness. A key consideration is how a particular response will actually be applied, with how much effectiveness, and how long this will take.
Other key points Michael noted in relation to biomedical approaches and the Australian epidemic:
  • Australia biomedical approaches have achieved  lower rates of  morbidity and a 90%+ fall in AIDS diagnoses and deaths; and, for many, the promise of ordinary longevity.
  • Australia has high treatments access and uptake rates by international standards.
  • Amongst people living with HIV with other pre-existing health conditions and co-infections,there is a higher risk of compromised health and longevity. This challenges simple versions of HIV infection as a ‘chronic’ illness.
A key theme emerging from many presentations was the strong, sustained evidence that treatments can significantly lower likelihood of sexual transfer of HIV between HIV-positive and HIV-negative people in contexts of unprotected sex (assuming good rates of adherence and an absence of untreated STIs).
Regarding the current state of HIV epidemic in Australia, Michael highlighted a range of issues emerging from presentations and comments from the floor:
(a) HIV infections in Australia are slowly increasing, but are still primarily occurring amongst gay men.

(b) There are epidemiological reports of an increasing trend of new HIV infections amongst heterosexuals; however, ‘heterosexual’ here aggregates a variety of contexts associated with immigration, high prevalence countries and travel. Even so, this makes the issue of strategic relationships and collaborations with CALD health service organisations, groups and communities more pressing.

Some states have a productive history of organisational collaboration. Others are still developing organisational relationships between ‘older and ‘newer’ epidemics and populations, and a wider political spectrum of immigration, refugees, asylum seekers, international students and holders of 457 work visas.

These diagnoses are often distinguished by low CD4s at diagnosis, sometimes including an AIDS diagnosis.

(c) There is a trend towards increased geographic dispersal of populations of PLHIV outside of major metropolitan areas, often associated with ageing and sea changes, and within metropolitan areas, often associated with housing costs and housing availability. This has implications for mainstreaming and provision of housing, support and medical services to PLHIV.

(d) There is ongoing pressure to reformulate prevention in biomedical terms. While biomedical and socio-behavioural prevention are best not thought in opposition to each other - but as elements in a mix - there is uneven attention being paid to difference between scientific efficacy and social effectiveness, especially - but not only for - local gay populations.
New challenges to HIV health promotion are posed by the 2011 UN Declaration on HIV/AIDS, with its focus on treatment as prevention. This focus:

              (i) puts people living with HIV and PLWHA organisations at the centre in terms of treatments uptake goals; and

              (ii) in Australia, for historical and epidemiological reasons, puts gay men (including CALD) and AIDS Councils also at centre.

 (e) Aboriginal and Torres Strait Islander HIV networks and programs continue to evolve nationally without specific Commonwealth funding. Much higher rates of intravenous drug use amongst  Aboriginal and Torres Strait Islander  communities, with associated risks of HIV and Hep C infection in a context of multiple other pre-existing health conditions.

(f) The reorganisation of the public health system, e-health transferable records and Medicare Locals with attendant issues of (possibly) better individual service, challenges for privacy and confidentiality, cultural and clinical capacity in terms of HIV and sexuality, localised service delivery possibilities and problems and long developmental lead times.

(g) HIV sector and health sector collaboration around HIV and sexual health presents several cultural challenges, including in:
                (i) gay and lesbian communities and in GLBTI politics the ongoing negotiation of current tensions between sexual practices including unprotected sex, representation and some politics of respectability (‘this is a family event’).

                (ii) some CALD communities the negotiation of culturally appropriate sexual health and homophobia, secularism and traditional values.

                (iii) A need for revived and new forms of collaboration and partnership between old and new HIV and sexual health groups. See points (c) and (d).

(h) Overwhelming support at forum for decriminalisation of HIV exposure and transmission and for Public Health management of difficult individual cases. Current context of criminalisation continues circulation of a series of hysterical mythical figures in media, political and popular cultures associated with allegedly wilful HIV infection - gay HIV positive predators, HIV positive sex workers, syringe users generally and HIV positive ‘African’ men as a threat to women and the nation.

Michael concluded his summary by identifying several intersections between different characterisations of the epidemic.

He noted that the largely successful response to HIV in Australia over 30 years was due to the responses of gay men, sex workers, and people who inject drugs; and yet, within the wider community negative stereotypes such as the predatory gay man, and the disease spreading sex worker / injecting drug user still prevail. As a society, we owe these groups for contributing to a lower infection rate.
Other views that persist and need to be challenged - both within and outside the sector - include notions of immigrants/refugees and Africans as ‘AIDS Carriers’; the tensions that around expressions of gay sexuality verses notions of ‘respectability’; and homophobia that exists within some CALD communities (as well as within the wider community).

The key to a continued successful response to HIV is collaboration and partnership; Michael warned that if our responses continue to operate in silos, the relationships between communities affected with HIV will fall over; collaboration and inclusion are the only way forward.

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