HIV and Mobile Populations: exploring the complexities

A montage that captures the HIV and mobility issues.

It's been clear for some time that the HIV epidemic in Western Australia is different to that in the rest of Australia, with heterosexuals and people from high prevalence countries accounting for a higher proportion of new diagnoses (around 50%) than in other states and territories where the majority of diagnoses (67%) are among gay men.

Research and advocacy on the issue has been bubbling along for a while now, and in July, capitalising on the momentum of the AIDS 2014 conference in Melbourne, key players in WA's HIV response hosted a one day seminar on 29 July - HIV and Mobile Populations - to explore the complexities of the local epidemic and exchange information and ideas about the way forward.

I attended the seminar in my capacity as the Project Officer for AFAO's African Communities Project.

After Sean Nannup's thoughtful and interactive Welcome to Country reminded us all about the importance of human connection through art, dance, song, language, story and touch, the day kicked off with an address by WA's Acting Director General of Health, Professor Bryant Stokes. Professor Stokes gave a general overview of the issues related to the increase in cases of HIV acquired overseas and reaffirmed the WA government's commitment to addressing the issues.

Setting out the context

Australia is not alone in finding high rates of HIV among mobile and migrant populations, and the first presentations of the day provided some international context, with Dr Valerie Delpech (Public Health England) reporting on European epidemiology and Dr Chris Lemoh (Monash Health, VIC) discussing the impact of HIV on Africa diaspora populations globally and in Australia.

Dr Delpech is an epidemiologist who has been analysing UK and European HIV data for several years. She noted that collection of data throughout the European Union (EU) is patchy, but that overall, around 36% of all cases of HIV in the EU are among migrants, primarily Black Africans. She noted that while the experience of these migrants is not 'homogenous', there are some identifiable trends, with African migrants more likely to be diagnosed late (over 50%), or not at all (est. 25%).

I was intrigued to learn that HIV prevalence among African migrant communities in the UK, at 5%, was higher than in many of these communities' countries of origin. It was also interesting to hear that 50% of HIV cases among African migrants were acquired after migration. We don't have this level of detail for diagnoses among African Australians, although there are indications that some infections do occur here. However, the African population is much larger in the UK than in Australia, which is likely the reason for the high percentage of UK-acquired infections.

Delpech also noted a recent drop in heterosexual transmissions in the UK, but attributed this to changes in the law and migration patterns, rather than to the success of testing and prevention programs. She stressed that community engagement around an expansion of HIV testing is crucial to addressing the UK epidemic among African migrants.

Chris Lemoh.

Dr Lemoh, who has worked with AFAO's African project since its inception in 2009 and is a founder of the Victorian African Health Advocacy Network (VAHAN), placed the disproportionate impact of HIV on African migrants firmly in the context of colonisation and globalisation before elaborating on trends in Australia (particularly Victoria). He identified the key issues for African diaspora people with HIV globally as stigma, discrimination, late diagnosis and barriers to accessing treatment. These are all key issues for African people with HIV in Australia, as AFAO's African project work over the past few years has confirmed.

Carolien Giele (WA Department of Health) drilled into local data in her presentation on HIV epidemiology in WA. She said that the mobility of WA's populations is reflected in the HIV notifications, with almost 60% of cases reported in 2013, having been acquired overseas. Broadly speaking, the pattern of HIV transmission outlined in the WA data suggests that people born in Australia who acquire HIV overseas are more likely to be men who have sex with men, and people born overseas are more likely to be women who acquired HIV in their country or region of origin.

Associate Professor Jaya Earnest (Curtin University) explored issues related to HIV vulnerability for people born overseas, with case studies from Curtin University research projects in Uganda, Timor Leste, India and Papua New Guinea. She highlighted stigma, the role of conflicts, and gender inequity as key issues, particularly for women in these countries.

Treatments access

Barriers to accessing treatment were a significant theme throughout the day. Ineligibility for Medicare among people born overseas is an obvious barrier, but social worker Morgan Bonnett from the Royal Perth Hospital used a harrowing case study to highlight other potential barriers, such as discrimination or indifference from services and government departments. He spoke of an African asylum seeker's extreme difficulty in accessing treatment and Centrelink support to which she was actually entitled, due to bureaucratic obstacles.

Leah Williams, also from the Royal Perth Hospital, said that even when treatments were available, it could be difficult retaining people in care. Obstacles included cultural and language issues, stigma, access to childcare and transport,  and lack of GP services, as well as specific issues for fly-in fly-out (FIFO) workers such as shared rooms and shift patterns which could inhibit the use of treatments. In spite of this, the Royal Perth is getting good results with their Medicare ineligible patients, with 70% of them achieving an undetectable viral load and only 14% not on treatment.

This is a fantastic result which points to the potential for even better outcomes if legal and structural barriers to accessing treatment were removed; and data linkage research presented by Delia Hendrie's showed that this need not be expensive. Hendrie (Curtin University) reported that in WA, the cost of providing healthcare to people not eligible for Medicare is negligible (3-4% of total Medicare costs) and does not appear to be increasing.

Australian men abroad

While the main focus of the day was HIV among people born overseas, two sessions explored the issues related to Australian-born men who acquired HIV outside Australia.

Professor Peter Aggleton (Centre for Social Research in Health), got the audience laughing when he commented that HIV is an 'epidemic' of acronyms, but he was making a serious point. Alluding to the emergence of a term, 'mobile men with money - MMM', to describe 'cashed-up' men for whom sex is an integral part of their travel experience, Aggleton reminded us that the language we use to describe different groups of people often creates stigma and erases complexity, resulting in narrow (thus ineffective) policy and program responses.

Peter Aggleton discusses the damage caused by stereotypes.

'MMM plays to some unhelpful stereotypes about men', he said, noting that there is a growing body of literature that is critical of the way men have been represented globally in HIV research: as 'perpetrators', and as a 'problem'. Mobility is also often represented as entirely problematic, with little recognition of the economic and social benefits of travel (such as remittances).

The stereotyping of heterosexual Australian men who travel for work or pleasure, as 'predatory men, away from home, with sex workers, and posing a threat to "innocent" wives', is part of this narrative. Ironically, this stereotype was implicit in the headline above reporting on the seminar a few days later: 'Climbing rates of HIV infection in WA blamed on mobile population', although the story itself presents a more balanced view than the headline suggests.

Aggleton concluded his presentation with a recommendation that effective programs should be based on the realities of these men's lives. This requires a better, more nuanced understanding of the relational factors that influence their behaviour and how these interplay with HIV risk, he said.

Gemma Crawford (WA Centre for Health Promotion Research - WACHPR) presented research which will go some way towards addressing the research inadequacies that Aggleton identified. Her interview-based research with Australian men who live in, or travel regularly to Thailand explored the role of men's social networks in travel, sex, and risk.

The project sought to identify the culture and attitudes of these men's social networks in order to inform health promotion activities. Key findings included that there was inconsistent knowledge about HIV and STIs, and that there are influential 'change agents' within social networks whose engagement could perhaps be leveraged in STI/HIV prevention programs.

Crawford made a number of recommendations for next steps in relation to this group, including the suggestions that online strategies may be effective and that Australia could advocate regarding access to and the quality of HIV testing in the region. She also noted the importance of not buying into the stereotypes about these men.

Moving forward

Graham Brown.

Dr Graham Brown (Australian Research Centre for Sex, Health and Society - ARCSHS) tied many threads of the day's discussions together in his presentation on the HIV and Mobility discussion paper which has been circulated to various stakeholders, including AFAO member organisations, over the past few months.

The discussion paper was produced by the HIV and Mobility project, a joint initiative of ARCSHS, WACHPR and the Sexual Health and Blood Borne Virus Applied Research and Evaluation Network (SiREN) in WA. The discussion paper outlines the global and national context for the increase in HIV diagnoses among mobile populations and sets out a draft 'roadmap' for developing a strategic approach to HIV management for mobile populations and migrants in Australia. The document identifies six areas for action:

• international leadership and global health governance
• commonwealth and state leadership
• community mobilisation
• development of services for mobile or migrant people and groups
• surveillance and monitoring
• research and evaluation.

Dr Brown also identified five immediate actions for WA community organisations, service providers and government. The first of these is to 'Get HIV and mobility on the interstate and national agenda, and highlight the national legislative and policy barriers to effective programs in WA'. He said he believed that WA is well placed to a lead in strategising to reduce mobility-related HIV infections nationally.

Participants were invited to submit feedback on the discussion paper (which AFAO has done) before 21 August. The final version of the paper is expected to be released in mid-November. Email siren@curtin.edu.au if you would like to be advised when it's available.

The seminar concluded with a lively panel and audience discussion which focussed on Medicare ineligibility, human rights, and the need to reform Australia's migration law; the accessibility of HIV and STI testing; and how to best engage with migrant communities around HIV prevention and care. There was clearly plenty of passion in the room, for taking action on these issues.

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The HIV and Mobile Populations Seminar was hosted by the WA Department of Health, the Sexual Health and Blood Borne Virus Applied Research and Evaluation Network (SiREN) and the WA AIDS Council on 29 July 2014, in Perth. It was an affiliated independent event of AIDS 2014.

Most of the presentations can be downloaded from the SiREN website and you can also get a taste of the program highlights via the Twitter hashtag #HIVMobile