We re­ally do show the world how to man­age HIV/AIDS

The Weekend Australian - Travel - - Health - JOHN IM­RIE

HIV/AIDS comes un­der the mi­cro­scope from this week­end as the largest con­fer­ence ever held in the Asia/Pa­cific gets un­der way. Aus­tralia’s suc­cess in man­ag­ing its HIV epi­demic is cer­tain to be a talk­ing point for ex­perts seek­ing ways for­ward in this global pan­demic. Up to 7500 del­e­gates are ex­pected at the In­ter­na­tional AIDS So­ci­ety’s fourth IAS Con­fer­ence on HIV Patho­gen­e­sis, Treat­ment and Pre­ven­tion.

For the first time this highly sci­en­tific con­fer­ence is de­vot­ing an en­tire track to HIV pre­ven­tion. Aus­tralian ex­perts will gather in ad­vance of the con­fer­ence to re­flect on 20 years of Aus­tralia’s HIV re­sponse, and at­tempt to un­pick for our in­ter­na­tional au­di­ence what we’ve done that’s worked and what lessons might be trans­lated else­where.

Dis­cus­sions will start from an ac­cep­tance that Aus­tralia has been very suc­cess­ful at keep­ing HIV in check. And we have. We took coura­geous steps early on, trusted our in­stincts and took charge of HIV in part­ner­ship.

As a re­sult, Aus­tralia has the sec­ond low­est level of HIV in the in­dus­tri­alised world. In­no­va­tive pro­grams and sus­tained com­mit­ments by af­fected com­mu­ni­ties mean HIV in Aus­tralia re­mains vir­tu­ally con­tained in small, read­ily iden­ti­fi­able pop­u­la­tions.

It’s a re­mark­able achieve­ment. What have we done right? What lessons might be trans­lated?

The Na­tional Cen­tre in HIV So­cial Re­search at the Univer­sity of NSW be­lieves it all boils down to high and sus­tained lev­els of con­dom use by ho­mo­sex­u­ally ac­tive men, and com­mit­ment by suc­ces­sive gov­ern­ments to nee­dle and sy­ringe pro­grams.

Nee­dle pro­grams and part­ner­ships forged with gay com­mu­ni­ties were bold steps in the 1980s — a po­lit­i­cal death sen­tence for their sup­port­ers if they failed. But Aus­tralia’s nee­dle pro­grams have pre­vented at least 25,000 HIV in­fec­tions, and Syd­ney is one of the few cities where HIV in­fec­tions among gay men have sta­bilised — and are pos­si­bly de­creas­ing.

Out­side Aus­tralia, po­lit­i­cal op­po­si­tion to nee­dle and sy­ringe pro­grams re­mains strong de­spite ev­i­dence they re­duce trans­mis­sion of HIV and blood-borne viruses. Had Aus­tralia fol­lowed the US approach and re­fused to con­sider nee­dle and sy­ringe pro­grams, in­stead of 6600 deaths from AIDS to­day we would have seen 50,000. In­stead of 22,615 peo­ple with HIV to­day, we would have 150,000.

The 2005 Aus­tralian Gov­ern­ment’s Re­turn on In­vest­ments in Pub­lic Health re­port con­cludes the ben­e­fits of its HIV/AIDS pub­lic health pro­gram mas­sively out­weigh the cost. Over the pe­riod 1984 to 2010, the pro­gram’s pro­jected ben­e­fit is es­ti­mated to be $3.1 bil­lion, a fig­ure that in­cludes $416 mil­lion in avoided treat­ment costs. Es­ti­mated ben­e­fits from na­tional nee­dle and sy­ringe pro­grams are $7.8 bil­lion rel­a­tive to $130 mil­lion in­vested. This same re­port claims HIV ed­u­ca­tion and pre­ven­tion will avoid 6973 new sex­u­ally trans­mit­ted HIV in­fec­tions. Th­ese are mas­sive mone­tary sav­ings, apart from the hu­man costs of ill­ness, dis­abil­ity and death avoided.

The Na­tional Cen­tre in HIV So­cial Re­search ar­gues that it’s not just what we’ve done, but the way we’ve done it that’s im­por­tant. The Aus­tralian re­sponse has been based on a part­ner­ship approach, in­volv­ing ex­ten­sive com­mu­nity en­gage­ment. Com­mu­nity en­gage­ment means peo­ple liv­ing with and af­fected by HIV par­tic­i­pate in pol­icy-mak­ing and de­liver es­sen­tial pre­ven­tion ed­u­ca­tion.

Be­cause of this, HIV poli­cies are not im­posed from above, but grap­pled with, de­signed and im­ple­mented by the very peo­ple whose health de­pends upon it. The part­ner­ship model may not be eas­ily grafted onto dif­fer­ent cul­tural set­tings, but work­ing with pop­u­la­tions at risk and com­mu­nity en­gage­ment are im­por­tant lessons that can be shared.

Re­cent in­creases in HIV no­ti­fi­ca­tions across Aus­tralia are a gen­uine cause for con­cern and have brought ac­cu­sa­tions that gay men are be­com­ing com­pla­cent about HIV. True for a few per­haps, but the re­al­ity is that gay men in Aus­tralia have em­braced and sus­tained con­dom use like no oth­ers.

Rather than com­pla­cency, gov­ern­ment, com­mu­nity and aca­demic ex­perts agree the rises are more likely due to a weak­en­ing in some con­texts of the part­ner­ship model that has long un­der­pinned our re­sponse. Re­spon­si­bil­ity for one’s own sex­ual health and one’s part­ner’s is an in­grained so­cial norm of Aus­tralian gay life that can only work well in a sup­port­ive en­vi­ron­ment.

But any lost ground can be re­gained. Aus­tralia’s gay cap­i­tal, Syd­ney, is ac­tu­ally buck­ing an in­ter­na­tional trend — see­ing small de­creases in new HIV in­fec­tions. The 2006 fig­ures show a 9 per cent drop in new HIV no­ti­fi­ca­tions among gay men, or 22 fewer new cases than in 2005.

What stands out is that the HIV de­creases ob­served in Syd­ney are al­most cer­tainly at­trib­ut­able to in­creased up­take of safe sex by gay men. Sur­veys in Syd­ney and Lon­don show nearly twice as many Syd­ney gay men rou­tinely use con­doms as gay men in Lon­don.

We have done well. The fact of our suc­cess means there is much to lose and much to do. Vig­i­lance is the key. Main­tain­ing our en­vi­able po­si­tion re­quires hard work, gutsy tar­geted poli­cies, sus­tained fi­nan­cial in­vest­ment and plenty of creative think­ing.

The 4th In­ter­na­tional AIDS So­ci­ety Con­fer­ence will be held at the Syd­ney Con­ven­tion Cen­tre from to­mor­row un­til Wed­nes­day. As­so­ci­ate Pro­fes­sor John Im­rie is head of the HIV pro­gram at the Na­tional Cen­tre in HIV So­cial Re­search, at the Univer­sity of NSW in Syd­ney

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