Recommended ACT Priorities for Action: HIV (Detailed Version)
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- Implement targeted and evidence-based prevention programs to meet the United Nations and Australian target of zero new transmissions, focusing on working with young people and at-risk communities, supporting peer based approaches and promoting access to new and emerging prevention treatments;
- Increase provision of accessible testing for HIV and other STIs (including rapid testing), with a focus on supporting at-risk communities and providing testing in community based settings;
- Improve implementation of best practice treatment of HIV in the community, increasing early treatment of HIV and promoting peer support models as a key delivery mechanism; Support treatments cascade and implement appropriate support for ‘the other 10%’.
- Increase provision of care and support services for people diagnosed and impacted by HIV and their families, ensuring that this is continued to be person centred, peer based and community based wherever possible. In this, ensure that services are meeting the needs of the growing group of ageing individuals who have survived and are managing long term multiple chronic conditions;
- Ensure a human rights approach for people impacted by HIV in the community, eradicating stigma and discrimination of people impacting HIV in our community, and improving the community's understanding of HIV;
- Improve collection and access to local and relevant data regarding prevalence and management of HIV in the community, and support for high quality research that involves people impacted by HIV in the design, planning and implementation of research and data collection process.
1. Prevention Programs
The prevalence of HIV in Australia is low compared to other countries, and strong health promotion and prevention programs have been credited with delivering the low rates of HIV infection in Australia.
Over the last decade, new HIV diagnoses, in Australia, have stabilised rather than decreased. Over the last ten years, diagnoses rates in the ACT have increased and reached a similar level to New South Wales in 2014 (4.6 per 100 000 in 2014). Over this period there has been a general increase in the rates of other STIs, particularly amongst young people.
Every new HIV diagnosis is estimated to cost $500,000 over a lifetime, with an annual approximate cost to the Commonwealth Government budget of $14,000.
Particular groups in our community are disproportionately impacted by HIV. Men who have sex with men (MSM) are a group that have much higher rates than the rest of the community. Nationally there was a HIV prevalence rate of 17% of MSM in 2014. Young people are also at particular risk.
Risky behaviours continue to be a key factor in new HIV infections. Sexual contact between men accounts for 70% of new HIV diagnoses in 2014 (758 of the 1081 cases). Other common routes of reported HIV transmission include heterosexual sex (19%), sexual contact between men and injecting drug use (5%) and injecting drug use only (3%).
New treatments such as pre-exposure prophylaxis (PrEP) are proving to be effective as a tool to stop new HIV exposure. PrEP has been approved by TGA, including exploration of whether or not it may be subsidised through the PBS.
Low rates of new infections, effective prevention and health promotion interventions mean that a vision of zero new infections is achievable. In 2014, Australia’s Ministers for Health signed the 2014 AIDS Legacy Statement which committed to a virtual elimination of new HIV transmissions by 2020. This moves beyond the global target of no new HIV transmissions by 2030.
2. Effective Testing
Regular testing, particularly within high-risk communities is acknowledged as an important tool to responding to HIV.
There are still high number of people who delay testing and a HIV diagnosis. At the end of 2014, an estimated 27 150 (range 24 630 to 30 310) people were living with HIV infection in Australia, of whom an estimated 3 350 (12%) were unaware of their HIV positive status. This is a significant improvement on the previously estimated 30% undiagnosed HIV cases.
Within high risk populations, the rate of testing is well below national guidelines.
Over a quarter (28%) of the new HIV diagnoses in 2014 were determined to be late, in that they were in people who were likely to have been HIV positive for at least four years without being tested.
Rapid HIV testing has been proven to be an effective complement to traditional testing. Australia lags behind many other countries in its use of this technology. There is emerging evidence regarding the acceptability and effectiveness of rapid testing in community based settings, and being used as part of a peer based education and health promotion approach.
3. Treatment programs for HIV
Effective treatment of HIV has seen people impacted moving from potentially facing a complex and acute terminal condition, to managing a life-long chronic health condition.
A high number of individuals with a HIV diagnosis in Australia access effective treatments. Among the estimated 88% of people with HIV in Australia who were diagnosed by the end of 2014, an estimated 73% were receiving treatment with antiretroviral therapy, with therapy successfully controlling the infection (“viral suppression”) in 92% (range 84 to 97%). These three figures compare well to the United Nations targets of 90%.
HIV treatment is an area where there is significant research effort, and there is a need for Australia to ensure access to these treatments. Services and support need to also be available for PLHIV who choose not to take treatments, or whose treatments do not reach an undetectable viral load.
PEP is one area which has emerged in recent years as an effective intervention for early treatment for HIV exposure. Guidelines have been developed in Australia to support the use of PEP treatment.
Ease of treatment is a continued important area of research, with efforts continuing to develop therapies that are easy to administer and do not require multiple medications. It will continue to be important to ensure that individuals can access the most effective and streamlined treatments.
Effort is required to ensure that the costs of treatment reduce for both individuals and the community, with the aim that these costs continue to fall in coming decades. The Australian health system needs to be agile to respond to new treatments and be able to deliver in a way that is affordable, for individuals, governments and the community.
4. Care and Support
A HIV diagnosis has a significant impact on an individual, their family and their community. While this no longer means a rapid health decline, it does mean the need of life long management of a life threatening disease. Beyond the issues of testing and medical treatment, there is a need to respond to the physical, physiological and mental dimensions of this change in health status.
The United Nations recognises that comprehensive care must include psychological support as well as social supports to support HIV positive people, their families and their communities. It recognises the vital role that communities and community organisations play in promoting social solidarity, providing emotional support and protecting individuals and communities against discrimination and a violation of their rights.
There is recognition that a range of other lifestyle factors will assist individuals impacted by HIV live healthy lives. Programs that are evidence based, located in community settings, and where appropriate use peer based approaches should be a key feature of services provided to individuals, families and communities impacted by HIV.
Given the success of HIV treatment options, there is a growing number of people who are managing HIV as a chronic illness. The United Nations global commitment is that by 2030, life expectancy of people with HIV will mirror that of the general population. As the group of individuals with HIV age, there will be increasing complexity in health needs, and a requirement for specialist support to manage HIV as a chronic condition, manage comorbidities and the impacts of ageing on health and wellbeing.
5. Stigma and Discrimination
The ACT has enacted the Human Rights Act 2004. This Act recognises the fundamental human rights of individuals.
The Melbourne Declaration that was made at the conclusion of the 2014 International AIDS Conference recognised the interconnection of criminalisation, stigma and discrimination and poor outcomes in relation to the prevention and treatment of HIV. It stated that
“…We, the signatories and endorsers of this Declaration, affirm that non-discrimination is fundamental to an evidence-based, rights-based and gender transformative response to HIV and effective public health programmes…we reaffirm our unwavering commitment to fairness, to universal access to health care and treatment services, and to support the inherent dignity and rights of all human beings. All people are entitled to the rights and protections afforded by international human rights frameworks”.
In practical terms, the human rights approach should ensure that testing is always seen as a voluntary activity and should never be mandated, that sex work continues to be decriminalised, and HIV positive sex workers are not discriminated against, that all individuals are able to access appropriate treatment and cost must not be a barrier to effective treatment, and people should not be subject to limitation in movement or migration as a result of the HIV status.
6. Research, data and information
Globally the importance of collecting HIV information, particularly prevalence data is recognised, with the United Nations Declaration and the World Health Organisation’s Global Health Sector Strategy on HIV/AIDS 2011–15 highlighting the critical importance of ‘knowing’ the HIV epidemic to ensure an effective response. The United Nations Program on AIDS releases regular country, regional and global reports. The Commonwealth Government’s Seventh HIV Strategy notes that “…high quality surveillance, monitoring, research and evaluation inform our knowledge of our epidemic and the most effective response in the Australian context”.
In Australia, HIV data is collected in each state and territory and analysed by the Kirby Institute for infection and immunity in society.
It is important that research and data collection is conducted in a way that protects the dignity and human rights of participants in these studies, particularly people impacted by HIV. The efficacy of interventions, including community based and peer based models should be tested and promoted. People impacted by HIV should be involved in the design and implementation of research and data collection processes.
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