Increase in new HIV cases in Australia

Monday 28 October 2013 5:30PM (view full episode)

Australia used to be on the forefront in controlling the spread of HIV. However, figures released last week at the Australasian HIV and AIDS and Sexual Health Conference in Darwin suggest that we might be losing control of HIV. There's a 10% increase in new HIV infections across Australia and the HIV statistics from the Indigenous community don't sound encouraging either. There's a 20-year-high in the number of new cases of HIV in Indigenous Australians. The Aboriginal and Torres Strait Islander Surveillance Report was also launched at this conference.

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Norman Swan: Hello and welcome to the Health Report with me, Norman Swan.

Today, is a cure in sight for HIV infection, or will it be a Clayton's cure where it's the cure you have when you're not being cured?

Taking a tablet before a big weekend to prevent HIV infection; does it work, can it make things worse, and if not, is it too expensive for the public purse?

Disturbing news on Chlamydia rates in young teenagers, and the impact of aid reduction on AIDS in our region, and last week at the Australasian HIV and AIDS Sexual Health conference in Darwin, statistics were released suggesting that we're losing control of HIV in this country. It's not good news, especially since Australia once led the world in HIV prevention.

I was in Darwin for the conference and spoke to David Wilson who is head of Surveillance and Evaluation at the Kirby Institute at the University of New South Wales.

David Wilson: It's the largest increase we've seen in HIV since the beginning of the epidemic in the 1980s.

Norman Swan: You're kidding?

David Wilson: Unfortunately that's the truth.

Norman Swan: So give me the numbers.

David Wilson: In the year 2012 we had 1,253 people diagnosed with HIV for the first time, and that's not even the total number of people who become infected. We have about 10% to 25% of the population who are under-diagnosed with their infection.

Norman Swan: And where are they?

David Wilson: The largest numbers are in New South Wales. We also saw increases in Queensland and Western Australia.

Norman Swan: This is gay men?

David Wilson: Towards 75% of all of our cases of HIV are among gay men, and other men who have sex with men, with other cases among heterosexuals who come from Africa and Southeast Asia. Of the gay men, they are now getting younger, they are in their 20s and maybe their 30s, compared to 30s and 40s in the past. The problem is they are not using condoms as much as what they were in the past, and it's very simple, we know condoms work.

Norman Swan: Is it because they've lost the fear of HIV/AIDS?

David Wilson: It's a new generation. Twenty or 30 years ago people were dropping dead all around us, we didn't know what this disease was, then we learned it was virus, we didn't know how to contain it. We now know that we've got effective treatments and these treatments keep people alive. They can almost have a full life expectancy. So it's a very different disease than what it was 20 or 30 years ago. So for that reason the young gay men who enter the scene don't have the same fear, but they don't realise that it's still a very serious condition.

Norman Swan: And the drugs are not trivial.

David Wilson: They are not at all. It requires the individual patient to take them every single day for the rest of their life. There are some toxicities associated with them. Anybody with HIV has an increased risk of cardiovascular disease, renal failure, liver failure, various cancers. The ageing process is accelerated for people with HIV. So there are many issues. HIV is still a very serious concern.

Norman Swan: Of that 1,200 or however many were diagnosed with HIV in the last 12 months, what percentage of those will progress to AIDS?

David Wilson: Well, if they do not have effective treatment, almost 100% will progress to AIDS in about 8 to 10 years. However, if they go on to effective treatment then it can restore the immune system closer towards a healthy, non-infected person.

Norman Swan: And of people who are controlled under highly active retroviral therapy, what percentage of them eventually progress to AIDS?

David Wilson: If they are regularly monitored and taking effective treatment, that it will be basically 0%.

Norman Swan: Really? So it literally does normalise your lifespan?

David Wilson: HIV will still shave a few years off life, maybe five, 10, 15 years off life, but it's much better than obviously without the treatments.

Norman Swan: Associate Professor David Wilson of the Kirby Institute in Sydney.

And the HIV statistics from the Indigenous community aren't good either. The Aboriginal and Torres Strait Islander Surveillance Report was also launched at the Darwin conference.

James Ward is deputy director of the Baker IDI Institute in Central Australia based in Alice Springs.

James Ward: What the surveillance tells us from 2012 is that we've had the highest number of notifications for HIV ever recorded in a year among Aboriginal and Torres Strait Islander people. Last year we had 32 notifications and every other year we've had around 20 notifications. This mirrors the non-Indigenous population, and in addition to HIV the surveillance report highlights what we already know, that there are very high rates of Chlamydia, gonorrhoea, infectious syphilis and Trichomonas in remote communities.

Norman Swan: These are very small numbers, albeit they are worrying numbers. Is it patchy or is it evenly spread throughout communities across Australia?

James Ward: No, for HIV notifications they are mostly notified from the eastern seaboard, so along Brisbane, Sydney, Melbourne, and that mirrors the non-Indigenous increases in HIV.

Norman Swan: So Indigenous people living in cities?

James Ward: Yes. About 70% of the notifications last year were notified among gay Aboriginal men. The other 30% are among heterosexual people, and some of those have acquired HIV through injecting drug use, and that has been a bit of an issue over the last five or eight years really compared to the non-Indigenous population.

Norman Swan: The great fear 15, 20 years ago was that HIV would run completely riot through Aboriginal communities because of the higher rates of other sexually transmissible diseases. Even though this is not good news, what we are hearing now, why isn't the news worse?

James Ward: Well, we've had a very strong policy response, we've had a very strong health promotion, education campaign for a very long period of time. We've had needle syringe programs provided in communities that reach Aboriginal people for a very long period of time. It is of concern for us. Canada's First Nations people suffered through escalated rates of HIV infection compared to the non-aboriginal population. We don't want to go down that same path.

Norman Swan: You've been also surveying behaviours and attitudes amongst young Aboriginal people. Does that give you any clues as to what's going on here? What have you found?

James Ward: Yes, we just finished a national survey of young Indigenous people where we collected 2,900 surveys from young Aboriginal people across the country, and what we find is not very much difference between risk behaviours of Aboriginal young people compared to non-Aboriginal people. So age of sexual debut is very similar, the number of partners is very similar, condom use is actually higher in youngest age groups, particularly in the eastern seaboard in major cities. That's very good results for us. What I think that really points out though is that for young people living in communities where there is a higher prevalence, their chances of acquiring an STI, if they do have unprotected sex, are very high compared to somebody living in the city.

Norman Swan: Because your chance of having sex with somebody who happens to have the infection is higher, it's just simple statistics.

James Ward: Yes, a much higher background prevalence driving new infections in the community.

Norman Swan: It still begs the question, given that what protects you against HIV is the same as what protects you against other sexually transmissible diseases, why there has been a protection against HIV.

James Ward: Good question. I think what we can speculate is that there are very closed sexual networks in remote Aboriginal communities, but that is being breached at the moment in terms of mining communities opening very close to remote Aboriginal communities. There have been a significant number of notifications of guys who work in the mines who go overseas, acquire HIV, come back and work in those communities right next to Aboriginal communities. That's one area where we think that there could be breaches of sexual networks.

The other area that I am concerned about is where people from high prevalence countries come to Australia, migrate to Australia, and are resettled in remote areas or regional areas where there are high numbers of Aboriginal people. They make relationships, and people knowingly transmit HIV to our population. So there are two real areas that I worry about with breaking down of the sexual networks.

Norman Swan: So what can you do then to nip this in the bud, given the experience of indigenous communities overseas where if you don't it can get very bad?

James Ward: I think we need to maintain our messages around safe sex, the main lesson of prevention for HIV. I think we need to reinvigorate our response around people who inject drugs. We also need to have some targeted interventions for gay Aboriginal people that are living in major cities, and really work hard at trying to reduce the other STIs that are present in communities.

Norman Swan: Tell me about this randomised trial you are doing of service improvement?

James Ward: We've been working for the last four years with 67 remote communities in the Northern Territory, and North Queensland and the Kimberley. Health services in those remote communities have got a lot to deal with, they are dealing with trauma and high rates of chronic disease and a very sick population. So that means STIs get pushed off the agenda. And the premise of our randomised trial was to provide extra support to health services to reach a set of best practice targets in STI control, things like coverage of testing for community members once a year, retesting at three months, improving the number of contacts treated, which might have an impact on community prevalence in the longer term.

Norman Swan: And what sort of results have you had so far?

James Ward: About 58% increase in testing among men aged 16 to 34, and 66% increase in testing among young women.

Norman Swan: And it's a huge issue, this issue of testing, both in Indigenous communities and the non-Indigenous community. What evidence is there that it tracks to better sexual behaviour or more effective control?

James Ward: Testing provides an opportunity for health education and health promotion while in the clinic. If we can improve our testing rates we have a much better knowledge base within the community.

Norman Swan: James Ward is deputy director of the Baker IDI Institute in Central Australia based in Alice Springs.

So what's going to be done about this rise in HIV infection rates overall? Does Australia have a plan? Well, not yet.

David Wilson from the Kirby Institute again:

David Wilson: I think we need to step back. What we've done has not worked. We're at the end of 2013 now, this is the end of national strategies against HIV that have occurred over the last four years. So we need to scrap them and let's start again. The federal government is now in a process of devising some new national strategies. These need a completely new, fresh approach, rethinking how we deal with HIV.

Norman Swan: Have you got them in place yet?

David Wilson: They are in development. We have had international evidence of what works.

Norman Swan: And what would that look like?

David Wilson: That would look like a vast change in testing and treatment practices. We've now got evidence that people who are on effective treatment, if they get into treatment  very early, not only does it restore their immune system and improve their survival…

Norman Swan: They become less infectious.

David Wilson: They become much less infectious, they are less likely to infect other people, and it's also very good in terms of other clinical symptoms that they might develop.

Norman Swan: And you're giving up on condoms?

David Wilson: Absolutely not. Condoms work, condoms are the most effective way of preventing HIV from being transmitted.

Norman Swan: In the past Australia has had some pretty way-out promotion practices for condoms, you know, teaching male prostitutes how to hold a condom in the mouth and that sort of thing, things that really haven't got through to the general public in case it develops moral ire. But are we still out there experimenting with ways of getting condom use into the community of men who have sex with men?

David Wilson: Well, we need to be innovative. So the community organisations need to continue to come up with creative strategies for how to educate men and others about using condoms well. We have seen declines in condom use, and we are seeing increases in infection. One is causing the other. The only thing that really works close to 100% is condoms. So until a partnership gets into a situation where they negotiate that maybe we ought not to use a condom, before that time they need to check that they are both clear, get a test, have open disclosure and discuss the situation, and if there is a risk, to figure out together how they might mitigate it.

Norman Swan: And needless to say, our problem with HIV, even though it's getting worse, is tiny compared to some of our neighbours in the region. David Wilson is working with a UN initiative to halve HIV rates in poorer nations in our part of the world. And he's worried.

David Wilson: I'm very concerned about prevention across the region, because what we've seen over the past 10 years or so is a lot of international donors, that's foreign aid through the Global Fund, the United States government, even the Australian government through AusAID that's providing a lot of funding for low and middle income countries across the region. The money that is provided by these international donors is largely going towards prevention, and it's the governments that are largely providing treatment.

But what we know is that over the next few years foreign aid is going to start to dry up. The donors are withdrawing, and any foreign aid that we are seeing worldwide, most of it is going now towards Africa where the largest burden is. So the onus will be on the governments to come up with the extra shortfall. However, the governments are not willing to spend a lot of money on prevention, they are more likely to spend on curative therapies. So unfortunately without prevention we are going to see large increases in new infections and an increasing wave of new people going to require treatments in the long term.

Norman Swan: So what's your strategy?

David Wilson: My strategy is to provide a rational argument to governments, that they cannot give up on prevention. I'm going to show them what's going to happen if they do not invest in prevention, and I'll show them how many new infections they can expect to see. I think the argument is not just a health argument, it's an economic one. There's going to be large numbers of people in need of treatment in the future in, say, five, 10 years time. If they do not invest in prevention now they are going to have to spend a lot more money in the future, and that's money that they don't want to have to spend. So I'm going to make that economic argument to them.

Norman Swan: David Wilson.

And you're listening to the Health Report here on RN with me, Norman Swan



Associate Professor David Wilson
Head of Surveillance and Evaluation
Kirby Institute
University of New South Wales
Dr James Ward
Deputy Director of the Baker IDI Institute in Central Australia
Alice Springs


Dr Norman Swan
Brigitte Seega

Comments (1)

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  • GaryF ®:

    30 Oct 2013 7:31:19am

    Twenty years ago when I was working in HIV prevention and education, researchers, governments and educators collaborated to produce innovative and, sometimes, controversial campaigns targeted at gay and other homosexually active men. A fine example of this was the Victorian AIDS Council's "When You Say Yes, Say Yes To Safe Sex" campaign, which was often referred to as the "Two Boys Kissing" campaign. We based these campaigns not only on what we knew about the virus but also how we understood the social contexts in which gay men were having sex. Twenty years on the approach should be the same; the only difference is that we know a lot more about the virus. It's time for campaigns to "speak" to those most at risk in ways which are socially contextual and relevant. There needs to be a will to disseminate information in accessible formats, based on what we know about the virus today. For example, we know that there are contexts in which it's safe for gay and other homosexually active men to have anal intercourse with one another, without using condoms. While this might be controversial, it opens up debate, stimulates social discourse and creates campaigns which are relevant for new populations of gay men. The key is to have those most at risk involved in the development of these strategies. Only then will campaigns be effective in reducing the transmission of HIV.