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HIV in Australia: we’ve come a long way but there’s more to do

Prevention messages and consistent condom use have broken the nexus between sex work and HIV transmission in Australia. publik16/Flickr, CC BY-NC-SA

In the three decades since the virus was identified, Australia has done well by international standards in keeping HIV infection rates down. But certain aspects of our national approach continue to risk the national prevention strategy, and stigmatise people with HIV.

The last 32 years have seen numerous advances in HIV, from the early deaths in 1983, including the deaths of four Queensland babies who received blood transfusions, which led to the blood-screening program; through to the introduction of early combination therapy in 1992 and the reduction in people dying from AIDS-related illnesses after the introduction of combination therapy in 1996.

Since 1999, there has been a small but significant yearly increase in the number of people newly diagnosed with HIV; more people living relatively well with HIV increases the risk of exposure through unsafe sex.

Today, there are an estimated 25,708 people living with HIV infection in Australia, the majority of whom are gay men.

The good and the bad

One of the testaments to the medical successes in dealing with the virus is the significant number of HIV-positive people living into old age. They are coping with the same crises that beset us all as we get older, but with the additional burden of a chronic condition that interacts unpredictably with other diseases.

Despite the downsides of ageing, the fact that HIV-positive men and women are growing old is an outcome that far exceeds what we anticipated 30 years ago. Back then, most people infected with the virus could not expect to still be alive after five years.

Sitting alongside these celebrated advances is the necessity of a pragmatic public health approach to HIV and the frequent challenges posed by the need to regulate or legislate on HIV-related matters.

And there’s some good news here too: a strategic and policy-driven approach has been the most consistent feature of Australia’s response to HIV. The brave steps taken by the then-health minister Neal Blewett, and others in successive governments were critical to HIV prevention.

Fundamental to this success was respect for the views of affected communities. A genuinely national approach in the early days, encapsulated in the first and subsequent national strategies, also ensured local – and sometimes parochial – views did not hold sway.

Nonetheless, there remains a conflicted relationship between government and HIV, particularly in the area of criminal law, reflecting society’s double standards with regard to sex and drugs.

Drugs and prison

Perhaps the best evidence of a successful public health initiative to prevent HIV transmission was the establishment and maintenance of needle and syringe exchange programs, early in the epidemic. These contributed to keeping HIV rates among injecting drug users very low indeed.

The criminalisation and prosecution of illicit drug use still exposes people to risks of blood-borne viruses within the prison system. Brian Yap/Flickr, CC BY-NC-SA

Only 1.9% of newly-acquired HIV infections in Australia are attributable to injecting drug use and the rate has been around 3% for the past decade. In contrast, an average of one in ten new HIV infections internationally is caused by injecting drug use and, in parts of Eastern Europe and Central Asia, that figure is over 80%.

Despite its clear success, Australia’s well-resourced needle and syringe exchange program is constantly under threat, always at risk of de-funding by a disapproving public (and media). But it remains the single most effective public health measure in Australia to reduce the harms of HIV and other blood-borne viruses.

Unfortunately, the criminalisation and prosecution of illicit drug use still exposes people to risks of blood-borne viruses within the prison system.

The recent introduction of a trial of safe injecting equipment in an ACT prison is a step in the right direction, and there’s a chance other jurisdictions may follow suit. Similarly, the confirmation of a safe injecting facility in Sydney is a leap forward for public health, despite constant attacks from conservative forces.

Sex, crime and stigma

Internationally, sex work has been closely linked with HIV transmission but, in Australia, HIV-prevention messages and consistent condom use have broken this nexus, and rates of HIV remain very low among sex workers.

Still, the regulation of sex work has an even more chequered history. The various states and territories criminalise different elements of sex work, and there are plans in both Western Australia and South Australia to increase the legal attention on it.

But there’s very little hard evidence that a punitive approach improves the health and welfare of sex workers and their clients. Consider the hundreds of charges of soliciting or selling sex (or both) that go through the courts with little obvious deterrent or protective value.

Criminal law has also been used to prosecute potential exposure and transmission of HIV transmission. As with sex work, regulation varies across Australian jurisdictions.

One of the most striking state differences is that Victoria, South Australia and the Northern Territory criminalise HIV exposure (where there’s no transmission) while other states do not. This connection between HIV and the law exacerbates the stigma and discrimination associated with living with the virus.

So when we welcome international HIV communities to Melbourne next month, we must be prepared for not only the praise and celebration of Australia’s long-standing effective HIV response, but also some criticism of our laws and regulations. They continue to support stigma and discrimination and run counter to efforts to make HIV a virus of the past.

This article launches our coverage of the 20th International AIDS Conference, to be held in Melbourne from July 20 to 25. Look out for more pieces in the following weeks and full coverage during the conference.

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