Policy and strategic implications of Australia's divergent HIV epidemic among gay men

Abstract

The importance of this issue of Sexual Health has technical, strategic and policy dimensions. Overall Australia continues to have a relatively well-controlled HIV epidemic, contained by and large to gay men. The lack of significant transmission affecting intravenous drug users continues to bear testament to sound public health policies, for which we continue to be the envy of countries that took a different route. There has, however, been an increasing rate of notifications among gay men in Victoria, Queensland, South Australia and Western Australia and the numbers of such transmissions for Australia as a whole has also increased as a result. This gives rise to the first impetus for this issue of the journal. It provides a timely basis for considering adjustments to our to-date successful prevention strategies. In New SouthWales (NSW), the state hardest hit by the HIV epidemic since its arrival in Australia, the trend has been different, with notifications among gay men falling since a spike in 2001 and flat overall since 1998. Grulich and his colleagues point out that this may make NSW unique among countries where reliable records are kept. This difference gives rise to the second impetus for this issue. What lessons are there to learn from the different trend in NSW? There is not cause for a panicked knee jerk reconsideration of strategy, although there is reason for immediate analysis and for careful response. The trend increases in notifications among gay men in several states do not mean that we have lost control of the Australian epidemic. On several key indicators, other states could be said simply to have increased from lower rates up to those of NSW, which on some measures have come down. Nonetheless a country with Australia’s successful record, resources and epidemic infrastructure should aspire to do better and to be able quickly to act to prevent any more alarming development. Otherwise Australia may be in danger of a different, less-controlled epidemic. Australia is blessed with internationally envied capacity, in four national HIV research centres and in an HIV community sector, non-government organisations providing services to and advocating for both people with HIV and those from affected communities. The community sectors have been led in each state by AIDS Councils, membership-based non-government organisations set up by the gay community in collaboration with other affected communities. For the most part Australia has also been advantaged by the strength of relationships between both these sectors, the clinical sector and governments. It is significant that the work reported in this issue started under the auspice of the intersectoral NSW Ministerial Advisory Committee on HIV/AIDS Strategy and draws heavily on collaboration between the national centres, the community sector and a couple of other key groups. The NSW Ministerial Advisory Committee wanted to know whether the apparent difference between NSW and other states’ apparent trends in notifications among gay men was real and what they needed to do to secure that record and avoid an increase in infections. This issue of the journal follows a workshop where much of this data was presented, focusing on the difference between NSW, Queensland and Victoria. It shows that the difference is real. NSW is experiencing a different trend and there are lessons to be drawn, not just for the three states examined in the NSW Think Tank but for our national response. The analysis of the NSW rates among gay men does not point to a single explanation for a lower notification rate, nor a magic bullet to stem the trend elsewhere. It does, however, point to a combination of several factors that need to be understood by policy makers and those active in the epidemic response. Important facets of an explanation lie in surveillance data, in clinical and behavioural trends and in policy, investment and relationship dynamics. One immediate advance would be the uniform adoption of new ‘detuned’ testing technology that could be applied nationally at very low cost to all positive HIV tests and allow us to move from a reliance on notification rates to being able to count new infections in our surveillance. This is an immediate priority issue for consideration by the Commonwealth Department of Health and Ageing and would give us much more sensitive and real-time data. There are several factors that limit increases in infections among gay men. In each of these the trend in NSW is either stable or decreasing whereas in other states some are increasing or stable. Within the surveillance data the effect appears to be cumulative. Facets of an explanation include, for example, the high HIV testing rate among gaymen and the high proportion of