Sunday, 16 October 2011

My old job

The national HIV surveillance figures were released last week.  They are released every year at the conference of the Australasian Society for HIV Medicine: it’s a tradition.  Anyway, the figures show that about 1,000 people were diagnosed with HIV in Australia last year.  As the report says, this annual figure has been pretty much the same for the last five years, which is about how long since I started working in HIV.  I’ve since left, but I still take an interest in the figures, so I thought I’d jot down a few thoughts about them. 

The precise figure was 1,043 people diagnosed with HIV.  That doesn’t mean people all the people with HIV in Australia – of whom there are about 30,000 - it just means the people diagnosed in 2010.  New cases, if you like.  It doesn’t include everyone who was infected last year – probably some haven’t been diagnosed yet.  By the same token, some of those 1,000 people had HIV for some time before they were diagnosed; some of them had actually been diagnosed previously, overseas.  But it’s a pretty accurate figure.  One of the things that surprised me when I started working this was just how much research there is on HIV in Australia, and how much money is spent on it, in comparison to other areas of social policy.  This research – like most HIV services in Australia – is a product of the great fear of HIV when it first appeared in the 1980s. But it gives us excellent data, so let’s look at who these people are, and what this says about HIV in Australia. 

The most obvious thing is about these 1,043 people is that most of them are gay men.  Exactly two-thirds – nearly 700 - are ‘men who have sex with men’.  One of the things I couldn’t understand when I was a teenager in high school in the early 80s and AIDS was big news was, ‘Why is it gay men who get AIDS, if it’s contagious?’  And people said, ‘because they get it from other gay men.’ And I thought, ‘Ok, sure.  But if just one gay man had sex with a woman, and that woman had sex with someone else, wouldn’t AIDS soon be equally distributed throughout the population?’  And that was what everyone was afraid of, of course – that AIDS would spread to the ‘general population’.  That is, to normal, straight people (there's something rather revolting about listening to people talk - as I often have - about how Australia has been so successful at 'containing' HIV to the gay male community - and I'm not even a gay man).  But anyway, what they didn’t tell me – and maybe didn’t even know – was that HIV is transmitted more readily through anal sex than other kinds of sex.  It’s not that it can’t be transmitted through vaginal sex – it can and it is.  But it’s more likely in anal sex.  So the answer to my adolescent question was probably half right: most gay men only fuck other gay men (indeed, in Australia I get the sense that this is almost a point of honour) and the sex they have is more likely to transmit HIV. 

HIV in Australia has always been primarily an epidemic among gay men.  It’s less gay than it was: in the early years gay men accounted for 90% of those infected; that proportion has slowly declined but has been stable over the last few years at about 65%. I’ll say more about this later.  These men mostly live in the major cities: Sydney, Melbourne and Brisbane, with smaller numbers in other states.  Each year the states watch the data eagerly for trends: NSW has remained pretty stable, but the numbers in Queensland have risen steadily over several years, for reasons unknown...probably because Queensland is growing and more gay men want to live there than they did in the 1980s. 

Such differences are of minor consequence, though, against the basic logic that people generally get HIV where there’s someone to get it from.  Duh.  That is, gay men in Sydney, Melbourne and Brisbane get it from other gay men in Sydney, Melbourne and Brisbane.  But there’s more to this than location: as the number of people living with HIV rises, the number of infections could be expected to also rise.  Since the advent of antiretroviral drugs in the mid-1990s, people with HIV have been living longer; someone diagnosed in 2010, for example, has a life expectancy that’s close to normal.  They are likely to have more health problems than someone without HIV, but they will probably almost as long.  So the population of people with HIV is growing – by about 1,000 people a year. 

This is an important point to remember, because it’s about the infection rate.  Think about it like this: there are 20,000 people with HIV and 1000 people got infected last year.  That could mean that 1 out of every 20 people with HIV infected someone else.  Of course, it doesn’t work like that at all.  There are thousands of people with HIV who never infect anyone, but there may be one guy who doesn’t even know that he has it and infects ten people.  But statistically speaking, it’s about the infection rate – that is, the number of new infections versus existing infections.   Paul Kidd has spoken about this quite eloquently: despite all the hype about increasing numbers of cases, the infection rate is actually pretty stable or even going down.  Think about it: over the last five years, the number of people living with HIV has gone up by 5,000, but the number of diagnoses last year was still 1,000 – the same as it was five years ago.  People with HIV are less likely to infect others than they were. 

There are a number of reasons for this that I don’t fully understand.  The biggest factor is probably drugs.  By this I mean anti-retroviral drugs.  As well as keeping people with HIV alive, anti-retroviral drugs also make people less infectious.   So, if you shag someone with HIV who is on medication, you are much less likely to get infected than if you shag someone with HIV who is not on medication.  And more people with HIV are on medication, and that medication is better.  This dynamic is something that is highly political in HIV circles, and it’s called ‘treatment as prevention’.  That means: by treating people with HIV, you are also preventing transmission.  I’ll talk more about this later. 

The other reason is that mysterious thing called ‘behaviour’.  Put simply, people with HIV act to prevent transmission.  They know how HIV is transmitted and they know how to prevent transmission and, overwhelmingly, that’s what they do.  And the people most likely to get HIV – gay men, injecting drug users and sex workers – mostly do the same.  In Australia, this started early in the epidemic, because gay men and sex workers and injecting drug users got together and talked and educated each other and started having safe sex and injecting safely.  Governments helped them.   This is why the epidemic that everyone was so afraid of in the 80s was largely ‘contained’ among gay men, some injectors, and sex workers hardly at all.  Of course, transmissions do still occur – including to people on medication - they occur when people make mistakes or take risks or accidents happen. 

But back to people with HIV.  So that leaves 350 people who aren't gay men.  Who are they?  Well, about 150 of them are women.  The proportion of women with HIV in Australia has remained at between 10 and 15% for years.  Apart from a handful who got HIV through injecting drugs, these women were all infected through heterosexual sex.  Women, as a group, are not at risk for HIV in Australia.  This is, of course, no comfort to the women who do get HIV, who often take a long time to get diagnosed because nobody considers the possibility that they might have contracted the virus. 

The other 200 are straight men.  There are more straight men than women with HIV in Australia,  which is counter-intuitive when you consider that, biologically speaking, it's easier for a woman to get HIV from a man than it is for a man to get it from a woman.   Gay men who work in sexual health tend to be quite sceptical about whether any man is really heterosexual, and believe that men say that they are straight and got HIV from a woman when, in fact, they are gay.  I'm very sceptical about this argument.  The same thing was said for years about the small number of 'undetermined' cases – the people who don't know how they were infected.  In fact, when researchers looked at these cases more closely, they found that the transmissions in question were likely to have been roughly similar to the profile of known transmissions: some from gay sex, some from straight sex, some from injecting drug use.  It's an essentially ego-centric assumption on the part of gay men, and while there is anecdotal evidence that this kind of mis-reporting does happen, I'm inclined to doubt that it happens a lot.  I suspect the differences between the numbers of straight men and women living with HIV are more likely related to the men's sexual behaviour.  Straight men are, as a group, likely to have more sexual partners than women, and engage in more risky behaviour – like having sex with hookers in Thailand or injecting drugs. 

Just on that point, it's worth noting that of those 1,000 people who are diagnosed with HIV each year, about 40 are infected through injecting drug use.  It's not a lot of people, either in relation to the total number of people who inject drugs, or the total number of people diagnosed with HIV.  The reason that it's so low is simple: when HIV first emerged, policy-makers in Australia did something right, and found ways to provide clean syringes to people who inject.  And drug users used them, because they aren't stupid.  This saved thousands of lives.  The number of people in Australia who got HIV through an infected needle was quite small, compared to most other countries.  And it remains small, because Australia never had a big epidemic of HIV among injecting drug users.  Nonetheless, the number of users living with HIV grows by about 40 a year.  Most of these people go on using and having sex; often safely, sometimes not. 

Ok, so 200 men and 150 women – that doesn't include the injecting drug users.  These are straight people – men and women.   They are mostly adults; the number of children and young people who get HIV in Australia is tiny – a handful each year.  About 120 – over a third – of these people are from what are called ‘high prevalence countries’.  That is, they are migrants from countries where HIV is much more prevalent - mostly from countries in Africa: South Africa, Zimbabwe, the Congo, Sierra Leone.  In South Africa, for example, about 15 to 20% of the entire population has HIV – in Australia that figure is like 0.1%. 

It’s worth remembering that Australia’s African population is quite small – about 250,000 people.  A lot of these people are migrants from South Africa or Zimbabwe, or refugees: from Ethiopia and Somalia, Sierra Leone, Liberia, the Congo.  It’s also worth remembering that everyone who applies to migrate to Australia has to take an HIV test.  Australia routinely rejects applications from people with HIV, and that includes refugees with HIV, because they cost too much to treat.  Once I talked to a woman from the UN High Commission for Refugees, who said, ‘we have women in refugee camps in the Sudan – women whose husbands have been killed while they were gang-raped.  These women got HIV as a result of that gang rape and Australia will not accept their application for refugee status.’

Despite this, some HIV-positive migrants do arrive in Australia.  Indeed, 140 of the 1,043 people diagnosed last year had previously been diagnosed overseas.  Not all of these people are migrants, or from Africa.  Some are, no doubt, Australians who were travelling or living overseas when they were diagnosed, and came home.  But some are migrants who have managed to get an exemption: people who have partners in Australia, refugees who were already living in Australia when they were diagnosed, children being adopted by Australian families. There are also migrants who test negative when they apply for immigration but later become positive, or are already living in Australia and get HIV on visits home, or have been living here for years and get HIV from a partner in Australia.  There are many different stories, different scenarios.  Such diversity makes targeting groups for prevention difficult, but I’ll leave prevention for part 2... 


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