a peer-reviewed article
Aboriginal and Torres Strait Islander peoples experience significantly poorer health compared to the general Australian population. This health inequality is highlighted in comparisons between Indigenous and non-Indigenous sexual health. Pre-exposure prophylaxis (PrEP) is a new HIV prevention technology that protects gay and bisexual men. Social, economic, cultural and historical barriers may exist that prevent Aboriginal and Torres Strait Islander gay and bisexual men from accessing PrEP, and therefore widen the sexual health inequality that already exists.
Aboriginal and Torres Strait Islander (hereafter ‘Indigenous’) peoples living in Australia have significantly poorer health than non-Indigenous Australians, inextricably linked to a history of disempowerment and oppression through colonialism.[2, 3] Indigenous Australians are often identified as a priority population for public health interventions due to their generally lower health status. Discrepancies between Indigenous and non-Indigenous sexual health have been re-contextualised as a human rights issue to draw awareness and urgency to the matter of inequity of sexual health between Indigenous and non-Indigenous Australians.
HIV and Indigenous Australians
Human immunodeficiency virus (HIV) is a retroviral infection that is both blood-borne and sexually transmissible. HIV exhibits epidemiological differences between Indigenous and non-Indigenous Australians. Sexual contact between men is responsible for 75% of HIV notifications for non-Indigenous Australians, compared to only 51% of HIV notifications amongst Indigenous peoples. Twenty-one percent of Indigenous HIV notifications are attributable to injecting drug use and 16% to heterosexual contact.[6,7] Worryingly, since 2011, the age-standardised rate of Indigenous HIV notifications has been steadily rising despite nationwide slowing of HIV notifications in the general population. In 2015, the age-standardised rate of new HIV notifications in Indigenous people was more than double that of non-Indigenous people (6.8 per 100,000 vs 3.1 per 100,000).
Men who have sex with men (MSM) are at elevated risk of becoming infected with HIV compared to the general population. It is unclear how many Indigenous Australians identify as gay or bisexual, and many Indigenous MSM may not identify as gay or bisexual, sometimes due to stigma. A survey of Indigenous youth aged 16 to 29 found 6% of male respondents identified as gay, 2% as bisexual, and a small but significant number as transgender.
Indigenous gay and bisexual men (GBM) and other MSM may be at increased risk of contracting HIV compared to non-Indigenous GBM. Indigenous peoples experience higher rates of sexually transmitted infections (STIs), namely gonorrhoea and chlamydia, particularly in remote areas. The presence of an STI predisposes individuals to HIV infection. Furthermore, Indigenous GBM report higher rates of risky sexual behaviours compared to non-Indigenous GBM.[11, 12] Rates of unprotected anal intercourse with casual partners are higher in Indigenous GBM compared to non-Indigenous, a known risk factor for HIV infection. Likewise, illicit drug use before or during group sex was reported at higher rates in Indigenous GBM compared to non-Indigenous GBM.[11, 14] Coupled with the worrying epidemiological pattern of HIV notifications among injecting drug users and heterosexual people, these elevated rates of risk factors among Indigenous people could increase the risk of HIV transmission for Australia’s Indigenous peoples. Indeed, steady increases in Indigenous HIV notifications and an elevated age-standardised rate of Indigenous HIV notifications are causes for concern (Figure 1).
Figure 1. The age-standardised rate of new HIV notifications by Indigenous status.
A pill a day to prevent HIV
Antiretroviral (ARV) medications have been used since the 1990s as an effective treatment for HIV. More recently, at-risk individuals have used ARVs as an effective HIV prevention method. At-risk individuals can take one pill daily containing two antiretroviral medications, preventing replication of the virus within the body so that viral exposure is not seroconverted, thus preventing HIV infection. Randomised control trials have found that ARVs taken as pre-exposure prophylaxis (PrEP) can prevent 40-99% of HIV infections when taken more than four times a week.[17-21] PrEP implementation trials are currently being run in New South Wales, Queensland, Victoria, South Australia, and the Australian Capital Territory. These trials are supported and funded by state health departments, allowing free or heavily discounted access to expensive drugs that cannot be accessed as PrEP via the Australian Pharmaceutical Benefits Scheme (PBS).
In New South Wales, the Kirby Institute runs the Expanded PrEP Implementation in Communities (EPIC) trial in conjunction with NSW Health. After a year of recruitment, over 5000 at-risk individuals have been enrolled and given access to PrEP. Most of these participants are GBM, identified as being at high risk of HIV exposure. This represents a major expansion from a small pilot study to a large demonstration trial.
Are Indigenous gay and bisexual men accessing PrEP?
Studies in the United States (US) have found that identified priority populations, including Black (African-American) men who have sex with men, may have difficulty in accessing PrEP compared to the general population. This may be due to lack of awareness about PrEP, stigma, poor healthcare coverage, or lack of culturally-appropriate services providing access. Indeed, Black men who have sex with men in the US were successfully recruited, engaged and retained in PrEP programs that employed “culturally-tailored techniques”.
Research shows that in order to target interventions like PrEP to Indigenous communities, culturally-appropriate services owned and governed by the community are in the best position to deliver positive health outcomes.[27-29] Likewise, health promotion materials should be designed and produced by the community for the community, and should avoid blocks of text and overly technical terminology. Therefore, Aboriginal community-controlled health services (ACCHSs) may be best placed to help promote and educate PrEP to at-risk members of the community, facilitating referral to specialised sexual health clinics for assessment and preventative methods that may or may not include PrEP. ACCHSs provide holistic care, and are well equipped to focus on prevention and primary healthcare. ACCHSs are considered manifestations of self-determination and autonomy for Indigenous communities.[29, 32]
Self-determination in Indigenous Australian health services
The United Nations has identified ACCHSs as best practice models of self-determination, and the United Nations Declaration on the Rights of Indigenous Peoples advocates for the right of all peoples, especially Indigenous, to be able to “freely determine their political status and freely pursue their economic, social and cultural development”. However, self-determination in healthcare alone cannot improve health outcomes. Secure, long-term funding coupled with equitable partnerships between Aboriginal community-controlled and mainstream health services is required to address the gap between Indigenous and non-Indigenous health.[29, 32] Facilitating community empowerment reduces the rates of HIV and STIs in female sex workers (FSWs) in low- and middle-income countries.[34, 35] Community empowerment in Australian FSWs during the initial years of the HIV epidemic was essential in enshrining effective HIV prevention focused on universal condom use among FSWs. This case study could be applicable to the Indigenous population, and similar community empowerment in the form of well-funded ACCHSs may allow the gap between Indigenous and non-Indigenous health.
Furthermore, Aboriginal Sexual Health Workers administer culturally-appropriate health services throughout Australia, increasing the involvement of Indigenous people in the healthcare workforce.[28, 37] However, Indigenous peoples need to be consulted and involved in the decision-making process and not just in the delivery of health services.[38, 39]
PrEP is touted as a crucial part of the HIV eradication strategy throughout the world. However, efforts to prevent HIV transmission may be hampered by a failure to engage priority populations, including Aboriginal and Torres Strait Islander Australians. PrEP implementation projects such as EPIC need to ensure adequate coverage of at-risk Indigenous peoples through culturally-appropriate health promotion and security of access to medication. This would be facilitated through the involvement of Indigenous Australians in the decision-making process. Further research will explore PrEP-related health promotion to Indigenous peoples and communities, and attempt to identify any gaps or facilitators.
Alec is a 4th year medical student at the University of New South Wales who is conducting qualitative research into the health promotion of PrEP to Aboriginal and Torres Strait Islander gay and bisexual men. Alec’s research interests include immunology, sexual health, and health inequality. He is looking forward to completing his last two years of medical school in Wagga Wagga.
Dr Bridget Haire, The Kirby Institute
Conflict of Interest
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