Guarding against an HIV epidemic within an Aboriginal community and cultural framework; lessons from NSW

"No-one's driving this bus" - qualitative analysis of PrEP health promotion for Aboriginal and Torres Strait Islander gay and bisexual men

OBJECTIVE

HIV prevention tools such as pre-exposure prophylaxis require equitable access and uptake to protect all at-risk populations. This project assessed the perceived barriers to accessible HIV prevention for Aboriginal and Torres Strait Islander gay and bisexual men (GBM) and evaluated the presence of health promotion for pre-exposure prophylaxis (PrEP) for this population from the perspective of service providers.

METHODS

Eighteen semi-structured interviews with healthcare providers, researchers and AIDS Council employees were qualitatively analysed for themes and concepts related to PrEP-specific health promotion.

RESULTS

Respondents noted AIDS Councils and affiliated sexual health clinics had been instrumental in promoting PrEP to at-risk GBM. However, many Aboriginal gay and bisexual men who are not well connected with these communities and services may not have been exposed to this health promotion and therefore have not accessed PrEP effectively.

CONCLUSIONS

Aboriginal community and gay community controlled health organisations need to collaborate to ensure they deliver effective and tailored health promotion to Aboriginal communities. Implications for public health: The rising HIV notification rates in Aboriginal Australians is an example of the health gap experienced by First Nation people. Effective HIV prevention is required to ensure this gap does not widen further, and that Australia meets its goal of preventing all new HIV infections. However, these efforts will be hampered by ineffective health promotion of HIV prevention tools, such as PrEP, for Aboriginal Australians.

HIV Among Indigenous peoples: A Review of the Literature on HIV-Related Behaviour Since the Beginning of the Epidemic

From the early days of the HIV epidemic, Indigenous peoples were identified as a population group that experiences social and economic determinants-including colonialism and racism-that increase exposure to HIV. There are now substantial disparities in HIV rates between Indigenous and non-Indigenous peoples in some countries. We conducted a comprehensive literature review to assess the evidence on HIV-related behaviors and determinants in four countries-Australia, Canada, New Zealand and the United States-in which Indigenous peoples share important features of colonization and marginalization. We identified 107 articles over more than 20 years. The review highlights the determinants of HIV-related behaviors including domestic violence, stigma and discrimination, and injecting drug use. Many of the factors associated with HIV risk also contribute to mistrust of health services, which in turn contributes to poor HIV and health outcomes among Indigenous peoples.

Antiretroviral treatment use, co-morbidities and clinical outcomes among Aboriginal participants in the Australian HIV Observational Database (AHOD)

Background

There are few data regarding clinical care and outcomes of Indigenous Australians living with HIV and it is unknown if these differ from non-Indigenous HIV-positive Australians.

Methods

AHOD commenced enrolment in 1999 and is a prospective cohort of HIV-positive participants attending HIV outpatient services throughout Australia, of which 20 (74 %) sites report Indigenous status. Data were collected up until March 2013 and compared between Indigenous and non-Indigenous participants. Person-year methods were used to compare death rates, rates of loss to follow-up and rates of laboratory testing during follow-up between Indigenous and non-Indigenous participants. Factors associated with time to first combination antiretroviral therapy (cART) regimen change were assessed using Kaplan Meier and Cox Proportional hazards methods.

Results

Forty-two of 2197 (1.9 %) participants were Indigenous. Follow-up amongst Indigenous and non-Indigenous participants was 332 & 16270 person-years, respectively. HIV virological suppression was achieved in similar proportions of Indigenous and non-Indigenous participants 2 years after initiation of cART (81.0 % vs 76.5 %, p = 0.635). Indigenous status was not independently associated with shorter time to change from first- to second-line cART (aHR 0.95, 95 % CI 0.51-1.76, p = 0.957). Compared with non-Indigenous participants, Indigenous participants had significantly less frequent laboratory monitoring of CD4 count (rate:2.76 tests/year vs 2.97 tests/year, p = 0.025) and HIV viral load (rate:2.53 tests/year vs 2.93 tests/year, p < 0.001), while testing rates for lipids and blood glucose were almost half that of non-indigenous participants (rate:0.43/year vs 0.71 tests/year, p < 0.001). Loss to follow-up (23.8 % vs 29.8 %, p = 0.496) and death (2.4 % vs 7.1 %, p = 0.361) occurred in similar proportions of indigenous and non-Indigenous participants, respectively, although causes of death in both groups were mostly non-HIV-related.

Conclusions

As far as we are aware, these are the first data comparing clinical outcomes between Indigenous and non-Indigenous HIV-positive Australians. The forty-two Indigenous participants represent over 10 % of all Indigenous Australians ever diagnosed with HIV. Although outcomes were not significantly different, Indigenous patients had lower rates of laboratory testing for HIV and lipid/glucose parameters. Given the elevated risk of cardiovascular disease in the general Indigenous community, the additional risk factor of HIV infection warrants further focus on modifiable risk factors to maximise life expectancy in this population.