by Simon Yam, Manager, Organisational Development
Towards the end of April, we were able to send five of our staff to attend the National Gay Men’s Health Promotion Conference in Sydney. The group that went covered a diverse range of our activities, from counselling to the M Clinic, to media and our Needle Syringe Exchange Program. Of course, linking these activities is the number of gay men that are our interface through our entire organisation.
Before they left, we asked that they consider four important questions and provide feedback to all of us about ways in which our work can be both relevant and meaningful in terms of the lived experience of gay and bisexual men. The questions were;
1. How should AIDS councils be adapting to the new prevention landscape as it affects gay men?
2. How are we (WA) gearing up for new service models in key areas like HIV testing and PrEP compared to other jurisdictions?
3. How realistic are the 2020 targets and in what ways are they oriented towards gay men in Australia?
4. There are concerns that wide scale adoption of PrEP will lead to significant rises in other STIs amongst gay and other homosexually active men. What are some alternative responses to this? What kind of language should we be adopting?
Naturally, the responses were quite varied as you would expect, with so many different perspectives among the participants. Nonetheless, a number of significant themes certainly emerged that were consistently reported.
Not only has it become even more important to be fully inclusive of all the diversity we work with, it has also become harder. In the past, programs may have been designed for a primary priority population and subsequently adapted, but this is no longer effective. Building programs from the ground up that have a degree of relevance to wide audiences and then supplementing them with additional resources that are audience-specific seems to be the way forward.
An AIDS Council is fundamentally a community-based organisation that was born from a community facing disaster, and from the beginning was deeply embedded and connected to the community from whence it sprung. As time has gone by and as AIDS Councils have become dependant on delivering services contracted by governments, the level of embeddedness in community has somewhat dissipated. And yet, at this stage in the epidemic where new bio-medical technologies are arriving that make ending HIV a real possibility, being driven by community need is vital. There needs to be a rethink about how prevention organisations can again become more embedded, and new ways found to communicate. Whilst social media provides opportunities from one perspective, another view is that the entire communication landscape has become more convoluted and difficult to navigate.
It was no surprise that PrEP had a dominant place in the conference, given that it presents both opportunities and challenges. It is also clear that around the country there are a number of different approaches based on population size, government attitude and community mobilisation. Indeed, it was said that there has been a level of activism around access to PrEP that we have not seen for two decades. Conversations about PrEP will play out in the community and not in the doctors’ surgeries or sexual health clinics. Those who control the prescribing pen cannot control the real-time decisions being made in and amongst the communities of homosexually active men. It is therefore essential that any PrEP program, regardless of whether there are demonstration projects, is built at a grassroots level.
The 2020 Targets
There is a general consensus that achieving a virtual elimination of HIV transmission amongst gay and bisexual men is a realistic proposition, whilst there is also a consensus that this is unlikely to actually happen. There is actually no definition of what a “virtual elimination” is, so there remains doubt around the question. The two areas of new understanding - PrEP and the impact of treatment as prevention (TasP) - are the ‘game changers’, but present difficulties. There seems to be a general view that increasing uptake of PrEP and an increase in numbers with an undetectable viral load will be accompanied by a decrease in condom use and an increase in other STIs. This will not only further accentuate a need for expanded testing programs, but also points to a need for new testing models such as ‘pop-up’ testing sites and outreach services. And there was a note of caution too. Linking rising STI rates to increased use of PrEP will lead to further dissemination of ‘sex stigma’ in the community, and this will be counter-productive in terms of boosting and maintaining community connectedness.