James Ward¹, Marisa Gilles², Darren Russel^3,4

1. Poche Centre for Indigenous Health, The University of Queensland, Brisbane, QLD
2. WA Country Health Service, Health Department of Western Australia, Perth, WA
3. Cairns Sexual Health Service, Cairns, QLD
4. College of Medicine and Dentistry, James Cook University, Cairns, QLD

Last reviewed: June 2021

Introduction

Of the 4,289 HIV diagnoses in Australia between 2015 and 2019, 173 were among Aboriginal and Torres Strait Islander (ATSI) peoples, with the rate of diagnosis of HIV infection in 2019 higher among ATSI people (3.3 per 100,000) than Australian born non-Indigenous peoples (2.8 per 100,000).¹ In the five year period 2015-2019, the reported exposure to HIV infection in ATSI people differed from that of Australian-born non-Indigenous cases, with a lesser proportion of cases occurring among men who have sex with men (61% vs 73%) and a higher proportion of cases attributed to heterosexual contact (19% versus 11%) and injecting drug use (20% versus 3%).^2,3,4

Rates of other sexually transmissible infections (STIs) are also much higher in the ATSI population compared to the non-Indigenous population, with Chlamydia infection being three times higher and gonorrhoea seven times higher in 2017.^2,3 In addition, in the Northern parts of Australia there is an outbreak of infectious syphilis spanning multiple jurisdictions. This higher prevalence of other STIs increases the risk of HIV transmission in this population. As such, ATSI people remain a key population for STI and HIV prevention and management strategies of Australian government agencies.^5,6

Barriers to diagnosis

There exist many barriers to the diagnosis of HIV infection in ATSI people, which may explain the higher rates of HIV infection in this population.⁷  Structural and social determinants such as late or non-diagnosis, less than optimal testing, lack of uptake of interventions such as TasP and PEP and discrimination and stigma regarding HIV have been previously reported.⁸ Others determinants include poorer physical, financial and cultural access to clinical services, as well as crowded housing, limited transport, and lower education and employment levels, all of which create competing demands on individuals, so that personal health is often de-prioritised.⁹

Opportunities for early diagnosis

A focus on the detection and control of other STIs in ATSI populations provides an opportunity for screening for HIV infection and a space to have a discussion related to safe sex practices and the benefits of early diagnosis and treatment of STIs and HIV infection. As it is common to find concurrent STIs, particularly in regional and remote areas, such opportunities must not be missed. Screening for HIV infection and other STIs during the antenatal period should be already happening routinely.¹⁰

Management – cultural differences

Evidence from various sources has demonstrated that, to ensure similar outcomes are achieved in the management of ATSI peoples with HIV infection, it is critical that services provided are equitable (the level required to achieve the same results) and not equal (the same as provided for other populations)^11,12,13,14. This means that services may often need to be tailored to the individual, including management strategies to accommodate greater disparity in structural and social determinants.  Further, HIV management services should be mindful of community and cultural issues such as enabling ATSI health staff and/or respected community members to advise on the place, timing, situation and relationship between patient and health care provider in all stages of HIV testing and care.  Having experienced and well-connected ATSI and other local health service staff to carry out contact tracing also facilitates early diagnosis and promotion of timely treatment reducing the ongoing transmission of HIV infection in this population. In some remote locations in Australia, it is often difficult to ensure continuity of care and in this situation having a cohort of ATSI staff who are more likely to remain in the work force makes this more achievable.

Optimising treatment adherence

Once again, the importance of highly valued ATSI staff, the provision of continuity of care and the development of a strong relationship between patient and health care provider is critical to achieving long-standing adherence to treatment and good therapeutic outcomes. A holistic service provision that goes beyond the provision of therapeutic medical care and encompasses social supports such as assistance in finding stable housing, financial support to attend funerals and cultural events, maybe even extending to the provision of financial support for birth certificates and help in accessing food, are required.

References

1. The Kirby Institute, 2020, HIV data portal, accessed on line 2 March 2021 at: https://data.kirby.unsw.edu.au/hiv
2. The Kirby Institute. Bloodborne, viral and sexually transmissible infections in Aboriginal and Torres Strait Islander people, Annual Surveillance Report 2017. UNSW, Sydney.
3. The Kirby Institute. Australian Needle and Syringe Program Survey, National Data Report 2012–2016. UNSW, Sydney.
4. Ward J, Crooks L, Russell D. High level summit on rising HIV, sexually transmissible infections (STI) and viral hepatitis in Aboriginal and Torres Strait Islander communities, Final Report – April 2016. Accessed 20 February 2018 at: ashm.org.au
5. Australian Government Department of Health. Eighth National HIV Strategy 2018-2022. Accessed online at: https://www1.health.gov.au/internet/main/publishing.nsf/Content/ohp-bbvs-1/$File/HIV-Eight-Nat-Strategy-2018-22.pdf
6. Australian Government Department of Health. Fifth National Aboriginal and Torres Strait Islander Blood Borne Viruses and Sexually Transmissible Infections Strategy 2018–2022. Accessed online at: ATSI-Fifth-Nat-Strategy-2018-22.pdf (health.gov.au)
7. Bowden F. Controlling HIV in indigenous Australians. Med J Aust 2005; 183:116–117.
8. Ward JS, Hawke K, Guy RJ. Priorities for preventing a concentrated HIV epidemic among Aboriginal and Torres Strait Islander Australians. Med J Aust 2018; 209:56.
9. Bonar M, Greville H, Thompson S. Just getting on with my life without thinkin’ about it. The experiences of Aboriginal people in Western Australia who are HIV positive. Department of Health, Western Australia, 2004.
10. Ziegler J, Graves N. The time to recommend antenatal HIV screening for all pregnant women has arrived. Med J Aust 2004; 181:124-125.
11. Gilles MT, French MA, Cain A, McGuckin R, Turner K, Prescott, Loh R, Dickinson J. Perinatal HIV transmission and pregnancy outcomes for Indigenous women in Western Australia. Aust New Zealand J Obs Gynae 2007; 47:362-367
12. Cunningham J, Cass A, Arnold PC. Bridging the treatment gap for Indigenous Australians. Med J Aust 2005; 192:505-506.
13. Coory M, Walsh W. Rates of percutaneous coronary interventions and by-pass surgery after acute myocardial infarction in Indigenous patients. Med J Aust 2005; 182:507-512.
14. Harrod ME, Ward J, Graham S, Butler T. Australian prisons: the key to closing the gap and ensuring HIV remains low in Aboriginal and Torres Strait Islander communities. HIV Australia 2011; 9:17-19.