World AIDS Day breakfast: Hobart

Terrace Room, Best Western Hobart, 156 Bathurst St, Hobart
Speaking notes

Acknowledgements:

• Muwinina [pron: ‘mou wee nee nar’] people
• TasCAHRD (who invited me to speak)
• Elders in the LGBTI community.

Introduction

15 years ago, when I was an idealistic law student with lots of enthusiam and no grey hair, I went to South Africa with a vague desire to help in the newly-democratic and hopeful rainbow nation.

This trip was personally significant, because my mother and her family had fled Apartheid-era South Africa in the 1960s. My mum’s twin brother, Bill Frankel, was a lawyer who throughout his career used the law to fight apartheid and its racist ideology… and indeed he was one of the reasons why I studied law in the first place.

Before arriving in South Africa, of course I was aware of the HIV/AIDS pandemic that was sweeping through sub-Saharan Africa. But I was unprepared to see what that meant in reality.

At just the moment when anti-retroviral drugs were transforming the lives of people with HIV and AIDS in the Global North, in the Global South a grotesque and horrifying game seemed to be taking place in HIV/AIDS policy:

• The pharmaceutical companies that held patents to anti-retroviral medication insisted that the full price be paid on these life-saving drugs. This included drugs like Nevirapine, which can inhibit the spread of HIV from mother to child.
• Governments of poorer countries, especially in sub-Saharan Africa, said that they simply could not afford to pay for these drugs – let alone the cost of the broader treatment needed to ensure the best possible outcomes for people with HIV/AIDS.
• Wealthier, donor countries were largely wringing their hands – many waiting for the pharmaceutical companies to blink first.

Meanwhile, the spread of HIV/AIDS was rampant. Because HIV can spread through sexual intercourse, it disproportionately affects adults in the most productive period of life – their prime working and child-rearing years. This, in turn, had catastrophic effects on social structures with many children being brought up by their grandparents and compounding poverty and disadvantage.

When I was in South Africa, I met an incredibly inspiring young lawyer, Brendon Christian. Brendon was working to prise open the law to make anti-retroviral therapies more widely available.

Brendon worked hand-in-glove with the communities he was trying to help, and he had a deep understanding of the scale of the problem. Over time, through extraordinary energy, persistence and creativity, treatment has started to become more available for the most disadvantaged people living with HIV/AIDS. But there is still a great deal of work to do.

World AIDS day and Australia

This is the 28th year we mark World AIDS Day, and that history and context are, for me, important to remember. Today is an opportunity for people worldwide to unite in the fight against HIV, show their support for people living with HIV and to commemorate people who have died.[i]

The situation in Australia differs, of course, from sub-Saharan Africa. We should be proud of our success in addressing HIV/AIDS, but there is still much work to do.

In 2015, 1,025 people were newly diagnosed with HIV in Australia. This figure has remained stable over the past three years [1,028 cases in 2013; 1,081 cases in 2014; and 1,025 in 2015].

The Australian Federation of AIDS Organisations (AFAO) attributes the stabilisation of new diagnoses since 2012 to “a doubling of HIV testing rates in Australia and efforts to encourage earlier access to HIV treatments”, which has been “driven by increasing evidence about improved health outcomes for people with HIV who access antiretroviral treatment early and a reduced risk of onward transmission of HIV for people on antiretroviral”.[ii]

By the end of last year, an estimated 25,313 people were living with HIV in Australia, of whom an estimated 2,619 (10%) were unaware of their HIV-positive status.[iii]  Of the people in Australia who were aware of their HIV-positive status [estimated 22,694], approximately 84% were receiving anti-retroviral (ARV) treatment. 92% of people accessing ARV treatment were estimated to have an undetectable viral load.[iv]

AFAO notes that these figures compare well to the UN '90-90-90' targets – ie, that by 2020, 90% of people living with HIV know their status, 90% of people diagnosed with HIV are on treatment, and 90% of people on treatment have suppressed viral loads.[v]

Aboriginal and Torres Strait Islander Australians

There remain, however, significant areas of concern in Australia. In particular, the Kirby Instituted reported that “the trend in HIV notifications among Aboriginal and Torres Strait Islander peoples is very different, with a steady increase in the notification rate in Aboriginal and Torres Strait Islander males over the past five years”.[vi]

Associate Professor James Ward, a leading expert in this area, has expressed concern that some successful strategies haven’t penetrated all parts of the Australian community:
"These test and treat strategies probably haven't filtered into the primary healthcare providers for Aboriginal people which are predominantly Aboriginal medical services. I think we need to put a real lot of effort into ensuring that test and treat strategies are rolled out."

Recent developments in Australia

National HIV Strategy

Two years ago, Australian Health Ministers committed to “working towards the virtual elimination of Australian HIV transmissions by the end of 2020”.[vii]  That same year, Australia launched its Seventh National HIV Strategy (2014-2017). Unlike earlier strategies, this one includes numeric targets.

One of the six objectives of the Strategy is to ‘eliminate the negative impact of stigma, discrimination, and legal and human rights issues on people’s health’. [viii]

Criminalisation and other barriers to access and equal treatment

The High Court’s decision earlier this year in the Zaburoni case (Zaburoni v The Queen [2016] HCA 12) highlights some of the incredibly difficult issues that arise in the criminal context. In that case, Mr Zaburoni was diagnosed with HIV in 1998 and started a relationship with a woman in 2006. Mr Zaburoni did not inform her of his HIV status. They had unprotected sex for three years until she was diagnosed with HIV.

Mr Zaburoni was charged with various criminal offences. Eventually, the High Court found him guilty of the lesser charge with which he was charged (grievous bodily harm). The Court found that Mr Zaburoni was reckless about transmitting HIV, not that he had intentionally done so.

This case shows how complex these criminal issues are. It seems that some state governments are actively considering this issue. Last week, on 27 November 2016, the Sydney Morning Herald reported that the NSW Government will draft a bill to remove s 79 of the Public Health Act 2010 (NSW) in 2017.[x]

Under s 79, anyone who knows that they have a sexually transmissible infection, including HIV, must first inform that person before they have sex, and that person must voluntarily accept the infection risk. The problem is that forced disclosure of HIV status “can encourage HIV-related stigma and discrimination, both real and perceived” [Scott Harlum, Communications and Policy Officer at Positive Life NSW]. In some circumstances it can lead to violence. More often, it can lead to rejection, loss of control over who knows a person’s status, discrimination on the basis of HIV status or the premature ending of relationships.[xi]

Discrimination on the basis of HIV status

Over the last year, the Commission received nine complaints of discrimination on the basis of HIV status under the Disability Discrimination Act 1992 (Cth):

To give you a sense of what discrimination in this area looks like, a complaint handled by the Queensland Anti-Discrimination Commission[xii] was as follows.

When an apprentice chef was diagnosed as HIV positive he informed his employer, and the next day he was dismissed. The owners of the restaurant had been advised by their insurance broker that their insurance may be cancelled if they continued to employ the apprentice.

At the conciliation conference the apprentice explained that a large volume of blood would be required to pass on the condition, and that universal hygiene measures meant there was an extremely low risk of this occurring. He also told them he was now working in another restaurant where the employer was aware of his HIV status.

The restaurant owners acknowledged they should have investigated the risks and sought advice elsewhere. They agreed to pay compensation to the apprentice for hurt and humiliation as well as one month's loss of income.

Conclusion

Finally, looking to the future, so much hope in the community has been invested in research to find some kind of HIV/AIDS vaccine. None yet exists, but we might be getting closer.

This year, the Therapeutic Goods Administration approved the use of Truvada (commonly known as PrEP) as a pre-exposure prophylaxis.[xiii]  However, the independent Pharmaceutical Benefits Advisory Committee (PBAC) decided not to recommend listing PrEP on the PBS. In its decision, PBAC acknowledged the importance of PrEP but was unable to recommend it for a number of reasons, including the cost-effectiveness of the price submitted by the manufacturer of Truvada.[xiv]

Whether or not this is the right decision, it shows that major change is afoot. But the science of HIV/AIDS is only one dimension of the broader issues. While we await a definitive vaccine and cure, there remains a great deal of work to do to ensure that people with HIV/AIDS are treated fairly and equally.

References

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1. National AIDS Trust, About World AIDS Day (2016) World AIDS Day <https://www.worldaidsday.org/about&gt;.
2.   Australian Federation of AIDS Organisations, ‘HIV Statistics in Australia’ http://www.afao.org.au/about-hiv/the-hiv-epidemic/hiv-statistics-austra…
3. The Kirby Institute, HIV, Viral Hepatitis and Sexually Transmissible Infections in Australia Annual Surveillance Report 2014 (UNSW Australia, 2016) 26 <http://kirby.unsw.edu.au/sites/default/files/hiv/resources/2016%20BBVST…;.
4. Australian Federation of AIDS Organisations, ‘HIV Statistics in Australia’ http://www.afao.org.au/about-hiv/the-hiv-epidemic/hiv-statistics-austra…
5. Australian Federation of AIDS Organisations, ‘HIV Statistics in Australia’ http://www.afao.org.au/about-hiv/the-hiv-epidemic/hiv-statistics-austra…
6. The Kirby Institute, HIV, Viral Hepatitis and Sexually Transmissible Infections in Australia Annual Surveillance Report 2014 (UNSW Australia, 2016) 12 <http://kirby.unsw.edu.au/sites/default/files/hiv/resources/2016%20BBVST…;.
7. Peter Dutton, ‘Health Ministers Sign on to End HIV Transmissions by 2020’ (Media Release, 20 July 2014) <http://www.health.gov.au/internet/ministers/publishing.nsf/Content/6DA3…;.
8. Department of Health, Seventh National HIV Strategy 2014-2017, 5 <http://www.health.gov.au/internet/main/publishing.nsf/content/8E87E65EE…;.
9. Ibid, 27.
10. Kirsty Needham, ‘Removing Disclosure Law will Help Stop HIV Spread, Health Experts Say’, The Sydney Morning Herald (online) 27 November 2016 <http://www.smh.com.au/nsw/nsw-to-drop-hiv-disclosure-rule-20161126-gsy6…;.
11. Scott Harlum, ‘The Problem with Section 79’: The Call to amend HIV disclosure laws in NSW (2016) 14(1) HIV Australia, 14 <https://www.afao.org.au/library/topic/prisoners/HIVA-14-1-hiv-policing-…;.
12. Queensland Anti-Discrimination Commission, Impairment Case Studies (20 October 2016) <https://www.adcq.qld.gov.au/resources/case-studies/impairment&gt;.
13. The Kirby Institute, HIV Researchers Welcome TGA Approval for Truvada for Pre-exposure Prophylaxis HIV Prevention (6 May 2016) <http://kirby.unsw.edu.au/news/hiv-researchers-welcome-tga-approval-truv…;.
14. Australian Federation of AIDS Organisations, Australian PrEP Roundup (Australian Federation of AIDS Organisations, 2016) < https://www.afao.org.au/.../Australian-PrEP-Roundup_August_2016.pdf&gt;.