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Monday 08 November 2010

The HIV Services Review - summarised

Posted in: HIV, Features
By Jacqui Stanford - 5th November 2010

At 60 densely packed pages of details, observations, recommendations and enough health-related acronyms to give the United Nations a run for its money, the long-awaited HIV Services Review has just gone public. has quickly done the hard work for you and extracted what we believe are the most salient and important points affecting men who have sex with men, the group hardest hit by HIV and AIDS in New Zealand.

Hint: There is a summary of the seven primary issues and recommendations Dr Miller has identified at the end of this article.


Dr David Miller
The days of the New Zealand AIDS Foundation being a convenient 'one stop shop' destination for Ministry of Health HIV funding may be numbered.

Currently the NZAF is the only NGO, or Non-Governmental Organisation, which receives Ministry funding.
However, Dr David Miller's HIV Services Review concludes that smaller players need funding.

"Smaller NGOs with demonstrated records of service provision and defined constituencies are having difficulty coping. Even though their constituencies may be well-defined and relatively small, the demands of those constituencies are significant and growing, in terms of both practical and emotional needs," Dr Miller writes.

"These NGOs need and deserve help. The Ministry of Health should consider core funding in each case to support sustainable, outcomes-based activities so these NGOs are not constantly distracted from their primary missions by the need to find funding for survival. Possible benchmarks could be implemented for providing funds to smaller community-based HIV support services."

The report does not specify whether Dr Miller believes the groups should receive separate funding, or whether they should be given a slice of the rolling annual grant of around $4 million the NZAF currently receives from the Ministry of Health.

The review outlines the statistics on HIV, the HIV services provided by District Health Boards (DHBs), the HIV services provided by NGOs and includes contributions from people living with HIV/AIDS.

Dr Miller then discusses the overall situation and draws a number of specific conclusions and makes recommendations.

Dr Miller concedes a review of this nature focuses on the gaps rather than the successes and describes it as effectively a 'stock-taking' of services for people living with HIV. "It is important to stress that it is not a qualitative review or an audit of service processes or functioning," he says.

Overall he finds that the services for people living with HIV and AIDS (PLHA) in New Zealand are successfully reaching those for whom they are designed.  "It is acknowledged that the majority of PLHA services are in Auckland, the region hardest hit by HIV. However, there are gaps in the administration, monitoring and evaluation of PLHA services in Auckland, as there are elsewhere. One way to address current service provision for PLHA in New Zealand is to ask whether it is necessary and sufficient to address current needs. The answer, for now, is: Necessary, yes; sufficient, not yet."

Dr Miller makes, but does not clarify, the comment that there is a "reported current absence of a condom culture" in the groups where HIV has hit hardest in New Zealand. Condom usage has been the key, unwavering NZAF prevention message throughout its 25 year history and is something it has produced much research to back up as the best method of preventing the spread of HIV.

One gap Dr Miller identifies for people living with HIV and AIDS is a lack of mental health coverage, particularly for those with longer-term psychiatric and psychological issues. He says there need to be benchmarks in this area and options for access to quality mental health services and personnel need to be explored.

He says primary health care fees such as for GP visits are also a major obstacle and suggests downsizing fees for PLHA and their families as a significant and inexpensive solution.

Dr Miller says there are significant variations in HIV testing processes and the fact New Zealand has its own protocols was not known to the majority of those who took part in the review. He says a national discussion appears necessary.

Stigma was repeatedly mentioned as a major issue during the review process, which Dr Miller says can cause, among other things, reluctance among men who have sex with men to use community-based NGO services, reluctance to use condoms and reluctance to identify as gay or bisexual.

"It is evident that stigma is the elephant in the waiting room of HIV public health responses – often invoked as the cause of sub-optimal population responses to prevention and support activities, yet hard to quantify or isolate by region or population."

Dr Miller suggests a national conversation on stigma in health to enable a broad understanding of what it is, how it works and how it can be addressed. "An action agenda can then be initiated to systematically take evidence-based experimental approaches with populations concerned. Unless stigma is addressed in a mature manner in the management of HIV, diagnostic, preventive, treatment and care initiatives and interventions will always be playing ‘catch-up’ as stigma effects are subsequently revealed."

Dr Miller says in the course of the review, many comments were made regarding challenges for HIV prevention, something which he was not asked to examine but is crucially linked to other areas of HIV services. "It would seem reasonable to consider a review of HIV prevention services in New Zealand in the future," he says.

Research is another area the author delves into, saying although there are research groups such as the NZAF which provide regular compilations of statistics and analysis relating to both HIV/AIDS and STIs, there is an absence of a coordinated or comprehensive research agenda.

"This means that there is a continual and pressing absence of data for policy and programme refinement, for example in relation to the almost mythic issue of the impact of stigma on HIV service engagement, or in relation to geographical and demographic differences in the availability, structure and effect of HIV services in New Zealand.  Development of such an agenda with Ministry of Health backing would strengthen service delivery and the evidence base for service development."  
He says as part of the development of this agenda, a system also needs to be set up for external quality audits of both DHB and NGO services, something he says is well overdue.

Other Conclusions:

The Ministry of Health HIV/AIDS Action Plan (2003) is out of date and needs revision. The operational content of the plan needs to be strengthened and the activities it covers need greater definition, to enable greater specificity in benchmarking of performance against objectives.

In addition to this is the need for an action plan linked to the Sexual and Reproductive health strategy. Given the obvious and often-remarked link between Sexually Transmitted infections (STIs) and HIV transmission, and the concerning increases in STI rates around the country, development of such a plan is a necessary component in terms of future HIV prevention and management. It would also provide an excellent opportunity for a coordinated process of reflection on prevention approaches and how they can be supported in this new decade, as a counter to the apparent behavioural complacency linked to community perception of HIV treatment successes.

The individual services:

Dr Miller looks at all the DHBs and NGOs which provide HIV services in the review, including NZAF and peer support organisations Auckland-based Body Positive and Wellington's Absolutely Positively Positive. Here is a summary of what he writes about the NZAF and Body Positive:

NZ AIDS Foundation

Based on the NZAF’s presentation of the nature and scope of the services it provides and feedback from other organisations the Miller report gives a glowing outline of the Positive Health services the NZAF provides across the country. "Service users and DHB colleagues alike interviewed for this review conspicuously and spontaneously praised the quality of NZAF counselling staff and procedures in all centres," Dr Miller says.

One of the issues raised about the Foundation was its links with its sister NGOs. "The NZAF has convening and advocacy authority that many of its sister NGOs lack – it wields the authority of 25 years of front-line experience and advocacy, it has the funding, and it maintains the networks within and outside DHB services," Dr Miller says.

"Given the operational limits of NZAF Sexual Health services delivery, a degree of ‘friendly territoriality’ can be detected among NGOs outside of the NZAF when it comes to defining the scope of people living with HIV//AIDS services.

"While the NZAF remains the only Government-funded HIV NGO, it inevitably retains a position of paternal authority over its companion NGO services, and this may be raising avoidable tensions."

Dr Miller says there was also concern about excessive expectations among the Foundation's 'constituencies'. He says it could be argued that the NZAF is somewhat handicapped by its ubiquity in discussion about HIV services. "It has a substantial and respected footprint, but many service-users want more service support than the NZAF is able to provide. Many people living with HIV and AIDS perceive that the NZAF is not providing the longer-term services for psychosocial support or mental health that they want. This may generate a degree of defensiveness that is unwarranted, given the NZAF’s primary role of HIV prevention.

"That primary role, and the others the NZAF fulfils alongside the Sexual Health initiatives that Positive Health services provide, is simply not understood – and is therefore sometimes apparently resented."

Another issue raised about the Foundation is that like DHB services, it's seeing people who choose not to visit their primary caregiver for HIV and even sexual health testing.

Dr Miller says the NZAF has been the subject of regular external audits, but not of its process quality, something he says it would be timely to consider.

Body Positive

Dr Miller is complementary about Body Positive's work and points out that it receives no Government funding. "All its funding comes from philanthropic organisations, making the organisation vulnerable to broader economic circumstances. The recent recession has led to three staff positions being disestablished."

Dr Miller says rapid testing has been one of the most visible developments in Body Positive's recent history. It carries out rapid tests on-site at Body Positive House, at the K Road Clinic and in five sex on site venues in Auckland. 

"By providing those who otherwise might never access formal HIV test services with the opportunity to be tested, Body Positive sees itself having a vital role in developing HIV awareness and supporting engagement with appropriate health and social services," Dr Miller writes.

"Body Positive reported identifying as many people living with HIV and AIDS ‘on-site’ as NZAF has done nationally. It sees its accompanying/facilitative role for those found to be HIV positive through its own channels to be a crucial one – indeed, the spectrum of support services BP offers directly matches the needs that PLHA themselves express."

Dr Miller points out that although Body Positive is a national service it has a physical base only in Auckland. He says its main national initiatives are the dissemination of information, the annual HIV+ Men’s Retreat, the HIV Treatment Update and its national 0800 helpline.

"There were no funds available for the establishment of branches elsewhere in New Zealand at the time of this review."

Dr Miller says Body Positive reported this lack of resources also particularly impacts social work and counselling.

INA HIV/AIDS Foundation Charitable Trust

INA is a group which was set up in Tirau in 2008 as a reaction to what its creators saw as a lack of engagement of the NZAF with Māori men and women affected by HIV/AIDS.  The trust is still in its development phase, with one partially-paid staff member and a team of volunteers.

Dr Miller notes that despite its development constraints, INA has already established a national presence, obtaining a place at the table at national forums and representation at national and international meetings.
INA asserts the need for whanau-based Māori and Pacific Island (MPI) -focussed services.

"The contention of INA is that as long as services are perceived as being ‘gay’, ‘white’ and ‘in Auckland’, most MPI will remain un-engaged.  With STI rates among MPI currently causing serious concern, and with ‘stigma keeping Māori away from health services’, the INA asserts that the need for developing specific approaches for MPI is stronger than ever," Dr Miller says.

INA claims the NZAF and other community-based services 'do not engage gay/bisexual Māori men and women, because the outreach and education programmes employed are not based on whanau'.

INA wants to work with DHBs in partnership, ‘as an equal partner in facilitating MPI HIV engagement’.

Other peer support organisations

Wellington-based support group Absolutely Positively Positive also had input into the report, but there is no particular section focused on its thoughts or needs. Dr Miller notes, in the data it gave to the review, the NZAF says it has been supporting the Absolutely Positively Positive group, along with a group which emerged in Christchurch, Poz Plus. [Note: Absolutely Positively Positive is strongly disputing the claim it receives NZAF support - Ed.]

Summary of recommendations:

Issue 1: Ministry of Health HIV/AIDS Action Plan (2003) is out of date and needs revision; there is no Sexual and Reproductive Health Strategy action plan.
Recommendation: Review and update the HIV/AIDS Action Plan; develop a Sexual and Reproductive Health Strategy action plan.

Issue 2: There is no national HIV research strategy; evaluation of quality of service delivery across sectors is absent.
Recommendation: Develop a national HIV research agenda; develop a framework for external evaluation of HIV service quality.

Issyue 3: Mental health coverage for PLHA – particularly longer-term mental health support – is difficult to access in most areas.
Recommendation: Establish benchmarks for
Mental Health coverage for PLHA; explore new pathways for access to qualified Mental Health services.

Issue 4: Cost is an obstacle to accessing primary care for many PLHA; DHB and NGO HIV services are a proxy for primary care services.
Recommendation: Review primary care fee costs for PLHA; review core primary care staff training in HIV.

Issue 5: There are variations in Testing & Counselling for HIV according to sector and service.
Recommendation: Initiate a national conversation on standards and guidance for T&C provision, training and monitoring

Issue 6: Stigma, particularly in minority populations, creates obstacles to HIV service engagement.
Recommendation: Initiate a national conversation on stigma in health – examining experiences to date from a variety of perspectives; develop an action agenda.

Issue 7: NGOs are experiencing difficulties in coping with demand.
Recommendation: Identify possibilities for core funding of sustainable, outcomes-based activities to enable NGOs to survive without being distracted from their primary mission; explore implementation of benchmarks for funding smaller support services.

Jacqui Stanford - 5th November 2010

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