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Wednesday 09 November 2016

HIV prevention: It's time for a change

Posted in: Health & HIV, Our Communities
By Jay Bennie - 29th September 2016

(You can read part 1 of this conversation with Jason Myers here.)

Gay social scientist and gay men's health advocate Jason Myers has come to the job of Executive Director of the NZ AIDS Foundation at a time when it is clear there are, year by year, more and more new diagnoses of HIV infection in New Zealand, especially amongst gay and bisexual men. The line on the graph has for the past few years relentlessly risen.


JM: 2015 saw the worst numbers ever with 224 new diagnoses in New Zealand and we're not shying away from calling it an upward trend.

If you look back to 2000 it's been increasing since then and that's a deep concern to us and our goal is to get that trend line going down. Over the last 12 – 18 months there's been a lot of work going on internally about recognising that with all the scientific breakthroughs and real world evidence we may have a whole range of tools in the toolbox to address this problem, not just condoms.

So the strategic plan we're about to release really does bring life to making use of all those tools in a New Zealand context. So, condoms? Yes! But also increasing our testing, not only internally but also across the whole sector so we are finding those people with HIV who don't know they've got it, linking them to appropriate and effective care so we can get them on treatment at a time that's best for them and addressing the policy issues that are in that such as the CD4 threshold.

It's about making the most of the opportunity that sits in that test and treat space. Because we know that if we can suppress viral load at a community level it's the best thing we can do as well as getting the best possible clinical outcomes for people living with HIV.

In the primary prevention space it's adding pre-exposure prophylaxis, or PrEP, to the equation in a way that honours the NZAF's job of advancing a population-level response to HIV. This is not going to be a quick lolly scramble, it's going to be about trying to get guys to understand who PrEP might be good for and getting them access to it. And we're at the very beginning of those conversations.

I've had a number of conversations with gay guys in the community and I hear: “I want PrEP... I want PrEP”. I ask: "Why do you want PrEP, tell me about your sexual practices... ok well PrEP might not actually be for you and here's why.” And you see the light bulb going on.

So there's going to be a whole heap of work in the PrEP space and the complexity is going to be finding a way through, essentially messaging four behaviour changes: “Put a condom on your cock,” “If you're really struggling with that then PrEP might be for you, let's have a conversation and let's get you on it,” “Let's make sure you're testing relative to your risk” and "If you have HIV let's link you to care and help you understand that adhering to your treatment it's the best thing for you and it's going to have a secondary impact on HIV prevention."

We're going to have to think through the ways in which we engage with the community and doing that in potentially different ways that enable us to help everybody understand. That needs to be a two-way conversation, it can't be just us going here's all the information now make a decision. In many ways it's going to be a new campaign and a new strategy that's going to come out of it, with lots of opportunities because it going to give everybody a role to play in this game. It's not going to be just: “Wear a condom? No I'm not interested in that so I'm off.” It's going to be: “If you don't want to wear a condom help us understand why and help us work with you to try to come up with the best possible alternative.”

JB: Does the worst annual level of new diagnoses since the epidemic began thirty years ago mean the AIDS Foundation is failing?

JM: No, we've still got one of the best adult HIV prevalence levels in the whole OECD, and that's a huge success story. I think we would say is that it's a sign of an ever-complex environment that we're operating in and that there are a number of drivers of that increase. At the base level is that prevalence is going to drive incidence, so the more HIV you've got in the network the more chance there will be of contracting it.

The other thing we need to be careful of is understanding the impact of testing rates and that we need to find a way through communicating that seeing a huge spike in infections could well be a success story for the NZAF and for the sector. The interesting thing there is understanding are these new diagnoses of people who've been sitting around with HIV for years and now we've found them? If it is that's a huge tick. If this is a huge spike in recent diagnoses then, yes, we've all got a problem.

JB: How do we know whether the diagnoses are recent or older infections?

JM: That's a very important piece of information and the AIDS Epidemiology Group can and does report on recent versus late diagnoses and from memory we've got a mix at the moment... we're seeing some recent infections which obviously are a great concern and we're catching some of the earlier ones which may be a result of our ramped-up testing campaigns and testing levels.

JB: The NZAF, over it's thirty years, has had a variety of cultures along the way. In the early days it was more of a risk-taker, then gradually it seemed to become more professionalised, reporting and accountability became more important, something required by the Ministry of Health. Is the NZAF now a cautious beast and if so is that good or bad?

JM: I don't know if cautions is the right word. Ultimately we're contracted by the ministry of health and the government to deliver a contract which sees us addressing preventing HIV and helping people living with HIV. Within that there are boundaries.

We're at a critical juncture of this country's response to HIV, we're seeing numbers worse than ever, we have all of the tools - and that's the irony because they are there in front of us to grab - and you have my commitment that the NZAF will not shy away from grabbing them, and that may mean taking some risks. It's our duty to do that. Of course that's in the context of a government that doesn't have HIV as a priority, doesn't have sexual health as a priority, at a time when we are about to go into negotiating a new contract with the Ministry of Health... so there are many ducks lining up to make the first months of next year very interesting.

My commitment is that we will not shy away from taking a leadership role not only in the gay community but also in the sexual health sector. But we cannot do it alone and it's going to need urgent and new political leadership and levels of collaboration and partnership that I don't think the Foundation has seen in recent times. We need to be in bed with all of the people who can get the different parts of the job done.

Jay Bennie - 29th September 2016

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