AIDS Education and Prevention, 26(3), 245–255, 2014 © 2014 The Guilford Press HETEROSEXUAL POPULATIONS IN AUSTRALIA PERSSON ET AL.
TRANSMISSION AND PREVENTION OF HIV AMONG HETEROSEXUAL POPULATIONS IN AUSTRALIA Asha Persson, Graham Brown, Ann McDonald, and Henrike Körner
In Australia, unlike much of the rest of the world, HIV transmission through heterosexual contact remains a relatively rare occurrence. In consequence, HIV-prevention efforts have been firmly focused on male-to-male sex as the most frequent source of HIV transmission. There are emerging signs that this epidemiological landscape may be shifting, which raises questions about current and future HIV prevention strategies. Over the past decade, national surveillance data have shown an increase in HIV notifications for which exposure to HIV was attributed to heterosexual contact. This paper offers an epidemiological and sociocultural picture of heterosexual HIV transmission in Australia. We outline recent trends in heterosexually acquired HIV and discuss specific factors that shape transmission and prevention among people at risk of HIV infection through heterosexual contact. To illustrate the contextual dynamics surrounding HIV in this diverse population, we detail two key examples: HIV among people from minority ethnic backgrounds in New South Wales; and overseas-acquired HIV among men in Western Australia. We argue that, despite their differences, there are significant commonalities across groups at risk of HIV infection through heterosexual contact, which not only provide opportunities for HIV prevention, but also call for a rethink of the dominant HIV response in Australia.
Since the start of the HIV epidemic in Australia, sexual contact between men has been the primary source of transmission, accounting for about two thirds of newly diagnosed HIV infections annually (Kirby Institute, 2010). In response, HIV programs have long and successfully engaged gay men as the most affected population. Heterosexual transmission of HIV remains low compared with other parts of the world, but there is an emerging trend of gradually increasing HIV notifications attributed to heterosexual contact. This trend is particularly noticeable among specific populations who have arrived from or who travel to countries with a high prevaAsha Persson is with the Centre for Social Research in Health and Ann McDonald is with The Kirby Institute, both at the University of New South Wales, Australia. Graham Brown is with the Australian Research Centre in Sex, Health and Society at La Trobe University, Australia. Henrike Körner was formerly with the Centre for Social Research in Health at the University of New South Wales, Australia. The Centre for Social Research in Health and The Kirby Institute are funded by the Australian Government, Department of Health and Ageing. The views expressed in this publication do not necessarily represent the position of the Australian Government. Address correspondence to Asha Persson, Centre for Social Research in Health, UNSW Arts and Social Sciences, University of New South Wales, Sydney NSW 2052, Australia. E-mail: [email protected]
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TABLE 1. Number of New HIV Diagnoses in Australia, 2002–2011, by Exposure Category and Year Exposure category
Year of HIV diagnosis 2002–2003
2004–2005
2006–2007
2008–2009
2010–2011
2002–2011
MSM +/– injecting drug use
1,223
1,286
1,375
1,357
1,480
6,721
Injecting drug use
48
68
54
55
44
269
Heterosexual contact
318
372
486
547
531
2254
Other/undetermined
137
149
128
99
118
631
1,726
1,875
2,043
2,058
2,173
9,875
Total
lence of HIV (Kirby Institute, 2012). This has led to calls from within sections of the Australian HIV sector for a different and broader approach to HIV prevention. In this paper, we draw on surveillance data and qualitative research to outline this emerging trend and to highlight issues that shape HIV transmission and prevention among populations at risk of HIV infection through heterosexual contact, including factors such as culture, gender, and mobility. We discuss two key populations: people from minority ethnic backgrounds in New South Wales; and men in Western Australia who have acquired HIV overseas. These examples illustrate the diversity among heterosexual communities increasingly affected by HIV, but also a common perception of being at low risk of HIV infection. This, we argue, is an unintended consequence of the dominant response to HIV in Australia to date, which thus requires critical rethinking given the rise in heterosexual transmission.
SURVEILLANCE DATA Results of national surveillance for newly diagnosed HIV infection (Guy et al., 2007; Kirby Institute, 2012) indicate that 9,875 cases of HIV infection were diagnosed in Australia over the past ten years, 2002–2011 (Table 1). The number of new HIV diagnoses increased by 26%, from 1,726 in the years 2002–2003 to 2173 in 2010– 2011. The number and proportion of new HIV diagnoses attributed to heterosexual contact increased from 318 (18.4%) in 2002–2003 to 531 (24.4%) in 2010–2011. The average annual age standardized rate of HIV diagnosis in the Australian population for which exposure to HIV was attributed to heterosexual contact increased from 0.91 in 2002–2006 to 1.21 per 100,000 in 2007–2011 (Figure 1). The rate of HIV diagnosis in the Australian-born population was stable at 0.5 throughout 2002–2011. The Australian-born population accounted for 76.7% and 73% of the total population in 2002 and 2011, respectively. People from a high HIV prevalence country and those with a partner from a high prevalence country together accounted for 53.7% of diagnoses attributed to heterosexual contact, where high prevalence, countries are those within which HIV is transmitted predominantly through heterosexual contact, with an estimated HIV prevalence of 1% or higher among adults aged 15–49 years. In 2002–2011, almost all countries in sub-Saharan Africa were classified as high prevalence. In South East Asia, Thailand, and Cambodia had an estimated prevalence above 1%, while the HIV incidence rate increased by more than 25% in Indonesia and the Philippines during the same time period (United Nations Program on HIV/AIDS [UNAIDS], 2012).
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FIGURE 1. Rate of HIV Diagnosis in Australia Among Cases Attributed to Heterosexual Contact, 2002–2011, by Country/Region of Birth.
Of the 2,254 HIV diagnoses attributed to heterosexual contact in 2002–2011, 796 (35%) were attributed to exposure in a high prevalence country. Three quarters of these diagnoses occurred among people born in countries in sub-Saharan Africa and 25% among people born in countries in South East Asia. The female to male sex ratio among those from sub-Saharan Africa and South East Asia was 1.2:1 and 5.2:1, respectively, indicating that women were diagnosed more frequently than men in Australia. The average number of new diagnoses per year in the population from subSaharan Africa almost doubled from 42 in 2002–2006 to 78 in 2007–2011, whereas the average number in the South East Asian-born population remained stable at 20 per year. The average annual rate of HIV diagnosis in the sub-Saharan population increased from 16.7 in 2002–2006 to 22.4 per 100,000 population in 2007–2011. The rate in the South East Asian population increased from 3.4 in 2002–2006 to 4.4 in 2007–2011 (Figure 1). Between 2002 and 2011, the sub-Saharan African and South East Asian-born populations in Australia increased by 77% and 43%, respectively, accounting for 1.3% and 3.6% of the Australian population in 2011 (Australian Bureau of Statistics, 2011). Of the 2,254 diagnoses attributed to heterosexual contact in 2002–2011, exposure to HIV was attributed to contact with a partner from a high prevalence country in 421 (18.7%) cases. The exposure to HIV may have occurred either in Australia or overseas, or both. Men (325) far outnumbered women (96) in this exposure category, and tended to be diagnosed in their mid-to-late 40s, compared with early 30s for women. Australian-born people accounted for the majority of cases (241, 57.2%). A partner from a high prevalence country in South East Asia was reported in 44.4% of cases, sub-Saharan Africa in 17.8%, Oceania in 5.4%, and the partner’s country of birth was not reported in 32.4%. People born in high HIV prevalence countries accounted for 13.5% (57) of the 421 cases whose exposure to HIV was attributed to heterosexual contact with
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a partner from a high prevalence country. These 57 people had evidence of HIV acquisition after having emigrated from their country of birth. The majority (54.4%) reported a partner from sub-Saharan Africa, 29.8% a partner from South East Asia, and 15.8% a partner from another or unreported region. Heterosexual contact with a partner from a high prevalence country was also reported in 123 cases from low prevalence countries in Europe (87), Asia (9), Oceania (15), and unreported countries (12). A partner from a high prevalence country in South East Asia was reported by 54.5%, sub-Saharan Africa by 15.4%, Oceania by 4.1%, and was not reported by 26%.
HIV IN MINORITY ETHNIC COMMUNITIES IN NSW As noted above, Australia has seen an upward trend of HIV notifications among people from minority ethnic backgrounds, with rates doubling over the past decade among those born in Asia and sub-Saharan Africa (Kirby Institute, 2012). A similar trend is seen among migrants and minority ethnic communities in other developed countries. Diverging from the historical pattern of the Australian epidemic, the main mode of HIV transmission in these communities tends to mirror that of the epidemics in individuals’ regions of birth, with higher proportions of heterosexual transmission of HIV (Stackpool & Luisi, 2011; McMahon, Moreton, & Luisi, 2010). In the Australian context, members of minority ethnic groups are also overrepresented among people with a late HIV diagnosis (Asante, Körner, & Kippax, 2009; Kirby Institute, 2012). New South Wales is one of Australia’s most culturally diverse states. People from minority ethnic backgrounds accounted for slightly over half of heterosexual transmissions reported in NSW in 2000–2007 (McMahon & Luisi, 2011). In 2005–2010, 26% of all HIV diagnoses in NSW were among people born in non-English speaking regions, with 17% among those born in Asia and sub-Saharan Africa (Diversity News, 2012). This trend can be attributed to a substantial increase in immigration from these two regions over the past decade. But there are additional risk contexts that contribute to the emerging HIV situation among these populations, including high rates of undiagnosed and therefore untreated HIV infections, low levels of HIV literacy, misconceptions that Australia is HIV free, and significant levels of stigma attached to HIV which prevent people from being tested, treated, or from seeking information (Gu, 2011; McMahon & Luisi, 2011). However, research has also identified more complex relationships between HIV knowledge and perceptions of risk. Recent studies in Sydney minority ethnic communities found high levels of accurate knowledge about modes of transmission and prevention. Yet, this did not necessarily translate into greater personal protection against sexual transmission of HIV. There was a considerable disconnect between knowledge as an abstract construct and knowledge as applied—or rather not applied—to people’s lives, including practices that could expose them to HIV (Asante, Körner, McMahon, Sabri, & Kippax, 2009). At the personal level, HIV risk was removed from the self; HIV was something that only happened to others (Asante & Körner, 2012). Women especially expected that being married or in a regular relationship provided protection from HIV infection (Asante, Körner, & Kippax, 2009;
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Asante, Körner, McMahon, Sabri, & Kippax, 2009; Körner, 2007a). Heterosexual men thought that certain risk practices, such as having multiple sexual partners, were not a risk as long as such practices remained within socially acceptable limits (Körner, 2007a). A similar disconnect appeared to exist between knowledge and use of preventive health care among these minority ethnic communities. One study found high levels of knowledge of health services and where to get an HIV test, as well as a common perception that regular health checks, including knowing one’s HIV status, were important. Yet, actual use of health services, including regular HIV tests, was low. There were several reasons for this. Migration and culture played a role in the sense that new experiences in the host country were interpreted in terms of past experiences in the country of origin. Many study participants came from resourcepoor countries where HIV meant social ostracism and death, which posed ongoing barriers to testing and health seeking in the new country. Furthermore, health care services in the country of birth usually had to be paid for and were used for serious illness only (Asante, Körner, & Kippax, 2009; Asante, Körner, McMahon, Sabri, & Kippax, 2009). Gender was also found to be an obstacle to using sexual health services, particularly when the identities of migrants continued to be shaped by the gender norms of their country of origin. A key issue for women was the role of male partners in controlling women’s access to health services even when a woman wanted to see a doctor of her own accord. This was particularly salient for new migrants who had little or no English and who were not familiar with the Australian health care system. However, it could also be an issue for women who had lived in Australia for a long time; a man might simply refuse to take his partner to a doctor. A further barrier for women to seek health services, especially sexual health services, was the fear of disclosure in their ethnic communities (Körner, 2007b, 2010). As these researchers observe, migration requires a considerable restructuring of life and many tasks need to be accomplished for resettlement: dealing with residency issues, learning a new language, finding work and housing, taking care of children’s education and well-being, and building new social relationships. In this scenario, health is not necessarily a top priority, especially when a health issue such as HIV is perceived to be far removed from the self. Add to this the challenges of having to navigate an unfamiliar health care system in an unfamiliar language. Research on HIV in minority ethnic communities in Australia remains limited and there have been few systematic reviews of interventions targeting these communities in high-income countries (McMahon & Ward, 2012). However, these studies from NSW suggest that knowledge about HIV and access to health services are clearly not enough for successful prevention. They also suggest that HIV health promotion messages need to be framed differently to resonate with these communities. In modern Western health care systems, individuals are expected to make decisions about their own health. Neoliberal models of health assume a rational, autonomous, and informed actor who weighs costs and benefits to maximize individual gain. But for migrants from diverse and more collectivist cultural backgrounds, health care decisions are often located in broader social and cultural contexts that encompass families and ethnic communities (Bhattacharya, 2004), and might continue to be shaped by cultural norms and gender dynamics in the country of origin (Körner, 2010).
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OVERSEAS ACQUIRED HIV AMONG MEN IN WESTERN AUSTRALIA (WA) Compared with the rest of the country, the HIV epidemic in WA is unique, in that a greater proportion of new HIV diagnoses have been attributed to heterosexual transmission for more than a decade. In 2005, for the first time in any state, the number of heterosexually-acquired infections in WA exceeded those acquired through sex between men. During the period 2006–2010, there was a significant rise in the number of men reporting heterosexually acquired HIV, the majority of whom reported being infected overseas (Department of Health Western Australia, 2010), most commonly in Thailand and Indonesia (Combs & Giele, 2009). Data show that WA residents travel far more frequently to those countries than people in other states (Australian Bureau of Statistics, 2007). This is partly due to greater proximity to those countries, but there has also been a significant rise in overseas travel for business and leisure among WA residents due to a rapidly expanding local economy driven by a resource industry boom (Brown, Ellard, Mooney-Somers, Hilderbrand, & Langdon, 2012). A proportion of this increased travel includes fly-in, fly-out (FIFO) work schedules, often used in the mining and resource industries, whereby employees are flown to WA rural, remote, or off-shore work locations for a few weeks’ work and then flown out for a similar period of time off. Employees have the option of flying home or somewhere else of similar distance for their relaxation. For workers from WA, this may mean South-East Asia, where some have also established permanent homes. Concerns about rising HIV infections among FIFO resource workers have attracted increased and sometimes sensationalist coverage in the WA and national mainstream media. There have been recent reports that doctors are seeing a spike in FIFO workers acquiring HIV and other STIs through unprotected sex in Asia and Australia during their weeks off. High levels of boredom, stress, and a disconnection from normal social restraints are purported to lead to reckless behavior among cashed-up FIFO workers (Jones, 2011a, 2011b; Rickard, 2011; Spooner, 2012). However, there is currently little research available and, therefore, the increase in overseas-acquired HIV is poorly understood. It is generally assumed that the increased risk of HIV infection is linked to FIFO workers’ use of international sex workers during their time off, as well as sex workers in rural communities where FIFO operations are located (Scott, MacPhail, & Minichiello, 2012). But there is scant evidence that FIFOs are acquiring HIV from sex workers within Australia, leading commentators to label this a classic moral panic (Cox, 2012), especially given that Australian sex workers have among the lowest rates of HIV infections among any population in the community (Donovan et al., 2012; Scott et al., 2012). In addition, it would be a mistake to frame rising rates of HIV infections in WA as an issue of FIFO per se. Rather, they are linked more broadly to the high proportion of men who travel internationally to high prevalence countries, either as part of work, for recreation, or as their adopted home. This includes a range of FIFO workers, not all employed in the resource industry, as well as expatriates and retirees who set up businesses in South-East Asia. The prosperous WA economy has increased these opportunities generally, as many people beyond the resource industry have benefitted from being in a boom state and having greater disposable income. It would also be overstating it to imply that the majority of HIV transmission overseas in these situations is occurring within sex work contexts.
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A more complex picture emerged in the only study to date on the cultural and sexual context of overseas-acquired HIV among WA men (Brown, Ellard, Prestage, & Mooney-Somers, 2010). This qualitative study included nine heterosexual and five gay men who believed they acquired HIV while traveling or working abroad, primarily in Asia. All were residents of WA prior to acquiring HIV and all had traveled overseas multiple times in recent years. In-depth interview provided insights into how these men positioned and engaged with risk within their life while traveling or living abroad. The men described themselves as experienced travelers or expatriates and sought to distinguish themselves from others who they identified as short-term or naïve tourists. In various ways, the men’s narratives invoked a concept of physical and emotional distance from Australia, including past relationships. There was often a sense of transition or in-betweenness in these accounts, such as being neither a tourist nor a local. Entry into the local culture was usually facilitated by highly influential social networks consisting of other foreign travelers and expatriates. Many men highlighted the experience of receiving or providing guidance and advice within these networks, which created a dynamic of support and camaraderie (Brown et al., 2012). In relation to their sexual experiences, the men did not see themselves as riskaverse people. For some, seeking and embracing risk was articulated as a response to a significant period of being risk-averse or being in risk-managed employment (such as a highly safety-conscious mine site). For them, HIV infection was likely to have occurred because of a change in their sexual practices as a result of being in a different cultural context, but also as a result of being in a different affective state. For others, there was little indication that they were ever particularly risk-averse. In such cases, the HIV transmission reflected a consistent behavior of noncondom use (or occasional nonuse) established in Australia, which was taking place in the context of higher prevalence of HIV in the host country (Brown et al., 2010). Related to this, it is significant to note that, compared with gay men in the study, heterosexual men were less familiar with HIV prevention campaigns, were less likely to have tested regularly for HIV, and tended to be diagnosed later after their infection (Brown et al., 2012). These overarching factors pose significant challenges to programs endeavoring to reach and engage similar men about sexual practices that place them and their sexual partners at risk. The active seeking of risk, adventure, escape, or connection may be a key element of their desire for travel, and may impact on how they understand risk, give meaning to relationships, and respond to sexual health messages. Hence, these men may require different engagement strategies to complement generalized travel safe campaigns. Engaging these men with a message to minimize all risk is likely to be ineffective. However, messages that are pitched to appeal to their desired experiences may have more resonance, such as feeling connected to the local culture, maintaining a fantasy experience, sustaining a new or adventurous life, or reinforcing their view of themselves as an experienced, knowledgeable traveler (Brown et al., 2010).
DISCUSSION AND CONCLUSION New HIV diagnoses attributed to heterosexual contact have increased in Australia, particularly among people who come from or travel to high prevalence countries.
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This trend has led to their identification as priority populations in Australia’s national HIV strategy (Commonwealth of Australia, 2010). Although these two populations tend to be differentiated, there are some overlaps in terms of the epidemiology of overseas acquired HIV. It can be difficult to separate those who were living in Australia prior to acquiring HIV overseas and those who have traveled from overseas to Australia for the first time (as migrants or on temporary work visas) and had likely acquired HIV prior to arrival (whether or not diagnosed). We have discussed these two populations separately here to highlight some of the specific factors that shape HIV transmission and prevention among heterosexuals in different communities and settings. However, there are some significant commonalities that also need to be emphasized, such as migration, but also the influence of social networks and cultural contexts. One key issue that cuts across both populations is that, whatever their personal approach to risk, heterosexuals tend to perceive themselves as being at low risk of HIV infection. This is born out by low rates of condom use and HIV testing among heterosexuals (Adam et al., 2011; de Visser, Smith, Rissel, Richters, & Grulich 2003; Grulich, de Visser, Smith, Risse, & Richters, 2003) and by high rates of late diagnoses among people who acquired HIV through heterosexual contact, regardless of background or context (Kirby Institute, 2012). One explanation for this is the particular history of the HIV response in Australia. Given that HIV transmission has occurred predominantly through sexual contact between men since the start of the epidemic, HIV prevention and education strategies have long and rightly been shaped around gay men as the most affected population. There have been very few HIV-specific awareness campaigns aimed at the general public, and no national ones since 1988 (Newman & Persson, 2009). HIV programs for the general community have been subsumed within broader prevention campaigns where the focus is largely on other STIs, given the significantly higher prevalence of STIs among heterosexuals compared with HIV, but these campaigns have been targeted primarily at young people (Commonwealth of Australia, 2010). One unintended consequence of this is that HIV has become culturally coded and socially invisibilized in heterosexual society as a disease that mainly affects gay men, whilst heterosexuality has become inscribed as safe and as exempt from risk (Persson & Newman, 2008). The scant research available on HIV-positive heterosexuals in Australia shows that they were largely oblivious to HIV prior to their diagnosis, or else did not consider HIV as personally relevant and, therefore, HIV rarely figured as a concern in their sexual practices (Down et al., 2012; Persson, Barton, & Richards, 2006). From a public health perspective, it would be costly and unwarranted to implement HIV testing and prevention campaigns aimed at the heterosexual population in general. There is no evidence of an emerging generalized heterosexual epidemic. However, as we have outlined, there is an emerging concentrated epidemic among heterosexual subpopulations, alongside the concentrated epidemic among gay men. Thus, the question needs to be asked whether we can afford to continue to conduct business as usual in the face of this diverging epidemic. There have been significant shifts in both immigration and migration patterns since HIV first emerged. This includes a greater intake of immigrants from high prevalence countries, as well as unprecedented mobility among the population as a whole, which focuses attention on travel to and from high prevalence countries in particular “as a potential driver of HIV transmission” (McMahon, Moreton, & Luisi, 2010, p. 84)
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These changes in migration patterns and in populations affected by HIV pose major challenges for public health policy and practice, but they also “provide the impetus for re-orienting approaches to prevention, treatment, and care to better meet the needs of emerging communities” (Stackpool & Luisi, 2011). The successful community-driven response to HIV among gay men is not readily transferable to heterosexual populations at risk of HIV, due to their diversity and different cultural engagement with the epidemic. However, although these populations are diverse, they are also relatively distinct, which creates opportunities for more targeted HIV prevention strategies that could combine information provision and social marketing with the fostering of peer-based initiatives among overseas travelers, FIFOs, and minority ethnic communities. For example, in relation to overseas-acquired HIV, Brown and colleagues (2012, p. 686) suggest that, “interventions that engage with and utilize frequent traveler and expatriate social networks may be effective in reaching this target group.” Rather than relying solely on ad hoc provision of information to travellers, these networks are likely to facilitate more direct avenues for communication given their apparent centrality. But for this kind of peer intervention model to work optimally, it is critical to understand how these networks operate, both in term of patterns of influence and belonging, as well as sexual behavior and assumptions about HIV and risk (Brown et al., 2012). Likewise in relation to minority ethnic communities, where it is imperative to better understand the complex nature of HIV stigma and its implications for peer-based initiatives. More broadly, better support for immigrants seems key, especially strategies to help women make the transition to full citizenship in their new home. In addition to expanding targeted strategies, advocates in the multicultural HIV sector have called for a new framework to respond to the shifting epidemiological landscape, one based on cultural competence. This would include the development of capacities and skills to work with Australia’s diversity to ensure “equitable access to services and ultimately better health outcomes, regardless of cultural background” (Stackpool & Luisi, 2011). Such a framework requires support and commitment at systemic and organization levels, and the will of the HIV sector as a whole to engage with and hold the increasing complexity of the epidemic. In part, it also requires, as McMahon and Luisi (2011, p. 13) argue, that we “challenge the dominant paradigm of how the HIV response has been stratified and targeted in Australia to date.”
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Persson, A., & Newman, C. (2008). Making monsters: Heterosexuality, crime and race in recent Western media coverage of HIV. Sociology of Health and Illness, 30, 632–646. Persson, A., Barton, D., & Richards, W. (2006). Men and women living heterosexually with HIV: The Straightpoz Study, volume 1. Monograph 2/2006 Sydney, Australia: National Centre in HIV Social Research, the University of New South Wales. Retrieved February 10, 2103, from http://nchsr.arts. unsw.edu.au/pdf%20reports/Straightpoz. pdf Rickard, J. (2011, September 9). HIV spike among mine workers. The West Australian. Scott, J., MacPhail, C., & Minichiello, V. (2012). Bang and bust: Almost everything you wanted to know about sex and the mining boom (but were afraid to ask). Preview, 160, 26–31. Spooner, R. (2012, April 17). STIs spreading, doctors forced out: AMA warning to FIFO inquiry. WAToday.com.au. Stackpool, G., & Luisi, B. (2011). Building the capacity of the HIV sector in Australia: Taking a culturally competent approach. HIV Australia, 9, 17–19. United Nations Program on HIV/AIDS. (2012). Report of the global AIDS epidemic 2012. Geneva, Switzerland: Joint United Nations Programme on HIV/AIDS. Retrieved July 20, 2013, from http://www.unaids.org/en/ media/unaids/contentassets/documents/epidemiology/2012/gr2012/20121120_UNAIDS_Global_Report_2012_en.pdf
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TRANSMISSION AND PREVENTION OF HIV AMONG HETEROSEXUAL POPULATIONS IN AUSTRALIA Asha Persson, Graham Brown, Ann McDonald, and Henrike Körner
In Australia, unlike much of the rest of the world, HIV transmission through heterosexual contact remains a relatively rare occurrence. In consequence, HIV-prevention efforts have been firmly focused on male-to-male sex as the most frequent source of HIV transmission. There are emerging signs that this epidemiological landscape may be shifting, which raises questions about current and future HIV prevention strategies. Over the past decade, national surveillance data have shown an increase in HIV notifications for which exposure to HIV was attributed to heterosexual contact. This paper offers an epidemiological and sociocultural picture of heterosexual HIV transmission in Australia. We outline recent trends in heterosexually acquired HIV and discuss specific factors that shape transmission and prevention among people at risk of HIV infection through heterosexual contact. To illustrate the contextual dynamics surrounding HIV in this diverse population, we detail two key examples: HIV among people from minority ethnic backgrounds in New South Wales; and overseas-acquired HIV among men in Western Australia. We argue that, despite their differences, there are significant commonalities across groups at risk of HIV infection through heterosexual contact, which not only provide opportunities for HIV prevention, but also call for a rethink of the dominant HIV response in Australia.
Since the start of the HIV epidemic in Australia, sexual contact between men has been the primary source of transmission, accounting for about two thirds of newly diagnosed HIV infections annually (Kirby Institute, 2010). In response, HIV programs have long and successfully engaged gay men as the most affected population. Heterosexual transmission of HIV remains low compared with other parts of the world, but there is an emerging trend of gradually increasing HIV notifications attributed to heterosexual contact. This trend is particularly noticeable among specific populations who have arrived from or who travel to countries with a high prevaAsha Persson is with the Centre for Social Research in Health and Ann McDonald is with The Kirby Institute, both at the University of New South Wales, Australia. Graham Brown is with the Australian Research Centre in Sex, Health and Society at La Trobe University, Australia. Henrike Körner was formerly with the Centre for Social Research in Health at the University of New South Wales, Australia. The Centre for Social Research in Health and The Kirby Institute are funded by the Australian Government, Department of Health and Ageing. The views expressed in this publication do not necessarily represent the position of the Australian Government. Address correspondence to Asha Persson, Centre for Social Research in Health, UNSW Arts and Social Sciences, University of New South Wales, Sydney NSW 2052, Australia. E-mail: [email protected]
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TABLE 1. Number of New HIV Diagnoses in Australia, 2002–2011, by Exposure Category and Year Exposure category
Year of HIV diagnosis 2002–2003
2004–2005
2006–2007
2008–2009
2010–2011
2002–2011
MSM +/– injecting drug use
1,223
1,286
1,375
1,357
1,480
6,721
Injecting drug use
48
68
54
55
44
269
Heterosexual contact
318
372
486
547
531
2254
Other/undetermined
137
149
128
99
118
631
1,726
1,875
2,043
2,058
2,173
9,875
Total
lence of HIV (Kirby Institute, 2012). This has led to calls from within sections of the Australian HIV sector for a different and broader approach to HIV prevention. In this paper, we draw on surveillance data and qualitative research to outline this emerging trend and to highlight issues that shape HIV transmission and prevention among populations at risk of HIV infection through heterosexual contact, including factors such as culture, gender, and mobility. We discuss two key populations: people from minority ethnic backgrounds in New South Wales; and men in Western Australia who have acquired HIV overseas. These examples illustrate the diversity among heterosexual communities increasingly affected by HIV, but also a common perception of being at low risk of HIV infection. This, we argue, is an unintended consequence of the dominant response to HIV in Australia to date, which thus requires critical rethinking given the rise in heterosexual transmission.
SURVEILLANCE DATA Results of national surveillance for newly diagnosed HIV infection (Guy et al., 2007; Kirby Institute, 2012) indicate that 9,875 cases of HIV infection were diagnosed in Australia over the past ten years, 2002–2011 (Table 1). The number of new HIV diagnoses increased by 26%, from 1,726 in the years 2002–2003 to 2173 in 2010– 2011. The number and proportion of new HIV diagnoses attributed to heterosexual contact increased from 318 (18.4%) in 2002–2003 to 531 (24.4%) in 2010–2011. The average annual age standardized rate of HIV diagnosis in the Australian population for which exposure to HIV was attributed to heterosexual contact increased from 0.91 in 2002–2006 to 1.21 per 100,000 in 2007–2011 (Figure 1). The rate of HIV diagnosis in the Australian-born population was stable at 0.5 throughout 2002–2011. The Australian-born population accounted for 76.7% and 73% of the total population in 2002 and 2011, respectively. People from a high HIV prevalence country and those with a partner from a high prevalence country together accounted for 53.7% of diagnoses attributed to heterosexual contact, where high prevalence, countries are those within which HIV is transmitted predominantly through heterosexual contact, with an estimated HIV prevalence of 1% or higher among adults aged 15–49 years. In 2002–2011, almost all countries in sub-Saharan Africa were classified as high prevalence. In South East Asia, Thailand, and Cambodia had an estimated prevalence above 1%, while the HIV incidence rate increased by more than 25% in Indonesia and the Philippines during the same time period (United Nations Program on HIV/AIDS [UNAIDS], 2012).
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FIGURE 1. Rate of HIV Diagnosis in Australia Among Cases Attributed to Heterosexual Contact, 2002–2011, by Country/Region of Birth.
Of the 2,254 HIV diagnoses attributed to heterosexual contact in 2002–2011, 796 (35%) were attributed to exposure in a high prevalence country. Three quarters of these diagnoses occurred among people born in countries in sub-Saharan Africa and 25% among people born in countries in South East Asia. The female to male sex ratio among those from sub-Saharan Africa and South East Asia was 1.2:1 and 5.2:1, respectively, indicating that women were diagnosed more frequently than men in Australia. The average number of new diagnoses per year in the population from subSaharan Africa almost doubled from 42 in 2002–2006 to 78 in 2007–2011, whereas the average number in the South East Asian-born population remained stable at 20 per year. The average annual rate of HIV diagnosis in the sub-Saharan population increased from 16.7 in 2002–2006 to 22.4 per 100,000 population in 2007–2011. The rate in the South East Asian population increased from 3.4 in 2002–2006 to 4.4 in 2007–2011 (Figure 1). Between 2002 and 2011, the sub-Saharan African and South East Asian-born populations in Australia increased by 77% and 43%, respectively, accounting for 1.3% and 3.6% of the Australian population in 2011 (Australian Bureau of Statistics, 2011). Of the 2,254 diagnoses attributed to heterosexual contact in 2002–2011, exposure to HIV was attributed to contact with a partner from a high prevalence country in 421 (18.7%) cases. The exposure to HIV may have occurred either in Australia or overseas, or both. Men (325) far outnumbered women (96) in this exposure category, and tended to be diagnosed in their mid-to-late 40s, compared with early 30s for women. Australian-born people accounted for the majority of cases (241, 57.2%). A partner from a high prevalence country in South East Asia was reported in 44.4% of cases, sub-Saharan Africa in 17.8%, Oceania in 5.4%, and the partner’s country of birth was not reported in 32.4%. People born in high HIV prevalence countries accounted for 13.5% (57) of the 421 cases whose exposure to HIV was attributed to heterosexual contact with
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a partner from a high prevalence country. These 57 people had evidence of HIV acquisition after having emigrated from their country of birth. The majority (54.4%) reported a partner from sub-Saharan Africa, 29.8% a partner from South East Asia, and 15.8% a partner from another or unreported region. Heterosexual contact with a partner from a high prevalence country was also reported in 123 cases from low prevalence countries in Europe (87), Asia (9), Oceania (15), and unreported countries (12). A partner from a high prevalence country in South East Asia was reported by 54.5%, sub-Saharan Africa by 15.4%, Oceania by 4.1%, and was not reported by 26%.
HIV IN MINORITY ETHNIC COMMUNITIES IN NSW As noted above, Australia has seen an upward trend of HIV notifications among people from minority ethnic backgrounds, with rates doubling over the past decade among those born in Asia and sub-Saharan Africa (Kirby Institute, 2012). A similar trend is seen among migrants and minority ethnic communities in other developed countries. Diverging from the historical pattern of the Australian epidemic, the main mode of HIV transmission in these communities tends to mirror that of the epidemics in individuals’ regions of birth, with higher proportions of heterosexual transmission of HIV (Stackpool & Luisi, 2011; McMahon, Moreton, & Luisi, 2010). In the Australian context, members of minority ethnic groups are also overrepresented among people with a late HIV diagnosis (Asante, Körner, & Kippax, 2009; Kirby Institute, 2012). New South Wales is one of Australia’s most culturally diverse states. People from minority ethnic backgrounds accounted for slightly over half of heterosexual transmissions reported in NSW in 2000–2007 (McMahon & Luisi, 2011). In 2005–2010, 26% of all HIV diagnoses in NSW were among people born in non-English speaking regions, with 17% among those born in Asia and sub-Saharan Africa (Diversity News, 2012). This trend can be attributed to a substantial increase in immigration from these two regions over the past decade. But there are additional risk contexts that contribute to the emerging HIV situation among these populations, including high rates of undiagnosed and therefore untreated HIV infections, low levels of HIV literacy, misconceptions that Australia is HIV free, and significant levels of stigma attached to HIV which prevent people from being tested, treated, or from seeking information (Gu, 2011; McMahon & Luisi, 2011). However, research has also identified more complex relationships between HIV knowledge and perceptions of risk. Recent studies in Sydney minority ethnic communities found high levels of accurate knowledge about modes of transmission and prevention. Yet, this did not necessarily translate into greater personal protection against sexual transmission of HIV. There was a considerable disconnect between knowledge as an abstract construct and knowledge as applied—or rather not applied—to people’s lives, including practices that could expose them to HIV (Asante, Körner, McMahon, Sabri, & Kippax, 2009). At the personal level, HIV risk was removed from the self; HIV was something that only happened to others (Asante & Körner, 2012). Women especially expected that being married or in a regular relationship provided protection from HIV infection (Asante, Körner, & Kippax, 2009;
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Asante, Körner, McMahon, Sabri, & Kippax, 2009; Körner, 2007a). Heterosexual men thought that certain risk practices, such as having multiple sexual partners, were not a risk as long as such practices remained within socially acceptable limits (Körner, 2007a). A similar disconnect appeared to exist between knowledge and use of preventive health care among these minority ethnic communities. One study found high levels of knowledge of health services and where to get an HIV test, as well as a common perception that regular health checks, including knowing one’s HIV status, were important. Yet, actual use of health services, including regular HIV tests, was low. There were several reasons for this. Migration and culture played a role in the sense that new experiences in the host country were interpreted in terms of past experiences in the country of origin. Many study participants came from resourcepoor countries where HIV meant social ostracism and death, which posed ongoing barriers to testing and health seeking in the new country. Furthermore, health care services in the country of birth usually had to be paid for and were used for serious illness only (Asante, Körner, & Kippax, 2009; Asante, Körner, McMahon, Sabri, & Kippax, 2009). Gender was also found to be an obstacle to using sexual health services, particularly when the identities of migrants continued to be shaped by the gender norms of their country of origin. A key issue for women was the role of male partners in controlling women’s access to health services even when a woman wanted to see a doctor of her own accord. This was particularly salient for new migrants who had little or no English and who were not familiar with the Australian health care system. However, it could also be an issue for women who had lived in Australia for a long time; a man might simply refuse to take his partner to a doctor. A further barrier for women to seek health services, especially sexual health services, was the fear of disclosure in their ethnic communities (Körner, 2007b, 2010). As these researchers observe, migration requires a considerable restructuring of life and many tasks need to be accomplished for resettlement: dealing with residency issues, learning a new language, finding work and housing, taking care of children’s education and well-being, and building new social relationships. In this scenario, health is not necessarily a top priority, especially when a health issue such as HIV is perceived to be far removed from the self. Add to this the challenges of having to navigate an unfamiliar health care system in an unfamiliar language. Research on HIV in minority ethnic communities in Australia remains limited and there have been few systematic reviews of interventions targeting these communities in high-income countries (McMahon & Ward, 2012). However, these studies from NSW suggest that knowledge about HIV and access to health services are clearly not enough for successful prevention. They also suggest that HIV health promotion messages need to be framed differently to resonate with these communities. In modern Western health care systems, individuals are expected to make decisions about their own health. Neoliberal models of health assume a rational, autonomous, and informed actor who weighs costs and benefits to maximize individual gain. But for migrants from diverse and more collectivist cultural backgrounds, health care decisions are often located in broader social and cultural contexts that encompass families and ethnic communities (Bhattacharya, 2004), and might continue to be shaped by cultural norms and gender dynamics in the country of origin (Körner, 2010).
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OVERSEAS ACQUIRED HIV AMONG MEN IN WESTERN AUSTRALIA (WA) Compared with the rest of the country, the HIV epidemic in WA is unique, in that a greater proportion of new HIV diagnoses have been attributed to heterosexual transmission for more than a decade. In 2005, for the first time in any state, the number of heterosexually-acquired infections in WA exceeded those acquired through sex between men. During the period 2006–2010, there was a significant rise in the number of men reporting heterosexually acquired HIV, the majority of whom reported being infected overseas (Department of Health Western Australia, 2010), most commonly in Thailand and Indonesia (Combs & Giele, 2009). Data show that WA residents travel far more frequently to those countries than people in other states (Australian Bureau of Statistics, 2007). This is partly due to greater proximity to those countries, but there has also been a significant rise in overseas travel for business and leisure among WA residents due to a rapidly expanding local economy driven by a resource industry boom (Brown, Ellard, Mooney-Somers, Hilderbrand, & Langdon, 2012). A proportion of this increased travel includes fly-in, fly-out (FIFO) work schedules, often used in the mining and resource industries, whereby employees are flown to WA rural, remote, or off-shore work locations for a few weeks’ work and then flown out for a similar period of time off. Employees have the option of flying home or somewhere else of similar distance for their relaxation. For workers from WA, this may mean South-East Asia, where some have also established permanent homes. Concerns about rising HIV infections among FIFO resource workers have attracted increased and sometimes sensationalist coverage in the WA and national mainstream media. There have been recent reports that doctors are seeing a spike in FIFO workers acquiring HIV and other STIs through unprotected sex in Asia and Australia during their weeks off. High levels of boredom, stress, and a disconnection from normal social restraints are purported to lead to reckless behavior among cashed-up FIFO workers (Jones, 2011a, 2011b; Rickard, 2011; Spooner, 2012). However, there is currently little research available and, therefore, the increase in overseas-acquired HIV is poorly understood. It is generally assumed that the increased risk of HIV infection is linked to FIFO workers’ use of international sex workers during their time off, as well as sex workers in rural communities where FIFO operations are located (Scott, MacPhail, & Minichiello, 2012). But there is scant evidence that FIFOs are acquiring HIV from sex workers within Australia, leading commentators to label this a classic moral panic (Cox, 2012), especially given that Australian sex workers have among the lowest rates of HIV infections among any population in the community (Donovan et al., 2012; Scott et al., 2012). In addition, it would be a mistake to frame rising rates of HIV infections in WA as an issue of FIFO per se. Rather, they are linked more broadly to the high proportion of men who travel internationally to high prevalence countries, either as part of work, for recreation, or as their adopted home. This includes a range of FIFO workers, not all employed in the resource industry, as well as expatriates and retirees who set up businesses in South-East Asia. The prosperous WA economy has increased these opportunities generally, as many people beyond the resource industry have benefitted from being in a boom state and having greater disposable income. It would also be overstating it to imply that the majority of HIV transmission overseas in these situations is occurring within sex work contexts.
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A more complex picture emerged in the only study to date on the cultural and sexual context of overseas-acquired HIV among WA men (Brown, Ellard, Prestage, & Mooney-Somers, 2010). This qualitative study included nine heterosexual and five gay men who believed they acquired HIV while traveling or working abroad, primarily in Asia. All were residents of WA prior to acquiring HIV and all had traveled overseas multiple times in recent years. In-depth interview provided insights into how these men positioned and engaged with risk within their life while traveling or living abroad. The men described themselves as experienced travelers or expatriates and sought to distinguish themselves from others who they identified as short-term or naïve tourists. In various ways, the men’s narratives invoked a concept of physical and emotional distance from Australia, including past relationships. There was often a sense of transition or in-betweenness in these accounts, such as being neither a tourist nor a local. Entry into the local culture was usually facilitated by highly influential social networks consisting of other foreign travelers and expatriates. Many men highlighted the experience of receiving or providing guidance and advice within these networks, which created a dynamic of support and camaraderie (Brown et al., 2012). In relation to their sexual experiences, the men did not see themselves as riskaverse people. For some, seeking and embracing risk was articulated as a response to a significant period of being risk-averse or being in risk-managed employment (such as a highly safety-conscious mine site). For them, HIV infection was likely to have occurred because of a change in their sexual practices as a result of being in a different cultural context, but also as a result of being in a different affective state. For others, there was little indication that they were ever particularly risk-averse. In such cases, the HIV transmission reflected a consistent behavior of noncondom use (or occasional nonuse) established in Australia, which was taking place in the context of higher prevalence of HIV in the host country (Brown et al., 2010). Related to this, it is significant to note that, compared with gay men in the study, heterosexual men were less familiar with HIV prevention campaigns, were less likely to have tested regularly for HIV, and tended to be diagnosed later after their infection (Brown et al., 2012). These overarching factors pose significant challenges to programs endeavoring to reach and engage similar men about sexual practices that place them and their sexual partners at risk. The active seeking of risk, adventure, escape, or connection may be a key element of their desire for travel, and may impact on how they understand risk, give meaning to relationships, and respond to sexual health messages. Hence, these men may require different engagement strategies to complement generalized travel safe campaigns. Engaging these men with a message to minimize all risk is likely to be ineffective. However, messages that are pitched to appeal to their desired experiences may have more resonance, such as feeling connected to the local culture, maintaining a fantasy experience, sustaining a new or adventurous life, or reinforcing their view of themselves as an experienced, knowledgeable traveler (Brown et al., 2010).
DISCUSSION AND CONCLUSION New HIV diagnoses attributed to heterosexual contact have increased in Australia, particularly among people who come from or travel to high prevalence countries.
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This trend has led to their identification as priority populations in Australia’s national HIV strategy (Commonwealth of Australia, 2010). Although these two populations tend to be differentiated, there are some overlaps in terms of the epidemiology of overseas acquired HIV. It can be difficult to separate those who were living in Australia prior to acquiring HIV overseas and those who have traveled from overseas to Australia for the first time (as migrants or on temporary work visas) and had likely acquired HIV prior to arrival (whether or not diagnosed). We have discussed these two populations separately here to highlight some of the specific factors that shape HIV transmission and prevention among heterosexuals in different communities and settings. However, there are some significant commonalities that also need to be emphasized, such as migration, but also the influence of social networks and cultural contexts. One key issue that cuts across both populations is that, whatever their personal approach to risk, heterosexuals tend to perceive themselves as being at low risk of HIV infection. This is born out by low rates of condom use and HIV testing among heterosexuals (Adam et al., 2011; de Visser, Smith, Rissel, Richters, & Grulich 2003; Grulich, de Visser, Smith, Risse, & Richters, 2003) and by high rates of late diagnoses among people who acquired HIV through heterosexual contact, regardless of background or context (Kirby Institute, 2012). One explanation for this is the particular history of the HIV response in Australia. Given that HIV transmission has occurred predominantly through sexual contact between men since the start of the epidemic, HIV prevention and education strategies have long and rightly been shaped around gay men as the most affected population. There have been very few HIV-specific awareness campaigns aimed at the general public, and no national ones since 1988 (Newman & Persson, 2009). HIV programs for the general community have been subsumed within broader prevention campaigns where the focus is largely on other STIs, given the significantly higher prevalence of STIs among heterosexuals compared with HIV, but these campaigns have been targeted primarily at young people (Commonwealth of Australia, 2010). One unintended consequence of this is that HIV has become culturally coded and socially invisibilized in heterosexual society as a disease that mainly affects gay men, whilst heterosexuality has become inscribed as safe and as exempt from risk (Persson & Newman, 2008). The scant research available on HIV-positive heterosexuals in Australia shows that they were largely oblivious to HIV prior to their diagnosis, or else did not consider HIV as personally relevant and, therefore, HIV rarely figured as a concern in their sexual practices (Down et al., 2012; Persson, Barton, & Richards, 2006). From a public health perspective, it would be costly and unwarranted to implement HIV testing and prevention campaigns aimed at the heterosexual population in general. There is no evidence of an emerging generalized heterosexual epidemic. However, as we have outlined, there is an emerging concentrated epidemic among heterosexual subpopulations, alongside the concentrated epidemic among gay men. Thus, the question needs to be asked whether we can afford to continue to conduct business as usual in the face of this diverging epidemic. There have been significant shifts in both immigration and migration patterns since HIV first emerged. This includes a greater intake of immigrants from high prevalence countries, as well as unprecedented mobility among the population as a whole, which focuses attention on travel to and from high prevalence countries in particular “as a potential driver of HIV transmission” (McMahon, Moreton, & Luisi, 2010, p. 84)
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These changes in migration patterns and in populations affected by HIV pose major challenges for public health policy and practice, but they also “provide the impetus for re-orienting approaches to prevention, treatment, and care to better meet the needs of emerging communities” (Stackpool & Luisi, 2011). The successful community-driven response to HIV among gay men is not readily transferable to heterosexual populations at risk of HIV, due to their diversity and different cultural engagement with the epidemic. However, although these populations are diverse, they are also relatively distinct, which creates opportunities for more targeted HIV prevention strategies that could combine information provision and social marketing with the fostering of peer-based initiatives among overseas travelers, FIFOs, and minority ethnic communities. For example, in relation to overseas-acquired HIV, Brown and colleagues (2012, p. 686) suggest that, “interventions that engage with and utilize frequent traveler and expatriate social networks may be effective in reaching this target group.” Rather than relying solely on ad hoc provision of information to travellers, these networks are likely to facilitate more direct avenues for communication given their apparent centrality. But for this kind of peer intervention model to work optimally, it is critical to understand how these networks operate, both in term of patterns of influence and belonging, as well as sexual behavior and assumptions about HIV and risk (Brown et al., 2012). Likewise in relation to minority ethnic communities, where it is imperative to better understand the complex nature of HIV stigma and its implications for peer-based initiatives. More broadly, better support for immigrants seems key, especially strategies to help women make the transition to full citizenship in their new home. In addition to expanding targeted strategies, advocates in the multicultural HIV sector have called for a new framework to respond to the shifting epidemiological landscape, one based on cultural competence. This would include the development of capacities and skills to work with Australia’s diversity to ensure “equitable access to services and ultimately better health outcomes, regardless of cultural background” (Stackpool & Luisi, 2011). Such a framework requires support and commitment at systemic and organization levels, and the will of the HIV sector as a whole to engage with and hold the increasing complexity of the epidemic. In part, it also requires, as McMahon and Luisi (2011, p. 13) argue, that we “challenge the dominant paradigm of how the HIV response has been stratified and targeted in Australia to date.”
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