Centre for Primary Health Care and Equity

Centre for Primary Health Care and Equity

Meeting Australia’s targets for HIV prevention and treatment – implications for health promotion in the new era

Congratulations

To you and all those who have preceded you and collaborated with you since the beginning of the epidemic:

• you’ve built a system that is recognised internationally for its success in

• containing the HIV/AIDS epidemic – preventing deaths

• preventing the spread of HIV – preventing infection

• enabling people living with HIV to enjoy good health and live full lives –

delivering treatment, care and promoting health and reducing harm

you’ve pushed back stigma and social exclusion

• strengthening and expanding the social movement that has resulted in such profound changes in the rights, opportunities and quality of life of so many men (and women);

• and through your work you’ve changed society – environments,

norms and policies, knowledge and attitudes; and individuals.

What worked?

• Quick action by the affected community and a political leader

• Political and policy support over time

• High level of population-wide concern

• Sustained action by the communities, civil society, health sector, governments, NGOs, private sector

multiple responses

• information (including anecdote) • to identify patterns of infection, illness, and death;• to identify causes/determinants of these;• and to identify, implement, evaluate effective responses

• community building – recognition, respect, autonomy • education • mobilisation• advocacy• partnerships

and

• building the organisational capacity to design and deliver policies,

services, programs – within the gay community, in civil society and

governments, and in the health sector – hospitals, general practice,

palliative care, etc.

and

• building the workforce capacity – multiple workforces

actions were taken by

• Politicians

• Policy makers

• Community activists, volunteers, members

• NGOs

• Researchers

• Health service managers and health professionals

• Health promotion professionals and volunteers

• Police

• Professional associations

• Unions

• Owners/managers of sex premises

• Teachers

• Media

• Advertising agencies

• Pharmaceutical companies and retailers

• Volunteers

what changed?

• Personal knowledge, attitudes, skills

• Health and other social services

• Public policy

• Environments

• Communities

the context in 2012

• Self-determining social movement – social inclusion – slow but significant progress

• Policy advocates and policy makers within as well as outside the health system

• Health care system testing, diagnosing, treating, and providing ongoing care is no longer concentrated in a few institutions and is now available more broadly

and

• health promotion interventions have been targeted – narrowly focused on specific groups identified as ‘at elevated risk’ and to MSM

• policy and legislative frameworks broadly supportive

• research institutions, researchers, and evidence available

• reduction (although not elimination) of stigma attached to HIV and living with HIV

HIV in 2012

• rising rates of infection among MSM in some settings – a phenomenon shared among developed nations (except San Francisco)

• new population groups at high risk

• declining rates of testing

• increased rates of unprotected anal intercourse

and

• new evidence about preventing and treating HIV

• new treatments

• levels of knowledge about consistent, correct condom use, safe injecting practices, harm reduction, transmission risk and minimisation vary among population groups

• levels of testing among at risk populations are lower than optimum

• insufficient availability of rapid testing services and accessibility a problem

as well

• the system for dispensing pharmaceutical treatments is clumsy

• cost of treatment is a barrier for some

the questions now

• Is the system that’s in place the one that is needed to meet these new challenges?

• Does the system ‘fit’ the challenges?

• sustain virtual elimination of HIV transmission among sex workers and clients

• sustain virtual elimination of mother to child transmission of HIV

• increase HIV positive people on antiretroviral treatment in Australia from 70% to 90% by 2013

targets : what gets measured gets done

targets are:• public statements of aspiration • indicators to measure outcomes (national) resulting from investment

targets are not program goals

and achieving them will require action across all the sectors and agencies and people using the whole range of interventions available – including (but not only) health promotion

how does health promotion contribute?

health promotion is a method and a process

1. What is the problem?

2. What is causing or determining it?• predisposing – knowledge, attitudes, skills, confidence…• enabling – services, policies, environments, …• reinforcing – social norms

3. Who is affected – at all and most? Who has a role in acting to prevent infection, to diagnose and treat infection, to treat and care for PLHIV, and to reduce harm?

4. What needs to change? Who and/or what organisation is responsible for bringing about the change?

5. What evidence is there that it is feasible to bring about the changes?

6. What are priorities for action – given the level of resources available (or likely to be available)?

7. what are the most appropriate strategies (given the organisational and workforce capacity available)?

8. who is responsible for taking action?

9. what actions are taken?

10. what is achieved – immediately and over time?

what is the problem?

• Increasing incidence - new infections among MSM?• Increasing incidence – new infections among women?

• Increasing prevalence – growing number of people living with HIV – MSM and some immigrant populations from high prevalence countries?

• Inequitable distribution of new infections? • Inequitable distribution of life expectancy and quality of life among people

living with HIV?

we have a strong system - what has changed in the patterns of incidence?

• risk populations?

• the distribution of new cases?

• the distribution of PLHIV?

• the distribution of at risk populations?

among at risk populations

• knowledge, attitudes

• behaviours

• connection with community – social movement

• exposure to risk

• exposure to information, testing, diagnosis, treatment

• social, economic status and associated norms

in health care and health promotion services

• the distribution, quality, and reach of the testing, diagnostic, and treatment services?

• the distribution, quality, and reach of services providing information, support, education, care?

• the workforce(s) providing health care and health promotion and their locations vis a vis the populations in need?

• means of communication - of providing information and education?

political and social support

• political and policy leadership and support?

• community connectedness within gay communities?

• community connectedness within other ‘at risk’ communities?

• recognition by and connectedness with wider population?

technical leadership and support

• strategic direction, and investment?

• research?

what does this mean for responses?

• what and who need to change?

• what new actions need to be implemented;

• what existing components of the system need to retained and expanded;

• who is responsible?

• how will change be led, managed, evaluated?

what will it mean for the targets?

• review, reflection, analysis to build the logic framework describing the pathway from problems, planned and implemented actions, and the targets;

• create map of the cumulative effects of multiple actions by multiple sectors and systems and professionals and people;

• monitor the actions taken;

• changes measured across the logic framework that will, cumulatively, lead to achieving the targets.

as well, the new era points to the need to:

• highlight autonomy and social and political inclusion as independent contributors to reduced risk and harm – respect, esteem, confidence;

• and to build and sustain social connectedness;

• sustain internal and external policy influence;

• review distribution, reach, quality and impact of health care and health promotion services/programs/interventions and change as needed;

and

• reconsider why populations are ‘at risk’ – is it possible to work further upstream to reduce risk?

• are there opportunities to change the environments and psychosocial conditions within which populations are making decisions about health, including HIV?

and

• use the diffusion of innovations curve to highlight more intensive and comprehensive interventions for people who have fewer social resources;

• work with partner organisations – reach, range of services to include access to social determinants of health, and support, share knowledge and experience to reach new populations

• review organisational capacity – ? need for change in distribution of investment across portfolios within the sector; review distribution of services; use of communication technology

• review workforce capacity – roles, knowledge, skills, distribution

the system has evolved from

• responding to a crisis

• to building specialist research, health care, and social systems and a strong social movement

• to normalising responses, making them universally available and accessible

but what else is needed?

• has anything been lost from the past that is needed now?

• what new is needed for the future if the goal and targets are to be achieved in Australia and globally?