Dr Julian Gold
Director of the Albion Street Centre (Sydney AIDS Clinic)
Conference Paper: AIDS – Have we got it Right?
A conference organised by The Australian Doctors Fund Ltd.
Hosted by Professor Fred Hollows & ADF Chairman Dr. Bruce Shepherd
Sheraton Sydney Airport Hilton
May 14th and 15th, 1992
Thank you very much for inviting me to speak on the topic AIDS; Have We Got It Right. As we begin the second decade of this epidemic in Australia, I believe that we should be forward looking and asking the more important question how can we do better. This questioning is in no way meant to denigrate any of our national achievement so far. However, is our responsibility to search for the gaps in our knowledge and understanding and to constantly question any complacency that may arise from a belief that suggests we are doing enough, and that unlike any other country in the world, we alone have got it right and the spread of HIV is under control.
Tonight I would like to address several areas of the AIDS situation and I will divide them into four categories. First, three good things we have done. Second, three reasons why the situation could get worse. Third, a reason for caution in interpreting data about the status of AIDS in Australia and lastly three areas where we definitely need to do better.
First, I believe without any doubt, that Australia compared with any Western country, provides as good, if not better clinical care to patients with HIV disease. Every patient has access to the most up-to-date treatments, the newest drugs which may show some antiviral effect and core by dedicated experienced professionals, all at no cost to the patient.
Second, our Social Services system provides support, both financial and housing, without discrimination to the increasing number of people with HIV disease who are becoming totally dependent on the public system. By comparison, in the United States, AIDS is now one of the most important causes of homelessness, because people must sell all of their possessions in order to become eligible for government funded health care. In Australia, many of our community based organisations can be justifiably proud of maintaining their optimism and direction of purpose in face of the mounting death toll amongst their constituents.
Our third main achievement is the National AIDS Strategy, which has been running for three years at a cost of about $350 million and is currently being reviewed. Out of this process will come plans for our response to this most crucial and potentially dangerous period of the HIV epidemic and therefore it is necessary that during this conference we actively raise issues of concern.
Next I will address some reasons why I believe the situation could get worse and that in fact we may be entering a dangerous period.
Firstly, current data show that most HIV positive people could become increasingly infectious over the next five years. This is explained by data released last week from the National Centre for Epidemiology and Population Health in Canberra which indicate that the majority of currently infected people are entering the phase of their illness when they may be infectious by sexual contact and sharing needles.
Two graphs show this (Figure 1). This graph predicts that by ten years after infection nearly all HIV positive patients will have CD4 cells below 500, indicating that HIV has affected the immune system and that the body’s ability to suppress viral reproduction is waning. Biologically this may mean that they are more likely to infect their partners or, if female and become pregnant, their children. There is no current evidence to that anti-retroviral therapy reduces the level of infectiousness even though there is a delay in progression to AIDS (Figure 2). In order to predict the number of people who are approaching this situation, this second graph shows that most HIV infections in Australia occurred during a relatively confined time period between 1982 and 1985. Projecting this incidence ten years on shows that even with the use of currently available anti-retroviral drugs we would expect that over the next five years there will be a major increase in persons becoming symptomatic with HIV disease. We are really just in the early stages of the sickness burden that HIV causes.
It is therefore essential that we understand how people with HIV infection behave and what factors influence them to place uninfected people at risk. Research conducted amongst young men at Albion Street shows that those who are at risk of HVI infection, often consume excessive quantities of alcohol and other drugs. Guinan and others have shown that drug and alcohol intake, which could be defined as excessive, was reported by about one third of people interviewed, which is about three times higher than their age matched counterparts in the general population. Of concern is that 22% of HIV positive men had placed themselves at risk of transmission as a result of being drug or alcohol intoxicated. Anecdotally, we find that as illness progresses and the young patient loses the independence of working and becomes dependent on social security payments and subsidised housing they seek occasional comfort in escaping their situation by using substances and engaging in activities that could spread HIV. If their infectivity is increasing then fewer contacts would be required to transmit HIV to either their casual or regular partners. The psychological term for this lapse in resolve is called relapse and it is well documented in every country, but the reality is that it is just human and while we all try to maintain an ideal lifestyle, it is very difficult while living with the limited future of having a terminal illness. Studies in the United States show that women with HIV have exactly the same fertility rate as uninfected women of the same age. Is this just a failure of their carers to convince them not to have children or is it, as I believe, an example of our ability to accurately convey information about risks, but which is not necessarily translated into a change in behaviour. Locally, we are particularly concerned about the number of health care workers who have become infected in the past two years despite having an extraordinarily comprehensive knowledge about the mode of transmission of HIV and how to avoid it. It seems that we are stuck into a groove of providing more and more information about HIV to uninfected people, and not concentrating our efforts into studying the complex problems of behaviour and coping in infected people.
In a wider context, we have recently diagnosed several heterosexual men who have probably become infected after sexual contact in Thailand. These are not the first and will certainly not be the last given that there are an estimated 400,000 Thais who are currently Infected and that Australian men as well as men from other countries are such regular visitors to the young men and women of their neighbours. It is estimated that by 1995 more people will be infected in South-East Asia than in all industrialised countries. In other words our part of the world is on the brink of a common tragedy. This is undoubtedly on area where our situation, in Australia, can become much worse and where we could do better, by providing training and policy advice, especially in the area of drug related transmission of HIV.
Before covering the areas where I think we could do much better. I would like to touch on some concerns about the usefulness of data that are currently available. This was dealt with in much detail by John Kaldor, but I believe that it is imperative that agencies who are conducting programmes which are aimed at changing behaviour must show that are able to reduce the number of new infections which are occurring.
In San Francisco, important information on behaviour change is provided by conducting regular cross-sectional surveys of gay men independently recruited. These surveys show that over the past five years there has been a significant reduction in the average number of sexual partners. Nevertheless, because the prevalence of HIV infection has increased, each person in fact has a higher individual risk of having a sexual contact with on HIV infected partner. In a recent paper by Hoover from John Hopkin’s University data from their National HIV Cohort Study which Includes 4954 homosexual and bisexual men was used to give a probability that 50% of participating uninfected men would seroconvert by age 50, despite extensive education and having regular monitoring. In Sydney, our longitudinal studies of gay men are limited by their small numbers (less than 200) and very selected subjects and while they seem to show positive results, I am concerned that they are neither representative of the general population of gay and bisexual men nor can their observations be projected into the coming decade.
I would now like to briefly address three other areas where I think we have to do much better. These areas demonstrate an underlying problem in the way bureaucracy interacts with the political decision making process.
The first is with injecting drug users. Despite the fact that the estimated prevalence of HIV amongst injecting drug users in Sydney is about 5%, which is considered to be very low, data from this study in Sydney which was conducted by Drs Michael Ross, Alex Wodak, Mel Miller and myself and funded by CARG included 1245 respondents of whom 30% continue to share needles. This survey was conducted In 1989/1990 and so we have very little idea of the current situation. It is worthwhile noting that in Edinburgh the infection rate went from 5% to 50% in eighteen months and that in London which provides the some access to methadone programmes, as in Sydney clean needle and syringe exchanges the prevalence of infection has risen from 5% to 12% in the past year. Over 70% of our cohort interviewed in Sydney, said that they would prefer to use Marijuana rather than intravenous drugs if it was legally available. It is Interesting to note that we spend $280M annually on drug enforcement programmes; and it costs $30,000 per year to keep a prisoner in jail. By comparison, it costs $5,000 per person, per year for a drug rehabilitation programme and $2,000 per year to keep a drug user on methadone. It is therefore of much concern to me that oven though virtually every expert conference which addresses the issues of drug law reform in Australia recommends that addiction is regarded as an illness and not a crime, it has been impossible for the bureaucratic process to convince the political process that it is critical to redefine the priorities from making popular decisions to making necessary decisions. What is needed is a change in drug policy which should be influenced by our paramount need to contain the spread of HIV. Therefore, we need to evaluate ways of letting people use intoxicating substances whose administration does not spread a fatal disease.
Second is our approach to prisons where even after ten years of experience with AIDS there are still no condoms or clean needles in any prison in Australia and methadone programmes are almost non-existent. In fact, NSW and South Australia ore the only states where there is any methadone in any prisons, and there is still a possibility that these programmes will be scaled down. In my opinion, it is scandalous that bleach, which is a cheap, effective and safe method of cleaning syringes is not made available in prisons immediately. Perhaps because we hove not seen on explosion of HIV in our prisons there is no imperative. But HIV is not an explosive epidemic. It is a slow and insidious virus which can take months to diagnose and years to cause illness. Therefore, action needs to be taken now.
The third area of concern is the threat of HIV spreading through the Australian Aboriginal Community. I am sure this subject will be covered later in the conference by Professor Hollows. However. I feel it is important enough to stress that many of my colleagues believe that link between city based aboriginal people who are HIV positive and their country communities has the potential of spreading HIV throughout rural Australia. Again this may not be an explosive process which would interest the media, but unless we go beyond just providing information through pamphlets and posters and understand the process of behaviour change, including discrimination, we will have little influence on the course of the epidemic in the aboriginal population.
In conclusion, I have covered three good things we have done, three reasons why things could get worse, a reason for caution and three things we must do better.
Lastly. the review of the National AIDS Strategy I referred to earlier is probably the most important task currently being undertaken. It is therefore essential that all of its methods and conclusions are carefully scrutinised and that the review is independent of both government which provides funds, and the organisations which currently receive the majority of AIDS funding. This independence must be seen to exist, as well as actually existing. Their responsibility is not to tell whether we have got it right, but to critically assess how we can make it better.