Speech given by The Hon Brian Howe MP, Deputy Prime Minister, Minister for Health, Housing and Community Services
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
Mr Chairman, ladies and gentlemen. I am very pleased to be here and addressing the theme of your Conference. The timing is appropriate as Australia moves into the formal evaluation phase of the National Strategy.
We have taken this epidemic seriously from the outset. We have started with the premise that good government deals with reality. We must deal with the real epidemic, the real numbers, and try to determine what is the best scientific advice and educational strategies.
Australia’s own response was made so much stronger in 1989 when all Governments agreed to a National HIV/AIDS Strategy. This was a blueprint for managing the epidemic – for setting policy directions and defining the roles and responsibilities of Federal and State Governments, non-government organisation and individuals. The National Strategy was drawn up following an extensive process of consultation with all interested parties. Including scientists, members of the medical and allied health professions, community groups and the Churches. Few other countries have gone through this process, and Australia has rightly been given credit for its rapid response, and its direct and forthright education strategies.
Support for research into the scientific, medical and social aspects of AIDS is a key component of the National Strategy. The work of Australian researchers has helped to define the parameters of the epidemic in Australia; it has produced results of the international significance. Three National Centres have been established in the areas of HIV virology, HIV epidemiology and clinical research, and HIV social research.
In the area of virology. Australian researchers have been involved in such studies as the development of new diagnostic techniques evaluation of the immune response top HIV and the study of the complex interactions between virus surface proteins.
Australian researchers were the first to identify the acute illness which follows initial infection in about 50% of infected people. The concentration of resources and expertise at the National Centre in HIV Epidemiology and Clinical Research has supported a broad program of medical research and the running of low cost and effective clinical trials.
The National Centre also coordinates the monitoring of the epidemic. In tandem with a network of testing laboratories, it provides a comprehensive and timely picture of the progress of both HIV and AIDS in Australia. This picture is complemented by a variety of surveillance projects in populations of homosexual men and injecting drug users. The social and behavioural aspects of HIV infection and AIDS have also received considerable attention. Key studies have focused on such issues as what makes for behaviour change and the extent of the adoption of protection behaviour evaluating particular interventions, and the needs of people with HIV.
It has been a feature of Australia’s approach to AIDS that community organisation have been closely Involved with Government in developing and running education and community care programs. Involving community groups recognises the value of peer education, and the public health benefit of encouraging the people most affected by AIDS to co-operate with the Government in dealing with the problem – rather than alienating or punishing them. We have also been prepared to embrace controversial strategies to combat the epidemic including needle and syringe exchange schemes and tackling law reform in such areas as discrimination and public health.
After 10 years there is still no vaccine and no cure. But there is much more knowledge about the HIV virus and its devastating social and economic consequences throughout the developed and developing world.
In Australia we have constantly monitored and adjusted our response in implementing the National Strategy. It may he helpful to compare what we know 10 years ago with what we know today.
International scientific and medical opinion In 1982 was suggesting there had already been widespread transmission throughout the world. Early estimates of HIV infection in Australia, coming from the AIDS Task Force, chaired by Professor Pennington, indicated that as many as 50,000 could be infected in this country. That concern spawned “The Grim Reaper”. It was controversial, and It certainly put AIDS on the Australian health agenda.
In 1992 we have quite different projections from the National Centre in HIV Epidemiology and Clinical Research, which we established in 1990. The Working Party, which Dr John Kaldor released last week, has confirmed the estimates published in the 1989 White Papers, that at the end of 1990 between 15,000 and 20,000 Australians were infected with HIV and AIDS. The report also predicted that between 700 and 900 cases of AIDS could be expected each year from 1991 to 1994.
The great majority of cases will be among gay men. They, and people with medically acquired AIDS, have borne the brunt of the disease in Australia. Most of those cases wore infected before 1985 – before we were sure of how it was transmitted. In Australia, the expected spread among intravenous drug users, and to the heterosexual population, has not yet happened. Our clear task is to keep things that way.
The fact that HIV hasn’t affected many in the heterosexual community is no comfort for the few it has.
It is a communicable disease. mainly transmitted sexually or through IV drug use, but that fact – that in Australia it mainly affects groups who are seen as challenging to the social and cultural values of the majority – means that most people do not see, or wish to see, themselves as facing any risk, whatever, their private behaviour.
I’m not sure whether we’ll over be able to demonstrate, in strict scientific terms, a direct correlation between our education and prevention strategies and the fact that HIV/AIDS hasn’t spread into the wider population. But what we can show is that Australia, alone among the OECD countries, is containing the epidemic to the communities in which it first emerged. That means that we’ll need convincing arguments before considering any major change in direction. When the evaluation of our education strategy is finished, we should be in a better position to judge.
In 1985, research produced a test which could detect antibodies to the virus, and Australia became one of the first countries in the world to secure the blood supply. At the time, affected groups were resisting strongly any suggestion of compulsory screening and isolation. No treatment was available then, and fears of identification, victimisation and discrimination were high, and that was understandable considering the treatment dished out to a little girl In Gosford at the time. It is understandable that homosexuals, injecting drug users and wax workers expected less compassion. But that reaction was cause for real concern, too, that the presence of the virus would be driven underground. Hence the policy of encouraging voluntary testing, with guarantees of confidentiality, and appropriate counselling and funding for support groups to help affected people to come to terms with the virus.
By 1992 our scientific and medical knowledge has increased massively. Data are collected from a wide range of sources to track the epidemic.
There is now a body of GPs and specialists who are familiar with the disease and treatments. Information is spreading about the benefits of early testing and treatment and of full and frank education. Community groups are encouraging these measures. This is all because confidence in the partnership between the medical profession, Government and community groups has blossomed – in spite of the many instances of victimisation and discrimination, some of which were cited in a recent NSW report.
Our testing policy is clear and unambiguous. It was set out in the White Paper, and was based on guidelines the Australian Health Ministers’ Conference adopted, and the Australian Medical Association supported in 1989. Since then the Australian National Council on AIDS (ANCA) and the Australian Health Ministers have built on those principles. Infection control procedures have been developed and updated by ANCA, and ANCA, the National Health and Medical Research Council and the Health Ministers recently endorsed principles covering infected health care workers to guide the health Industry.
While Australia may not have perfect information about the levels of HIV infection here, and in fact cannot, we do have a better idea than most countries. To take an example cited in the media recently: Australia, with a population of around 17 million. Is carrying out 1.5 million tests each year – the UK (excluding Scotland) has a population of around 49 million, and carried out 775,000 tests in 1990. No wonder their reported HIV infection level is about the same.
In the area of education and prevention, Governments have had the responsibility to both inform the general public about the virus and its modes of transmission and to provide explicit educational material for those engaging in risk behaviour.
As our knowledge and monitoring has grown, and our experience in education has deepened. It has become clear that the priority now must be to direct our educational efforts in a more targeted way and in a way designed to achieve behaviour change. It is increasingly clear that most people now have a reasonable understanding of the ways in which HIV Is spread, which is why I am considering the priority which needs to be given in future to widespread media campaigns.
Governments, and especially health authorities have the responsibility to provide information and to ensure a climate which encourages people to take personal responsibility for their own behaviour – to protect themselves and others. For some the answer will mean abstinence, for many and for most of their lives it will mean monogamy, and for some it will be using condoms and other protective behaviours. We should all acknowledge that those are the realities. The bottom line is personal responsibility.
It is for this reason that from the outset the education strategies have involved a partnership with affected groups. Members of the medical profession seek and trust education and information from their colleagues – similarly, education and information about sexual or drug taking behaviours is more effective when it is developed by and with affected groups such as the gay community. Injecting drug users, Aboriginals and ethnic groups. Such information and educational material can be more targeted, more focused to community needs, when it comes from a trusted source and we need to strengthen the capacity of community groups to achieve their objectives.
The concerns which Professor Hollows and others have expressed about the special vulnerability of the Aboriginal community to AIDS are concerns which all Governments share with the Aboriginal community.
It was for precisely that reason that I was happy to sponsor the national conference in Alice Spring earlier this year to provide Aboriginals with a forum in which to assess their successes and failures, and to develop future strategies and directions. I look forward to seeing the results of that conference being translated into action. Some of you may like to take the opportunity to look at a video of the conference which is available here today.
There are many challenges in the 90s for Australia, but before I go to these it may be appropriate if I put Australia’s response to the epidemic in a regional context. Australia clearly dominates the AIDS profile in the Western Pacific and South-East Asian regions, at least in terms of AIDS diagnoses, with nearly three quarters of the total AIDS cases in the Western Pacific, and nearly 20 times as many AIDS cases as the entire South-East Asian region. However, AIDS cases represent the tip of the iceberg for the HIV epidemic in many countries – Thailand alone may have many times more HIV infected people than Australia. Clearly, the experience built up in Australia in responding to the AIDS epidemic places us in a position of responsibility to assist other countries in the region who can learn what we have encountered and achieved.
We need to maintain and build on the partnership which has been fostered between the medical professions, affected groups and Government to ensure our response is appropriate and balanced.
We must maintain and strengthen our monitoring of the epidemic, and be alert for and responsive to any signs of change.
We must continually review priorities for resources and ensure the balance between education and prevention, and treatment and care, is appropriate.
We need to maintain a solid scientific and social research base to ensure our response is adequately informed, and that we can continue to contribute to the international effort to control the epidemic both in Australia and in our region.
We must maintain our educational efforts as the only effective prevention measure against the virus. That includes their key role in reaching affected groups. But we must assess the balance between targeted programs and mass education programs in the light of the epidemiological trends.
To ensure our policies and programs are effective we must eliminate discrimination against affected groups, and we must ensure the civil rights of the infected and those who treat and care for them are protected.
We must plan ahead to ensure an appropriate system of hospital and community based care and treatment is available for people who are infected and now becoming ill.
There are no right or absolute answers in Australia or in any country, for combating this epidemic. Governments have a responsibility to umpire the debate and to take the leads based on the best scientific and medical advice available. They must also act in the best interests of the infected community and provide a climate of confidence in which their rights of privacy and confidentiality are protected and balanced with those of the wider community.
As a last thought, I’ll ask that you consider what I’ve said, and that as you discuss the issues you approach them with two questions in mind – is our approach fair? is it balanced?