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Destined to repeat history?

Destined to repeat history? The recent evaluation of the second Australian national HI‘V/AIDS strategy offered an opportunity to take stock of our efforts 13 years into the HIV epidemic. It also allowed us to re-examine that oftrepeated trope that the Australian response to HIV/AIDS has been among the best in the world. And it is to be hoped that the evaluation report, in revealing arty shortcomings, pre-empts the development of coimplacency in our response as the HIV epidemic wears on in Australia and, indeed, expands rapidly in the Asia-Pacific region. This need to fight complacency is highlighted by attacks in recent times on the levels of special funding to HIV/AIDS, in emotive appeals regarding other, no le:js worthy illness and conditions, and also in the sustained criticism that the gay communities still attract in Australia, in spite of the devastating effects of the epidemic among their members. This lack of recognition of the gay communities’ efforts in fighting HIV/AIDS and the lack of sympathy for their losses and pain is one cultural response to HIV/AIDS unremarkable to the Western world, but luckily for Australia, it has not driven the national HIN/AIDS strategies-in intent if not in practice. By this, I mean that those features that mark the significant differences between the Australian response and those of other countries are still present, according to Feachem, and are nominated again in this latest evaluation report as the major source of our success so far. These dif-ferent factors are nominated as: 1. having a centrally coordinated national strategy; 2. involving all sectors affected by the epidemic; 3. relying on ongoing consultative processes in order to keep the line of march clear; 4. providing adequate funding to maintain the effort while striving always for efficiencies and improvements; 5. framing the effort within a progressive and broad new public health model; and 6. documenting and monitoring the epidemic closely at all stages to ensure appropriate action. Corre5pondence to Dr Gary Dowsett, Department of Sociolog): Macqudrie University, NSU’ 2109. Fax (02) 850 9355. If we read Feachem in these terms, then the evaluation report certainly confirms that the national HIV/AIDS strategy is on target, is working well in its own terms, and with minor adjustments should continue for the next five years in much the same way. To nail this conclusion in place, the report relies in key places on various techniques of cost-benefit analysis to convince us that our efforts are very costeffective, particularly when the indirect costs of the epidemic, for example, loss of life and loss of economic productivity, are included. The report should put to rest any residual concerns that Australia’s efforts are not worth it or are not paying their way. That said, the Feachem report warns of more to be done, and in its often understated style, points to interesting ambiguities in our response to HIV/AIDS. In doing this, the report contains a strong suggestion of a need for more rigour and clarity of purpose in the national effort. Nowhere is this more obvious than in the need to order priorities for prevention efforts for the ‘continuing’ epidemic (as Feachem terms it) among gay and homosexually active men, and on the ‘emerging’ epidemic among indigenous Australians. Gay a n d homosexually active men in 1994 accounted for 90 per cent of accumulated AIDS cases and 85 per cent of newly diagnosed and 88 per cent of newly acquired HIV infections. While noting the dramatic decline in the infection rate in this population since the epidemic began in 1982, the report also recognises what many gay community AIDS activists have worried about for so long now: that the sheer volume of H N among inner-city gay communities, especially in Sydney, is sufficient to sustain an epidemic there, no matter how much sexual behaviour change is achieved by those communities, and that there will always be enough mistakes made, sufficient errors of judgment, and continued ignorance of HIV transmission modes to sustain a certain level of new H N infection. How to maintain the fight to minimise that level is the urgent question. This fear on the part of gay men would appear supported by the report. Feachem notes that a mere 10.34 per cent of available Commonwealth funds for prevention education was spent on gay and homosexually active men during the first two years of the second strategy-a situation that calls for Feachem’s first recommendation that gay and homosexually active men remain the ‘highest priority’ in any subsequent national strategy. Just exactly how this is to be done is not directly addressed by the report, but there are some hints of where efforts might be made. These are important areas to note as the development of the third national HN/AIDS strategy reaches the moment when the new Commonwealth Health Minister will be asked to make good his commitment to a third strategy (one to which no guaranteed level of funding was attached). So,just where might giving gay and homosexually active men highest priority occur? Feachem regarded the levels of funding for education allocated to the general population as unnecessarily high (recommendation 9 ) . Yet, as gay and homosexVOL. AUSTRALIAN AND NEW ZEALAND JOURNAL O PUBLIC HEALTH 1996 F 20 NO 4 DOWSETI ually active men attracted 10.02 per cent of funds, some reallocation toward them would still achieve considerably less than required in proportion to their numbers than the allocation (25.31 per cent) to injecting drug users. Recommendations to maintain levels of funding to injecting drug users (recommendation 3), to sex workers at 8.1 per cent (recommendation 7), and a hint at increased funding for young people, currently at 5.8 per cent (recommendation l o ) , would suggest that priority for gay and homosexually active men might appear almost as difficult to achieve in the third national strategy as it was in the second. Other improvements for gay and homosexually active men are to be achieved by efficiencies: more effective evaluation and monitoring; training programs (long overdue) for community-based HIV/AIDS educators, particularly in their utilisation of research and other information in program planning and delivery; less program delivery by the Commonwealth (traded against strategic initiatives and better coordination) ; a welcome strengthening of the link between research and practice (although this is not explicated); some streamlining of roles and goals of various consultative and coordinating bodies; and some strengthening of the accountability techniques. These are essentially refinements, as suggested earlier, not significant switches in strategy or process, and confirm the overall direction, efforts and achievements of the second strategy (to date), much as we have become used to regarding it: Australia is doing quite well. But this conviction fails to consider how a substantial shift in emphasis (funding) toward gay and homosexually active men might be achieved in future, within the maintenance of the existing HrV/AIDS budget over the life of the third strategy (recommendation 78). This difficulty is compounded by the recommendation that $2 to $2.5 million be re-allocated from the National Education Program to the Special Funding Program for HIV/AIDS and sexually transmitted diseases services to indigenous Australians. The argument in the report on the emerging epidemic among indigenous Australians is wholly convincing, and one wonders why it has taken so long for us to realise that possibility? The irreconcilability of the report’s recommendations amounts to a resignation to the repetition of the situation that has occurred throughout the life of the epidemic: when it comes to prevention of HIV infection, gay and homosexually active men have been asked to do most of the work with the least of the funds, and will be asked to continue to do so. There is evidence that this is not simply a wilful refusal by the Commonwealth to recognise the epidemiology (the same cannot be said of some of the states), but a deliberate recognition of the continuing willingness and commitment of the gay communities to the fight with HIV/AIDS. In a sense, as a nation we trade on the fact the gay men can do little else but keep on fighting. We do this partly because we fail to recognise that the gay communities’ efforts have achieved successes well beyond the narrow cost346 effectiveness model Feachem uses in the evaluation report. Australia’s lack of a ‘heterosexual’ epidemic and the failure of HIV to bridge the gap between gay communities and the heterosexual population may be due largely to the successes of prevention education in and by the gay communities in achieving such early and substantial behaviour change toward safe sex. In other words, it was notjust a reduction in nominated male-to-male sexual transmission of HIV that was achieved by efforts of educators in the gay community. Because sex in those blurred boundaries between ‘gay’ and ‘straight’ rapidly became safe sex, HIV transmitted heterosexually became increasingly unlikely. Were this to be factored into the cost-effectiveness model used to evaluate prevention efforts among gay and homosexually active men, we might really and finally realise how much has been done so well by so few for so long. The irony of this is that an argument is often mounted that funding for prevention cannot be tied directly to epidemiology because of the particular exigencies of reaching certain populations and because of the particular costs associated with the risk-related practices involved. This argument is rightly mounted in relation to Australia’s needleand-syringe-exchange programs. (In the Feachem report the cost-effectiveness of these programs is indisputably argued, and one wonders why the rest of the developed world has been so tardy in learning from Australia’s success here.) Yet, the suggestion that prevention education among gay and homosexually active men may be reaching its limits in the light of the continuing epidemic (p. 87) seems not to draw the same supportive argument; instead it merely gestures toward increased efficiency. It may be that decreases in new infections among gay and homosexually active men beyond the current plateau might require increasingly ingenious tactics. This might increase the cost of effectiveness, in exactly the same way that the effective program for injecting drug users seems at first glance funded out of proportion to its epidemiology. This points again to problems in implementing any recommendation concerning the highest future priority of a national HIV/AIDS strategy. Are we prepared as a nation to support the gay communities adequately as the task gets harder (because it undoubtedly will)? A final comment on the report concerns its recommendations on research. The overall conclusions support the institutional and funding arrangements of the research program, but hint at difficulties in the implementation of a recommendation from the evaluation of the first national HIV/AIDS strategy that has seen the gradual transfer of the HIV/AIDS research program from the Commonwealth AIDS Research Grants Committee slowly back to the NHMRC. As a social scientist working in HIV/AIDS research nationally and internationally for over 10 years now, I would argue that this barely registers the ongoing concerns of social researchers about the extra difficulties we have in working in HIV/AIDS, difficulties not only exacerbated by the recent shift to the NHMRC, but also evidenced in decreasing VOL. AUSTRALIAN AND NEW ZEALAND JOURNAL O PUBLIC HEALTH 1996 F 20 NO. 4 NATIONAL HIV/AIDS STRATEGY EVALUATION applications for annual grants from social researchers in the last few years. This is nowhere more evident than in the alarming absence of sufficient and adequate applications to undertake research on gay and homosexually active men, despite the obvious epidemiological significance of doing so. This absence suggests yet another aspect of Australia’s response to its largely ‘gay’ epidemic (but one unnoticed by Feachem), a response that may still have more to do with our sustained ambivalence to gay men (and lesbians), despite Mardi Gras, despite the disproportionate loss to Australia of its creative artists, and despite what is, when all is said and done, an effective and successful national HIV/AIDS s#trategy.Imagine what we might have achieved if we had put the whole of our hearts and minds to the task of supporting our gay communities earlier and more fully right along the way? And let’s ensure ithat we don’t repeat the error and also ask indigenous Australians to fight their emerging epidemic with one hand tied behind each back. Gary W. Dowsett Socrology Department, Macquane L’ntuerszty, Sydney 2. Cohort studies confirm a dramatic decline in HTV incidence for a male homosexual cohort followed from 1984 till 1994 (p. 41). 3. Australia ranks about the middle in a comparison of the per capita rate of HIV infection in a number of developed countries. Australia belongs to a grouping of about half the developed countries selected for comparison, in which the incidence of HIV appears to have plateaued (p. 3 5 ) . 4.Rates of sexually transmitted diseases (STDs) among homosexual men and female sex workers have declined substantially since the start of the AIDS epidemic. However, STD rates have not declined in indigenous communities (p. 97, p. 51). 5. Condom sales, which were about 20 million in 1985, have doubled in the last 10 years. 6. Over the last 10 years an increasing percentage of nonmonogamous heterosexuals claim to have altered their behaviour in response to the epidemic and in 1995 between about 30 per cent and 50 per cent claimed to have altered their behaviour (pp. 57-8). Reported condom use with casual partners has increased from about 10 per cent to 30-40 per cent (p. 58, p. 103). Condom use is close to 100 per cent among female sex workers in legal brothels (p. 100). 7. Multiple surveys have shown a decline by a factor of about two in unsafe sex among homosexual men over the period 1984-1994 and now only about 10-20 per cent of men surveyed admit to recent unsafe sex with casual partners (p. 43-4). Although these points of evidence for the effectiveness of Australia’s response to the sexual spread of AIDS may initially appear encouraging, they require deeper scrutiny. The items will be examined one at a time. Assessing; the National HIV/AIDS Strategy :Evaluation The evaluation of Australia’s National HIV/AIDS Strategy has resulted in a useful collection of information about the epidemic and Australia’s response to it.’ The report endorses the overall thrust of Australia’s response. There is indeed solid evidence for the success of Australia’s efforts in limiting the spread of the epidemic by iatrogenic means (p. 52), and among intravenous drug users (p. 89). There is also solid evidence of success in limiting the spread of HIV among female sex workers (pp. 54-5). However, endorsement of Australia’s success in otherwise limiting the sexual spread of HIV does not seem to be warranted on the basis of the quantitative evidence elicited. There are also contradictions and omissions in the report, which will be mentioned later. Quantitative evidence It is worthwhile to summarise the quantitative evidence of Australia’s success in limiting the sexual spread of HIV. The evidence cited comes from multiple sources referenced in the report and associated documents. ‘Thefigures given here are averaged and rounded to improve digestibility: 1. Indirect tlechniques show that the incidence of HIV in Australia peaked in the mid-1980s and then declined rapidly. The current incidence is around ablout one-sixth of the peak incidence and appears to have plateaued at about 400-500 per year (p. 30). Correspondence to Dr David Kault, Department of Mathematics and Statistics, James Cook University, Townsdle, Qld 481 1, Fax (077) 81 4028, e-mail david.kault@&u.edu.au. HIV incidence Although the incidence of HIV has declined dramatically from a mid-1980s peak, this decline does not necessarily reflect behavioural change. It is in the nature of epidemics that they have a peak followed by a decline. The decline following the peak in epidemic curves is explained by saturation effects, that is, by the epidemic itself diminishing the number of susceptible people left to infect. Behavioural change may also account for the decline in incidence. In the evaluation, an effort was made to measure how much of the observed decline in incidence was due to saturation effects and how much was due to behavioural change. This quantification necessarily used a mathematical model of HIV transmission. A model was chosen and it was shown that the model could fit the observed HIV incidence curve only if a decline in risky behaviour by a factor of 15 was assumed.2 Some of this assumed decline occurred in the period considered by the evaluation. The assumed decline, necessary for this particular model to give a good match to the data, was then ascribed (partly) to the effects of Australia’s HIV prevention program and forms the basis of the cost-effectiveness calculations. All such models necessarily make major simplify347 AUSTRALIAN AND NEW ZEAIAND JOURNAL O PUBLIC HEALTH 1996 vot. 20 NO. A F http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australian and New Zealand Journal of Public Health Wiley

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Publisher
Wiley
Copyright
Copyright © 1996 Wiley Subscription Services, Inc., A Wiley Company
ISSN
1326-0200
eISSN
1753-6405
DOI
10.1111/j.1467-842X.1996.tb01043.x
Publisher site
See Article on Publisher Site

Abstract

The recent evaluation of the second Australian national HI‘V/AIDS strategy offered an opportunity to take stock of our efforts 13 years into the HIV epidemic. It also allowed us to re-examine that oftrepeated trope that the Australian response to HIV/AIDS has been among the best in the world. And it is to be hoped that the evaluation report, in revealing arty shortcomings, pre-empts the development of coimplacency in our response as the HIV epidemic wears on in Australia and, indeed, expands rapidly in the Asia-Pacific region. This need to fight complacency is highlighted by attacks in recent times on the levels of special funding to HIV/AIDS, in emotive appeals regarding other, no le:js worthy illness and conditions, and also in the sustained criticism that the gay communities still attract in Australia, in spite of the devastating effects of the epidemic among their members. This lack of recognition of the gay communities’ efforts in fighting HIV/AIDS and the lack of sympathy for their losses and pain is one cultural response to HIV/AIDS unremarkable to the Western world, but luckily for Australia, it has not driven the national HIN/AIDS strategies-in intent if not in practice. By this, I mean that those features that mark the significant differences between the Australian response and those of other countries are still present, according to Feachem, and are nominated again in this latest evaluation report as the major source of our success so far. These dif-ferent factors are nominated as: 1. having a centrally coordinated national strategy; 2. involving all sectors affected by the epidemic; 3. relying on ongoing consultative processes in order to keep the line of march clear; 4. providing adequate funding to maintain the effort while striving always for efficiencies and improvements; 5. framing the effort within a progressive and broad new public health model; and 6. documenting and monitoring the epidemic closely at all stages to ensure appropriate action. Corre5pondence to Dr Gary Dowsett, Department of Sociolog): Macqudrie University, NSU’ 2109. Fax (02) 850 9355. If we read Feachem in these terms, then the evaluation report certainly confirms that the national HIV/AIDS strategy is on target, is working well in its own terms, and with minor adjustments should continue for the next five years in much the same way. To nail this conclusion in place, the report relies in key places on various techniques of cost-benefit analysis to convince us that our efforts are very costeffective, particularly when the indirect costs of the epidemic, for example, loss of life and loss of economic productivity, are included. The report should put to rest any residual concerns that Australia’s efforts are not worth it or are not paying their way. That said, the Feachem report warns of more to be done, and in its often understated style, points to interesting ambiguities in our response to HIV/AIDS. In doing this, the report contains a strong suggestion of a need for more rigour and clarity of purpose in the national effort. Nowhere is this more obvious than in the need to order priorities for prevention efforts for the ‘continuing’ epidemic (as Feachem terms it) among gay and homosexually active men, and on the ‘emerging’ epidemic among indigenous Australians. Gay a n d homosexually active men in 1994 accounted for 90 per cent of accumulated AIDS cases and 85 per cent of newly diagnosed and 88 per cent of newly acquired HIV infections. While noting the dramatic decline in the infection rate in this population since the epidemic began in 1982, the report also recognises what many gay community AIDS activists have worried about for so long now: that the sheer volume of H N among inner-city gay communities, especially in Sydney, is sufficient to sustain an epidemic there, no matter how much sexual behaviour change is achieved by those communities, and that there will always be enough mistakes made, sufficient errors of judgment, and continued ignorance of HIV transmission modes to sustain a certain level of new H N infection. How to maintain the fight to minimise that level is the urgent question. This fear on the part of gay men would appear supported by the report. Feachem notes that a mere 10.34 per cent of available Commonwealth funds for prevention education was spent on gay and homosexually active men during the first two years of the second strategy-a situation that calls for Feachem’s first recommendation that gay and homosexually active men remain the ‘highest priority’ in any subsequent national strategy. Just exactly how this is to be done is not directly addressed by the report, but there are some hints of where efforts might be made. These are important areas to note as the development of the third national HN/AIDS strategy reaches the moment when the new Commonwealth Health Minister will be asked to make good his commitment to a third strategy (one to which no guaranteed level of funding was attached). So,just where might giving gay and homosexually active men highest priority occur? Feachem regarded the levels of funding for education allocated to the general population as unnecessarily high (recommendation 9 ) . Yet, as gay and homosexVOL. AUSTRALIAN AND NEW ZEALAND JOURNAL O PUBLIC HEALTH 1996 F 20 NO 4 DOWSETI ually active men attracted 10.02 per cent of funds, some reallocation toward them would still achieve considerably less than required in proportion to their numbers than the allocation (25.31 per cent) to injecting drug users. Recommendations to maintain levels of funding to injecting drug users (recommendation 3), to sex workers at 8.1 per cent (recommendation 7), and a hint at increased funding for young people, currently at 5.8 per cent (recommendation l o ) , would suggest that priority for gay and homosexually active men might appear almost as difficult to achieve in the third national strategy as it was in the second. Other improvements for gay and homosexually active men are to be achieved by efficiencies: more effective evaluation and monitoring; training programs (long overdue) for community-based HIV/AIDS educators, particularly in their utilisation of research and other information in program planning and delivery; less program delivery by the Commonwealth (traded against strategic initiatives and better coordination) ; a welcome strengthening of the link between research and practice (although this is not explicated); some streamlining of roles and goals of various consultative and coordinating bodies; and some strengthening of the accountability techniques. These are essentially refinements, as suggested earlier, not significant switches in strategy or process, and confirm the overall direction, efforts and achievements of the second strategy (to date), much as we have become used to regarding it: Australia is doing quite well. But this conviction fails to consider how a substantial shift in emphasis (funding) toward gay and homosexually active men might be achieved in future, within the maintenance of the existing HrV/AIDS budget over the life of the third strategy (recommendation 78). This difficulty is compounded by the recommendation that $2 to $2.5 million be re-allocated from the National Education Program to the Special Funding Program for HIV/AIDS and sexually transmitted diseases services to indigenous Australians. The argument in the report on the emerging epidemic among indigenous Australians is wholly convincing, and one wonders why it has taken so long for us to realise that possibility? The irreconcilability of the report’s recommendations amounts to a resignation to the repetition of the situation that has occurred throughout the life of the epidemic: when it comes to prevention of HIV infection, gay and homosexually active men have been asked to do most of the work with the least of the funds, and will be asked to continue to do so. There is evidence that this is not simply a wilful refusal by the Commonwealth to recognise the epidemiology (the same cannot be said of some of the states), but a deliberate recognition of the continuing willingness and commitment of the gay communities to the fight with HIV/AIDS. In a sense, as a nation we trade on the fact the gay men can do little else but keep on fighting. We do this partly because we fail to recognise that the gay communities’ efforts have achieved successes well beyond the narrow cost346 effectiveness model Feachem uses in the evaluation report. Australia’s lack of a ‘heterosexual’ epidemic and the failure of HIV to bridge the gap between gay communities and the heterosexual population may be due largely to the successes of prevention education in and by the gay communities in achieving such early and substantial behaviour change toward safe sex. In other words, it was notjust a reduction in nominated male-to-male sexual transmission of HIV that was achieved by efforts of educators in the gay community. Because sex in those blurred boundaries between ‘gay’ and ‘straight’ rapidly became safe sex, HIV transmitted heterosexually became increasingly unlikely. Were this to be factored into the cost-effectiveness model used to evaluate prevention efforts among gay and homosexually active men, we might really and finally realise how much has been done so well by so few for so long. The irony of this is that an argument is often mounted that funding for prevention cannot be tied directly to epidemiology because of the particular exigencies of reaching certain populations and because of the particular costs associated with the risk-related practices involved. This argument is rightly mounted in relation to Australia’s needleand-syringe-exchange programs. (In the Feachem report the cost-effectiveness of these programs is indisputably argued, and one wonders why the rest of the developed world has been so tardy in learning from Australia’s success here.) Yet, the suggestion that prevention education among gay and homosexually active men may be reaching its limits in the light of the continuing epidemic (p. 87) seems not to draw the same supportive argument; instead it merely gestures toward increased efficiency. It may be that decreases in new infections among gay and homosexually active men beyond the current plateau might require increasingly ingenious tactics. This might increase the cost of effectiveness, in exactly the same way that the effective program for injecting drug users seems at first glance funded out of proportion to its epidemiology. This points again to problems in implementing any recommendation concerning the highest future priority of a national HIV/AIDS strategy. Are we prepared as a nation to support the gay communities adequately as the task gets harder (because it undoubtedly will)? A final comment on the report concerns its recommendations on research. The overall conclusions support the institutional and funding arrangements of the research program, but hint at difficulties in the implementation of a recommendation from the evaluation of the first national HIV/AIDS strategy that has seen the gradual transfer of the HIV/AIDS research program from the Commonwealth AIDS Research Grants Committee slowly back to the NHMRC. As a social scientist working in HIV/AIDS research nationally and internationally for over 10 years now, I would argue that this barely registers the ongoing concerns of social researchers about the extra difficulties we have in working in HIV/AIDS, difficulties not only exacerbated by the recent shift to the NHMRC, but also evidenced in decreasing VOL. AUSTRALIAN AND NEW ZEALAND JOURNAL O PUBLIC HEALTH 1996 F 20 NO. 4 NATIONAL HIV/AIDS STRATEGY EVALUATION applications for annual grants from social researchers in the last few years. This is nowhere more evident than in the alarming absence of sufficient and adequate applications to undertake research on gay and homosexually active men, despite the obvious epidemiological significance of doing so. This absence suggests yet another aspect of Australia’s response to its largely ‘gay’ epidemic (but one unnoticed by Feachem), a response that may still have more to do with our sustained ambivalence to gay men (and lesbians), despite Mardi Gras, despite the disproportionate loss to Australia of its creative artists, and despite what is, when all is said and done, an effective and successful national HIV/AIDS s#trategy.Imagine what we might have achieved if we had put the whole of our hearts and minds to the task of supporting our gay communities earlier and more fully right along the way? And let’s ensure ithat we don’t repeat the error and also ask indigenous Australians to fight their emerging epidemic with one hand tied behind each back. Gary W. Dowsett Socrology Department, Macquane L’ntuerszty, Sydney 2. Cohort studies confirm a dramatic decline in HTV incidence for a male homosexual cohort followed from 1984 till 1994 (p. 41). 3. Australia ranks about the middle in a comparison of the per capita rate of HIV infection in a number of developed countries. Australia belongs to a grouping of about half the developed countries selected for comparison, in which the incidence of HIV appears to have plateaued (p. 3 5 ) . 4.Rates of sexually transmitted diseases (STDs) among homosexual men and female sex workers have declined substantially since the start of the AIDS epidemic. However, STD rates have not declined in indigenous communities (p. 97, p. 51). 5. Condom sales, which were about 20 million in 1985, have doubled in the last 10 years. 6. Over the last 10 years an increasing percentage of nonmonogamous heterosexuals claim to have altered their behaviour in response to the epidemic and in 1995 between about 30 per cent and 50 per cent claimed to have altered their behaviour (pp. 57-8). Reported condom use with casual partners has increased from about 10 per cent to 30-40 per cent (p. 58, p. 103). Condom use is close to 100 per cent among female sex workers in legal brothels (p. 100). 7. Multiple surveys have shown a decline by a factor of about two in unsafe sex among homosexual men over the period 1984-1994 and now only about 10-20 per cent of men surveyed admit to recent unsafe sex with casual partners (p. 43-4). Although these points of evidence for the effectiveness of Australia’s response to the sexual spread of AIDS may initially appear encouraging, they require deeper scrutiny. The items will be examined one at a time. Assessing; the National HIV/AIDS Strategy :Evaluation The evaluation of Australia’s National HIV/AIDS Strategy has resulted in a useful collection of information about the epidemic and Australia’s response to it.’ The report endorses the overall thrust of Australia’s response. There is indeed solid evidence for the success of Australia’s efforts in limiting the spread of the epidemic by iatrogenic means (p. 52), and among intravenous drug users (p. 89). There is also solid evidence of success in limiting the spread of HIV among female sex workers (pp. 54-5). However, endorsement of Australia’s success in otherwise limiting the sexual spread of HIV does not seem to be warranted on the basis of the quantitative evidence elicited. There are also contradictions and omissions in the report, which will be mentioned later. Quantitative evidence It is worthwhile to summarise the quantitative evidence of Australia’s success in limiting the sexual spread of HIV. The evidence cited comes from multiple sources referenced in the report and associated documents. ‘Thefigures given here are averaged and rounded to improve digestibility: 1. Indirect tlechniques show that the incidence of HIV in Australia peaked in the mid-1980s and then declined rapidly. The current incidence is around ablout one-sixth of the peak incidence and appears to have plateaued at about 400-500 per year (p. 30). Correspondence to Dr David Kault, Department of Mathematics and Statistics, James Cook University, Townsdle, Qld 481 1, Fax (077) 81 4028, e-mail david.kault@&u.edu.au. HIV incidence Although the incidence of HIV has declined dramatically from a mid-1980s peak, this decline does not necessarily reflect behavioural change. It is in the nature of epidemics that they have a peak followed by a decline. The decline following the peak in epidemic curves is explained by saturation effects, that is, by the epidemic itself diminishing the number of susceptible people left to infect. Behavioural change may also account for the decline in incidence. In the evaluation, an effort was made to measure how much of the observed decline in incidence was due to saturation effects and how much was due to behavioural change. This quantification necessarily used a mathematical model of HIV transmission. A model was chosen and it was shown that the model could fit the observed HIV incidence curve only if a decline in risky behaviour by a factor of 15 was assumed.2 Some of this assumed decline occurred in the period considered by the evaluation. The assumed decline, necessary for this particular model to give a good match to the data, was then ascribed (partly) to the effects of Australia’s HIV prevention program and forms the basis of the cost-effectiveness calculations. All such models necessarily make major simplify347 AUSTRALIAN AND NEW ZEAIAND JOURNAL O PUBLIC HEALTH 1996 vot. 20 NO. A F

Journal

Australian and New Zealand Journal of Public HealthWiley

Published: Aug 1, 1996

There are no references for this article.