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Editorial: Feachem's report on Australia's National HIV/AIDS Strategy

Editorial: Feachem's report on Australia's National HIV/AIDS Strategy reviews of time trends in sexual and injecting behaviours related to the risk of HIV transmission were carried out. In the end, however, all such endeavours are limited by the inherent methodological difficulty in providing proof, in an empirical sense, of the effectiveness of health programs. It is true that Australia has had good outcomes compared with many countries, few of which have had comparable national HIV/AIDS policies. The rate of HIV transmission through sex between men declined precipitously after the peak in the mid-l980s, but did governmentfunded programs, started in a serious way well after the decline had begun, play a role? Indisputably, injecting drug use has not been a major vehicle for HIV transmission in Australia, but was the massive provision of free needles and syringes the only way this could have been achieved? It is unarguable that heterosexual HIV transmission is rare in Australia, even though it is the most common route of spread on a global basis. But do we have evidence that a national strategy has anything to do with this situation? These questions are posed not with the intention of questioning the value of the National HIV/AIDS Strategy itself, but to underline the fundamental challenges facing a formal attempt to evaluate the strategy’s success. Critiques of the evaluation that do not recognise these difficulties are simplistic. The evaluation correctly went beyond empirical measures of Australia’s success in preventing HIV transmission to consider the extent to which we have responded as a country to the care, in the widest sense, of people with and at risk of HIV infection, including measures aimed at minimising discrimination, and providing personal support, as well as full access to health care. Although Professor Feachem’s evaluation of the second National HIV/AIDS Strategy was published barely nine months ago, much has happened in the intervening period. For one thing, the government changed: the era of AIDS had until then coincided entirely with national Labor governments in Australia. Despite longstanding bipartisan support for the strategy, it would be unrealistic to assume that a Liberal-National government will construct an AIDS policy identical to that of its predecessors. Even before the change of government, there had been extensive discussion about the eventual ‘mainstreaming’ of HIV/AIDS programs. To those opposed, this ultimately stands for the elimination of designated HIV funding, with state and local health services being required to make their own budgetary allocations, either with existing resources or with some overall supplementation. It is perhaps inevitable that declining, or even stable, rates of HIV infection will lead to pressure to lower the priority of program funding, even if the behavioural conditions that predispose to HIV transmission still exist. The Feachem report recognises particular vulnerability to HIV infection in two Australian population groups: homosexual men, on whom the greatest effect of HIV infection has fallen in Australia, and Aboriginal and Torres Strait Islander communities, whose rates of other sexually transmitted diseases are many times higher than those of nonindigenous AUSTRALIAN AND N W ZEALAND JOURNAL O PUBLIC HEALTH 1996 vot. 20 NO 4 E F NATIONAL HIV/AIDS STRATEGY EVALUATION people. The highly heterogeneous distribution of both these population groups around the country means that the burden of service provision falls very unevenly on the various health authorities. For this simple demographic reason alone, resource allocation for HlrV and AIDS cannot be directly proportional to total population sizes. A national strategic approach with designated funding provides a way to achieve the appropriate allocation. People who inject illicit. drugs are a third key population group to be taken into consideration, particularly in view of the ongoing high rate of hepatitis C transmission in this group. A second major change since the report’s release has been in the area of HIV management. After several years of little apparent progress, the last year has brought new hope that HIV disease progression can be stopped, or at least substantially retarded, through co’mbinations of new and potent antiretroviral drugs.. Complemented by new techniques for quantifying; viral load, these combinations represent great promise at the same time as pointing towards a vast increase in funding needs. It is not clear whether existing mechanisms for approving and paying for drugs and diagnostic tests can cope adequately with the rapidly evolving developments in this area. The rapid spread of HIV infection into a number of countries of the Asia-Pacific region had begun well before the delivery of the Feachem report, but it is clearly continuing at high levels. As the country with the longest experience of HIV and AIDS in the region, Australia’s role and responsibilities must expand, even if we experience a relative decline in the impact of the epidemic in our own country. It is easy to portray a national strategy as a potential budgetary burden, even if it does not provide for specific funding. In fact, under a federal system of government, a national approach can provide a framework for developing and monitoring best practice across all jurisdictions, obviating the need for these processes to take place separately in eight states and territories, and ensuring that Australia as a whole continues to benefit from optimal policies to prevent HIV transmission, and care for people who have acquired HIV infection. John Kaldor Nati#onalCentre in H N Epidemiology and Clinical Research, Sydney The National Centre provided substantial support for the evaluation of the National HIV/AIDS Strategy through provision of data and related advice. Valuing the past . . . investing in the future Acquired immune deficiency syndrome (AIDS) struck an Aastralian society ill-prepared to handle a new communicable disease, especially a communicable disease for which we had no cure and no vaccine. The last comparable outbreaks had been the poliomyelitis epidemics, and they were more than a Correspondence to The Hon. Dr Neal Blewett, Australian High Commission, Australia House, Strand, London WC2B 4LA, UK. generation past. What bureaucratic mechanisms existed had become rusty, and politicians and public servants were unready. Australia’s first case of AIDS was identified in late 1982, but had no impact o n the upper echelons of the health bureaucracy in Canberra when Labor came to power in March 1983. At that time, as incoming Minister for Health, I was presented with a ministerial briefing, a fat folder with health issues roughly organised in order of priority. Well down the list, at 34 or 35, there was a reference to a phenomenon entitled GRID-gay-related immune deficiency. I was informed that this was a fatal immune deficiency disorder affecting homosexuals in the United States, the aetiology of which was unknown; explanation was suspected to lie in the environmental conditions or ‘life styles’ of American gays. It was not, I was assured, likely to be of any immediate priority for an Australian health minister. Within two years we had close to 1000 cases of identified human immunodeficiency virus (HIV) infection in Australia. AIDS, as it was by then called, had moved near the top of the national health agenda. Unpreparedness has advantages. There was no bureaucratic elite to struggle against, as bureaucracy in the communicable disease area had atrophied. Indeed, public health in general was in a debilitated state with no authority to impose solutions. There was no group of medical specialists with a vested interest in the field, nor any medical research lobby with a monopoly of wisdom on the subject. In one sense we were all amateurs. And the relief with which state ministers duck shoved responsibility for AIDS to the national arena meant that for a short period, the chronic tensions between the Commonwealth and the states in the health sphere were of little relevance. We had therefore a rare opportunity for creative policy making, and, no doubt, creative mistake making, given the near absence of private or public bureaucracies in the AIDS field. This essentially creative period (in which there was much ad hockery) lasted throughout the eighties; we might term it the Primitive or Heroic Period in AIDS policy and administration in Australia. It was followed by the Early Bureaucratic Period 1990-1993; and the Middle Bureaucratic Period 1993-1996. These two periods closely corresponded to the first and second national AIDS strategies. It is the second of these strategies that Valuing the past . . . investing in thefuture assesses. Coming to the subject after an absence, I am struck by how much of what was developed in the Primitive Period remains and is endorsed by this evaluation. The strategic philosophy developed in the mid-l980s, that of a partnership between affected communities, governments at all levels, and medical, scientific and health care professionals, remains the cornerstone today. My concept of such a partnership-particularly among homosexuals, doctors and government-was variously ascribed to ideological blinkers, anti-doctor sentiments, or even more reprehensible motives. I am afraid it had no grand visionary or philosophical source. It simply VOL. AUSTRALIAN AND NEW ZEALAND JOURNAL O PUBLIC HEALTH 1996 F NO http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australian and New Zealand Journal of Public Health Wiley

Editorial: Feachem's report on Australia's National HIV/AIDS Strategy

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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.tb01041.x
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Abstract

reviews of time trends in sexual and injecting behaviours related to the risk of HIV transmission were carried out. In the end, however, all such endeavours are limited by the inherent methodological difficulty in providing proof, in an empirical sense, of the effectiveness of health programs. It is true that Australia has had good outcomes compared with many countries, few of which have had comparable national HIV/AIDS policies. The rate of HIV transmission through sex between men declined precipitously after the peak in the mid-l980s, but did governmentfunded programs, started in a serious way well after the decline had begun, play a role? Indisputably, injecting drug use has not been a major vehicle for HIV transmission in Australia, but was the massive provision of free needles and syringes the only way this could have been achieved? It is unarguable that heterosexual HIV transmission is rare in Australia, even though it is the most common route of spread on a global basis. But do we have evidence that a national strategy has anything to do with this situation? These questions are posed not with the intention of questioning the value of the National HIV/AIDS Strategy itself, but to underline the fundamental challenges facing a formal attempt to evaluate the strategy’s success. Critiques of the evaluation that do not recognise these difficulties are simplistic. The evaluation correctly went beyond empirical measures of Australia’s success in preventing HIV transmission to consider the extent to which we have responded as a country to the care, in the widest sense, of people with and at risk of HIV infection, including measures aimed at minimising discrimination, and providing personal support, as well as full access to health care. Although Professor Feachem’s evaluation of the second National HIV/AIDS Strategy was published barely nine months ago, much has happened in the intervening period. For one thing, the government changed: the era of AIDS had until then coincided entirely with national Labor governments in Australia. Despite longstanding bipartisan support for the strategy, it would be unrealistic to assume that a Liberal-National government will construct an AIDS policy identical to that of its predecessors. Even before the change of government, there had been extensive discussion about the eventual ‘mainstreaming’ of HIV/AIDS programs. To those opposed, this ultimately stands for the elimination of designated HIV funding, with state and local health services being required to make their own budgetary allocations, either with existing resources or with some overall supplementation. It is perhaps inevitable that declining, or even stable, rates of HIV infection will lead to pressure to lower the priority of program funding, even if the behavioural conditions that predispose to HIV transmission still exist. The Feachem report recognises particular vulnerability to HIV infection in two Australian population groups: homosexual men, on whom the greatest effect of HIV infection has fallen in Australia, and Aboriginal and Torres Strait Islander communities, whose rates of other sexually transmitted diseases are many times higher than those of nonindigenous AUSTRALIAN AND N W ZEALAND JOURNAL O PUBLIC HEALTH 1996 vot. 20 NO 4 E F NATIONAL HIV/AIDS STRATEGY EVALUATION people. The highly heterogeneous distribution of both these population groups around the country means that the burden of service provision falls very unevenly on the various health authorities. For this simple demographic reason alone, resource allocation for HlrV and AIDS cannot be directly proportional to total population sizes. A national strategic approach with designated funding provides a way to achieve the appropriate allocation. People who inject illicit. drugs are a third key population group to be taken into consideration, particularly in view of the ongoing high rate of hepatitis C transmission in this group. A second major change since the report’s release has been in the area of HIV management. After several years of little apparent progress, the last year has brought new hope that HIV disease progression can be stopped, or at least substantially retarded, through co’mbinations of new and potent antiretroviral drugs.. Complemented by new techniques for quantifying; viral load, these combinations represent great promise at the same time as pointing towards a vast increase in funding needs. It is not clear whether existing mechanisms for approving and paying for drugs and diagnostic tests can cope adequately with the rapidly evolving developments in this area. The rapid spread of HIV infection into a number of countries of the Asia-Pacific region had begun well before the delivery of the Feachem report, but it is clearly continuing at high levels. As the country with the longest experience of HIV and AIDS in the region, Australia’s role and responsibilities must expand, even if we experience a relative decline in the impact of the epidemic in our own country. It is easy to portray a national strategy as a potential budgetary burden, even if it does not provide for specific funding. In fact, under a federal system of government, a national approach can provide a framework for developing and monitoring best practice across all jurisdictions, obviating the need for these processes to take place separately in eight states and territories, and ensuring that Australia as a whole continues to benefit from optimal policies to prevent HIV transmission, and care for people who have acquired HIV infection. John Kaldor Nati#onalCentre in H N Epidemiology and Clinical Research, Sydney The National Centre provided substantial support for the evaluation of the National HIV/AIDS Strategy through provision of data and related advice. Valuing the past . . . investing in the future Acquired immune deficiency syndrome (AIDS) struck an Aastralian society ill-prepared to handle a new communicable disease, especially a communicable disease for which we had no cure and no vaccine. The last comparable outbreaks had been the poliomyelitis epidemics, and they were more than a Correspondence to The Hon. Dr Neal Blewett, Australian High Commission, Australia House, Strand, London WC2B 4LA, UK. generation past. What bureaucratic mechanisms existed had become rusty, and politicians and public servants were unready. Australia’s first case of AIDS was identified in late 1982, but had no impact o n the upper echelons of the health bureaucracy in Canberra when Labor came to power in March 1983. At that time, as incoming Minister for Health, I was presented with a ministerial briefing, a fat folder with health issues roughly organised in order of priority. Well down the list, at 34 or 35, there was a reference to a phenomenon entitled GRID-gay-related immune deficiency. I was informed that this was a fatal immune deficiency disorder affecting homosexuals in the United States, the aetiology of which was unknown; explanation was suspected to lie in the environmental conditions or ‘life styles’ of American gays. It was not, I was assured, likely to be of any immediate priority for an Australian health minister. Within two years we had close to 1000 cases of identified human immunodeficiency virus (HIV) infection in Australia. AIDS, as it was by then called, had moved near the top of the national health agenda. Unpreparedness has advantages. There was no bureaucratic elite to struggle against, as bureaucracy in the communicable disease area had atrophied. Indeed, public health in general was in a debilitated state with no authority to impose solutions. There was no group of medical specialists with a vested interest in the field, nor any medical research lobby with a monopoly of wisdom on the subject. In one sense we were all amateurs. And the relief with which state ministers duck shoved responsibility for AIDS to the national arena meant that for a short period, the chronic tensions between the Commonwealth and the states in the health sphere were of little relevance. We had therefore a rare opportunity for creative policy making, and, no doubt, creative mistake making, given the near absence of private or public bureaucracies in the AIDS field. This essentially creative period (in which there was much ad hockery) lasted throughout the eighties; we might term it the Primitive or Heroic Period in AIDS policy and administration in Australia. It was followed by the Early Bureaucratic Period 1990-1993; and the Middle Bureaucratic Period 1993-1996. These two periods closely corresponded to the first and second national AIDS strategies. It is the second of these strategies that Valuing the past . . . investing in thefuture assesses. Coming to the subject after an absence, I am struck by how much of what was developed in the Primitive Period remains and is endorsed by this evaluation. The strategic philosophy developed in the mid-l980s, that of a partnership between affected communities, governments at all levels, and medical, scientific and health care professionals, remains the cornerstone today. My concept of such a partnership-particularly among homosexuals, doctors and government-was variously ascribed to ideological blinkers, anti-doctor sentiments, or even more reprehensible motives. I am afraid it had no grand visionary or philosophical source. It simply VOL. AUSTRALIAN AND NEW ZEALAND JOURNAL O PUBLIC HEALTH 1996 F NO

Journal

Australian and New Zealand Journal of Public Health – Wiley

Published: Aug 1, 1996

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