Developing regional responses to HIV in the era of combination prevention

Developing regional responses to HIV in the era of combination prevention

HIV Australia | Vol. 10 No. 2 | October 2012

DERMOT RYAN compares HIV prevention needs and risk indicators among gay men in urban and rural areas, finding more similarities than differences.

Although the majority of the population in NSW live in Sydney, it is not surprising that many regional and rural communities are scattered along NSW’smagnificent coast line.

The majority of infrastructure is based along the coast, affordable housing is often available, and public transport is more accessible. There are also greater employment opportunities along the eastern seaboard, as well as more options for community participation.

The majority of people affected by HIV in NSW are gay men, with the largest gay male population located in the inner Sydney area; in fact, around 25% of Australia’s HIV-positive population lives in or adjacent to the South Eastern Sydney Local Health District (SESLHD).

Smaller but significant communities of people living with HIV, gay men and men who have sex with men (MSM) are located in the major coastal regional centres of Newcastle and the Illawarra, with population pockets in the Mid North Coast and Far North Coast areas.

This year there has been momentum towards including the targets set out in the United Nations 2011 Political Declaration on HIV/AIDS (UNPD) into our collective response to HIV.1

These include: reducing the sexual transmission of HIV among gay men and men who have sex with men; reducing transmission among injecting drug users; sustaining the virtual elimination of mother-to-child transmission; sustaining the virtual elimination among sex workers; and increasing the number of people living with HIV on antiretroviral treatmentby 2015.

Initiatives to achieve these targets include increasing community access to improved HIV testing technologies, and improving access to HIV treatments for people living with HIV by acknowledging and addressing barriers to the supply of medications.

In 2011, approximately 10% of HIV diagnoses notified to NSW Health and recorded in surveillance data were among people living outside the wider Sydney area.

The majority of these were located in just a few key rural areas, mainly on the NSW coast north of Sydney. ACON provides services along the coast of NSW, with a presence in the Illawarra, Hunter, Northern Rivers, Port Macquarie and Coffs Harbour.

The concentration of people living with HIV and our target populations for HIV prevention education (gay men, MSM, injecting drug users and sex workers) in inland NSW is low, and direct services to people living with HIV focus on primary health care delivered through NSW Health Clinics; however, ACON provides outreach services as needs are identified. ACON regional offices provide client services, health promotion and counselling programs along with a variety of other community development and education programs based on local community needs.

For example, HIV Health Promotion programs specifically targeting HIV-positive gay men are delivered by ACON in the Northern Rivers where a significant population of people living with HIV has resided since the epidemic first emerged in Australia.

In the Hunter, ACON has provided alcohol and other drugrelated therapeutic services and counselling. More recently, the Sex Worker Integrated Care Coordination Project has been delivered to address the health, wellbeing and safety issues faced by street-based sex workers in the Islington area.

Across most Australian jurisdictions, the Gay Community Periodic Surveys (GCPS) provide an important set of behavioural data to inform HIV prevention strategies.

The survey provides information on gay men’s sexual practices, drug use, and testing for HIV and sexually transmissible infections (STIs).

Surveys have been conducted, generally in metropolitan settings, across six Australian states and territories since 1996.2

Town and country: comparing risk behaviour between rural and urban gay men

In 2009, ACON’s regional services collaborated with NSW Health, three regional HIV and Related Programs (HARP) Units of the then Area Health Services and the National Centre in HIV Social Research (NCHSR) in a one-off research project which applied the GCPS approach to regional settings in NSW.

The aim was to identify similarities and differences in risk behaviour between rural gay men and MSM, and their city counterparts. The findings were reported in a number of ways, principally in Town and Country, published by NCHSR.3

The research compared survey responses of 1,371 men recruited for the Sydney GCPS in August 2009 with responses of 469 men recruited for a survey of gay men in regional NSW between August and November 2009.

The data compared these two groups of men (from the city and regional areas) on a range of risk indicators.

A key finding of Town and Country was that there was a much greater degree of similarity than there was difference between the two groups.

While it is important to understand the differences and what impact they may have in developing appropriate regional responses to HIV prevention and HIV health promotion, it is just as important to note that in a regional context, much of the data from the Sydney GCPS is highly relevant and applicable for rural gay men and men who have sex with men.

This regular data source can be useful as a planning tool for delivering services to gay men and MSM, including those with HIV.

Some of the key similarities highlighted in the report are summarised here:

  • Gay men in regional NSW and Sydney were equally likely to:
    • have a boyfriend/regular partner (~½)
    • be recently tested for HIV (last 12 months), if they have previously tested for HIV
    • use condoms (or have unprotected sex) with casual and regular partners
    • tell partners their HIV status (disclose)
    • meet men at beats, dance parties, private sex parties and through the internet or sex workers.

Some of the key differences highlighted were:

  • Gay men from regional NSW are more likely than Sydney men to be:
    • under 25 or over 50 (more younger men, more older men)
    • involved in the local gay community
    • introduced to partners through friends
    • in a relationship with a man of untested/unknown HIV status
    • in a monogamous relationship.
  • Gay men from regional NSW are less likely to:
    • have ever been tested for HIV (89% vs. 93%)
    • be recently tested for STIs
    • meet partners through gay venues (bars, gyms, saunas)
    • have high numbers of casual partners.

These findings reflect the experience of many service providers in regional and rural areas who identify that some gay men will leave rural areas to obtain employment or further their careers and will retire to rural areas later intheir lives.

Gay men in rural NSW are less likely to meet partners through a gay venue, which is hardly surprising given the much greater concentration of gay venues in the inner metropolitan area.

Other survey data highlights the need to address lower HIV and STI testing rates among gay men in rural NSW by providing incentives to deliver campaigns to increase testing.

To achieve testing targets, education campaigns and better access to modern and user-friendly testing technologies will be required.

Organisational partnerships to increase testing

ACON’s regional offices have Memoranda of Understanding (MOUs) with a number of local community and health partners. MOUs with Local Health Districts establish the framework for developing and maintaining effective partnerships that work to improve service delivery to the community and to specific populations.

These local partnerships have enabled innovative responses to achieve shared goals. Such responses have included provision of regular sexual health clinics offered from some ACON regionaloffices.

These clinics have provided sexual health testing for a number of years. Collaboration with local sexual health services developed through the MOU framework means that clinic access is increased and offered from a community setting.

The recent introduction of rapid testing services at four NSW Health Sexual Health Clinics in Sydney is heralding a new age of testing access and availability in Australia. While these rapid testing services are currently trialling, they represent an important advance in the HIV prevention response in NSW andacross Australia.

A challenge for our regional and rural services will be to ensure that such rapid testing technologies are also offered as a standard part of service delivery.

Barriers to regular testing include inconvenient service hours, limited access points, and lack of access to newer testing modalities such as express clinics, and provision of same dayresults.

The impact of travel to services in regional and rural areas also needs to be considered. The lack of equity in accessing testing services between capital cities and regional and rural areas requires immediate and effective action.

Limiting rapid testing to capital cities would potentially widen the gap in testing levels between city and rural gay men and other MSM. When the impact of travel is considered, the option of home testing with online support starts to look very attractive – from both a convenience and a funding perspective.

Regional and rural areas need to create, and be a part of, developing innovative responses to improving HIV testing, including opportunities to be included in existing and future trials. Initiatives should include utilising the existing community-based outreach clinics, and take advantage of community events and festivals as possible testing venues.

It is early days, but regional and rural communities do not want to miss out on capitalising on the current advances.


1 Joint United Nations Programme on HIV/AIDS (UNAIDS). (2011). Political Declaration on HIV/AIDS: Intensifying our Efforts to Eliminate HIV/AIDS. UNAIDS, Geneva.

2 National Centre in HIV Social Research (NCHSR). (2011). NCHSR Annual Report 2011. NCHSR, the University of NSW, Sydney.

3 Holt, M., Zablotska, I., Lee, E., Ryan, D., Down, D., Heard, T., et al. (2009). Town and country: gay community survey Sydney and regional NSW, August– November 2009. NCHSR, the University of NSW, Sydney.

Dermot Ryan is manager at ACON Southern Region based in the Illawarra.