Unique Territory: an overview of the HIV epidemic in the Northern Territory

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

PANOS COUROS¹ examines current and emerging challenges in providing HIV services to some of Australia’s most diverse communities.

There is nothing typical about the Northern Territory (NT). A region of vast dimension and diversity, it is the third largest Australian federal division. Despite this it is populated with only 233,000 people, making it the least populated state or territory in Australia,² representing 1% of the total population.

The Northern Territory has two distinctive climate zones. The northern end (commonly known as the ‘Top End’) includes Darwin, Katherine and Nhulunbuy and has a tropical climate with high humidity and two seasons, while the desert centre of the country (‘the Centre’) is a semi-arid central area which includes Alice Springs, Tenant Creek and Uluru. All of the Northern Territory is considered regional or remote.

Due to the unique history of the Territory, the population demographics are different from the rest of Australia. Trading began here over 500 years ago with the people of what is now mainly Indonesia and PNG, and the diversity of culture has been an ongoing feature of the Top End ever since. More than 100 nationalities are represented in the Northern Territory’s population, with more than 50 organisations representing various ethnic groups.³

The 2011 Census shows that Indigenous Australian people make up 26.8% of the Northern Territory’s population.⁴ All of this basic demographic information helps us to understand how HIV has affected the Northern Territory since records began in 1985.

While in the early years of the epidemic the HIV notification patterns were in line with national trends, with gay men presenting as the foremost affected population, we have seen this pattern shift significantly – especially over the past 10 years.

Figures published by the NT Department of Health in 2010 show that overall almost 60% of all diagnosed HIV cases in the NT were acquired through unprotected heterosexual sex, which is quite different compared to the rest of Australia at 27%.⁵

Also surprising is whilst the NT has the highest rate ofthere is a relatively low proportion of HIV exposure in these populations, being 8.5%.⁶

Compared to the national figures, a large proportion of cases have been diagnosed in primary health care or hospital settings and these also often fall outside of the recognised risk groups.

The majority of heterosexual cases have been associated with the person having a sexual partner from a high prevalence country.⁷

In response to these figures, the Royal Darwin Hospital has recently introduced policy that recommends HIV testing to be conducted on all adults admitted by the Division of Medicine. A guideline released by the NT Department of Health on 4 September 2012 stated:

‘In order to both improve individual outcomes, and reduce transmission to other people, an increase in HIV testing is needed.

‘In keeping with this aim routine opt out testing for HIV on admission to all health facilities is now recommended in the USA, UK and France.’ ⁸

Whilst there have only been 203 notifications of HIV in the Northern Territory, proportionally this figure is 0.087% compared with the national rate of 0.14%.⁹

Currently most people with HIV living in the Northern Territory live in Darwin, with some in Katherine and Nhulunbuy and the remainder in Alice Springs.

There are currently no cases of Aboriginal people being managed in remote communities.

Until recently NT prisons had a policy of mandatory testing for HIV and due to the high rates of incarceration of indigenous people passing through NT prisons, this gave a reasonable indication of HIV rates in remote Aboriginal communities.

Whilst mandatory testing has now ceased, in keeping the current national HIV testing policy, the prison health service is supported to provide access to routine testing with informed consent.

Also, with high birth rates among indigenous women, the national recommendation that pregnant women be tested for HIV is practised in the NT. Overall the surveillance data continues to give us a clear picture that HIV remains relatively localised within these centers.

Another large pool of HIV in the NT can be found in people arriving as either refugees or sponsored work visas, as well as in people travelling from Darwin to South East Asia.

Clinical services for HIV are delivered by the NT Department of Health’s Sexual Health and Blood Borne Virus Unit, Centre for Disease Control. These are called Clinic 34 and are run out of clinics in Darwin, Katherine and Alice Springs. Staffing for the clinic includes a HIV nurse on a three day per week basis in Darwin and a sexual health nurse in Alice Springs¹⁰ and Katherine.

There is one full-time doctor in Alice Springs and one full-time and one part-time doctor in Darwin. Attracting qualified medical staff is a real and constant challenge to the NT and retaining HIV specialists in the NT has been a consistent problem.

The Northern Territory AIDS and Hepatitis Council (NTAHC) is the main support service in the Northern Territory, with offices in Darwin and Alice Springs. The principle role of NTAHC is to provide care and support for people living with HIV, often via a shared care arrangement with Clinic 34.

NTAHC is at the forefront in the delivery of prevention interventions and community education programs to affected individuals and communities.

The specific challenges faced in the NT in delivering effective prevention messages are complex. In particular, communication strategies used with other jurisdictions may not work with the same effectiveness here due to the socio-demographic and geographic differences.

Many online and print resources are developed with a specific target audience in mind, and this is not easily translatable to people in the Territory. Although this material can be disseminated, the reach and effectiveness of this information is still limited due to the uniqueness of our target audiences, and due to the fact that these external resources are not developed with our audiences or context in mind.

NTAHC has responded by producing bold pictorial in-house information and education resources, which began with the ‘Keeping our Blood Strong’ campaign launched in 2011.¹¹ This has met with wide praise from many of NTAHCs priority populations.

NTAHC provides services that are both responsive to community and consumer needs whilst addressing the emerging issues in HIV care and support.

Our care and support services for people living with HIV respond to accommodation and housing difficulties; issues regarding stigma and discrimination and disclosure of HIV status; the need to establish and maintain primary and specialist care relationships; nutrition education; promotion of safe sex behaviour; and the need to reduce harms associated with injecting drug use.

NTAHC also prioritises viral hepatitis (B and C) programs and activities. NTAHC delivers three primary needle and syringe programs (NSP), outlets the NT Sex Worker Outreach Project from Alice Springs and Darwin, and an Aboriginal and Torres Strait Islander Sexual Health Program.

In both Darwin and Alice Springs the issues around low-income and accommodation are significant. The NTAHC Alice Springs Program Coordinator, Jyoti Jadeja, reports that stigma and lack of information around HIV are still major issues for people with HIV in Central Australia.

She states, ‘People who live in towns may have heard of HIV, while in remote communities their knowledge on HIV is almost nonexistent.’

NTAHC runs regular support groups for people living with HIV in Darwin in the form of weekly lunches and a quarterly event called Eat, Indulge, Connect (EIC). This event combines the novelty of a live chef cooking session around a dinner party with up-to-date nutritional advice from visiting HIV specialist dietician Jenny McDonald.

The sessions have health themes, such as the renal system and kidney function; cardiovascular health; oral health; diet and nutritional – low income cooking.

EIC has been steadily growing in popularity since its inception in 2011. In June 2012, Nurse Mim O’Flynn and Jenny McDonald joined forces with NTAHC to provide our first HAART to Heart/EIC session for people living with HIV.

Future challenges

An emerging concern among populations of people living with HIV is ageing, with most people utilising NTAHC’s services being 50 years of age or over. We are seeing a considerable challenge for our ageing HIV population relating to primary care.

Access to a good GP is becoming far more difficult, with only one GP in Darwin who has HIV experience and a handful of GPs who see HIV-positive clients for general physical health checks.

This factor combined with the cost of travel to GPs in Darwin or Alice Springs poses some daunting prospects in terms of future access to health care for HIV-positive people.

Compare this to life in Sydney or Melbourne where people have a choice of GPs that can deal both with specific HIV and general health issues, most people in the Northern Territory need a separate GP for issues that are not HIV-related.

Craig Cooper, NTAHC’s Executive Director, sees the growth area for NTAHC services focus on dealing with the ageing HIV-positive population. This will necessitate the development of strategies to deal with complex care and support needs such as out of home care or other care and support options.

With an ageing population, an older HIVpositive population, advanced HIV disease, as well as other co-morbidities associated with living longer with HIV, this will be a challenging body of work as there is limited understanding within the health system about how to meet the needs of people living with HIV.

To begin with, there will be low numbers presenting in acute and chronic hospital admissions, but over time this will become a large proportion of NTAHC’s work.

How best to reach people unknown or disengaged from the health system also poses a challenge. These are clients who are not engaged with NTAHC or Clinic 34. The new hospital testing policy is likely to identify increasing numbers of late presenters.

The challenge for Clinic 34 and NTAHC will be to have adaptive and accessible services that people living with HIV feel comfortable returning to in times of needs, especially when they’re lost to follow-up.

Overall the situation in the Northern Territory presents a very different picture to many other parts of Australia and there is often an assumption that what occurs nationally – even at a regional or remote level – is then easily translatable or transferrable to the Territory.

Because of the unique set of circumstances that shape the history and demographics of the Northern Territory, the remoteness of many desert communities, and the unique multicultural mix that is found in the Top End – as well as its proximity to areas of high HIV prevalence – we see a different picture here.

These differences are very important to consider whenever national strategies, in particular communication strategies, are being designed. This is unique territory.

References

1 With input from Craig Cooper, Executive Director, NTAHC and Jyoti Jadeja, NTAHC Alice Springs Coordinator.

2 Australian Bureau of Statistics. (27 Sep, 2012). 3101.0 – Australian Demographic Statistics, Mar 2012.

3 Northern Territory Government. (2007, 14 June). Our Different Cultures. Northern Territory Government, Darwin.

4 Australian Bureau of Statistics. (2011). Census QuickStats, Northern Territory. Retrieved from: http://bit.ly/WKFaC6

5 Holt, J. (2010). The Northern Territory Disease Control Bulletin Vol 17(2), 9.

6 Personal communication, Jiunn-Yih Su, Department of Health, Northern Territory Government.

7 Ryder, N. (2010). Newly diagnosed HIV infection in the Northern Territory, 2003– 2009. The Northern Territory Disease Control Bulletin, 17(3), 27–29.

8 Ryder, N., Broadfoot, J., Currie, B. (2012). RDH IFD: HIV Testing Guideline for Adults Admitted Under A Division Of Medicine Bedcard. Northern Territory Government, Darwin.

9 The Kirby Institute. (2012). HIV, viral hepatitis and sexually transmissible infections in Australia Annual Surveillance Report 2012. The Kirby Institute, the University of New South Wales, Sydney.

10 On writing, this position is recruiting. Staffing is currently a half day per week.

11 Northern Territory AIDS and Hepatitis Council (NTAHC). (2011). Blood-borne Virus campaign (includes posters, cards, online animations). Retrieved from: http://on.fb.me/VTXTM4

Panos Couros is Care and Support Coordinator at NTAHC.