ASHM Report Back

Clinical posts from members and guests of the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) from various international medical and scientific conferences on HIV, AIDS, viral hepatitis, and sexual health.

By Lauren Coelli.

Refugees from DRC

Client Experiences -

Torture and trauma

Many women have been exposed to HIV through rape and may have witnessed the murder or rape of family members.  Many have fled without their children to safety or experienced the trauma of their children being kidnapped.  

Attitudes to HIV

Highly anxious about the diagnosis, fear of death, fear of transmission, fear of disclosure, discrimination, worry of children's futures and difficulty understanding the need for monitoring and management processes.

Living with HIV-

Confidentiality

Anxiety about attending for monitoring and medication especially if other people from their community or culture are also there.  Distrust of phone interpreters.

Pregnancy

Bottle feeding identifies the mother as having HIV.  Fear of disclosure during pregnancy, anxiety about family and case workers finding out during the monitoring processes.  Baby requiring ART and repeated blood tests being potentially identifying.

Strategies

Build trust and rapport, use a flexible walk-in model and spend time upskilling clinical staff.  Work arounds to avoid identifying HIV status - use of immunocompromised on medical files to reduce risk of disclosure. 

Education needs to include health professional, community, WLWHA and the Men from DRC.

 

 

 

 

Dr Roanna Lobo

There has been significant progress towards the virtual elimination of new HIV transmissions in Australia by 2020.  This is evident by collaboration and community partnerships, combination of prevention strategies such as PrEP, PeP and TasP and the quality of life focus for PLHIV.  

Despite this there are still many challenges with late diagnoses and undiagnosed rates higher in Aboriginal peoples, heterosexuals, SE Asian populations, CaLD communities and other regional communities.  There is both a moral and human rights approach to leave no-one behind.


How can this be achieved -

  • Equitable access to new HIV testing, harm reduction services and biomedical intervention for groups at highest risk
  • Reduce barriers to accessing treatment and care
  • Increase health literacy
  • Meaningful involvement with affected communities
  • Shared care models
  • Improved data and surveillance, research and evaluation
  • Continued investment and partnerships

 

 

“There has probably never been a population both more heavily impacted and less discussed at scientific meetings than the transgender population around the world” Dr Tonia Poteat CROI 2016

This was a recurring theme at the ASHM conference this year and not before time!  Zahra and Teddy spoke to a paper that they plan to launch on World AIDS Day this year.

As background, trans people have been severely underserved in HIV/AIDS responses worldwide, and in Australia, with Victoria as the only state listing trans people as a priority population.

There is a lack of data on the prevalence of trans people living with HIV worldwide, however figures presented were:  19.1% of trans women, limited data for trans men, and no data for non-binary people. Australian figures from the Kirby ACCESS data showed of 696 people, 5.2% were HIV positive - 8.9% for trans women and 4.5% for trans men. However 40% had no gender identity recorded.

An interesting comment was the lack of knowledge by health professionals about trans gender issues and how, as a patient, they end up educating their health providers about trans gender issues, especially when having to meet narrow medical models for care which doesn't always sit well.

I thought this presented quote summed up further risks for HIV for trans people very well:

“Other barriers to health and health care are the numerous socioeconomic determinants of health that legally, economically and socially marginalize trans people. These include discrimination in employment, education, housing, and relationship recognition: police harassment, often as a result of actual or assumed association with sex work; and identity document policies that deny many trans people legal recognition in their true gender. They also include aspects of structural violence such as racism, violence against women, and poverty.”  Open Society Foundation, 2013

So what can we do to support trans people in the HIV response?

  •  Include trans and gender diverse people as priority populations in HIV strategies
  • Start collecting gender and sexuality data better! See attached photo of a suggested way of collecting gender data
  •  Positive interactions with medical community
  •  Access, informed consent
  • Meaningful inclusion in health promotion campaigns
  • Meaningful engagement and decision making by communities

I’ve also included a photo of the fab presenters. Thank you for an articulate and engaging presentation and panel discussion. 

Warning: this report deals with torture, trauma and rape/sexual violence so a trigger warning is provided.

Lauren gave a strong, emotionally challenging presentation regarding the setting up of a specific service to cater for the needs of women who are refugees from the Democratic Republic of the Congo.

Wodonga in regional Victoria began receiving refugees via women at Risk Visa 204 of the Humanitarian Refugee Resettlement program in 2015.

Lauren spoke about the history of trauma, torture and rape that these women had experienced in their former lives and how this impacted on the service delivery model established. She spoke of how these women have been unwilling to engage and maintain engagement in care, and strategies used to resolve this situation.

The Democratic Republic of Congo (DRC) is incredibly unstable with wars that have been ongoing for more than 20 years. There are up to 70 separate militia, with internal mini-wars frequently occurring. DRC has the world’s largest UN peacekeeping force and is described as ‘dangerously unstable’.

Traditional cultural values regarding women’s status are vastly different to our own. For example,  DRC has legislated that a wife ‘owes obedience to her husband’ and  that marital rape is not an offence. Marital rape is common, with 1 in 3 women reporting this. Women have no right to own property or wealth.

Rape has occurred to many of the girls and women of women of the DRC regardless of marital status. The reasons for rape are many reflect both the incredible instability created by war and the powerlessness of the women in the society. These include: punitive rape – to punish or silence; status rape; ceremonial rape; exchange rape as a bargaining tool; theft rape –abduction; and survival rape.

All of the women in the service acquired HIV as a result of rape. Many witnessed the murder of their husband and other family members; kidnapping, rape and loss of their children; were subjected to extreme physical violence and often fled with children other than their own e.g. nieces and nephews. Families fleeing were separated with no knowledge of the whereabouts or outcome of family members.

Attitudes to HIV were very fearful in this community. Fears included disclosure, death, transmission, ostracism and discrimination. Women with HIV are often blamed for the infection. This leads to lack of understanding for reasons both for ongoing monitoring of health but also engagement at all due to fears of being seen at any of the points of care. Some of the strategies to encourage the receiving of healthcare included: not having specific HIV clinics so that clients would not meet each other; flexible walk in model; not noting HIV on medical notes – the generic ‘immunocompromised’ was used instead; and care with interpreters – using only trusted phone interpreters, not using names nor using the term HIV.

Lauren talked about issues around pregnancy; so far they have had one baby born and another baby is due. This involved upskilling of staff – both community health and maternity staff. One GP decided to get her S100 prescribers approval which was a great outcome for the community. However pregnancy and parenting has provided further issues for the women such as questions about why they are bottle feeding,  questions about why the child is receiving medication and having blood tests, as well as fears of disclosure during the contact with health workers.

Lauren saw the future as education involving all those involved: Women living with HIV, men from the DRC, the community and healthcare professionals.

I was very keen to attend this presentation as I work in a sexual health service in a nearby town and state, and this service has offered further choice for HIV care in the regional community.  I congratulate Gateway Health staff – Lauren, Catherine and Ange on this successful ground-up initiative, which is inherently very difficult to achieve. I look forward to refugee women finding a voice to tell their own stories at future events.

 

 

The symposiusm on Trans-inclusion in clinical care was stimulating discussion with a diverse and representative panel facilitating the talk. 

Discussion started with the gender experience rather than identity and the identification of the trans-gendered women, trans-gendered men and non binary people who seek health care.  Important points raised included highlighting the need for education and upskilling of health professionals, if you are unsure, ask...ask about pronouns; ask "are you enjoying the sex you are having?", ask about the body parts used.  There is decreased sexual health literacy in this group as they feel they "aren't part of the conversation".

In relation to HIV, the concern was that they are "not seen as a target group" by some, and yet trans women who have sex with men have higher rates than MSM groups.

Another important point around health for trans people raised was that there is not one group who takes the lead for Trans Health Care and this needs to happen - a Mandate for Trans Health!  Normalised Health Care with GPs who are comfortable rather than care by endocrinologists is the way forward.  

 

 

Please join us for a memorial event celebrating the life of one of Australia’s leading HIV advocates, Levinia Crook… https://t.co/N7dof5xaGa

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