Sexual Health from an Indigenous Perspective

Professor Gracelyn Smallwood

Prof. Smallwood, a Professor of Nursing and Midwifery at Central Queensland University lead an inspiring session, capturing the audience’s attention not only with her outstanding achievements on a global level but her strong presence, proud ties to her Indigenous heritage and great sense of humour.

Coming from a family of 19 children, Prof. Smallwood’s rise to success has been remarkable. As a young Indigenous female, stating “I want to be a doctor and I want to buy a pair of shoes” her parents ensured she strived towards what they called “a white education” to achieve her goals. Progressing through the world of academia from Midwifery to Masters and later PhD and even meeting Nelson Mandela, Prof. Smallwood has excelled as a global leader in sexual health.

“Name a disease, you name it, they’ve got it”, referring to her people, seemed to be an inspiration for her efforts to achieve greater health outcomes for Indigenous communities.

While Prof. Smallwood has worked on many International projects, what stood out the most was her success in designing and implementing a culturally appropriate program “Condoman”, as an alternative to the famous 1997 Grim Reaper HIV campaign. Pushing barriers, Prof. Smallwood recruited a young, fit Indigenous footy player to dress up as Condoman in a tight lycra outfit to roll out their campaign and it was an absolute hit! Their aim was to promote the use of condoms to minimise disease transmission in Indigenous communities. The impact of the campaign was recognised on a global scale, attracting International attention and support from the World Health Organization.

A take home message was that her people are not after ‘Equality’, they are after ‘Equity’. We need to empower Indigenous communities, increase their access to health care, educate and uphold their human rights.

Started in Cairns in 2014-

Prominently young indigenous males, facing social challenges consistng of poor housing situations, employment issues, drug and alcohol use, high mobility and low health literacy.  MSM and sporadic IDU use.  Coinfection with STI's especially syphilis.

Challenges -

Low levels of testing occurring in this group, with individuals not identifying as being at risk, low health literacy and lack of knowledge of HIV.  Knowledge of TasP poor and known sporadic engagement with health services and treatment compliance issues.  Stigma, shame, cultural factors and lack of trust are contributing to challenges in culturally appropriate contact tracing.

The way forward-

Urgent culturally appropriate health promotion activities, increasing point of care testing, access to condoms,TasP, PrEP, NSP's.  Treatment and support needs to be individualised using a multidisciplinary outreach approach.

HIV infection in young people in Australia has thus far not been well characterized. In the  ‘Trials, Treatment and Toxicity’ session, Dr Carly Hughes from Monash Medical Centre in Melbourne used the Australian HIV observational database (AHOD) to compare demographics between adolescents/young adults (13-24yo) to those over 25years. She described the need to further characterize the population of young adults who are newly diagnosed, given the complexity adolescence and young adulthood places on management of chronic diseases. This has been experienced in other sectors such as patients with type 1 diabetes. Main points from the presentation:

-       223 new diagnoses of HIV were made in those <25 years of age since 1997

-       A significantly higher proportion if females are represented in new diagnoses made in young adults (<25years) compared to over 25

-       The <25yo group had higher CD4 counts and lower VL at diagnosis, but this difference was lost at time of treatment initiation

-       There was significantly higher loss-to-follow up in the <25yo group  compared to >25yo (incidence rate of 8.8 vs 4.68 per 100 person years)

-       There were significantly higher rates of treatment interruption in the <25yo group

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Data from this study highlights the challenges of managing adolescents and young adults with newly diagnosed HIV and the need for additional methods to engage younger adults in medical care. Social support networks could play a role here - the opening plenary talk by Nic Holas on ‘Living with HIV online’ discussed the growing role of online support networks for people living with HIV. He described the role his online support network , 'The Institute of Many' (TIM), has played over the last few years in providing another avenue for people living with HIV to obtain information and find additional support. Clinicians could play an increasing role in this space to help engage younger individuals.

Integrated service provision is essential in the delivery of consumer-centred care that is accessible, acceptable and affordable.  Through ongoing engagement with the key populations in the community, services can be mapped to ensure that there is ongoing assessment of marginalised communities in particular those living with HIV, multiple co-morbidities and poor social situations.  Access doesn't always equate to acceptable services it therefore is essential to consider what the community identifies they need and considers safe.  Signalling safety is best achieved with a broad approach through the multiple social layers.  Partner organisations play a pivotal role in extending access to prevention strategies aimed at improved consumer outcomes.  This holistic address of multiple needs can only be achieved through enabling service principles that are integrated and promote, equitable, affordable, acceptable services to exist within the communities most in need.

Professor Michael Levy, Australian National University, ACT, Australia

Within this session, Professor Michael Levy discussed harm minimisation strategies within the prison environment, including the controversial provision of a needle exchange program in Alexander Maconochie Centre (Prison), Australian Capital Territory (ACT), Australia and achievements in reaching global targets for hepatitis C treatment.

Prof. Levy, a tireless advocate for prison needle and syringe programs, led us through the session by providing a background on the situation and the barriers encountered.

His passion was clear as he spoke about the frustrations of being so close yet so far from achieving the ultimate goal of implementing a needle exchange program in the ACT. Prof. Levy expressed the challenges faced in getting Corrective Services to share the same enthusiasm.

The event that occurred in 1990 in New South Wales, Australia where a detainee living with HIV used a blood-filled syringe to stab an Officer who subsequently died still remains a major barrier to moving forward in the harm reduction response. This case, he states, is nested within Professor Kate Dolan’s PhD thesis on HIV transmission in Australia. Since this time, agitation among Corrective Services has remained.

While Switzerland is recognised as the leader, commencing the first needle exchange program in prison in the world, various other countries have progressed, implementing programs since. However, this progression is yet to follow in Australia, where we sadly lag behind other countries in the global response.

The ACT had an aspirational plan to comply with the human rights of prisoners, advocating for the equivalence of healthcare by recommending a needle exchange pilot to minimise the transmission of disease, however their efforts were to no avail.   

While there is Government commitment from the Greens, the ACT Human Rights Commission, the Australian Medical Association and Public Health Association, the battle continues. While harm minimisation programs such as needle exchange services are yet to be implemented, other strategies such as therapeutic prevention, such as hepatitis C treatment, have been adopted as an alternative to managing the within prison risk behaviours of the sharing of syringes.

Prof. Levy discusses the remarkable achievements in reaching global targets of a reduction in hepatitis C prevalence. From a HCV Ab prevalence of 48% in 2010, to 20% in October 2016, an impressive reduction was achieved in just 18 months.

What we can be assured of is that while passionate leaders in global health such as Prof. Levy continue to be at the forefront, striving for improved public health outcomes, there is still hope. The dream may one day become a reality, where we see prison needle exchange programs, achieving universal health for all as we know ‘good prison health is good public health’.