Article Title:Facing up to the second wave of HIV
Category:HIV
Author or Credit:Chris Banks
Published on:27th March 2004 - 12:00 pm
Published by:GayNZ.com
Story ID:192
Text:New HIV infection rates amongst gay men have surged to the highest level for a decade and the graph is pointing upwards. Why is this so, and what does the AIDS Foundation plan to do next, asks Chris Banks. Last month the New Zealand AIDS Foundation announced to the country that 2003 had seen the highest numbers of new HIV infections ever. A media blitz saw HIV being discussed on television, radio and newspapers in depth for the first time in years. The widely-feared second wave of HIV infections in gay men had hit with a vengeance. The figures look bad – very bad. But, as the Foundation acknowledges, this phenomenon is not new. Infection rates have been rising steadily overseas for a number of years now, and even in New Zealand a rising trend has been apparent as far back as 2001. One look at the epidemiology graph reveals an upward curve that looks disturbingly similar to the period 1985-88, when the first wave of the epidemic kicked in. This was a time when very little was known about HIV, its transmission, and how to prevent it. Towards the end of this period the safe sex message and public campaigning really began in earnest, which paid off with declining numbers of new infections in 1988-90. What's truly frightening, however, is the knowledge that we have already surpassed the first peak of the epidemic with the latest numbers, yet there is nothing to suggest that 2003's figures will level off. We now live in a time when HIV/AIDS education and campaigning has been going on steadily for over a decade. Dare we ask what figures are projected for 2004? “It's difficult to make projections at any time during an epidemic,” says the Foundation's research director, Tony Hughes. “The numbers are still relatively small in a population of 4 million, but it's evidence of a change in the picture of this epidemic the like of which we haven't seen since the beginning. If you were to ask me what is 2004 going to look like, I'm a scientist... I can't say, but I have to say I'm worried.” Rachael LeMesurier, the Foundation's executive director, agrees, and suggests that there needs to be greater examination of what the 2003 figures actually mean. “I don't think there's been any great deal of thought around what the future may look like other than ‘bad',” she says. “I think that what's most apparent is people who have been tested last year as positive are highly unlikely to have caught the infection last year. It's more than likely from the statistics that a significant number got it the year before, maybe even a couple of years before that.” LeMesurier says there is the constant problem of delay when working with the epidemic. Any changes made now in respect to increased media coverage or different campaigns may not change behaviour for 4-6 months, which would actually result in people getting tested 6-8 months after that. The 2003 figures are frustrating in light of the fact that the Foundation has been increasing its output over the last few years, she says. “For the last year and a half we have been pouring material out, it has been going out in massive quantities,” Hughes confirms. “It's all very well to put a message out there but we don't know about the receptivity. Receptivity was very high in the early days of the epidemic because people were very concerned about it. People do things to protect their health when they sense they need to.” So if nobody's listening, then what's wrong with the message? What feedback has there been from the community? The Foundation's health promotions manager Kerry Price says they engage in focus groups for testing their campaigns, but these groups are used more for testing style and delivery mechanisms rather than content – ie. the colour of the brochures. But he is adamant that community feedback is taken on board. “Whether people believe me or not, we are actually constantly listening to what people say in the community. There are health promoters out there on the ground, listening to things and feeding back stuff into the campaign,” he says. “People make a lot of assumptions about what needs to happen, but the fact is research actually shows us what's really going on, so we use that.” A great amount of community feedback has been asking the Foundation to concentrate on mainstream media more, which is isn't always easy because of the cost involved. However, he says, the Foundation is looking into a strategically-placed billboard campaign. What are we likely to see on the billboards, though? The Foundation's last attempt at a billboard campaign was the infamous National Penis Day in 2002, which was blocked at the starting gate by community watchdogs who didn't want pictures of penises displayed on billboards. Could that be part of the problem? Has an organisation dedicated to the reduction of an infectious disease sexed things up too much in its presentation? “The NZAF is not dedicated to the reduction of sex,” LeMesurier counters. “I think one of the fundamental things about how we've always operated is to ensure that our community is healthy and well, and that means ensuring that issues of discrimination, stigma, and negative factors that can impact on someone's self-esteem are also part of our campaign. “We will never cease to say that sex is a positive, healthy aspect of our integral spirit, and we will always be encouraging safer sex. However, we need to make sure that people are doing that in an informed way, and right now we don't believe they are.” Hughes stresses that it is important to realise that the rise in HIV infections now are taking place in an entirely different context to the first wave. “There was an enormous amount of social awareness and concern in the early days of the epidemic, due to there being no treatments available and the fact that it was new,” he says. “People tend to accomodate things that are new – look at the public response generated by SARS and bird flu for example. People notice it, the media cover it left right and centre.” One startling revelation amongst the figures showed that the highest increases were among men aged between 30-39, who should theoretically know about the safe sex message, but that's only one of the many issues perplexing the Foundation – there's also the possibility that people just don't want to listen. Could the new infections be among a core group of people who simply have a different risk-taking psychological profile? “There are people who are naturally protective of their health in all areas, they don't drink, don't smoke, etc. They have a different risk-taking profile, probably in a whole range of issues, not just health, and these are the individuals that I suspect are long-term committed to condom use,” says Hughes. “But we all know there are some people who don't have the same level of concern about the consequences of their behaviours, and we have to understand more about that.” Without diminishing the severity of the new figures, the Foundation feels New Zealand should be proud of the fact that the rate of infection compared to the size of the MSM population has been kept so low. Surely an advantage of this is that research into causes should be easier to carry out, with such a small number of infected people to talk to? “There are many parties involved in the collection of that data,” says LeMesurier. “The majority of reports come through GPs. They have thousands of forms to complete across the range of things that they have to do. To ask for another page of questions, in the view of the AIDS Epidemiology Group, risks the whole thing not being completed effectively. The collection of the data is inadequate because of the huge weight that falls on the GPs in general.” Research is carried out through people who come to the Foundation via avenues such as the Burnett Centre, but the numbers are statistically quite low. “We're not likely to see a greater level of that sort of information in the future. We are only a population of 4 million. Our ability to get data out of a small pool is challenging.” The public face of HIV has changed over the past decade. It has morphed from one of death and emaciation to healthy, happy, rock-climbing, windsurfing studs whose lives are seemingly even better with the virus, thanks to the miracle of pharmaceuticals. Drug companies have been heavily criticised for the imagery they use to sell their wares, but in the absence of any countering argument, are the bronzed antiretroviral pinups merely filling a vacuum? The cumulative effect of less visible death throughout the 90s cannot be underrated, LeMesurier believes, as it has led to the risk fading into the background. “What was happening in the 80s/early 90s is that people were dying, and they were dying unpleasantly. Those are really significant drivers for changing your behaviour. If someone you love dies of AIDS, you're far more likely to look after yourself and make sure others do.” So, if the real risk has faded from public consciousness somewhat, is it time to bring out the heavy artillery and disturb people with the reality of what HIV leads to? Sickness and death? “Well, I think the problem is that there may not be more people dying this year, or next year, or the third year, but there sure as hell will be at some point in the future because we've got more people, and the drugs are not always going to be there,” says LeMesurier. “[But] it's a bit like telling a young guy not to get in a car and get drunk, because he'll always say that won't happen to me. Far more important to work with him about how to stay safe in the car, work on different formulas. That's sort of what were looking at now, how to get family, partners and friends to remind everyone about safe sex.” But there were 93 new MSM infections in 2003, and though it may be considered insensitive to say so, that means 93 more people dead. It may not happen next week, but it is going to happen. Why not promote that? “We can lose some credibility if the actual numbers of people who are that sick aren't as high as it may appear. There are lots of people dying in car crashes, we all know someone who's been in a car crash, so when you see it on TV or on a poster, it does resonate through. These days, there's not as many people who know someone who's ill. We think there will be more, but until that happens, we risk not being believed.” So what can the Foundation do? “Trying to find out what's going on is multi-faceted. The first thing is to find out what researchers in other communities around the world are doing. Already there is data which has been referred to in this report, we'll be looking to see how many more of those types of articles are coming through. GAPSS (Gay Auckland Periodic Sex Survey) is coming through its second year, there will be hopefully data out of that around behaviour that will help us understand what's going on.” “We should work with what we have got now, and that is a myth about living with HIV” according to Lemesurier. “Right now there are plenty of men who are struggling, who aren't having a good time, who are risking losing their jobs and their livelihood, who have ongoing exhaustion, diarrhoea, nightmares... that's the reality, and we need to have what we're saying being affirmed by what people feel, see and know. Our campaign will be to talk about HIV realities.” HIV Realities is a forthcoming campaign. Kerry Price says it is the most negative campaign they've engaged in for a long while, and there is concern about taking it too far. “I think there is a fine line when dealing with negative images. In this campaign we're looking at working with HIV+ men to get them to deliver the message. We don't want to be stigmatising or making the lives of HIV+ men worse whilst trying to deliver a message about what it's really like living with HIV,” he says. “We're also talking through how people will receive these messages. We don't want to do something that's so far to the left that it turns people off and they don't actually look at what the messages are.” Another HIV reality is the fact that overseas trends were showing a rise in infections several years before our own. An NZAF discussion paper prepared by the Hughes in December 2002 notes his feeling that it is time to “develop some short, fresh and uncomplicated messages around HIV prevention for MSM that require little effort to read or understand”. In examining campaigns used overseas, Hughes said he believed that too many were assuming sophisticated knowledge, and that New Zealand should be moving in the opposite direction and focussing on “clear and basic advice”. Despite the change in the context of the epidemic, the basic prevention method has not changed. Even with the wider range of treatments available, the definitive method of HIV prevention is the use of condoms. Has this simple and universal truth been communicated simply and effectively enough through the NZAF's recent campaigns? Price believes so. He says the simplicity of the messages is always a consideration in the development stage, and cites the recent Roger the Ranger “Risk-o-Meter” as an example. Forthcoming campaigns, including HIV Realities, will have similarly clear and simple messages. “We're aware that a lot of people haven't had contact with an HIV+ person. They don't know what it means to live on treatments,” says Price. “So we'll be addressing that in this campaign, along with treatment issues, side effects, non-availability of drugs, the assumption that taking a simple pill will keep you well, psychosocial aspects of living with HIV – disclosure, power imbalances between men, desirability, risk-taking...we'll also be talking about assertiveness in using condoms.” There's a cocktail of complex issues to be addressed there. How will this be distilled into something digestable? “There will be a unifying theme for it, but we're not that far along yet, we're still in the formative stages. With the release of the latest stats, our thinking was that it would actually be a good time to put something out quickly – so within the next 4-6 weeks we'll have some material released that will be a leader for the main campaign, supporting the core messages.” When GayNZ.com spoke to Rachael LeMesurier last year, a few weeks after her appointment, we asked her to outline her goals for the coming year, one of which included a review of the Foundation's infrastructure. In light of the severity of the latest figures, is it time for the Foundation to re-examine not only its messages, but itself? Will the infrastructure review be brought forward? "I believe that constant review is a healthy way to manage any organisation and have the staff involved in that management, so we remain flexible and responsive and nothing remains rigidly in concrete," LeMesurier says. "The infrastructure review is partly about me getting to know it, and I think there may well be tweaking that was going to happen anyway... there's also a quality accreditation programme that we're going through that staff are leading, they will be coming up with things that they feel they've been wanting to change or be improved." LeMesurier describes the timeframe for discussions and strategy as "ongoing". The NZAF's first public assault was visible with the flurry of media coverage on announcement of the epidemiology figures, which gave the distinct impression that there was an embattled council of war at work within the Foundation. “There is. But we're dealing with human behaviour. So you have to have a whole range of weapons. There are different groups in there. In respect of what are we going to do, what we're doing is what we're doing, we just have to try and crank up the message. Perhaps find new places to put it, try to work more directly with gay men in the community, and say – it's not just us, we haven't got the sole answer to this. We really need everybody to be sitting thinking how this is going to be done.” Both Hughes and Price are encouraging more feedback from the community as well. “Various mechanisms and various places round the country are used to recruit our focus groups,” Price says. “We haven't found advertising particularly successful for doing that. But if people want to participate in them, all they need to do is give us a call. We keeps lists of people.” LeMesurier is ensuring that they're not just waiting for the phone to ring, however. A full-time communications co-ordinator position has been created within the last week to focus solely on strengthening the Foundation's relationship through the mainstream media, and there are community forums being planned. “We're thinking of having forums for the gay community with the question being, what's going on, what can we do about it because it is about 'we'," she says. "It's not the AIDS Foundation, it's not the gay community on its own, it's about everybody together, because we do feel that we've got to find out why, and then we have to work together to try and revamp the safer sex message because that hasn't gone away." Chris Banks - 27th March 2004    
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