Sat 30 Nov 2013 In: Health and HIV View at Wayback View at NDHA
PART ONE: SUCCESS VS FAILURE PART TWO: DIVERGING PREVENTION PATHS By 1985 HIV/AIDS was front and centre on the world health agenda. Clinicians struggled to understand it, gay communities fought valiantly against it. Leading western politicians still railed against the homos who had been unwittingly infecting each other and post-colonial African power-brokers dismissed it, and homosexuality, as white men's diseases. Movie idol and TV star Rock Hudson soon became the first of many international celebrities to publicly die from HIV infection. In New Zealand Bruce Burnett died but left a legacy of nascent groups supporting those infected and trawling through the latest international theories of treatment and prevention. Lew Prime Over the coming years three highly-reported cases of HIV and AIDS started to shape public opinion here. '60s pop singer and latterly boss of the Auckland Rugby Union, Lew Prime, was revealed to be infected and dying. To national acclaim a little HIV-positive Australian girl, Eve van Grafhorst, very publicly fled schoolyard and official persecution in her homeland to the embrace of a more caring Kiwi community in Hawkes Bay. And African singer and chick-magnet Peter Mwai left a trail of HIV-positive women throughout the country, illustrating the dangers of unchecked HIV spread. As our small HIV support groups merged bit by bit, the better to lobby government and pool resources, they attracted highly motivated gay men on a mission, some with a history of social and environmental reform. They already knew the dos and don'ts of lobbying the public and government, and the biggest lesson they brought with them was that government bureaucrats can't ignore demonstrable facts. They were also aided by the head-start northern hemisphere gay communities had in addressing the epidemic. NZ was several years behind in the spread of HIV and its consequences. They could learn from the successes and failures of other countries, piggyback on international research and conduct small local research programmes to verify the situation here. A change of government in 1984 had seen the socially-progressive Labour party start to shake up the country's conservative complacency. In the crucial late-1980s Helen Clark was, as then-Minister of Health, a staunch and clear-headed ally at the highest levels of power and influence. Pink Triangle announces NZ's first government funding for HIV community work in June '85 The new government listened and backed logical, forward-thinking and compassionate action. More importantly, it stayed at arm’s length and handed over the funding and authority to gay men (and, separately, intravenous drug users and sex workers). The main at-risk groups were thus empowered, the programmes which emerged targeting men who have sex with men were controlled by our own community, the tenor of the work done increasingly reflected the reality of our sex lives. A viciously-contested but ultimately successful campaign for decriminalisation of homosexual acts brought the reality of gay lives into the nation's livingrooms via generally fair and un-judgemental, by international standards, media coverage. Some of the fairness was part of the innate New Zealand culture, the rest had to be worked for by generally amateur and always unpaid lobbyists and strategists, reinforcing positive attitudes and coverage, instantly and aggressively countering the negativity and bigotry with facts, realities and humanity. Those in charge of the country came to see that if gay men remained stigmatised, marginalised and criminalised no amount of HIV prevention work would reach them. The bill was signed into law on July 11, 1986. Despite the thundered warnings of those who had seen HIV/AIDS as another stick with which to beat down gay men even further, freeing us from officially mandated persecution did not lead to heaps more gay sex and therefore heaps more HIV. Quite the opposite. The nation breathed a sigh of relief and the educators and medics got on with the job. This same spirit flavoured media coverage of HIV and the NZ AIDS Foundation, which had evolved from the earlier fragmented groups, became a sane, sensible, well-briefed and non-threatening voice promoting condom use for anal sex. Despite huffing and puffing from church groups and dinosaur politicians the NZAF and the gay communities managed to maintain the high ground and as the 1980s segued into the '90s, and as the number of gay deaths stemming from HIV/AIDS soared, something quite remarkable happened. In the background the rate of newly-diagnosed HIV infections amongst gay and bi men plateaued off and even began to fall. From around 80 per year in the late 1980s the annual diagnosis figure for gay and bi men dropped to the low 30s by the end of the 1990s. It was a brilliant success, at least in line with, and generally way better than, results in similar gay populations in other western nations. Condoms and condom promotion clearly worked. But then subtle shifts began to occur. Advances in treatments which would have seemed miraculous only ten years earlier lowered the HIV-related death rate. AIDS and AIDS-related deaths became a rarity, as they are today. In gay communities everywhere the pool of HIV-infected men who were now living comparatively normal lives greatly increased. They felt well and wanted to get back to 'normal.' For some 'normal' meant not having to worry about condoms which they saw as intruding on their sexual pleasure and sense of well-being. Many uninfected men yearned to be able to have sex free of the constant reminder of the existence of grim sexually-transmitted diseases that condom use represented. All around the world 'condom fatigue' began to set in amongst men who have sex with men and two responses emerged: stick with and re-articulate the 'condoms every time' message, or re-tool for changing times. From a 1992 Australian campaign Strong lobbying by HIV-positive men and some clinicians in Australia, for example, saw a relaxation of the 'condoms for anal sex every time' mantra. Instead, a complex self-policing check-list was introduced to guide men in relationships into deciding whether or not they needed to use condoms in various situations. If two guys 'knew' each other didn't have HIV they could forgo condoms, as there was supposedly no danger of one picking up HIV from the other. But who really knew? Most men with HIV still didn't actually know they had it. And who was going to wait weeks for test results when they were horny right now! The word was out: condoms aren't always all that necessary! And you probably wouldn't die from it any more! And young gay guys, not traumatised by the wave of deaths as their oldre peers had been, didn't quite have the same sense of fear of HIV. Another downside was that this new approach reinforced the feeling of many highly sexually active HIV-positive men that if both partners had HIV, or thought they did, then condoms were no practical use for them either. After all they both already had it, or probably had it, so what was there to lose? And a related convention, particularly in highly-infected gay Sydney, and which was never successfully countered, emerged that if a guy said "we don't need to use condoms do we?" he meant he was already HIV-positive and was checking that the other guy was too. (The reverse remains the case in New Zealand.) Very quickly Australia's condom horse had bolted. In New Zealand, however, the condom every time mantra was adhered to due to its proven worth and the lack of evidence that Negotiated Safety, as the check-list system was called, was a viable community strategy. The sighs and derision were almost audible across the Tasman as the Aussies watched the NZAF and our gay communities determinedly stick to what they considered an outdated and simplistic philosophy. In essence, they advised, guys hate condoms so show them when and how they can not use condoms, hopefully safely. Negotiated Safety was to prove unsuccessful, even more-so when the emerging internet magnified the hunger of every horny gay man, HIV-positive or not, to hook up as often as he could find a willing partner. As the new millennium kicked in and the number of sexual encounters and partners shot up, so did the rates of new HIV infections amongst gay and bi men all around the online world. In New Zealand the resultant rise in infection rates was disturbing, in those countries which had relaxed their promotion of total condom use it was catastrophic. Frequently held to account by the gay communities and sometimes found wanting, in New Zealand the increasingly lonely NZAF nevertheless maintained the on-going support of our communities and was able to hold its ground. At international conferences it publicly took issue with the drift away from proven, research-based prevention programmes, but no-one much listened. At home it thrust it’s easy to convey and understand 'condoms every time' message deep into the internet, re-tooling its delivery but not its core message. Overseas, HIV prevention campaigns flailed and misfired. Complex messages and a now established pattern of condom avoidance spiralled out of control, fostering cultures of barebacking and worse with with prevention campaigns making barely a dent. The difference was stark and basic. New Zealand gay and bi men were, on the whole, sufficiently inculcated with the 'condoms every time' message that they carried it into all their sexual exploits. Attitudinal research in 2011 conducted by Gay Auckland Periodic Sex Survey indicated that 80% of gay and bi kiwis use condoms most or all of the time for anal sex with casual partners. It's a high enough level to make a serious difference on a personal and a community level. Their Aussie counterparts, to continue to use our nearest neighbours as an example of the sort of thing happening in much of the rest of the world, were too often in a very different head-space. Over the past decade the rate of locally-contracted new infections amongst men who have sex with men in New Zealand first levelled off then trended back down. Over the past two years, according statistics released in March by the AIDS Epidemiology Group at Otago University, the rate has dropped by around twelve percent. In Australia, to compare with our nearest non-New Zealand example, the rate amongst men who have sex with men has continued to soar year by year, up by a staggering twenty six percent over just the past two years. The picture is the same amongst men who have sex with men in most other countries, whether affluent or developing. Whilst other countries have rising rates of new infections year by year, New Zealand has levelled off and is trending back down. It's hard to avoid the conclusion that, when it comes to limiting the spread of HIV amongst men who have sex with men, New Zealand has been getting it right and everyone else not so much, if at all. In Part Three, tomorrow, we look at why the New Zealand way has worked and why there is continuing danger for the health and lives of gay and bi men in other nations if those directing their prevention programmes are seduced by the latest big new thing in global HIV prevention. PART THREE: TREATMENT AS PREVENTION? Jay Bennie - 30th November 2013