The management of people with HIV who place others at risk (POAR): implications for Aboriginal and Torres Strait Islander people

HIV Australia | Vol. 11 No. 3 | October 2013

By Natasha Pavlin

The National Guidelines for the Management of People with HIV Who Place Others at Risk (or ‘POAR’ for short) is a public health instrument that provides national guidance in relation to the management of people with HIV who are deemed to pose a public health risk of transmitting HIV to others.

These guidelines, which operate slightly differently in each state and territory, allow for staged levels of ‘coercive management’ of individuals in relation to areas including HIV testing and counselling, supervision, treatment, detention, isolation and/or apprehension.¹

In each State/Territory, an HIV Advisory Panel, overseen by a senior clinician, provides advice on the management of cases where support to the individual’s primary health care provider is deemed necessary to achieve behaviour change.

Disproportionate representation

While the number of people being managed by these mechanisms at any time is small,² we do know that Aboriginal people are over represented within these panels for assessment comprising somewhere between 20 and 30% of all panels cases.

Levels of Intervention as outlined in the National Guidelines³

The National Guidelines for the Management of people with HIV Who Place Others At Risk operate using five levels of intervention, with an underlying principle that ‘…for people with HIV who place others at risk, a variety of increasingly interventionist strategies may be needed, with preference being given to strategies that are least restrictive, as these will generally be the most sustainable and effective in the long-term.’⁴

The five recommended levels of intervention are:

Level 1: Counselling, education and support
Level 2: Counselling, education and support under advice from HIV Advisory Panel or the Chief Health Officer or Equivalent
Level 3: Management under Behavioural Order
Level 4: Detention and/or Isolation
Level 5: Referral of the individual to police.

Implementation of the Guidelines at jurisdictional level occurs with specific reference and attention to relevant jurisdictional legislation. Relevant provisions are primarily found within Public Health legislation and Crimes legislation.5

Are there implicit racist assumptions that make clinicians more worried about their HIV-positive Aboriginal patients and more concerned that they will place others at risk? What assumptions are these?

It is often assumed that Aboriginal people have particularly chaotic and mobile lives, that they have low levels of education and health literacy and low levels of self-efficacy.

If all this is true – and then you add in mistrust in medical/ health establishments, shame and fear, communication, language and cultural issues – then perhaps we can imagine why clinicians may have increased levels of concern and fear for Aboriginal patients with HIV.

But is this fear justified and is this always the best approach? Are there any other supports that could be activated earlier to help people look after themselves as best they can?

As we have moved to the treatment and management of HIV as a chronic illness and to the ‘treatment as prevention’ models, government-funded community supports – especially for those newly diagnosed and those not supported by not-for- profit groups – have dropped away.

The National Association of People with HIV Australia (NAPWHA) auspices a national network of Indigenous people living with HIV, PATSIN (Positive Aboriginal Torres Strait Islander Network).

PATSIN comprises a committee of ten members who provide expert advice and advocacy issues related to the lived experiences of Aboriginal people living with HIV/AIDS.

Epidemiology

The demographics of Aboriginal and Torres Strait Islander People diagnosed with HIV vary somewhat by jurisdiction; however, nationally – as is the case for the non-Indigenous Australian born population – Aboriginal and Torres Strait Islander people living with HIV are predominantly gay men and other men who have sex with men.

What differs from the non-Indigenous Australian-born HIV-positive population is that injecting drug use is more likely and there is a higher proportion of women and heterosexual people.

There has been much discussion and theorising as to why there has been no disastrous epidemic thus far within Aboriginal Australia, despite high rates of other sexually transmissible infections among this population.

Some of these theories include: relatively closed sexual networks; not a high rate of partner change nor of ‘risky’ partners; good public health and harm minimisation in Australia in relation to people who inject drugs (thus far, anyway); and resource intensive but effective interventions in ‘clusters’ of infection to minimise further spread.

There is no reason, however, that an epidemic among this population might not occur in the future – and fears of this possibility may well be contributing to clinicians perhaps over-referring Aboriginal people to POAR panels.

Is there any particularly negative consequence of all this for Aboriginal and Torres Strait Islander people? Perhaps.

One of the most important truisms across all different communities of Aboriginal people is the importance of family, the importance of community and of community and family responsibilities.

One consequence of this is that very little is private in Aboriginal and Torres Strait Islander communities. The benefits of close knit communities can also backfire – HIV status can be used to victimise and exclude; therefore, we need to be particularly conscious of patients’ privacy.

Urban-living people may choose to be in the city partly for this potential for anonymity and mainstreaming – but this also means they may be cut off from other sources of support and therefore further marginalised.

This can also be a reason why HIV-positive Aboriginal people may choose to seek their medical care in mainstream environments rather than from Aboriginal health organisations. Being involved with a POAR panel can significantly impact on a person’s capacity to maintain privacy about their diagnosis.

Even if an individual is an appropriate client for POAR, how can we minimise negative consequences for the individual?

What other supports can we create and how can we raise awareness both within the mainstream and the Aboriginal and Torres Strait Islander communities to help HIV-positive Aboriginal and Torres Strait Islander people remain safe, well and connected to community?

These are challenges which have, until now, gone largely unanswered but which need to be addressed.

HIV and Aboriginal and Torres Start Islander populations: the data

Although Aboriginal and Torres Strait Islander populations have rates of HIV similar to the general population, Aboriginal and Torres Strait Islander people are named as a priority population in Australia’s Sixth National HIV Strategy.⁶

This is for a number of reasons, including the potential for an acceleration of the HIV epidemic among Indigenous communities given:

high prevalence of sexually transmissible infections (increasing the likelihood of HIV transmission) in many remote and very remote communities
higher rates of injecting drug use and sharing of injecting and other equipment
limited access to culturally appropriate services, including primary healthcare services in many communities
the over-representation of Aboriginal and Torres Strait Islander men and women in prisons and juvenile detention
the geographical, cultural and social circumstances of many communities, including high mobility, lower health literacy, and issues such as shame and underlying poor health status.

For Torres Strait Islanders, the movement and interaction of people between Australia and the Western Province of Papua New Guinea is a significant concern.

The National HIV Strategy is designed to work in tandem with the Third National Aboriginal and Torres Strait Islander Blood Borne Viruses and Sexually Transmissible Infections Strategy 2010–2013.

Priorities include a focus on injecting drug harm reduction interventions, detection and treatment of STIs, measures to reduce HIV-related stigma, and provision of accessible and culturally appropriate health services staffed by a skilled workforce.

Testing and diagnosis

Australian Bureau of Statistics data indicate there were just over half a million people identifying as Aboriginal and Torres Strait Islander living in Australia in 2006, representing 2.5% of the total population.

More than a quarter of Aboriginal and Torres Strait Islander Australians reside in remote or very remote areas, compared with 2.3% of the non-Indigenous population.

Census data show a much younger profile for Aboriginal and Torres Strait Islander populations, with around 40% of people aged less than 15 years compared with 19% of the non-Indigenous population.⁷

Between 2002 and 2011, 219 Aboriginal and Torres Strait Islander people were diagnosed with HIV.

Diagnoses were made in major cities, regional, remote and very remote areas.

It is important to note that the total number of diagnoses among Aboriginal and Torres Strait Islander people is small so generalisations must be regarded with caution as changes may reflect localised occurrences rather than national patterns.

Rates of HIV diagnoses among Aboriginal and Torres Strait Islander populations have varied each year, although they declined slightly from around 4.5 per 100,000 (2002 to 2006) to around 4.3 per 100 000 (2007 to 2011).

During those same periods, HIV prevalence in non-Indigenous, non-high HIV prevalence country of birth populations increased slightly from around 3.2 per 100,000 (2002) to 5.0 (2011).

Between 2007 and 2011, HIV transmission among people from Aboriginal and Torres Strait Islander communities was attributed to sexual contact between men in 59% of cases (including 8% of cases attributable to either sex between men or injecting drug use), to heterosexual contact in 17% of cases and injecting drug use for 16% of cases.

A far higher proportion of HIV diagnoses in Aboriginal and Torres Strait Islander communities were among women: 21% of new infections among Aboriginal and Torres Strait Islander cases compared to 8% among non-Indigenous, non-high prevalence country of exposure cases (2007–2011).

Dr Natasha Pavlin is Public Health Medical Officer, Top End at Aboriginal Medical Services Alliance Northern Territory (AMSANT).

References

1 Australian Government Department of Health and Ageing (DoHA). (2008). National Guidelines for the Management of People with HIV Who Place Others at Risk. Commonwealth of Australia. Retrieved from: www.health.gov.au

2 ASHM. (2012). Management of People with HIV who Place Others at Risk. ASHM [online]. Retrieved from: www.ashm.org.au

3 DoHA, (2008), op. cit.

4 ibid., cited in ASHM, (2012), op. cit.

5 ibid.

6 Unless otherwise noted, all data in this section is sourced from the The Kirby Institute. (2011). HIV, viral hepatitis and sexually transmissible infections in Australia Annual Surveillance Report. The Kirby Institute, the University of New South Wales, Sydney.

7Australian Bureau of Statistics (ABS). (2006). Population Characteristics Aboriginal and Torres Strait Islander Australians, ABS cat no 4713.0. ABS, Canberra. Retrieved from www.ausstats.abs.gov.au