HIV Is On The Rise. What Are We Doing About It?

The 2013 Australasian HIV and AIDS Conference ran in Darwin last week, and it kicked off with a bang: on Monday, the conference revealed a 10% increase in HIV infections in Australia between 2011-2012, the highest jump in 20 years, with young people at the highest risk. The infection rate has been trending upwards nationally for a few years now — the year before saw an 8.2% increase — so why are we not paying attention to it?

The answer is, of course, incredibly complicated. Part of the reason is that HIV in Australia is not what it used to be. Living with HIV today means living long-term, not day-by-day with a high likelihood of death from AIDS-related causes.

Yet to have the highest increase of infection in 20 years suggests that the key messages behind sexual health and HIV have stopped permeating. There’s no singular cause at the heart of the rise, but there are a number of contributing factors.

People Are Getting Tested More Often

Here in Australia, we’re seeing the roll-out of rapid HIV testing services at sexual health and medical centres, as well as hospitals. These new tests are a lot quicker: 30 minutes gets you in and out with your results at the ready, meaning that those who are reluctant to engage with a lengthy and potentially nerve-wracking testing process have one less excuse. Rapid testing is working too, with high take-up rates in urban gay areas, and over 30 testing sites established in NSW, Victoria and Queensland. While this explains only a small portion of the increased diagnosis rate, it’s the most important factor to take into account.

Why is testing crucial? Well, up to 25% of people living with HIV in Australia are undiagnosed. That means they’re out there doing things that humans do under the impression that they are HIV negative, so they could unwittingly pass on HIV to someone else. The troubling thing is that they’re also the ones most likely to: newly infected people have much higher copies of the virus in their system (the ‘viral load’), which makes them more infectious. This is why increased testing avenues and focused messaging on getting tested is so important.

There’s a rub, though: before these numbers go down, they’re going to go up. We need them to because, if the figures are correct, up to 5000 people are living with undiagnosed HIV. It’s crucial we get them into a testing centre; after that point, there is access to medical professionals, excellent medication, and great support systems.

Which leads us to the next reason for increased infection: the idea that living with HIV isn’t actually that big a deal.

HIV Now Is Not HIV Then

Let me follow that statement with a disclaimer: I am a person living with HIV who is privileged enough to be in a country with accessible, subsidised medication.

For many people like me, the old days are over. In the Plague Era, HIV was perceived as a death sentence. If you managed to get on medication, the main one available was AZT, and it was nasty: it had terrible side effects, and there was no guarantee it would keep working. People went blind, succumbed to other AIDS-related illnesses, were abandoned by friends and lovers, and often became social pariahs. It was a genuinely awful time, and as a community we cannot forget it.

In the mid ’90s, the medications changed. Medical scientists realised they could use combination therapies to attack numerous elements of the virus instead of just hitting it head on with heavy doses of toxic meds. These combination therapies, or antiretrovirals, became the turning point for living with HIV. Over time, ‘AIDS Patients’ became ‘People Living With HIV’, and the disease became less visible and less obvious. These meds are crucial, as they minimise the likelihood of passing on the infection should a condom break or, in the heat of the moment, stay in the wrapper altogether.

For HIV positive people, going on treatment is the key to reducing HIV transmissions. But only around half of the people living with HIV in Australia are currently on these treatments, which isn’t enough. We need to get to around 90% to actually reduce the instances of HIV infections. To do so, we need more people accessing medication, which means the government has to relax subsidy requirements and the community has to actively promote treatment as an important step in ending HIV.

For negative people, there are now a variety of treatments available to reduce HIV transmissions. For those potentially exposed to HIV, you have a 72-hour window to get to a doctor and get on PEP (Post-Exposure Prophylaxis), a dose of meds that blasts the virus in the early stages of it entering your body. Think of it like the morning after pill for HIV. There is also PrEP (Pre-Exposure Prophylaxis) which operates like the contraceptive pill: you take it every day and it forms part of your prevention regime against infection. Both are becoming increasingly available in Australia.

These new treatments and preventative measures have changed the face of HIV, but for those not affected it’s a complex message to grasp: combination therapies are not a cure, but they are progress. While such change is welcome, it inevitably alters how people perceive risk relating to sex. When you do get diagnosed, one of the first messages you encounter in the community is, “It’s going to be okay.” This is where the messaging gets confusing: pre-exposure, we’re told, “Stay safe! Use condoms! Whatever you do, don’t become HIV positive!” But if you do get infected, the messaging quickly shifts to, “Trust us, it’s not going to affect your life.”

While being diagnosed as HIV positive is a difficult time that needs to be couched in sensitivity and awareness, there also needs to be a point not long after where HIV positive people are reminded of their responsibilities. HIV positive people should be empowered to live openly and do their part in being the last generation to live with HIV, not the latest. Not as cautionary tales to ward off new infections, but as perfectly able members of the community who are versed in the complex details of safe sex, meds, and viral loads, who can pass that information on and bust the myths of HIV wide open. That’s the new message, and its up to HIV positive people to own it and share it with the rest of the community.

Negative people need to share the responsibility too. Your sexual health is yours alone: it’s not a positive person’s responsibility to keep you safe. So when we all jump into bed together (yes, positive and negative people do that), everyone should be aware of how to behave. That includes knowing when it’s necessary to use condoms.

Hello Condom, My Old Friend, I’ve Come To Talk To You Again

Condoms work really well at preventing the spread of HIV; much better than anything else on the market. In truth, the rejection of condoms in casual sex situations is easily the highest contribution to these increases in HIV infections. And yet as a public service announcement, ‘CONDOMS! CONDOMS! CONDOMS!’ isn’t working anymore.

Like everything to do with sex these days, the message needs to be more nuanced. The core message is still the same: condoms work better than anything else. But if you’re not going to use one (which is what’s happening, whether we like it or not), you’d better know all the other info. What is your partner’s HIV status? Have you even asked? When were you and your partner last tested? Got tested six weeks ago, but have had a lot of unprotected casual sex since then? You’re not guaranteed to still be negative. Are there any other STIs that you may have? Are you the insertive or receptive partner? (Straight guys and gals: this one is easy to figure out.)

Answering these questions is not an insurance policy against contracting HIV, nor is it a get-out-of-jail-free card for condom use, but IF you are going to have sex without condoms, you’d better be using other risk-reduction strategies. As much as we may resent using them, abandoning condoms without understanding the full picture will see an increase in HIV infections.

HIV In 2013: Where To Now?

There’s no one reason why HIV is increasing. We can’t promote the incredible advancements in living long-term with HIV and at the same time evoke the ghosts of the past to scare us into behaving a certain way. We can’t just put condoms everywhere and expect people to use them, when the imperative to do so has become invisible. To honour the sad history of this epidemic, we need to move on from it. What once worked effectively has stopped working. This is not because young people are callous or uncaring; it’s because the same message can’t be rolled out over multiple generations without some degree of fatigue.

The key to the success of reducing HIV infections in the early days of the epidemic was galvanising the affected community: town hall meetings, high-profile spokespeople, and public protests. As our definition of community has moved into new territories, so too must our approach to reducing HIV — most crucially in those parts of the world where the luxury of one pill a day is hard to come by. Make us activists, not victims. Reclaim the oxygen lost by politely allowing HIV positive people to get on with their lives and disappear into the background. Remind everyone that we’re still here, that we haven’t solved this problem yet, and that, before we move on to symbolic measures of equality, we have real lifesaving to do.

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Nic Holas is a writer who focuses on the contemporary gay experience, and being a person living with HIV. His writing has appeared in Hello Mr Magazine, Star Observer, The Needle Prick Project, and Cosmopolitan. You can find him on Twitter @nicheholas, or in his role as co-founder of HIV social umbrella The Institute of Many.