Review of services for people living with HIV in New Zealand

It is evident that stigma is the elephant in the waiting room of HIV public health responses – ofteninvoked as the cause of sub‐optimal population responses to prevention and support activities, yethard to quantify or isolate by region or population.There is some debate over how best to engage minority populations (and, correspondingly, who isthe preferred service provider). One side of the argument is that a ‘by Māori for Māori’ (or a ‘byAfricans for Africans’) approach is necessary to ensure the quality of engagement with those most atrisk that would guarantee sustained, effective HIV/STI prevention and care. The other side suggeststhat the equal access guaranteed by current DHB and NGO services offers a greater degree ofanonymity and confidentiality that is crucial. In other words, the impact of stigma differentiateshealth care delivery for HIV and SH from that of other conditions. One physician noted, ‘We are bestplaced to deliver [to minority ethnic populations] because of our place within the health serviceculture.’ Another noted that the presence of health providers outside traditional family andcommunity networks encouraged engagement of some people with SH services citing the maxim, ashas been quoted elsewhere, ‘you don’t know my auntie’.The strength of the arguments on both sides is tempered by the limited data available for clarifyingthem. One example is the question over whether populations of Māori, or of Africans, andconsequently their responses to HIV at an individual and community level, are homogenous. Manystaff and PLHA asserted that they were not, and questioned public health responses relying onhomogeneity as an assurance of expected ethnic responses. The experiences of Māori and Africancommunity personnel employed by the NZAF and DHBs have been difficult to accurately evaluatebecause of individuals’ often reported fear of disclosing their HIV status within their communities,either in or outside New Zealand. The power of this fear is doubtless compounded by the sense ofvulnerability that is consistently reported among immigrant populations. It was also acknowledgedthat there was comparatively little literature focussed on Māori or African issues in SH.Research into ‘conventional’ STIs offers a starting point for assessment of such issues. The recentchlamydia study undertaken in the Waikato (Morgan and Bell 2009), identified that equitable accessto services was not an issue among Māori populations. In this study, Māori were as likely to betested for chlamydia, but were twice as likely as non‐Māori to test positive. Looking at patterns oftesting in the various provider locations surveyed seems to suggest that equity of access had beenachieved through initiatives to ensure access to free sexual and reproductive health services for allunder‐25s within the district. A Waikato DHB case management audit of 415 cases, 41 percent ofwhich were Māori, found that time between diagnosis and treatment following a positive chlamydiaresult was equitable. However, a small number with untreated infections were more likely to beMāori than non‐Māori.The Hamilton SH clinic (who noted that ‘we only have data from people who come in to services’)reported that attendance is influenced by both perception of service staff competency and bywhether such services are free or not. This study found that in general access was more affected bysocioeconomic aspects than by ethnicity. This is consistent with the request from groups of serviceusersfor HIV specialist services to provide essential primary care‐type functions, because of theprohibitive costs of primary care.While most adults are registered with a primary care practice, and at least 90 percent see theirprimary care physician at least once a year, data suggests this figure may be lower among those mostat risk of STIs and HIV. For example, primary care data suggests that only 60 percent of 15–24 yearoldsare engaged with a primary care physician. Also, recent data suggests that MSM often do notdisclose sexuality to their general practitioners (Adams, McCreanor and Braun 2008).REVIEW OF SERVICES FOR PLHA 41