Vector Volume 11 Issue 1 - 2017

prevention method.[15] At-risk individuals can take one pill
daily containing two antiretroviral medications, preventing
replication of the virus within the body so that viral exposure
is not seroconverted, thus preventing HIV infection.[16]
Randomised control trials have found that ARVs taken as
pre-exposure prophylaxis (PrEP) can prevent 40-99% of HIV
infections when taken more than four times a week.[17-21]
PrEP implementation trials are currently being run in New
South Wales, Queensland, Victoria, South Australia, and
the Australian Capital Territory. These trials are supported
and funded by state health departments, allowing free or
heavily discounted access to expensive drugs that cannot
be accessed as PrEP via the Australian Pharmaceutical
Benefits Scheme (PBS).[22]
In New South Wales, the Kirby Institute runs the Expanded
PrEP Implementation in Communities (EPIC) trial in
conjunction with NSW Health. After a year of recruitment, over
5000 at-risk individuals have been enrolled and given access
to PrEP. Most of these participants are GBM, identified as
being at high risk of HIV exposure.[13] This represents a major
expansion from a small pilot study to a large demonstration
trial.
Are Indigenous gay and bisexual men accessing PrEP?
Studies in the United States (US) have found that identified
priority populations, including Black (African-American) men
who have sex with men, may have difficulty in accessing PrEP
compared to the general population. This may be due to lack
of awareness about PrEP,[23] stigma,[24] poor healthcare
coverage,[3] or lack of culturally-appropriate services
providing access.[25] Indeed, Black men who have sex with
men in the US were successfully recruited, engaged and
retained in PrEP programs that employed “culturally-tailored
techniques”.[26]
Research shows that in order to target interventions
like PrEP to Indigenous communities, culturally-appropriate
services owned and governed by the community are in the
best position to deliver positive health outcomes.[27-29]
Likewise, health promotion materials should be designed and
produced by the community for the community, and should
avoid blocks of text and overly technical terminology.[30]
Therefore, Aboriginal community-controlled health services
(ACCHSs) may be best placed to help promote and educate
PrEP to at-risk members of the community, facilitating
referral to specialised sexual health clinics for assessment
and preventative methods that may or may not include
PrEP. ACCHSs provide holistic care, and are well equipped
to focus on prevention and primary healthcare.[31] ACCHSs
are considered manifestations of self-determination and
autonomy for Indigenous communities.[29, 32]
Self-determination in Indigenous Australian health
services
The United Nations has identified ACCHSs as best
practice models of self-determination,[29] and the United
Nations Declaration on the Rights of Indigenous Peoples
advocates for the right of all peoples, especially Indigenous,
to be able to “freely determine their political status and freely
pursue their economic, social and cultural development”.
[33] However, self-determination in healthcare alone cannot
improve health outcomes. Secure, long-term funding coupled
with equitable partnerships between Aboriginal communitycontrolled
and mainstream health services is required to
address the gap between Indigenous and non-Indigenous
health.[29, 32] Facilitating community empowerment reduces
the rates of HIV and STIs in female sex workers (FSWs)
in low- and middle-income countries.[34, 35] Community
empowerment in Australian FSWs during the initial years of
the HIV epidemic was essential in enshrining effective HIV
prevention focused on universal condom use among FSWs.
[36] This case study could be applicable to the Indigenous
population, and similar community empowerment in the
form of well-funded ACCHSs may allow the gap between
Indigenous and non-Indigenous health.
Furthermore, Aboriginal Sexual Health Workers administer
culturally-appropriate health services throughout Australia,
increasing the involvement of Indigenous people in the
healthcare workforce.[28, 37] However, Indigenous peoples
need to be consulted and involved in the decision-making
process and not just in the delivery of health services.[38, 39]
Conclusion
PrEP is touted as a crucial part of the HIV eradication
strategy throughout the world. However, efforts to prevent HIV
transmission may be hampered by a failure to engage priority
populations, including Aboriginal and Torres Strait Islander
Australians. PrEP implementation projects such as EPIC need
to ensure adequate coverage of at-risk Indigenous peoples
through culturally-appropriate health promotion and security
of access to medication. This would be facilitated through
the involvement of Indigenous Australians in the decisionmaking
process. Further research will explore PrEP-related
health promotion to Indigenous peoples and communities,
and attempt to identify any gaps or facilitators.
Figure 1. The age-standardised rate
of new HIV notifications by Indigenous
status.[8]
30