Expanding the Boundaries Expanding the Boundaries of Positive Prevention of Positive Prevention

ProgammesProgammes

Exactly one year after federal government Exactly one year after federal government announcement of AHP, there is more focus announcement of AHP, there is more focus

than ever on:than ever on:

Increasing knowledge of HIV statusIncreasing knowledge of HIV status Prevention services for HIV+ peoplePrevention services for HIV+ people

NAPWA has long advocated for wider NAPWA has long advocated for wider adaptation of both of these goalsadaptation of both of these goals

But AHP has been flawed from the But AHP has been flawed from the beginningbeginning

No prior consultation/ secretive roll-outNo prior consultation/ secretive roll-out Positive people not involved Positive people not involved Politically inspiredPolitically inspired Overly reliant on medical and individual level Overly reliant on medical and individual level

interventionsinterventions Lacks sound scientific basis in many areasLacks sound scientific basis in many areas Displaces important intervention fundingDisplaces important intervention funding Increases stigma and blameIncreases stigma and blame Includes no plan for care and treatmentIncludes no plan for care and treatment Unlikely to be effectiveUnlikely to be effective

Medicalizing/ Individualizing Medicalizing/ Individualizing HIV PreventionHIV Prevention

Initial announcement, April 2003Initial announcement, April 2003 TestingTesting ““On-going case management”On-going case management” ““Focused risk reduction counseling”Focused risk reduction counseling” ““Medical interventions”Medical interventions” ““Support of other psychosocial stressors”Support of other psychosocial stressors” Testing for pregnant women and newbornsTesting for pregnant women and newborns

Medicalizing/ Individualizing Medicalizing/ Individualizing HIV PreventionHIV Prevention

Ideology of individual responsibilityIdeology of individual responsibility

Ignoring social context of HIV riskIgnoring social context of HIV risk

Treating people living with HIV solely Treating people living with HIV solely as “vectors” of new infectionsas “vectors” of new infections

StigmatizationStigmatization

No language of shared responsibilityNo language of shared responsibility Background of criminalization, Background of criminalization,

discrimination, blamediscrimination, blame “…“…Initiative has the potential to Initiative has the potential to

increase stigma and discrimination increase stigma and discrimination against HIV positive persons” -against HIV positive persons” - CDC CDC

Care and treatmentCare and treatment

? How many new positives will the ? How many new positives will the initiative identify?initiative identify?

500, 5,000, 50,000, 150,000 ?500, 5,000, 50,000, 150,000 ?

Care and treatmentCare and treatment

What are the ethics of promoting What are the ethics of promoting mass testing with no provision for mass testing with no provision for care?care?

No national plan for care and treatmentNo national plan for care and treatment ADAP waiting listsADAP waiting lists Flat funding for Ryan WhiteFlat funding for Ryan White Medicaid/state level cutsMedicaid/state level cuts Medicare bill’s impact on 50,000 HIV+ “dual eligibles” Medicare bill’s impact on 50,000 HIV+ “dual eligibles”

Is history repeating itself?Is history repeating itself?

1985 CDC advice on prevention:1985 CDC advice on prevention:

““Know your partner” Know your partner”

““Don’t have sex with people who have Don’t have sex with people who have AIDS” AIDS”

““Avoid the exchange of bodily fluids”Avoid the exchange of bodily fluids”

Making AHP better!Making AHP better!

Demand new resources for prevention and Demand new resources for prevention and carecare

Embrace full range of prevention/ take a Embrace full range of prevention/ take a comprehensive approachcomprehensive approach

Stand up for scienceStand up for science Learn to use language of shared Learn to use language of shared

responsibility/ fight stigmaresponsibility/ fight stigma National plan for care and treatmentNational plan for care and treatment Reclaim the discussion of meeting the Reclaim the discussion of meeting the

prevention needs of HIV+ peopleprevention needs of HIV+ people

Redefining the “problem”Redefining the “problem”

900,000 HIV+ people900,000 HIV+ people

40,000 new infections annually40,000 new infections annually

Less than 5% annual transmission rateLess than 5% annual transmission rate

Redefining the “problem”Redefining the “problem”

CDC estimates:CDC estimates:

≈≈700,000 positive people know status700,000 positive people know status

Only ≈16,000 transmissions from Only ≈16,000 transmissions from those aware of status those aware of status

(2% transmission rate)(2% transmission rate)

Redefining the “problem”Redefining the “problem”

CDC estimatesCDC estimates

≈≈200,000 unaware of infection200,000 unaware of infection

≈≈24,000 transmissions from those 24,000 transmissions from those unaware unaware

(12% transmission rate)(12% transmission rate)

Redefining the “problem”Redefining the “problem”

Need to better understand what is behind Need to better understand what is behind these statsthese stats

- Health status, viral load, duration of infectionHealth status, viral load, duration of infection

- Demographic, sociological, geographicDemographic, sociological, geographic

- Accurate risk profile (MSM, IDU, Het)Accurate risk profile (MSM, IDU, Het)

- Partner status (long term, serial, casual) Partner status (long term, serial, casual)

- ““transactional” analysis of infection dynamic (intentionality, transactional” analysis of infection dynamic (intentionality, substance use, disclosure/ non-disclosure, social substance use, disclosure/ non-disclosure, social vulnerability, etc)vulnerability, etc)

Toward are broader view of HIV Toward are broader view of HIV Prevention for PositivesPrevention for Positives

Meeting the prevention needs of Meeting the prevention needs of positive peoplepositive people

A more comprehensive approach must A more comprehensive approach must include a full continuum of servicesinclude a full continuum of services

- HE/RR- HE/RR

- Social marketing- Social marketing

- Small and large group interventions- Small and large group interventions

- Structural interventions- Structural interventions

- Condom and needle availability- Condom and needle availability

- Bio-medical? - Bio-medical?

- Individual level in medical, social service - Individual level in medical, social service and community sectorsand community sectors

Elements of preventionElements of prevention

Expanding our definition of what prevention Expanding our definition of what prevention is to include:is to include:

- Health careHealth care- HousingHousing- Substance abuse treatmentSubstance abuse treatment- Education and economic opportunitiesEducation and economic opportunities- Mental health services/ self-esteem Mental health services/ self-esteem

supportsupport- Domestic violence prevention and servicesDomestic violence prevention and services

Defining a positive sexualityDefining a positive sexualityThe sexuality of HIV positive people is assaulted on many The sexuality of HIV positive people is assaulted on many

levelslevels- Guilt for becoming infectedGuilt for becoming infected- Post-diagnosis sexual shutdownPost-diagnosis sexual shutdown- Fear of infecting othersFear of infecting others- Assuming responsibilityAssuming responsibility- Message of “toxicity”Message of “toxicity”- CriminalisationCriminalisation- Demonisation (such as in “barebacking” debate)Demonisation (such as in “barebacking” debate)- Fear of rejectionFear of rejection- Body image (lipo, wasting, etc)Body image (lipo, wasting, etc)- Sexual function impacted by disease & treatmentSexual function impacted by disease & treatment- PTS (pre and post diagnosis) PTS (pre and post diagnosis)

based in experience of racism, homophobia, poverty, sexism, homelessness, based in experience of racism, homophobia, poverty, sexism, homelessness, incarceration, domestic violence, sexual & emotional abuse, addiction, dealing with incarceration, domestic violence, sexual & emotional abuse, addiction, dealing with complex system, HIV stigma, etccomplex system, HIV stigma, etc

Defining a positive sexualityDefining a positive sexuality

Prevention programmes must Prevention programmes must develop and offer a positive view of develop and offer a positive view of HIV+ sexualityHIV+ sexuality

Embracing sexual intimacy as a right Embracing sexual intimacy as a right and an important part of healthand an important part of health

Helping people identify and achieve Helping people identify and achieve a sexual life that meets their needs/ a sexual life that meets their needs/ priorities while negotiating the priorities while negotiating the complex choicescomplex choices

Right to accurate information to Right to accurate information to make decisionsmake decisions

Reinfection/ super-infection debatesReinfection/ super-infection debates Impact of viral load on transmission riskImpact of viral load on transmission risk Information about risk of specific sexual Information about risk of specific sexual

activities/ effectiveness of protectionactivities/ effectiveness of protection Reproduction optionsReproduction options Risk of non-HIV infectionsRisk of non-HIV infections PEP options for partnersPEP options for partners Non-judgemental medical adviceNon-judgemental medical advice

Overcoming social isolationOvercoming social isolation Near universality of social isolation among Near universality of social isolation among

HIV+ peopleHIV+ people The demise of support groups, PWA The demise of support groups, PWA

coalitions etc in age of more successful coalitions etc in age of more successful treatment, epidemiologic changetreatment, epidemiologic change

Need for meaningful social, emotional Need for meaningful social, emotional romantic and sexual opportunitiesromantic and sexual opportunities

Opportunity for dialogue and discussion Opportunity for dialogue and discussion among HIV+ peopleamong HIV+ people

Creation of a more welcoming community/ Creation of a more welcoming community/ overcoming stigmaovercoming stigma

Shared responsibilityShared responsibility

People living with HIV are willing to People living with HIV are willing to accept a special responsibility for accept a special responsibility for avoiding transmission, but we need avoiding transmission, but we need prevention programmes to prevention programmes to communicate a message of communicate a message of responsibility to our partners as well responsibility to our partners as well

Positive driven, positive deliveredPositive driven, positive delivered

We are the experts in our lives and We are the experts in our lives and our needsour needs

Economic, organizational Economic, organizational opportunitiesopportunities

Credibility, authenticity will help Credibility, authenticity will help produce successproduce success

Supported by prevention/ Supported by prevention/ behavioural expertisebehavioural expertise