AIDS 2014 SPECIAL EDITION HIV and the enabling environment: Australia and our region

Volume 12 • Number 2 HIV Australia ISSN 1446-0319 A NOTE FROM THE EDITORS Volume 12, No. 2 (July 2014) Welcome to this special edition of HIV Australia, Editors Finn O’Keefe and Linda Forbes published to coincide with the 20th International AIDS Conference (AIDS 2014) in Melbourne, Australia. Treatments Editor Jason Appleby 2014 marks the first time that an International AIDS Design + Production Ascending Horse Conference (IAC) has been held in Australia, and ten years since the IAC was held in the Asia-Pacific region. Last year’s ICAAP11 conference in Bangkok saw the international HIV community focus in on our region. This edition sharpens that focus – profiling community-led Correspondence responses in Australia and the region, at a time when we HIV Australia C/– AFAO, PO Box 51 Newtown NSW 2042 Australia are witnessing important new scientific developments and Telephone +61 2 9557 9399 understandings about HIV. Facsimile +61 2 9557 9867 This special edition is themed around HIV and the enabling Email [email protected] environment. The strong framework of policies and laws Website www.afao.org.au that exist in Australia has underpinned the success of our much-lauded partnership response to HIV, involving HIV Australia gratefully acknowledges the assistance of community, clinicians, researchers and government, since the Commonwealth Department of Health the beginning of Australia’s HIV epidemic. The edition Print post approved PP225920/00016 includes analysis of the current state of Australia’s policy framework, identifying laws that undermine the enabling legal environment. Several articles in this edition trace the history of Australia’s HIV response – from ‘medical emergency’, prompting strong community activism, to an era of focusing on AFAO is the national federation for the HIV community response, treatment uptake and increasing testing rates. Contributors providing leadership, coordination and support to the Australian policy, ponder the fact that as people with HIV live with a chronic advocacy and health promotion response to HIV/AIDS. Internationally, manageable disease, an urgency about the HIV response AFAO contributes to the development of effective policy and has stalled, highlighting a need to focus on enabling programmatic responses to HIV/AIDS at the global level, particularly in the social and legal environments to address ongoing stigma Asia Pacific region. and discrimination. AFAO’s aims are to: Other contributors outline innovative work across Asia and n Advocate on behalf of its members at the federal level, thereby providing the the Pacific, where community organisations and networks HIV community with a national voice; operate in social and political environments that are, in many cases, far from enabling. We hear how the rights of n Stop the transmission of HIV by educating the community about HIV/AIDS, people living with HIV, and communities most affected by especially those whose behaviour may place them at high risk; HIV are severely impinged, undermining access to health n Assist its members to provide material, emotional and social support to services, HIV testing, treatment, care and support – or to people living with HIV; simply the right to live free from persecution. n Develop and formulate policy on HIV issues; n Collect and disseminate information for its members; A number of articles in this edition discuss cross-country partnerships and capacity building initiatives that are n Represent its members at national and international forums; and strengthening community responses to HIV, nurturing n Promote medical, scientific and social research into HIV and its effects. emerging community leaders, and taking a successful AFAO Board ‘learning by doing’ approach in combating HIV. President Willie Rowe Vice President Bridget Haire This year’s IAC conference in Australia will see some Secretary Joanne Leamy Treasurer Andrew Burry important milestones, including a conference program Ordinary Member Kim Gates Staff Representative Finn O’Keefe that has been driven by the involvement of people living AIVL Damon Brogan Anwernekenhe National HIV Alliance Michelle Tobin with HIV and key affected communities at every level, NAPWHA Craig Cooper Scarlet Alliance Mish Pony Co-opted Member David and the first ever keynote address delivered by an Mejia Canales Co-opted Member Alison Coelho Indigenous person. This special edition of HIV Australia is designed to provide In recognising the fundamental importance of information and education in a snapshot of the energy, action and innovation that exists working against the HIV/AIDS epidemic, all material in this publication may be within Australia, Asia and the Pacific. We encourage reproduced for non-commercial use, personal research or educational purposes readers to network and start conversations with the people free of charge, provided the following citation is made: “Reprinted from and organisations driving the work you will read about Volume 12, No. 2 of HIV Australia, published by the Australian Federation of AIDS within these pages. Organisations”. Copyright of all images remains with the individual artists. The AIDS 2014 edition of HIV Australia will be formally Requests for permission to reproduce any written material in this publication for launched on Wednesday 23 July at 5.15pm in the G’day! commercial purposes should be made to AFAO directly. Welcome to Australia Networking Zone in the AIDS 2014 Global Village. Visit the G’Day! Zone to learn more about AFAO is a member of Copyright Agency Limited (CAL). If you have been engaged the Australian HIV response, or just to relax and network. by AFAO as a contributor to one of our publications in the past and are a member We look forward to seeing you there! of CAL, we may be holding CAL funds in trust for you. If you think this may be the case, please contact AFAO directly ([email protected]). Finn O’Keefe and Linda Forbes Volume 12, No. 2

Hopes for AIDS 2014 and beyond 4 AIDS 2014: Under the Baobab Tree 43 Professor Sharon Lewin Jill Sergeant and Finn O’Keefe Making history: the community heart of AIDS 2014 6 HIV and sexuality: why are people with disabilities 45 Brent Allan left behind? Our story, our time, our future: Indigenous culture, 8 Suzanne Lau Gooey and Dr Paul Chappell continuity and centrality to the global HIV response Learn from the past, live in the present, dream for 48 James Ward and Michael Costello-Czok the future: Melbourne Youth Force stepping up Creating an enabling environment: regional 11 the pace networks and community organisations are Alex Mindel, Karen Salter, Kristine Squire, leading the way Naveen Tenneti and Nitasha Kumar Moi Lee Liow, Midnight Poonkasetwattana, Community-based responses to HIV in developed 51 Joe Wong, Lieu Anh Vu and Phillip Salvador Asia: challenges and approaches for lesbian, gay, What AIDS 2014 can learn from Melbourne 14 bisexual and transgender (LGBT) people and what Melbourne can learn from the world Laurindo Garcia and Jane Koerner Michael Bartos Enhancing partnerships across the region: 56 A time to be loud and furious: AIDS activism 17 Australia Awards Fellowships in Australia James Malar Dr Abigail Groves Community engagement for improved outcomes 58 Are we victims of our own success? Addressing 19 for HIV/AIDS in Myanmar the gaps in Australia’s enabling environment Dr Paul McShane Sally Cameron ‘Using the heart’: law enforcement and people 60 Sex work legislation stands in the way of 22 who use drugs in Asia Australia’s commitments: decriminalisation for Fifa Rahman, Hong Reaksmey, Pham Hoi Thanh sex workers health, safety and rights and Olga Golichenko Janelle Fawkes Learning from each other: the Australian-Asian 63 Australia, migration and HIV: an evolving 26 partnership experience policy landscape Ele Morrison Linda Forbes and Michael Frommer Successful funding mechanisms to foster civil 65 How to spread gay rights beyond the West 28 society: which way forward in China? Dennis Altman Cai Lingping, Li Yue, RD Marte and Chris Connelly In memoriam: Vivienne Munro 29 For the community, by the community: 67 strengthening effective responses to HIV Developing the narrative of HIV-related stigma 30 Inad Rendon and discrimination in Papua New Guinea Dr John Rule and Annie McPherson Mobilising men who have sex with men 69 for HIV counselling and testing In memoriam: Don Liriope 31 Matthew Vaughan Walk with me: creating an enabling environment 33 A Papua New Guinea–Australia HIV Research 72 for men of diverse sexualities and transgender Partnership: generating new knowledge, building people in Papua New Guinea capacity and forging new friendships Finn O’Keefe and James Malar Clement Manineng, Dr David MacLaren, Michelle Redman- Australian support for community HIV responses 35 MacLaren, Rachael Tommbe and Dr Tracie Mafile’o in PNG: what works, how do we show it, and who Sex worker organisations’ partnerships and 75 will fund it anyway? collaborations for capacity development Tim Leach and Dr John Rule Maria McMahon The Pacific Sexual Diversity Network: 38 Treatment briefs 77 Strengthening enabling environments in the Pacific though capacity building and regional partnerships Ken Moala Comparing Pacific and Australian approaches to 41 gay men’s health: reflections on the 2014 AFAO HIV Australia welcomes submissions from interested authors. National Gay Men’s HIV Health Promotion Conference To submit an article or report for consideration, email [email protected] Isikeli Vulavou

HIV Australia, Volume 12, No. 2 | 3 AIDS 2014 SPECIAL EDITION

Hopes for AIDS 2014 and beyond By Professor Sharon Lewin

It is fitting in many ways, that Sex, Health and Society continue to of the past century’s greatest human after three decades of the HIV epidemic, inform us on how best to address harm achievements in health, and getting the International AIDS Conference in sexual and drug use behaviours – so 11 million people on ART in low and is finally coming to Australia. Fitting vital to getting the evidence to develop middle income countries in just over a because Australia has punched way and implement new prevention and decade has been a massive task. above its weight on a global level treatment strategies and to deliver Universal access to these life-saving in response to HIV – from the very the most effective messages as part of medicines must remain a priority – beginning. broader education campaigns. particularly given we now know that There’s much to admire in Australia´s The Australian Centre for HIV and antiretrovirals not only save lives but also well documented response to HIV: Hepatitis Virology Research has reduce transmission of the virus. its bipartisan political approach to diversified from a focus on basic virology Pre-exposure prophylaxis (PrEP) is the disease has undoubtedly been a to using translational science to find also now a part of the equation, and the major driver in Australia having one new diagnostics, new antivirals, and revitalised interest in HIV cure research of the lowest rates of HIV infection to accelerate the path to find effective has gained strong momentum since the worldwide. The inclusion of key affected vaccines for HIV, hepatitis B and first man cured of HIV, Timothy Brown, communities – sex workers, gay men, hepatitis C. Australian innovations was reported in 2009. Recent reports and people who inject drugs – as equal such as a bedside CD4 test could soon of HIV functional cure following very partners in the response from the outset transform HIV management in low early initiation of ART – such as the has been fundamental in an effective income countries. Mississippi baby and the VISCONTI response. And lastly, the capacity building Cohort – have given scientists great And of course the work of Melbourne’s in science and research around the hope that a cure is indeed possible. The Burnet Institute since the early 80s, epidemic has played a pivotal role in discovery that some patients produce whether in or out of the lab, or around driving evidence-based public health very effective antibodies has also recently harm reduction, malaria or HIV, has policy, innovation and access to the latest raised hopes for new directions in without doubt made a huge contribution treatments and prevention strategies for vaccine research. It is clear that science to global health and, closer to home, affected communities. will continue to deliver. played a key role in helping to guide As a scientist I am enormously proud of responses to the HIV epidemic in the But as the Australian experience has what Australian science has contributed Asia and Pacific regions. shown, science alone is not enough to in the fight against the epidemic and I am carry an effective response to HIV – it thrilled about where it is going, too. The launch of the Peter Doherty must be accompanied by a combination Institute for Infection and Immunity at For near on two decades now we’ve been of community engagement and political the University of Melbourne as a leading leadership, and unfortunately both guided by the annual surveillance reports infectious diseases research centre is also provided by the Kirby Institute (formerly have been in short supply in too many an exciting development, and one I’ll be countries. In many parts of the world, known as the National Centre in HIV very proud to lead over the coming years. Epidemiology and Clinical Research), stigma and discrimination fuelled by led by Professor David Cooper, previous Yes, these are exciting times for unacceptable government policies, President of the International AIDS Australian HIV science; indeed HIV cruelly prevent millions of people from Society. Professor Cooper has been a science is riding a renewed sense of accessing treatment, care and prevention, giant opinion leader in international optimism globally. and ultimately prevent us working towards the end of the epidemic. forums. The Kirby Institute’s new home The response to the HIV epidemic on campus at the University of New over the past three decades has been With 2.3 million new infections and South Wales will be officially launched more than 1.5 million deaths reported a monumental achievement in global 1 the week before AIDS 2014, and is set to health, both scientifically and logistically. globally in 2012 , we simply cannot further expand its influence beyond HIV In less than three decades, the discovery say that HIV is under control. Only 34 into the broader brief of ‘infection and of effective antiretroviral therapy (ART) percent of people eligible for treatment worldwide are receiving antiretrovirals.2 immunity in society’. has transformed HIV infection from an The Centre for Social Research in Health inevitable death sentence to a chronically Progress, as welcome as it is, is still and the Australian Research Centre in manageable disease. This has been one fragile and many challenges remain, the

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greatest of which is implementing the science that we know works. AIDS 2014 comes at a pivotal time in the epidemic: the Millennium Development Goals come to fruition next year and already there is much discussion on what a post-2015 global health scenario will look like and where HIV/AIDS will sit in that brave new world. It is my strong belief that besides showcasing some exciting new science around hepatitis and TB co-infection, HIV paediatrics, PrEP and cure research, the AIDS 2014 conference will allow Australia and the rest of the world to reflect on and consider some of the controversial retreats being made in many country responses to the epidemic. We need to reverse the dwindling political and financial support for proven, cost-effective harm reduction interventions. We need to strongly oppose the introduction of homophobic laws in countries like Russia, Nigeria and Uganda that on past experience are likely to drive those epidemics underground. And lastly, we need to urgently address the rising rates of infections in many key affected populations – men who have sex with men, people who inject drugs, sex workers and transgender women. The AIDS 2014 Melbourne Declaration, launched on 17 May 2014, states that non-discrimination is fundamental to an evidence-based response to HIV and effective public health programs, and calls for immediate and unified opposition to these discriminatory and stigmatising practices. I call on each of you to sign the declaration. Working together to end stigma and discrimination remains a fundamental Above: ‘A Cure for HIV: Dare to Dream?’, Seminar with Professor Sharon Lewin, AIDS 2014 part of our work to achieve what we Local Co-Chair, at the India International Centre in New Delhi, India. ©IAS/Dhillon Photographics. continue to dream for – an end to HIV. References Professor Sharon Lewin is Director Doherty Institute for Infection 1 Joint United Nations Programme on HIV/ of the Department of Infectious and Immunity at the University of AIDS (UNAIDS). (2013). Global Report: UNAIDS report on the global AIDS epidemic Diseases at The Alfred Hospital and Melbourne. She is the local co-chair 2013. UNAIDS, Geneva, 4. Monash University; co-head of the for the 20th International AIDS 2 ibid., 47. Centre for Biomedical Research, Conference (AIDS 2014), which Burnet Institute, Melbourne, will be held in Melbourne Australia; and Director of the Peter July 20–25, 2014.

HIV Australia, Volume 12, No. 2 | 5 AIDS 2014 SPECIAL EDITION

Making history: the community heart of AIDS 2014 By Brent Allan

For those who have attended an community of scientists, politicians, know to be effective prevention, testing international AIDS conference in the and people living with and affected and treatment programs. past, understand that this is a conference by HIV to share their voices across a This conference will call upon a unlike many others. Sure, it is large single conference program. global response to the human rights and it is diverse, but what truly sets Although amazing achievements have barriers, which are systemically this conference apart is the role of been made during the last 30 years in disabling effective responses including community – both inside and outside the fight against HIV, now is the time legislative, regulatory and policy the conference. From planning, through to step up the pace. As part of the barriers as well as societal and cultural to the delivery and evaluation of the community response, we must build ideologies that often breed HIV stigma conference, the community is involved the skills we need to assess and develop and discrimination. in all levels of decision-making, working the right ‘combination prevention mix’ alongside government and the scientific We are at a tipping point in Australia for different populations. How do we community as equal partners. and I believe we have the opportunity match the social and epidemiological to achieve the 2011 United Nations Included in our numbers are advocates, aspects of different infection Political Declaration targets. Achieving activists and agitators – both people patterns with the growing choices those targets would make the virtual living with and people affected by in biomedical, behavioural and eradication of new infections by 2020 a HIV. We are patients, clients, structural interventions? real possibility. consumers, test subjects, service users We need to turn our growing However I have no illusions. and service providers. understanding of the science into policy, We may not be able to radically For the first time in the conference’s and in turn into highly efficacious transform societal mores but we history, the vision for the Community community and clinical-based test and can reform institutional barriers, we Programme at AIDS 2014 explicitly treat systems to ensure that people living can work towards the goal of equal endorses the greater and meaningful with HIV are supported on long-term participation of people living with HIV engagement of people living with HIV. treatment success. in all aspects of civil society, and we can We have also explicitly named those key At the Barcelona conference in 2002 challenge ourselves and the roles we populations disproportionally affected I was on a panel to hypothesise about play as actors in research, government by HIV in the global response to this the treatment and prevention nexus. and civil society to ensure that our pandemic in our vision. Not only will we The question, as it logically followed, partnerships are healthy, robust and highlight examples of evidenced-based was that if people with HIV were effective to enable a shared response best practice in community responses remaining undetectable then could which ensures that no one truly gets to HIV, we will explore the innovation, there be a population benefit? The left behind. creativity and entrepreneurial enterprise person sitting next to me was an of promising practices. At the last International AIDS amazing woman from Uganda who Conference in Washington, I was In 1996, I stood outside a packed challenged my rather glib and elitist convinced that we must do better to conference session room at the 11th analysis. She spoke with passion about reduce HIV stigma and to develop International AIDS Conference in treatment access inequities in the resilience building programs for Vancouver where an impromptu developing world for people living with people living with HIV. I met two television monitor had been set up HIV, saying that its prevention effect colleagues, one from Malaysia and to listen to David Ho present about was not hypothetical but a fantasy. We another from Canada, and we hatched something called ‘combination therapy’, quickly became friends and she opened a plan in a hallway outside the session using what was a new class of drugs my eyes to issues in her country; we rooms to adapt a people living with called ‘protease inhibitors’. I will never remain close friends today. HIV leadership development course forget when a slide came up describing AIDS 2014 will provide an for use in Australia. In two short the results and the spontaneous opportunity for people from key years, this program had trained two cheers and applause that engulfed the affected communities to network and dozen future leaders living with HIV conference centre. consider how to take control of their across the country, all of whom are These international gatherings provide localised epidemics – how to dismantle showing sustained resilience levels on a unique opportunity for the global the barriers to putting in place what we standardised testing.

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Above: Members of the AIDS 2014 Conference Coordinating Committee (CCC) during a planning meeting. The CCC makes top-line program decisions, including selection of plenary topics and speakers. Photos: © IAS.

I challenge you to take advantage of website – www.aids2014.org – on a increased their immune system strength what AIDS 2014 offers, both in terms dedicated page entitled Welcome to and spurred what is now referred to as of content and connections. Currently Melbourne. Details will be accessed the ‘Lazarus Effect’. This was when we there are over 150 events being planned directly by delegates, sponsors, media first witnessed the truly transformative within the Australian Cultural Program, and other interested parties as they impact of antiretroviral medications on ranging from public forums and events, start to build their conference schedule. the lives of people with HIV. to performances, photo exhibitions, and Where appropriate, activity will also be large public gatherings. listed on the City of Melbourne ‘What’s On’ website, www.melbourne.vic.gov.au/ The aim of these activities is to ensure whatson. participants travelling to AIDS 2014 experience all that our city and country I leave you with one final reflection has to offer, in particular our vibrant about being a witness to history. arts, sports, music and cultural scene, Within a week after the 1996 Vancouver Brent Allan is Executive Officer at our excellent public amenities and our conference, over 75,000 people living Living Positive Victoria and Local educational and scientific facilities. with HIV were moved from antibiotics Co-Chair of the Community The Australian Cultural Program will and chemotherapy as treatment to Programme Committee, be featured on the AIDS 2014 official an effective antiviral regimen, which International AIDS Society.

HIV Australia, Volume 12, No. 2 | 7 AIDS 2014 SPECIAL EDITION

Our story, our time, our future: Indigenous culture, continuity and centrality to the global HIV response

By James Ward1,2 and Michael Costello-Czok1,2,3 1 Baker IDI, Alice Springs; 2 Co-convenors of the Australian Aboriginal and Torres Strait Islander Organising Committee (AATSIOC) for the International Indigenous Pre Conference on HIV and AIDS – Sydney, Australia (July 17–19, 2014); 3 Anwernekenhe National HIV Alliance, Newtown, Australia

In 2014 the International AIDS but are not able to attend the whole nation state’s stance) to come together Conference (AIDS 2014) will be held conference. to discuss strategies for moving forward for the first time in Australia, in the city as Indigenous peoples in the context of Our international keynote speakers of Melbourne. As a prelude to AIDS a world with HIV. will speak to current and topical 2014, Sydney will host the International issues related to HIV care, prevention Quite often under a United Nations Indigenous Pre-conference on HIV & and treatment, bringing with them (UN) definition, Indigenous peoples’ AIDS, on the land and home of the experiences from Canada, the USA and identity gets lost in other population Gadigal people of the Eora Nation. New Zealand. groups and they’re not identified The Pre-conference is being jointly as Indigenous – they’re identified Over 250 delegates have registered to convened by the International under other sub-groups. So when the attend, from locations including Mexico, Indigenous Working Group on HIV & International AIDS Conference is held Guatemala, Chile, New Zealand, AIDS (IIWGHA) and an Australian in a country like Australia or Canada, Canada, the Pacific, USA – as well, of Aboriginal and Torres Strait Islander where there’s a resourced Indigenous course, from Australia. We are pleased Organising Committee (AATSIOC). population that is participating in the to announce that we will be hosting International AIDS Conferences (IACs) HIV response in many different ways, First Peoples Elders from communities have been held every two years since this presents an important opportunity around Australia to be part of our 2006, but this year is first time that the for greater focus on Indigenous issues conference, whose responsibility it will International Indigenous Pre-conference and Indigenous Identity. be to influence and spread the word is an IAC independent affiliated event. among Elders groups nationally about For Indigenous people, a conference This will significantly raise the profile HIV. like this is not only about stepping up of Indigenous people being part of not the pace in the HIV response, it’s also only the conferences, but of the global Why the need for an Indigenous about acknowledging who we are as response to HIV. conference? people in that response: what we’ve done in the past, and where we need to The theme of this year’s Pre-conference A conference focusing specifically on go in the future. We wanted to make is ‘Our Story, Our Time, Our Future’, Indigenous issues is important for a the Indigenous Pre-conference theme a name which reflects and promotes number of reasons. Indigenous peoples’ culture, continuity inclusive, and ensure that Indigenous and centrality in the global HIV response. 1. Maintaining identity people’s culture is a part of the The three-day event runs from July Indigenous peoples’ identities are conference. Recognising the centrality 17–19, and includes keynote speakers, contested globally, both from within of maintaining identity is bound to plenary sessions, presentations and communities and, externally, from enable Indigenous people to participate yarning circles discussing culture, HIV international bodies, through questions more effectively in the larger context of and health, prevention and education, such as ‘who is Indigenous and who the conference. policies, programs and leadership, plus is not?’ 2. Achieving recognition research monitoring and evaluation. In many countries Indigenous A key aim of the conference is to There are two main satellite forums populations have endured multiple raise the profile of the issues affecting attached to the Pre-conference: a forum colonisation periods in history, and Indigenous people globally. Very few for people living with HIV, and a youth people’s rights to be recognised as high level documents relating to forum. There is also a luncheon for Indigenous are far from achieving HIV, especially those produced by leaders from the Aboriginal health and resolution. This contestability lies at the UNAIDS or the World Health HIV sectors, to bring together people heart of our conference, which provides Organization, mention Indigenous who have an interest in what’s happening an opportunity for all self-identifying people as a key or recognised population with Indigenous communities and HIV, Indigenous peoples (irrespective of their at risk of HIV.

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Of course, being Indigenous doesn’t need to do, such as tackle persistently 5. Reduce rates of sharing injecting place someone at special risk of HIV high rates of other sexually transmitted equipment by 50% among per se. It is the inequalities in health and infections (STIs) – particularly in Aboriginal and Torres Strait the social determinants of health that remote communities. We know the Islander people who inject drugs. profoundly affect Indigenous people, other factors that make people sick in In Sydney, we will also launch the first placing Indigenous people in special our communities – dispossession, poor national Aboriginal and Torres Strait and urgent need of being recognised as access to health care, racism, stigma, Islander youth committee, whose job a key population in international agency discrimination; and we are familiar with it will be to mobilise young people documents. If Indigenous people don’t the many social determinants of health in the areas of healthy messaging recognise ourselves in these documents affecting our communities: overcrowded around sexual health and HIV, STIs then we don’t see HIV. housing, poor education and lower incomes. Our Sydney conference is an and reproductive health rights using There are a range of different issues important opportunity to discuss these social media as a main platform. around HIV that affect Indigenous issues in depth. The committee, called ANTHYM communities differently. One country’s (Aboriginal Nations Torres Strait success may be another country’s barrier. A major focus area for AIDS 2014 will Islands Youth HIV Mob), is an exciting A key topic for discussion at this year’s be national commitment and responses initiative of both AIDS 2014 and Pre-conference is the impact of treatment to the targets of the 2011 United Nations the International Indigenous Pre- as prevention (TasP) on Indigenous Political Declaration on HIV/AIDS. conference, and will serve us well into people. Different countries are at As global Indigenous communities the future by ensuring that young galvanise towards these targets, the different stages in their understanding of people’s voices and perspectives are varying research, monitoring, prevention 1 TasP, and coming to grips with just how heard in future planning. it’s going to be implemented. and treatment initiatives of countries will impact successes and barriers. AIDS 2014 Specific issues relating to Indigenous people living with HIV, and how people At our Sydney conference we will After Sydney, many of our conference are dealing with those issues nationally launch the Eora Action Plan, a charter delegates will head on down to for us to commit to into the future. The and internationally, are always at the Melbourne to participate in AIDS Eora Action Plan (so named because we forefront of every Indigenous Pre- 2014. The AIDS 2014 main conference are meeting in the Eora nation, home conference. The idea is that raising the program includes a number of of the Gadigal peoples of the Sydney profile of Indigenous people living Indigenous-led sessions, including on basin) sets out clear goals: with HIV internationally will build a leadership, and James Ward will be the 1. Reduce the number of newly stronger network, which can be utilised first Indigenous person to present on diagnosed HIV cases among to assist some of the other developing Indigenous peoples issues in a main Aboriginal and Torres Strait Island Indigenous communities that participate plenary session at an International AIDS peoples by 50% in these conferences. Conference, on Wednesday 23 July. 2. Eliminate all mother-to-child 3. Securing our future transmission of HIV among A major focus of Indigenous activities It is essential that we look to the future. Aboriginal and Torres Strait at AIDS 2014 is Djamabanna Ngargee While in Australia we have been Islander peoples Birrarung Marr, the Indigenous successful in our approach so far, with 3. Ensure antiretroviral treatments Peoples Networking Zone at the HIV rates of diagnosis similar to non- are available and accessible and Global Village. The zone, which runs Indigenous people, the fact that our correctly utilised by 80% of for the whole week of the conference, communities remain vulnerable to HIV Aboriginal and Torres Strait includes a program of activities ranging lays somewhat dormant, and innovation Islander people living with HIV from cultural performances to informal is missing in current HIV prevention 4. Move toward reducing rates of discussions and interviews with people responses. We know what these other STIs in Aboriginal and Torres from the International Indigenous vulnerabilities are. We know what we Strait Island communities by 50% Working Group on HIV & AIDS

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(IIWGHA), the local Australian Aboriginal and Torres Strait Islander Organising Committee (AATSIOC), and relevant people associated with the International AIDS Conference. A range of cultural activities has been organised around Melbourne to raise awareness about the conference and its objectives and outcomes. There’ll be community forums, social events, and gatherings. The Victorian Aboriginal Community Controlled Health Organisation (VACCHO) has taken a leading role in organising and working with IIGWHA to plan and develop the through an annual Aboriginal and for Population Health and the Indigenous Peoples Networking Zone Torres Strait Islander HIV Awareness Commonwealth Department of Health. and local events. Week. Each year for the next four The AATSIOC members include: On Monday 21 July the First Peoples years, beginning in December 2014 James Ward, Baker IDI Heart & Welcome event for conference delegates and coinciding with World AIDS Diabetes Institute (Baker IDI); Michael will be held at Bunjilaka, Victoria’s Day, we will run a week of activities in Costello-Czok, Anwernekenhe National award winning Aboriginal Cultural communities across Australia. HIV Alliance (ANA); Mark Saunders, Centre at Melbourne Museum – For Sydney and Melbourne we have National Aboriginal Community featuring guests from VACCHO and its commissioned nine pieces of art of Controlled Health Organisations members, Aboriginal and Torres Strait special significance to HIV from (NACCHO); Michelle Tobin, Positive Islander delegates from across Australia renowned Aboriginal and Torres Strait Aboriginal & Torres Strait Islander and First Peoples’ representatives Islander artists. These artworks will Network (PATSIN); Sallie Cairnduff from around the world. This event be displayed during both the Sydney and Darren Braun, Aboriginal Health is of significant cultural importance conference and at the Indigenous & Medical Research Council of NSW to Indigenous people. Welcome to Peoples Networking Zone in the (AH&MRC); Peter Waples-Crowe, Kat country is about Aboriginal people Global Village at AIDS 2014 and will Byron and Andrew Bamblett, Victorian being welcomed onto the land before continue to be showcased at future HIV Aboriginal Community Controlled business takes place, and it is also hugely Awareness Weeks. Health Organisation (VACCHO), important for our international guests. Trevor Stratton, International AIDS 2014 has provided a massive We invite you to come and join Indigenous Working Group on HIV/ opportunity to reinvigorate our Aboriginal and Torres Strait Islander AIDS (IIWGHA) Jessica Danforth responses regarding HIV within our peoples along with international First and Krysta Williams Native Youth communities as well as an opportunity Peoples from Canada, North America, Sexual Health Network, James Saunders to motivate the big agencies involved in Chile, Guatemala, Fiji, Aotearoa and Mopoke Media and ANTHYM HIV to include Indigenous peoples as a many other Indigenous Nations to meet, coordinator, Victor Tawil and Meggan key population in future developments. discuss, learn and share information Grose, NSW Ministry of Health. It raises the opportunity for us to be about HIV, sexual health, sexuality and central to our HIV responses and for us harm reduction in our communities. Endnote to celebrate our successes. 1 Further information regarding ANTHYM is After the conference Drop by at Djamabanna Ngargee available at www.anthym.org or on Twitter @ANTHYMAUS We have planned a legacy strategy Birrarung Marr to have a chat or to build on the tremendous participate in many of the activities opportunities that hosting an planned for AIDS 2014. international conference can bring. Acknowledgements After the Pre-conference and AIDS 2014 have finished we will announce The Sydney International Indigenous an initiative that aims to bring about Pre-conference is funded by the NSW Further information about the 2014 International Indigenous Pre-conference improved understanding and awareness Ministry of Health – HIV, STI and on HIV & AIDS is available at of HIV in the broader Aboriginal Viral Hepatitis Harm Reduction www.indigenoushivaids2014.com and Torres Strait Islander community and Viral Hepatitis Branch, Centre

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Creating an enabling environment: regional networks and community organisations are leading the way

Community organisations and networks are essential to achieving effective effective leaders in their work towards HIV responses, and a diverse, strong and active civil society is leading the equal community partnerships in way in Asia and the Pacific. their country’s HIV response. The results of investments in an enabling environment are informed, empowered and committed community leaders. The Australian Federation of AIDS synergistic North-South collaboration. To learn more about Australia Organisations (AFAO) operates AFAO has also provided APCASO Awards Fellowships programs, see an International Program based in with valuable technical support that the articles on pages 56 and 58. Moi Bangkok, which implements advocacy, has enabled us to do our work better, Lee Liow discusses the Global Fund’s capacity building and community with improved linkages to global policy new funding model in HIV Australia mobilisation projects in collaboration and technical knowledge. online, available at: www.afao.org.au with key regional networks and From the initial APCOM and AFAO organisations throughout the Asia and Asia Pacific Coalition on Male partnership on the AusAID HIV/ Pacific regions. Below, some of AFAO’s Sexual Health (APCOM) AIDS Partnership Initiative (AHAPI) key community partners working across program in 2006 to the current Asia and the Pacific have submitted Community Advocacy Initiative (CAI) brief statements to welcome delegates program, dozens of community-based By Midnight attending AIDS 2014 to our region. organisations in Cambodia, China, Poonkasetwattana, Executive Director, India, Indonesia, Laos and Vietnam Asia Pacific Council of AIDS APCOM Service Organizations (APCASO) have gone through a dedicated capacity-development process of Welcome to the Asia-Pacific region! coaching, mentoring and training that It’s been ten years ago since the has progressed and increased advocacy International AIDS Conference was and effective engagement in strategic held in our region, in Bangkok in By Moi Lee Liow, areas such as domestic HIV financing 2004. At the time the response to HIV Executive Director, and investments, human rights of among men who have sex with men APCASO key populations, and employment was in its infancy – indeed it was not discrimination affecting people living In recent years, there have been many until 2007 that APCOM (Asia Pacific with HIV. Some of these issues will be success stories in response to HIV and Coalition on Male Sexual Health) was discussed at sessions in Melbourne. AIDS across Asia and the Pacific. There formed to highlight the need to address is progress in areas such as reducing In spite of many success stories, Asia rising HIV transmission rates among new infections, expanding antiretroviral and the Pacific still has many pockets men who have sex with men. (ART) coverage, increasing domestic of resistance affecting key populations, As a coalition, APCOM recognises the financing, and attempts by governments in particular men who have sex with need to work in collaboration across to address stigma and discrimination. In men (MSM), people who use drugs, sex different sectors and organisations this region, civil society and community workers and transgender communities. to effectively address HIV issues; leadership – among the most dynamic, Recognising this, the CAI program this includes working together with prevalent and organised in the world – is has adopted an inclusive approach to civil society, development agencies, credited with contributing to this success. ensure these communities take centre government, United Nations system APCASO is confident that we have stage in CAI program activities. and technical experts. In order to truly made some valuable contributions to this At the 2014 International AIDS address the challenge of HIV, we need enviable situation, working to strengthen Conference in Melbourne this July, to work together towards creating an community capacity to engage in 25 community advocates and activists ‘enabling environment’ to confront national processes and advocate at the from APCASO partner organisations stigma, discrimination, violence and national and regional level. will participate in the Australia Awards social exclusion of men who have sex APCASO’s partnership with AFAO Fellowships (AAF) program. The with men and transgender people. The is an example of a productive and AAF will strengthen participants as promotion and protection of rights to

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n life-saving health services is crucial, Transgender people, in particular expand quality training for health as is investment in the response – transgender women, face higher and other key service providers especially the resourcing of community risk of HIV infection – 49 times working with transgender people n organisations. Of key and fundamental higher than that of the general adult produce and disseminate 1 importance is the involvement of population , with many engaging in sex content appropriate and specific men who have sex with men and work or transactional sex because of information to health and other transgender people in framing and employment discrimination and lack service providers on transgender implementing responses to prevent and of economic opportunities. Data from issues. treat HIV, improve sexual health, and countries in the region, for example, reduce stigma and discrimination. Thailand, shows that transgender Transgender health needs (mental, women have high rates of substance transition, sexual and general We hope you have an opportunity to use. The Asia-Pacific Transgender healthcare) must be addressed get to know our work in the region Network (APTN) and United Nations holistically and comprehensively through our booth in the AIDS 2014 Development Programme (UNDP) and linked to the broader context of Global Village, or by attending our 2012 report, Lost in Transition – economic empowerment through sessions at the conference. Transgender People, Rights and HIV providing meaningful employment opportunities and access to education, Vulnerability in the Asia-Pacific Region, Asia Pacific Transgender as well as access to and enjoyment of suggests that HIV prevalence rates Network (APTN) – Making social protection benefits. are as high as 68% among transgender Trans people count in the HIV/ 2 communities. Information from APTN continues to work for the AIDS Response one South East Asian city indicated rights and recognition of transgender that between 2003 and 2007 HIV people through rights based advocacy, prevalence among transgender people policy influencing, and engagement rose from 25% to 34%.3 Little is known with community organisations at the By Joe Wong, about incidence and prevalence among regional and country level, ensuring Project Manager, transgender men in the region. that stakeholders and partners have the APTN evidence, understanding and alliances Transgender people are rarely necessary to enable transgender Social researchers estimate that the included as a separate key population communities across Asia and the number of transgender people living in in national HIV biological and Pacific to design and lead an effective Asia and the Pacific is approximately behavioural surveillance or population response to HIV. 9–9.5 million; however, the actual size estimation exercises, limiting population size remains undetermined. opportunities to respond effectively. Youth Voices Count (YVC) Improved evidence and data are crucial Transgender people are an integral to inform effective programming that part of the traditional culture of several meets the real needs of transgender countries in Asia and the Pacific and communities in Asia and the Pacific. in some settings hijra, waria, kathoey and fa’afafine have been accepted into The mission of APTN is to enable traditional daily life. Discrimination transgender women and men in remains entrenched, however, Asia and the Pacific to organise and By Lieu Anh Vu with transmen and transwomen advocate for improvements to health, (top), Interim encountering a wide range of challenges protection of legal, social and human Network Officer, in accessing equitable healthcare – rights, and enhancement of social YVC and Phillip including to general and transitional wellbeing and quality of life. Salvador, Interim Project Officer, YVC mental health care and sexual health In February 2014, APTN organised care. The challenges facing transmen its second major regional consultation, As data in Asia and the Pacific continues are not generally acknowledged and are designed to review the situation of to indicate that young men who have under-researched. transgender people and identify areas sex with men and transgender people Discrimination and the lack of societal for accelerated action. The following are at high risk of HIV infection, it is acceptance, understanding and support priorities were identified by community imperative that attitudes, policies, and of gender identification and varied sexual leaders: practices continue to stimulate and n orientation remain persistent barriers for increase healthcare provision support effective and efficient functioning transgender people exercising the right and access of organisations and individuals working n to access health, education, employment reduce stigma and discrimination on issues surrounding HIV and other and social services. in healthcare provision health services.

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In urban meccas such as Bangkok, create widespread challenges for young References Thailand, Ho Chi Minh City, people attempting to access health 1 Baral, S., Poteat, T., Strömdahl, S., Wirtz, Vietnam, and Chongqing, China, services. In addition, men who have sex A., Guadamuz, T., Beyrer C. (2013). Worldwide burden of HIV in transgender young men who have sex with men with men and transgender people aged women: a systematic review and meta- 7 have high HIV prevalence rates, with 18–29 report facing unique self-issues analysis. The Lancet Infectious Diseases, the primary mode of transmission and intense self-stigma, which further 13(3), 214–22. being unprotected sex. Young people increase their HIV vulnerabilities. 2 Asia Pacific ransgenderT Network (APTN) and United Nations Development face additional barriers to accessing When we talk about stepping up the Programme (UNPD). (2012). Lost in services due to criminalisation of Transition: Transgender People, Rights and pace in reversing the HIV epidemic, male-to-male sex in 19 out of 38 HIV Vulnerability in the Asia-Pacific Region. we must also guarantee that platforms countries in the Asia-Pacific region4, UNDP, Thailand. for young key populations exist and are 3 ibid. the non-recognition of gender identity working. Youth Voices Count, a youth 4 Joint United Nations Programme on of transgender people, and intense HIV/AIDS (UNAIDS). (2011). HIV in Asia initiative led by young men who have stigma and discrimination in their and Pacific: Getting to Zero. UNAIDS, sex with men and transgender people, environments5. HIV prevalence Bangkok. has been at the forefront of giving a 5 Altman D., Aggleton, P., Williams, M., has been increasing among young loud voice and a proud face to the issues Kong, T., Reddy, V., Harrad, D., et al. transgender people over the past (2012). Men who have sex with men: that directly affect young men who have several years6, indicating that young stigma and discrimination. The Lancet, sex with men and transgender people transgender people remain an invisible 380(9839), 439–45. by way of advocating, mainstreaming, 6 Unpublished data. UNICEF, KAP report, population whose needs are not and providing a regional platform for forthcoming November 2011. being addressed. 7 18–29 is the age range used by Youth the network’s strong membership in 19 Voices Count. Laws that require parental consent to countries around Asia and the Pacific. obtain HIV testing and counselling These efforts will not be fully realised for young people under 18 in some unless we ensure a working enabling countries in the region continue to environment is created and sustained.

Sex workers from Asia and the Pacific calling for decriminalisation of sex work at ICAAP11, Bangkok 2013. Photo: Janelle Fawkes. See the article on page 75, where Maria McMahon, Scarlet Alliance’s International Program Manager, discusses sex worker organisations’ partnerships and collaborations for capacity development.

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What AIDS 2014 can learn from Melbourne and what Melbourne can learn from the world

By Michael Bartos

Nineteen eighty-four was a pivotal viable, nuanced positions which New York, and San Francisco (among year for Melbourne’s AIDS response. were saleable to elected politicians. other places) and doctors serving these From 1981 to 1983 there was a kind of Underlying these tactical strengths gay men – many themselves gay – ‘phoney war’ about AIDS in Australia. was a more basic shift in the balance noticed unusual patterns of disease and People kept up with the latest news of power through the ability of the death. It required self-identification from the US, but while some key gay community sector to reshape the notion because gay men’s risk was constituted community journalists and public health of expertise. This entailed a mastery by private sexual practice, not easily bureaucrats were preparing the way, of the traditional sources of expertise: identified markers like race or specified for most Australians – including those gay community journalists became geographic location. among the gay community – AIDS still the most well-read HIV medical No test for gayness existed, but soon a felt far away. experts in the country, able to engage test for HIV was developed and came more traditionally medically-qualified The first harbinger of a shift to a more into use in 1985 and Australia was experts on their own terms and often urgent response came in mid-1983 one of the early adopters, at least for trumping them with more up-to- with the formation of the AIDS action blood screening. Once an HIV test date information obtained through groups prompted by the Red Cross became available, the issue was whether international community networks.1 In Blood Bank’s proposal to ban gay donors. the population of gay men could be addition to a strictly medical expertise, But it was not until November 1984, ‘flushed out’ by requiring them to test. the capacity to speak for and be when the ultra-conservative Queensland Policies around antibody testing rapidly embedded in the communities most government decided to make political polarised, including within community affected became recognised as a crucial capital out of the HIV infection of four organisations. The AIDS Council of aspect of the expertise necessary to the infants through blood from a gay donor, New South Wales was inclined to AIDS response. that the AIDS response really took hold. advocate in favour of testing, while the Within a month, a full-scale emergency The struggle over control coalesced policy stance of the Victorian AIDS response was underway with many of the around two major elements: HIV Council was that while individuals characteristics that continued to propel testing, and the development of health should be able to choose to test if its success into the subsequent decade. promotion using culturally appropriate they wished, there was no compelling Thirty years on, many of the things risk-reducing approaches. reason in favour of testing – a position it maintained until around 1988 when we take for granted in today’s HIV Today, the mantra that HIV testing is clinical evidence and early results from response have become so commonplace the gateway to HIV prevention and the use of AZT suggested there were it is hard to recall that they were the care is so often heard that it is hard health benefits for those testing positive.2 sites of struggle and heroic invention to even imagine that one of the most in the period of the mid-80s: safe sex successful responses to HIV/AIDS in The power over testing became a key for example, and even community the epidemic’s history gained its initial point of leverage in getting community involvement in a ‘medical’ issue. power and leverage precisely through a seat at the public health table. Initially, The key question that was defined in resisting testing. the national and state bodies charged with responding to AIDS refused that period in Melbourne, and Australia One of the reasons the initial petitions for community representation. more widely, was one of power – who emergence of AIDS among gay men In 1983 the National Health and was to control the AIDS response: caused such moral and political panic Medical Research Council’s AIDS Task paternalistic public health doctors or was that gay men were not a readily Force advised the Health Minister that mobilised, affected communities? In identifiable group. The classic public ‘there was no place for representation resolving this question largely in favour health tools in response to an emerging of individuals who do not have the of communities, the practice of public communicable disease are screening scientific understanding or discipline to health and health promotion was and quarantine. AIDS was identified fundamentally changed, for the better. contribute to the consideration of the as a singular disease rather than just issues on hand’.3 Community had on its side fundamental random mortality because by the late political skills of organising – disciplined, 1970s communities of self-identifying The introduction of compulsory sophisticated use of the media and gay men had emerged in Los Angeles, notification of HIV infection in New

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South Wales and Queensland in 1985 ignited testing controversies, and the inclusion of mandatory testing in Victoria’s 1987 HIV legislation was only defeated after a concerted lobbying effort. On one side, traditional public health authorities took testing as an article of faith. For them, surveillance was a necessary starting point for any response. Gay community saw the issue differently: what was the use of testing if there was no effective treatment, if it exposed people to discrimination, and especially if testing undermined the solidarity between those infected and uninfected at a time when the community was inventing safe sex as a mass response. The invention of safe sex was the second significant realm of political struggle over AIDS in the mid- 1980s. The invention of safe sex has been widely canvassed, but it is worth recalling the salient features of Melbourne’s version. In common with most, it was sex-positive, taking as a given that gay men should be supported to continue to enjoy sex. Exhortation to abstinence was considered unrealistic. In that sense, it was from the outset a risk-reduction rather than a risk-elimination strategy. Once the debate over a single viral cause or multiple germ and lifestyle factors was settled with the discovery of HIV in mid-1984, consensus rapidly developed that the most important priority was to get gay men to use condoms for anal sex, regardless of HIV status. Strategies such as reducing the number of partners, increasing the lighting in gay saunas (as proposed in San Francisco) or closing them altogether (New York), or opposing drug and alcohol use were dismissed as moralistic and hygenicist. A series of innovative HIV education efforts were put into effect by the

Pictured right: Displayed in gay clubs and saunas, this poster was part of the Victorian AIDS Council’s first education campaign, and one of the first safe sex posters devised by a non-government organisation in Australia. Image: Australian Lesbian and Gay Archives.

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Victorian AIDS Council in its first inevitable logic of the cumulative cost of continued over-selling of HPTN-05210 years (it was launched in December life-long therapy, especially as consensus and treatment as prevention. 1984). The Council’s first education suggests first-line ART costs have pretty In Melbourne, perhaps the weight of campaign included a poster which read, much bottomed out. history will be able to exercise some “Great Sex! Don’t let AIDS stop it” HIV prevention is not the same in counter-balance. and a pamphlet titled AIDS: Trying to the era of mass treatment access as it Michael Bartos was President of Reduce the Risk. Outreach activities were was before. But as Kippax and Race the Victorian AIDS Council from conducted in public places used for sex. presciently argued a decade ago, the 1993–1994. He is currently UNAIDS A genre of sexually explicit ‘pornucation’ increasing place of medical technologies, Country Director in Zimbabwe. was created.4 Alcohol and drug use was whether testing or ART, do not addressed but not discouraged: instead, References supplant the social, they just change the based on research that showed alcohol 1 Particularly notable in 1983 was the work of ground over which social and sexual Adam Carr in Outrage and John Cozijn in and drug use were part of intentional 8 practice is negotiated. Campaign. strategies to give internal ‘permission’ 2 See ‘Antibody testing’ in Victorian AIDS for unsafe sex, gay men were advised For much of the globe, community Council/Gay Men’s Health Centre (VAC/ ‘alcohol and drugs: no excuse’. Youth attempts to seize power over the AIDS GMHC). (2013). Under the Red Ribbon: Thirty Years of the Victorian AIDS Council/ campaigns carefully courted controversy response have been an uphill struggle. Gay Men’s Health Centre. VAC/GMHC, with a ‘two boys kissing’ poster driving Development assistance has been a Melbourne. Retrieved from: http:// recruitment into youth peer education double-edged sword. It has brought with undertheredribbon.com.au/vignettes/ groups. And by the end of the 1980s, it much needed resource assistance which antibody-testing/ and Jennifer Power. (2011). Movement, Knowledge, Emotion: HIV status was explicitly incorporated has enabled millions of HIV infections Gay activism and HIV-AIDS in Australia. into HIV prevention programming with to be averted and millions of lives to be ANU Press, Canberra. the appointment of an HIV-positive prolonged through ART access (after the 3 National Library of Australia, Greg Weir prevention officer and a 1992 campaign international aid community deemed in Archive. (1983). Doc. No: 123 – 9, Letter 1983.11.02, From: Blewett, N. Health under the slogan ‘one of us has HIV, the early 2000s that it was prepared to Minister (Federal) To: Secretary Trades & two of us have safe sex’.5 fund treatment). But with the resources Labor Council, Queensland: Outline of the has come the dreaded development Federal Government’s response to AIDS. New HIV infections in Melbourne 4 Leonard, W. (2012). Safe Sex and the expert, inserting another layer of power peaked in around 1985. They were largely Aesthetics of Gay Men’s HIV/AIDS getting in the way of local solutions to Prevention in Australia: From Rubba Me in among gay men. No doubt the simple 9 collective action problems. 1984 to F** k Me in 2009. Sexualities, 15(7), fact of news about the presence of HIV 834–849. doi:10.1177/1363460712454079 accounted for some of the change in For many in the AIDS world, the turn 5 VAC/GMHC. (1993). A Dangerous Decade: sexual practice that reduced transmission. to treatment has been embraced with a Ten Years of the Victorian AIDS Council. VAC/GMHC, Melbourne. Retrieved from: But at the same time, an active, politically sense of relief that medical technologies www.vac.org.au/sites/default/files/VAC- engaged mass response supported can leave the messy business of politics GMHC_Dangerous_Decade.pdf through community organising and in behind. But this just blinkers out the 6 Kaiser Family Foundation and UNAIDS. (2013). Financing the Response to AIDS tune with changing norms must have real negotiations of power that happen in Low- and Middle-Income Countries: made a major contribution. on a macro scale when, for example, International Assistance from Donor procurement contracts worth billions are Governments in 2012, September 2013 2014 is not 1984. Political organising negotiated out of sight, or on a micro 7 See: http://aids.gov/federal-resources/ has taken a backseat to the business of funding-opportunities/how-were-spending scale as people negotiate the minefields AIDS, with the latter driven largely 8 Kippax, S., Race, K. (2003). Sustaining safe of doctors’ instructions, neighbours’ practice: twenty years on. Social Science & by increasing access to antiretroviral contempt (or support) and the prospect Medicine, 57(1),1–12. therapy (ART) across the world. In 9 Booth D. (2012). Development as a of asking their new sexual partner to test 2012 total international and domestic collective action problem: addressing the him/herself for HIV. real challenges of African governance. AIDS spending in all low and middle- October 2012. Overseas Development income countries was around $19 The epidemic’s first decade was Institute. billion, 53% of which came from characterised by medicine’s impotence 10 In May 2011, the HPTN 052 clinical trial domestic sources – the main source in the face of HIV and a humility conducted by the HIV Prevention Trials Network (HPTN) reported that antiretroviral of recent spending growth since that came with it. The third decade medication reduced the risk of heterosexual international aid increases stalled from has been the opposite. Despite the transmission by 96%. Because of HPTN 2009.6 In comparison, in 2012 the measured restraint of the respective lead 052’s implications for the future response US alone spent $21.3 billion on its researchers, the last two International to the HIV epidemic, Science Magazine 7 named this the scientific breakthrough of domestic HIV epidemic. The share of AIDS Conferences succumbed to an 2011. For further information see HPTN AIDS resources going to treatment has overblown medical triumphalism – in 052 – HPTN Studies: HIV Prevention Trials been steadily increasing, and that share Vienna with the CAPRISA microbicide Network website. Retrieved from: www. hptn.org/research_studies/hptn052.asp will continue to increase through the trial results, and in Washington with the

16 | HIV Australia, Volume 12, No. 2 AIDS 2014 SPECIAL EDITION

A time to be loud and furious: AIDS activism in Australia By Dr Abigail Groves

Films like Dallas Buyers Club, which but in fact driven slightly mad by some Not everyone had such a background, won Matthew McConaughey an injustice, some cruelty, some unfairness. though. Lyle Chan is a classical Oscar®, and United in Anger, a history So much so that he or she is driven by composer who found himself in the of ACT UP, have turned HIV activists some internal moral engine to act to middle of an emergency. ‘I couldn’t into heroes. But what is striking about make it better.’ stand by,’ says Chan. ‘My friends were these movies is that the events they dying. I saw ordinary people turn Anger and a sense of injustice are depict are placed firmly in an historical themselves into activists, so I did the recurring themes in the accounts of context. This is a time that has passed. same. The prevailing atmosphere was, AIDS activists. The spectre of death The urgency of the AIDS crisis has “we will do whatever it takes”. I was a and dying added urgency. ‘They were largely, and thankfully, disappeared – musician, but I also had a background terrible times, just terrible. I was angry,’ at least in the developed west. Yet in molecular biology – though no one says Paul Kidd, a former President of there is a certain nostalgia for the was an expert in AIDS back then,’ Living positive Victoria and self- innovation and excitement that AIDS he adds. ‘The doctors and researchers identified “stirrer”. Anger, Paul feels, activism generated. had an advantage because of their was an appropriate response. ‘Anger is medical training but still, they knew ‘People are suddenly interested in what gets people off their arses in the no more about AIDS than the activists talking to me,’ says Lloyd Grosse, first place, so it has a motivating role. did, because we made a point of Sydney DJ and former HIV activist. Second, the expression of anger is an being well-informed.’ After coming ‘It’s like we are the heroes of the important part of activism. There’s a to Australia from America, he joined AIDS movement’. Grosse lays claim time to be respectful and polite, and ACT UP and also ran a ‘buyers’ club’ at to being the first Australian to come there’s a time to be loud and furious.’ ACON, importing drugs from the US out publicly as HIV-positive and an Being a gay man in the 1980s and early unavailable in Australia. old, yellowed copy of the Sydney Star 90s was one such time. Observer suggests he may be right. It Chan had over 400 clients. ‘The AIDS ‘At one stage,’ Lloyd Grosse recalls, carries a picture of Grosse in an ad Council gave it a euphemistic name: ‘ACON was telling people not to get encouraging gay men to ‘take control’ the Treatments Access Scheme. The tested, because there was nothing that and get tested for HIV. The piece now buyers club operated under cover of a they could do to help us. And there seems innocuous – another ad for HIV provision in federal law that allowed was a real fear, at that time, that the services, of the kind familiar to any people to import certain medical drugs government would put us in quarantine reader of the gay press. More striking under certain conditions. The law was or something like that.’ Grosse later did to me are the bouffant hairstyles and designed for drugs manufactured by get tested and, despite assurances that high-waisted pants of the early ‘90s. legitimate drug companies – but I he was not high risk, tested positive. But there is something from the Sydney was importing ddC [dideoxycytidine With a background in the union Star Observer of twenty years ago that I – an early antiretroviral medication] movement, activism came naturally had forgotten: the awful, gut-wrenching made in underground laboratories to him. Already a volunteer at AIDS death notices. ‘There was one period,’ in violation of multiple drug patents, organisations in Sydney, he became Lloyd says, ‘when the Bobby Goldsmith while the official drug company and involved with PLWHA (NSW) Foundation had five clients and seven the Australian government took their (today known as Positive Life NSW) friends die in one week. One week.’ time working out how to supply it’. and then ACT UP. Similarly Paul Events like these put Lloyd Grosse’s Kidd, who was diagnosed in the early Access to treatments was the big issue decision to come out in perspective. 1990s, says that, ‘I’ve always been a for people with HIV in Australia, as ‘An activist,’ writes Eve Ensler, author of politically aware/outspoken person and it was elsewhere. Access to treatments The Vagina Monologues, ‘is someone who AIDS was the issue du jour in the gay gave ACT UP its moment in Australia. cannot help but fight for something. community. I thought I was going to In Australia, the early trials of AZT – That person is not usually motivated die and I wanted to make some noise the first antiretroviral drug approved by a need for power, or money, or fame, before I did’. for use by the US Food and Drug

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Association – were run on a quota (the Australian Federation of AIDS system. This meant that those who Organisations) to get relief. These were unable to access the trial were left organisations had the same goals as with nothing, which incensed activists. ACT UP but were less antagonistic. ‘The process for approving new drugs ‘The range of players – government, was very bureaucratic and took no medical professionals, drug companies, account of the nature of the illness. NGOs and activist groups – made for You could have a drug for dandruff a volatile environment, especially when and a drug for cancer and they were sex and personal relationships were both treated in exactly the same way,’ added into the mix. explains Lyle. Where has it gone, this anger? Lyle Treatment issues also gave the impetus Chan says he made a conscious to ACT UP, the direct action group decision to leave activism behind, which had proved effective in the once it became clear that the protease US. However, ACT UP was never as inhibitors, the new generation of popular or widespread in Australia as it antiretroviral drugs, would ‘rescue was in the US. This may have been due people from the toilet’. ‘Activism is to the effectiveness of the Australian an attempt to reach some kind of government’s response to HIV. With normality,’ he reflects, ‘that you feel is Above: The AIDS candlelight vigil in Sydney, a Labor government in power during being denied for some reason. Once it as depicted on the cover of the National AIDS became clear, between 1994 and 1996, Bulletin, November 1993. The NAB was a the 1980s, Australia benefitted from monthly bulletin produced by the Australian progressive leadership on HIV issues. that we were no longer fighting against Federation of AIDS Organisations. ‘It was really down to three people,’ a constant backdrop of death, it became Photo: Jamie Dunbar. says Lloyd Grosse. ‘Neal Blewett was possible to imagine a future where the Health Minister. Bill Whittaker every day was not a state of emergency. was a great advocate. And Bill Bowtell Some activists continued, working their funders than doing what is who was Blewett’s advisor – he was in in Asia for instance, where the crisis right to protect people’s rights and the right place at the right time.’ It was continued for different social reasons. lives. I think it’s important to have through their leadership that Australia But I felt my work as an activist was independent voices calling out and adopted harm minimisation policies done, and with normality came the questioning the AIDS establishment such as needle exchanges, and funded responsibility of returning to my true and I try to continue doing that in organisations like the AIDS Councils purpose, which was to write music.’ my way’. to provide community-based education Chan has since written an acclaimed All readily acknowledged that while and services. string quartet memoir of his years as an AIDS activist. the AIDS crisis is over in Australia, But these community-based services it is still very present in other parts of could themselves become targets of Lloyd Grosse is no longer involved the world. The International AIDS attack from activists. ‘A lot of my anger in HIV issues, either, though he says Conference in Melbourne will see was directed at the AIDS movement,’ he took longer to move on. ‘The war some of the world’s most inspiring says Lloyd Grosse. ‘They were too ended,’ he says. ‘People are no longer AIDS activists in Australia. Paul Kidd caught up with their careers – they dying, so in a sense we won. I have is hopeful that the conference will would never stick their necks out.’ returned to my core, which is social re-invigorate Australian activists. ‘I Lyle Chan says ACT UP deliberately justice issues.’ think the AIDS conference will be cultivated its image as the ‘lunatic Paul Kidd, who became involved in an energising force for HIV activism fringe’ of the HIV movement. ‘ACT AIDS activism a little later than the in Australia,’ he says. ‘I hope it will UP had a love-hate relationship others, says he is no longer angry – at generate some anger and some with organisations like ACON,’ he least, not about HIV issues. ‘Anger willingness to challenge the status recalls. ‘ACT UP criticised the HIV doesn’t seem right in the current quo. It will also help local people see organisations and could also say and do context because the stakes just aren’t where they fit in the global picture, things that other groups couldn’t. But as high as they once were: people are and maybe contextualise the local we also knew that our extreme protests not dying.’ Kidd, however, still writes challenges and local complacencies in against government officials and drug about HIV issues. ‘I think our AIDS terms of a broader picture.’ companies would send them straight organisations have become dreadfully Dr Abigail Groves is a freelance into negotiations with ACON (the risk-averse,’ he says. ‘Too many of them writer and a former Policy Analyst AIDS Council of NSW) and AFAO are more concerned about upsetting at AFAO.

18 | HIV Australia, Volume 12, No. 2 AIDS 2014 SPECIAL EDITION

Are we victims of our own success? Addressing the gaps in Australia’s enabling environment1 By Sally Cameron

2 The trajectory of social values is not linier … progress is not assured. legal and policy interventions. Lack of political will is compounded by the unintended consequences of a great deal of great policy analysis and law reform Arguments for an enabling environment In early 1990, the Intergovernmental that has delivered impressive results. So are not simply about addressing Committee on AIDS established too the HIV prevention efforts of peer human rights or demonstrating a fine a Legal Working Party to review organisations of sex workers, people moral compass. They are pragmatic3 legislation impacting HIV/AIDS who use injecting drugs and their allies because effective HIV strategy requires and make recommendations for has proven so effective that there is inclusivity and ‘buy-in’ from affected law reform. Their report, including no HIV ‘crisis’ in these populations. communities. 89 recommendations for reform We’ve leveraged some fundamental of diverse laws5, was considered a reforms in Australian law and policy, We started well. The emerging public blueprint for national law reform. and consequently facilitated a shift in health crisis (known first as GRID, While acknowledging that different Australian social values and norms: a then AIDS and eventually HIV) jurisdictions would need to consider shift that has greatly improved the lives galvanised affected populations. It was a local needs and priorities, both the of many in affected populations. At this community crisis. Intergovernmental Committee on point, do we really need to take on the Gay men, people living with HIV, sex AIDS and the Australian Health hard stuff? workers and people who inject drugs Ministers Advisory Council Successive Australian national HIV organised. Some brave individuals outed unanimously endorsed the report strategies have lauded the enabling themselves – as having HIV, as gay, as and its recommendations. Australia’s environment and the importance a sex worker or as someone who injects approach to HIV became an of legal and human rights issues, drugs … and by putting a face to the international model, and accolades however, they are no longer priorities. ‘name’, they humanised the epidemic, followed, including invitations Although included in the strategy, they and owned it. Communities were active to Australian jurists to develop are linked only to broad not specific international guidelines on a human and adamant. Medical and nursing ‘priority actions’ or ‘implementation rights-based approach to HIV.6 staff risked their own health as well as strategies’? Despite sustained advocacy 4 social judgement. And by some stroke by some (more than others), the more Reform slows of great good fortune, our governments contentious issues of law reform have were interested and (mostly) brave. The introduction of antiretroviral been adrift for some time. In the absence of effective medical therapy (ART) in the mid-90s Discrimination interventions, attention turned to the facilitated a shift in focus to medical social and legislative factors driving interventions: HIV was treatable. Australian anti-discrimination law HIV stigma and increasing risk of Next, effective treatments triggered is unrecognisable when compared to HIV transmission. A new phrase was a reconceptualisation of HIV as a the legal landscape of the early 1980s. coined: the ‘enabling environment’. It chronic manageable condition, and we State and federal law make it unlawful described the necessity of a supportive started to ponder the implications of to discriminate against any person legal and policy framework required living with HIV long term. Recently with HIV or any person thought if HIV education and related public we’ve focused on (arguing about) the to have HIV. Under state law, it is health measures were to work. Those at importance of increasing HIV testing also unlawful to discriminate against risk of HIV infection and those living and early diagnosis, early treatment people on the grounds of sexuality initiation and treatment as prevention. with HIV must be engaged in the HIV (variously described in different response. As it turns out, attention to While treatment advances are jurisdictions), and gender identity (also the ‘enabling environment’ has proven a inarguably wonderful, they have meant variously described) in most instances. concept fundamental to the success of that HIV is no longer considered a Recent reform of Commonwealth Australia’s HIV response. community crisis requiring radical anti-discrimination law also makes

HIV Australia, Volume 12, No. 2 | 19 AIDS 2014 SPECIAL EDITION

discrimination unlawful on the grounds you Tasmania) had to be dragged expensive for governments and of sexual orientation, gender identity kicking and screaming to the United business20, and created a two-tiered and (a first in the world) intersex status. Nations Human Rights Committee system of legal and illegal workers, with (1994) with a three year lag before illegal workers wary of public health Anti-discrimination protections extend state legislation was introduced.10 Age services21. Criminalisation drives sex beyond ‘anti-discrimination law’. In of consent for sexual activity varies work underground, reducing access to 2008 the Australian Government across seven of Australia’s eight state health and other social supports and introduced legislation to remove jurisdictions (either age 16 or 17) but is impeding outreach. It increases risk of discrimination affecting same-sex otherwise uniform across heterosexual/ STIs for sex workers and clients as it couples and their children from 85 homosexual practice. Queensland reduces sex workers’ capacity to exercise Commonwealth laws. These included remains the notable exception, control over their work.22 Police changes to tax, superannuation, maintaining a lower age of consent for continue to use condoms as evidence social security, Medicare and the heterosexual sex (16 years) than sex that illegal sex work has occurred: a Pharmaceutical Benefits Scheme, between men (18 years). slap in the face to HIV prevention aged care, child support, immigration, strategies. Notably, criminalisation has citizenship and veterans’ affairs. Needle and syringe programs have 23 not eradicated criminalised practices. proven extremely effective, with an Despite such tangible achievements, Yet, despite the much researched estimated 32,000 HIV infections real gaps remain: notably, anti- health benefits of decriminalisation, averted, and net financial cost savings discrimination law exemptions allowing no other state or territory government exceeding a billion dollars between religious organisations to discriminate has moved to a decriminalised model, 2000 and 2009.11 Yet, incredibly, against individuals on the grounds and the NSW model has recently come peer distribution of clean injecting 24 of sexual orientation and gender under renewed threat. identity, including in employment and equipment (both common and provision of services. These exemptions effective) remains illegal in most states. Criminalisation of HIV are particularly galling given many Laws criminalising injecting drug use All Australian states and territories religious organisations now provide in all states and territories exacerbate have criminal laws that can be applied services previously provided by risk of harm as drug source and quality to cases of HIV transmission or Commonwealth agencies. There is also is frequently unknown, and injecting exposure through sex. Such cases have the seemingly intractable thorn in the often occurs in covert environments been reserved for instances where the side: federal marriage law precluding where injecting is hurried and (crucially accused is alleged to have failed to same-sex marriage. for HIV) clean equipment is not available. Peer-led organisations face disclose their HIV status before sex: People with a history of injecting drug an uphill battle implementing HIV effectively criminalising sex without use are completely locked out of anti- prevention measures in an environment disclosure – not HIV transmission per discrimination complaint mechanisms where the target group is criminalised, se, as many cases have involved only the despite stigma and discrimination ostensibly driving people who inject risk of HIV transmission (exposure) against people who inject drugs being drugs away from mainstream services. without HIV transmission occurring. ‘pervasive and entrenched’7, including There are 40 (known) prosecutions: in relation to access to health care8. The peculiar regulation of sex work across Australia includes not many given the more than 32,000 Anti-discrimination laws have largely HIV diagnoses that have been made in decriminalised, licensed and 25,26 failed to address discrimination against criminalised approaches, with no two Australia to date , but puzzling given sex workers. Sex work related anti- of the eight jurisdictions the same. that in many instances, there seems discrimination laws exist in the ACT, Things seemed to be looking up when little to differentiate these cases from Queensland, Tasmania and Victoria, and in 1979, the NSW Government many of the 1000 new HIV infections while it’s a start, those laws are narrowly decriminalised sex work.12,13 that occur through sex each year. Cases defined and their application limited. Research has consistently shown that are varied: a single or multiple sexual In other states, anti-discrimination laws encounter(s); short liaisons or long term 9 decriminalisation has facilitated health provide no protection. promotion14, improved occupational relationships; recent encounters or those 15 that occurred long before trial. Criminal laws health and safety , and eradicated police corruption16. It has not increased Prosecutions undermine the enabling By 1997, laws regulating or the incidence of sex work in NSW17, environment because they negate public criminalising gay sex had been or led to greater numbers of sex health messages of mutual responsibility repealed in all Australian states and workers compared to states where for safe sex practice. They create a territories, although it must be noted similar sex work practice is illegal18,19. false expectation that HIV-positive that the last government to fall (yes, By comparison, licensing has proven people will disclose27, and suggest

20 | HIV Australia, Volume 12, No. 2 AIDS 2014 SPECIAL EDITION

people can rely on disclosure as a core out in massive negative media coverage 2 Masters, J. (2005). Social Values and Public Policy: From Opportunities to Rights safe sex practice. There is no evidence of a 2011 ACT case in which a man and Back to Opportunities. Center for at all that HIV-related prosecutions was charged for undertaking sex work Community Futures. Retrieved from: http:// facilitate disclosure of HIV status prior while infected with an STI (HIV), www.cencomfut.com/social_values.htm 3 Elliott, R., Vonn, M. (2012). Treatment to sex or decrease risk taking. To the despite no suggestion that he placed as Prevention: Human Rights Imperative contrary, almost half (45%) of those any clients at risk of HIV infection and Concerns. Canadian HIV/AIDS Legal surveyed for HIV Futures 7 said they (hence no further charges were laid). Network and British Columbia Civil Liberties Association, Toronto and Vancouver. were concerned about disclosing their Australian research suggests that 4 Van Reyk, P. (2014). Life during wartime: HIV status prior to sex because of the mandatory testing is expensive, invasive, Nursing on the frontline at Ward 17 South law.28 Furthermore, disclosure has been unnecessary, and without benefit to the at St Vincent’s Hospital, HIV Australia, Vol. shown to decrease the likelihood of individual. Mandatory testing fails to 12, No. 1. AFAO, Sydney. 29 5 Commonwealth of Australia. (1992). The condom use , greatly increasing HIV reach the intended target group, draws Final Report of the Legal Working Party risk given some 30 percent of new HIV testing resources away from high risk of the Intergovernmental Committee on infections among men who have sex populations, and does not reduce HIV AIDS, Department of Health, Housing and 31,32,33 Community Services, Canberra. with men are the result of sex with men infection rates. 6 Office of the High Commissioner for who believe themselves to be HIV- Human Rights (OHCHR), Joint United A significant proportion of the negative30. The criminalisation of HIV Nations Programme on HIV/AIDS Australian prison population is (UNAIDS) (1998). International Guidelines is particularly frustrating given that incarcerated for drug related offences. on HIV/AIDS and Human Rights. OHCHR public health regulations offer remedies In turn, ‘having ever been in prison’ is and UNAIDS, Geneva. that can be tailored to the complexities 7 Anti-discrimination Board of NSW. identified as in independent risk factor (2001). C-Change: Report of the Inquiry of individual cases where a person is 34 for hepatitis C infection because into Hepatitis C Related Discrimination. putting others at risk. unsafe injecting practices occur in Attorney General’s Department, Sydney. 35 8 Treloar, C., Abelson, J., Cao, W., et al. Health systems prisons , yet clean injecting equipment (2004). Barriers and Incentives to Treatment is not available in Australian prisons. for Illicit Drug Users. Monograph Series. Australia is fortunate to have a Despite being announced in 2012, No. 53. Australian Government, Canberra. Medicare system (often) providing Australia’s first prison syringe program 9 Scarlet Alliance. (2011). Submission on the access to free or affordable medical Commonwealth Government’s Proposed (in the ACT) is yet to commence Consolidation of Anti-Discrimination Laws. services, a Pharmaceutical Benefits operation.36 Scarlet Alliance, Sydney. Scheme which heavily subsidises the 10 Coombe, R. (2006). Gay Law Reform. The cost of medication, and a social security Conclusion Companion to Tasmanian History. Centre for Tasmanian Historical Studies. Retrieved safety net which further reduces the Advocacy for a stronger legal and from: http://www.utas.edu.au/library/ price of medication for those on companion_to_tasmanian_history/G/ policy framework is not easy or without limited incomes. Those particularly Gay%20Law%20Reform.htm risks. Agencies have been defunded 11 Wilson, D., Kwon, A., Anderson, J., et al. concerned about issues of privacy, can for pushing their politicised agenda (2009). Return on investment 2: evaluating access sexual health clinics that are able the cost-effectiveness of needle and syringe ‘too hard’. Governments too fear an to offer HIV testing without requiring programs among injecting drug users in electoral backlash, and not without Australia. Commonwealth Department of disclosure of a name or address. reason. Still greater effort is required Health and Ageing, Canberra. Still, laws and regulation continue to 12 Egger, S., Harcourt, C. (1991). Prostitution to extend our enabling environment In NSW: The Impact Of Deregulation. undermine effective HIV strategy. The to deliver greater successes in HIV Easteal, P. McKilop, S. (eds.). Women cost of HIV treatments and treatment prevention, care and support. Without and the law: proceedings of a conference co-payments remain a major issue held 24–26 September 1991. Australian constant vigilance, hard won victories Institute of Criminology, Canberra. for many people living with HIV. can quickly be taken away … and there 13 Abuses such as sexual assault or trafficking Further, dispensing restrictions mean is yet more to be done. continue to be covered by criminal law. that frequently medication can only 14 Harcourt, C., Egger, S., Donovan, B. Sally Cameron is HIV Education (2005). Sex Work and the Law, Sexual be collected from hospital pharmacies and Health Promotion Officer – Health, 2(3), 121–128. during business hours: an onerous Policy at AFAO 15 Pinwill, S. (1999). Occupational Health requirement for many in terms of travel and Safety in the Australian Sex Industry: The ACT Experience. Social Alternatives and managing work commitments. References Journal, 18(3), 22–24. 16 Donovan, B., Harcourt, C., Egger, S., et al. In some states, public health laws 1 This article is based on research and (2001). Improving the health of sex workers analysis undertaken in the development require that sex workers undergo in NSW: maintaining success. New South of an article by Sally Cameron and Wales Public Health Bulletin, 21(3–4), 74–7. regular sexual health screening John Godwin for AIDS Education and doi:10.1071/NB10013 and prevent people working while Prevention, June 2014: ‘Barriers to Legal 17 Donovan, B., et al., (2012), op. cit. infected with an STI. The unfortunate and Human Rights in Australia in the Era of HIV Treatment as Prevention’. consequences of such laws were borne References continued on page 78

HIV Australia, Volume 12, No. 2 | 21 AIDS 2014 SPECIAL EDITION

Sex work legislation stands in the way of Australia’s commitments: decriminalisation for sex workers health, safety and rights

By Janelle Fawkes

Australia’s commitment many years of analysis, review of the and deregulated legislative framework Australia is a signatory to the 2011 available evidence – and perhaps most sex workers have increased control United Nations Political Declaration importantly – the lived experience of over their work and are able to achieve (UNPD) on HIV and AIDS. By signing sex workers working within different similar or better health outcomes legal frameworks. Decriminalisation without the expense and invasiveness the declaration, Australia has committed 8 to protecting and promoting human is also recognised as promoting and of mandatory testing.’ achieving high levels of compliance and rights and the elimination of stigma Whilst laws alone will not eliminate being a low cost model to maintain. and discrimination for people living stigma and discrimination, The additional benefit is that it does with HIV and prioritised communities decriminalisation has shown strong not divert policing resources away from (including sex workers) as a ‘critical signs of creating an environment crime prevention. element in combating the global where sex workers are able to address 1 HIV epidemic’ and achieving the New Zealand and New South discriminatory practices. Where in UNPD targets. Wales in Australia are the only two place, anti-discrimination legislation The declaration also commits Australia locations globally where versions of that specifically includes sex workers to action to achieve this, including decriminalisation have been introduced. sends a strong message to the ‘intensify[ing] national efforts to New South Wales introduced community that discrimination against create enabling legal, social and policy decriminalisation in 1995 and New sex workers is unacceptable, promotes frameworks’.2 Zealand in 2003. Both jurisdictions social inclusion, and supports sex have provided considerable evidence to workers’ own campaigns around access What is an enabling legal, social inform our understandings of how legal to social and legal justice. and policy framework for sex frameworks can provide an enabling The theory that decriminalisation workers? environment. Decriminalisation of sex results in the expansion of the sex work in NSW has demonstrated it is We know what works industry is refuted by evidence based the most effective legal framework for research. In New Zealand data from Within Australia most laws regulating supporting HIV prevention for sex prior to decriminalisation, compared to sex work are state or territory based. workers and achieving public health 3,4 data measured at the five-year review Each jurisdiction has taken a different objectives. A comparative study by 5 stage, shows the size of the sex industry approach, ranging from criminalisation Harcourt, et al. looked at HIV and STI in New Zealand has not increased as to licensing models to decriminalisation prevention with sex workers across three a result of decriminalisation.9 This was in NSW. As a result we are well jurisdictions, each with a different model also a finding of the Australian study placed to understand the impact of of regulation. The study demonstrated in NSW.10 different legal frameworks on sex work, that sex workers within a decriminalised sex workers and HIV. The complex setting maintained an extremely high It is widely recognised that matrix of laws combine with varying level of condom use, extremely low rates decriminalisation is the best policing practices and a variety of other of HIV and STIs, and had access to well legal framework to support HIV impacting laws including public health resourced peer education. responses and anti-discrimination legislation. There is also evidence demonstrating The 2010 UNAIDS Report on the Decriminalisation is the legal decriminalisation provides improved Global AIDS Epidemic states that framework that sex workers and sex occupational, health and safety for sex ‘countries should now take action to worker civil society or community-based workers6 and contributes to improved decriminalize sex workers’ and the 2012 organisations recommend as the best human rights7. The Sixth National HIV Global Commission on HIV and the practice model of sex work legislation. Strategy 2010–2013 refers to research Law recommends decriminalisation This recommendation is the result of that suggests within a ‘decriminalised of sex work. The United Nations

22 | HIV Australia, Volume 12, No. 2 AIDS 2014 SPECIAL EDITION

Above: Sex workers protesting for an end to discrimination. Photo: Zahra Stardust.

Population Fund, United Nations The Prostitution Licensing Board of in 2010–12 the highest number of Development Fund and UNAIDS all Queensland recognises in its annual criminal charges against women in support the decriminalisation of sex reports that in more than ten years Victoria were for street based sex work work and note that legal empowerment only 26 brothels have been licensed, related charges.17 of sex worker communities underpins at a cost of several million dollars to Unfortunately, at a time when effective HIV responses.11 United taxpayers.15,16 The concept sold to the significant sex workers campaigns are Nations Secretary General Ban Ki- community that brothel licensing fees calling for decriminalisation for our Moon called for change in countries would cover the operating costs of health and safety, we are experiencing a where discrimination against sex the regulatory bodies has never been backlash by a school of feminism that workers remains legal.12 achieved. While legal sex industry conceptualises all sex work as violence businesses are few and far between in against women (also ignoring the We know what doesn’t work Queensland, individual sex workers gender diversity of sex workers). This are prevented from working in pairs, Evidence from Victoria and wave of sex work abolitionists have significantly reducing the ability to Queensland demonstrates that consistently ignored the voices of sex work independently. Similarly, in licensing models have consistently workers and progressed a campaign Victoria independent sex workers face failed in Australia, and that licensing is for the Swedish laws (sometimes significant barriers to operate from ineffective, expensive and unworkable. incorrectly referred to as the Nordic their own homes or even separate A licensing model inherently creates model). Introduced into Sweden in in-call spaces. a two-tiered industry; the minority 1999 and simplistically referred to as who can comply with the excessive Across Australia street based sex the criminalisation of the clients of sex regulations and the majority that work continues, yet this sector of our workers, the model is in fact a complex cannot and are therefore considered community (approximately 5% of all set of laws that criminalise many aspects ‘illegal’.13 The illegal sector remains sex work) is heavily criminalised and of a sex worker’s experience, including under the regulation of police even targeted by police. Condoms continue supporting partners and children, though Royal Commissions have to be used as evidence in South and the leasing of accommodation to demonstrated high levels of corruption Australia and Western Australia, and sex workers. These laws significantly when police are the regulators of the recent statistics from the Victorian undermine the ability to work and are sex industry.14 Sentencing Advisory Council show not supported by sex workers.18

HIV Australia, Volume 12, No. 2 | 23 AIDS 2014 SPECIAL EDITION

Human Rights meet these aims, countries are required Looking forward Australia’s Sixth National HIV to both ‘conduct an analysis of the The ‘Stepping up the Pace’ 20th Strategy names the protection of human rights and legal environment International AIDS Conference human rights to be essential to the (including laws, law enforcement (AIDS 2014) profiles these issues for effective protection of public health.19 practices and access to justice by those sex workers, and Australia’s actions Sex workers universally advocate for affected by HIV)’ and consult with against these commitments will the decriminalisation of sex work, key affected populations, including sex be under the spotlight. Australia’s identifying the criminalisation of sex workers, through meaningful input Seventh National HIV Strategy is work, sex workers, our workplaces into proposals. likely to be released in time for the or our clients as approaches that event and provides an opportunity undermine sex workers’ human rights Well documented yet not for a recommitment to action on the and ability to work safely. progressed creating of enabling legal frameworks. This will not happen without a Through the Global Network of Sex The last decade could be described paradigm shift that makes the Work Projects (NSWP) sex workers as a period of strong advocacy, but integration of human rights and HIV have agreed to a ‘Sex Work, human no progress in achieving enabling into policy more than rhetoric. rights and the law consensus statement’ environments and human rights for sex consisting of eight rights. They are workers in Australia. This statement The work of the Commonwealth the right to: associate and organise; fails to represent the many sex workers Ministerial Advisory Committee on be protected by the law; be free from who have dedicated their time, BBV and STIs (MACBBVS) Legal violence; be free from discrimination; expertise, passion and commitment to and Discrimination Working (LDW) privacy, and freedom from arbitrary contributing to law reviews, briefings, Group has contributed to the start of interference; health; to move and hearings and many other mechanisms this process in the development of a migrate; and to work and free choice that should have resulted in full suite of seven papers including key of employment.20 However, for sex decriminalisation being recognised issues and recommendations, yet there workers in many parts of Australia and and introduced throughout Australia. remains no mechanism through which our region, there are many examples of However, sex worker advocates’ to progress this critical work.21 laws that undermine these basic human experience of these mechanisms is that In 2014 Australia stands at a threshold rights and create significant barriers they have not functioned transparently, in relation to HIV and human rights. to us working safely. Ironically they and were not accountable to the people The sex worker community is clear on are too often misguided attempts to most likely to be directly impacted as what equates to enabling legal, social protect sex workers or the community, the key stakeholders: sex workers. In too and policy frameworks for sex workers which fail dismally at both as well as many cases to cover here, sex workers – with strong research, clinical evidence undermining HIV prevention efforts. have been silenced, ignored, excluded or and the lived experiences of sex workers dismissed from policy development. This year the Global Fund, a major showing decriminalisation is the legal donor supporting country-level HIV So while there is significant evidence, framework that enables an effective responses, moves to the next phase of collected over a period of more than HIV response for sex workers – what its 2012–16 strategy which includes ten years, unfortunately evidence is not we call for now is the long awaited major policy and funding approach what is driving the direction of legal commitment from government. changes to ensure human rights are frameworks on these issues. Moral, Decriminalisation for sex workers positioned as critical to responding religious and sex work abolitionist health, safety and rights. to HIV. The changes aim to integrate voices seem to have drowned out human rights into countries’ HIV Australia’s commitment to progress this Janelle Fawkes is Chief Executive Officer, Scarlet Alliance, Australian programs, increase investment in area and the importance of progressing Sex Workers Association. programs that address human rights these issues in consultation with and ensure the Global Fund does not sex workers in line with Australia’s References support programs that undermine partnership approach seems to have human rights. As critical enablers to completely faltered. 1 United Nations. (2011). Resolution adopted by the General Assembly 65/277. Political Declaration on HIV and AIDS: Intensifying Our Efforts to Eliminate HIV Sex workers universally advocate for the decriminalisation of sex and AIDS, s39, s77. work, identifying the criminalisation of sex work, sex workers, 2 ibid. our workplaces or our clients as approaches that undermine sex

workers’ human rights and ability to work safely. References continued on page 78

24 | HIV Australia, Volume 12, No. 2

AIDS 2014 SPECIAL EDITION

Australia, migration and HIV: an evolving policy landscape

By Linda Forbes and Michael Frommer

Planning for AIDS 2014 in Melbourne, exceeds the threshold for passing barriers for people with HIV seeking Australia, has focused attention on how the Health Requirement – currently Australian residence. The economic people with HIV navigate Australia’s AUD$40,000 – prospective residents rationale for the Health Requirement is complex migration system. There is a with HIV generally fail the Health lost in the policy’s complexity and is not perception that Australia tests people for Requirement in the first instance. generally understood. The perception HIV with the aim of banning the entry While waiver is available for some visa of prospective migrants – and of the of HIV-positive people. While this categories, waiver requires provision of Australian community and international is not the policy rationale for testing, supporting evidence, including medical commentators – is that Australia screens this perception nevertheless can lead to evidence and evidence regarding the prospective migrants for HIV due to a alienation among potential residents, potential fiscal benefit the applicant desire “keep them out”. and perpetuate HIV-related stigma may bring to Australia. Waiver is, of The perception that HIV-positive among new migrants and the Australian course, of only limited relevance given migrants and their families are community more broadly. that waiver is only available for a few not welcome in Australia can feed specified visa types and, for those who HIV and the AustralIan perceptions that migrants from can seek waiver, people with means are mIgratIon process countries with high HIV prevalence advantaged over people without the are vectors for disease. This stigmatises All people aged 15 years or more capacity and the finances to organise people with HIV within migrant seeking permanent visas for Australia evidence and/or legal advice. communities – with HIV-positive are subject to compulsory screening for Proposed reforms to the Health people labelled by some as bringing HIV. Under Australia’s migration ‘health Requirement whereby applicants’ shame on their community – and requirement’, anticipated future costs potential economic contributions would feeds HIV-related stigma in the associated with any health condition or offset future healthcare cost assessments wider Australian community. This disability are assessed – including the are welcome. However, such changes stigma undermines affected migrant cost of HIV antiretrovirals. Migrants would represent a limited reform communities’ engagement in the have immediate access to subsidised given the challenges associated with development of HIV prevention, health care and medicines in Australia providing evidence of the economic care and support strategies targeting and the rationale for the Health contribution an individual applicant communities of people from high HIV- Requirement is stated to be economic would bring to Australia. prevalence countries. – aimed at ensuring that migration Reform of Australian migration does not place undue pressure on public How to make migratIon polIcy policy is required to bring Australia health costs. fairer into line with international human As the lifetime cost of providing HIV Health Requirement assessments rights standards and public health antiretrovirals to a person inevitably regarding HIV pose real and perceived best practice. Australia has ratified the United Nations Convention on the Rights of Persons with Disabilities The economic rationale for the Health Requirement is lost in the (CRPD); however, as the Migration Act policy’s complexity and is not generally understood. 1958 is exempt from the application of the Disability Discrimination Act The perception of prospective migrants – and of the Australian 1992, the legal framework, perversely, community and international commentators – is that Australia facilitates discrimination against people screens prospective migrants for HIV due to a desire with HIV. “keep them out”. Mandatory testing for HIV should be replaced There should be no compulsory with voluntary testing of applicants and of permanent visa holders HIV-testing of people applying for Australian residence. Mandatory upon arrival in Australia. testing for HIV should be replaced

26 | HIV Australia, Volume 12, No. 2 AIDS 2014 SPECIAL EDITION

AUSTRALIA’S HEALTH REQUIREMENT FOR PERMANENT VISA APPLICANTS

The process

All permanent visa applicants of 15 years of age or over are required to take an HIV test. Applicants under 15 are also required to be tested if being adopted, there is a history of blood transfusions or other clinical indications.

Positive result Negative result The Department of Immigration will estimate Applicant must still meet other aspects of whether the future costs in relation to the HIV visa Health Requirement, including cost person’s HIV status will exceed AUD$40,000 assessments in relation to any other chronic over their lifetime. test health conditions or disabilities.

Significant cost Is waiver available to all What is taken into account Will a person whose costs are An assessment is made of the HIV-positive applicants? for waiver? not considered to be “undue” person’s potential health care No – waiver of the Health Where waiver is available have the health requirement costs associated with HIV over Requirement is currently only the Department of Immigration waived? their lifetime. This is based on available for permanent visa will consider whether the Yes. the likely costs of providing sub-classes in the following assessed costs are “undue”. treatment/community services categories: Partner; Child; This involves consideration Will a person whose costs to a “hypothetical person” with Adoption; Humanitarian; and of whether the cost to the have been assessed as the same condition of the same specified employer sponsored. community or prejudice to “undue” be able to migrate to severity as the applicant. If waiver is not available for access of Australian citizens Australia? The current “significant cost” a particular visa sub-class, and permanent residents to No, they will be refused waiver threshold is AUD$40,000. the applicant fails the Health healthcare and community and their visa application will be Lifetime cost of HIV Requirement and they are services in short supply, rejected. antiretrovirals will always refused a visa. is unlikely to be “undue”. exceed this threshold, Evidence of any compassionate so HIV-positive applicants circumstances will be inevitably fail the Health considered, as will evidence Requirement, unless waiver is of the extent to which the available. applicant and their family are able to mitigate potential costs or “prejudice to access” identified by the Department of Immigration factors may include the family’s potential contribution.

with voluntary testing of applicants and of permanent visa holders upon A digital retrospective of arrival in Australia, with appropriate HIV health promotion materials, curated by L. K. Chan and counselling and support provided to all Raymond Donovan, will be on applicants who undertake HIV testing display in the G’Day Zone for migration purposes. It is now time at AIDS 2014. for long overdue migration reform. HIV Australia is available A catalogue accompanying the online with additional content. exhibition is available for download Linda Forbes is Manager, Policy and in HIV Australia online Communications, at AFAO. Michael www.afao.org.au Frommer is Policy Analyst at AFAO.

HIV Australia, Volume 12, No. 2 | 27 AIDS 2014 SPECIAL EDITION

How to spread gay rights beyond the West

By Dennis Altman

While the march of gay rights continues across the West, in parts of the arises that most of Britain’s former world they are going backwards, with states hardening their repression of colonies retain anti-sodomy laws in people on the basis of their sexuality, writes Dennis Altman. the name of their cultural heritage, ignoring the fact that these laws are in fact the legacy of the colonial era. The growth of state-sanctioned Currently Ethiopia is tightening its Islamic world, including countries homophobia is related both to religious laws against homosexual behaviour, in our region. Indeed, Pakistan and fundamentalism and nationalist already punishable by up to 15 Malaysia are among the most vigorous assertion. When the Indian Supreme Court recently upheld British-era years imprisonment. It appears the opponents of any recognition of “sexual sodomy laws it was noted that this was government is following the lead of rights”, and the recurring prosecution the only issue on which leaders from all Uganda and Nigeria, both of which have of Anwar Ibrahim for alleged sodomy religions could agree. recently introduced laws increasing the is a reminder that such attacks are penalties for both homosexual behaviour often politically motivated. The support of leaders such as and support for any “advocacy” of Let us be clear: these are not arguments US president Barack Obama and recognition of same-sex identities about whether or not homosexuals can UKPrime Minister David Cameron or behaviour. adopt children or have the right to for gay rights has ironically reinforced those political leaders who use the Similar hardening of repression of be married. issue to mobilise nationalist fervour by people for homosexual and transgender In Nigeria men have been publicly scapegoating people who can be linked identities appears to be increasing across whipped for homosexuality while to foreign influence. Africa. A recent documentary about crowds called for their execution. In Cameroon, Born this Way, highlights Iran it is known that homosexuals Both the current and previous the violence and persecution against have been executed, although Australian governments have worked anyone perceived as not conforming ironically gender transitions are legal. quietly to make clear their disapproval to sexual or gender norms. Lest we Violence against transgender people is of persecution on grounds of sexuality. think the repression is confined to men, widespread through much of the world. In this they are unfortunately ahead of that documentary highlights the fear most of Australia’s NGOs, who have of imprisonment and “corrective rape” At the same time there is a remarkable been largely disinterested in the issue. faced by women assumed to be lesbian. shift in attitudes in most of the Western world, symbolised by the Other than specific gay community Recent laws in Russia, supported by growing number of jurisdictions that organisations, only Amnesty has given President Vladimir Putin, which seek recognise same-sex marriage (including much prominence to this issue. Yet to penalise “propaganda” of several conservative American states), sexual rights, and the debate around homosexuality, generally with the intent and strong official statements against protection of people vulnerable because of “protecting” minors, have been used homophobia in a number of Latin of their sexuality or gender identity, as the excuse for right-wing thugs to American countries. apply to a number of countries in our engage in vigilante actions against region, including Papua New Guinea. Both the United Nations Human homosexuals, depicted in a recent Rights Council and Secretary General The Senate inquiry into asylum seeker Foreign Correspondent program. Ban Ki-moon have asserted that policies established that some people These laws became the focus of human rights should apply without seeking asylum because of fears of international attention because of the distinction on the basis of sexual persecution for their sexuality now fear Winter Olympics in Sochi, and Russia’s orientation or gender identity. further persecution when they are sent increasingly belligerent attacks on to Manus Island. Central to the rhetoric of countries “Western values”, using the language of as seemingly dissimilar as Russia, It is tempting to express outrage at “traditional values” and the “traditional Pakistan and Zimbabwe is the claim abuses done in the name of protecting family” to rally international support. that homosexuality is a western import, morality, but indignation is not the Similar arguments remain central in designed to weaken traditional cultures basis for good policy. The recent the rhetoric of governments across the and religions. Thus the ironic situation decision of the US administration to

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cut aid to Uganda’s health sector will mean some people will lose access to In memoriam vital therapies; it will do nothing to weaken President Yoweri Museveni’s government. Some European governments have been more strategic, TRIBUTES TO redirecting the funds to NGOs working in the country. VIVIENNE MUNRO Sexuality has become a polarising issue in the international arena, and Vivienne Munro was a pioneer of Australia’s early HIV response, both sides are tempted to play to much-loved and admired for her contribution to Australia’s their domestic audiences rather than community response and support for HIV-positive women. Vivienne passed away in May 2014. Below, some of Vivienne’s close colleagues consider the human costs. and friends pay tribute to her life and work. In the lead up to AIDS 2014, Oxfam Vivienne Munro was a courageous pioneering woman living with HIV. In the and La Trobe University’s Institute late 80s, Vivienne set up the first Positive Women’s group in Sydney. Vivienne for Human Security and Social was then instrumental in being the first women-specific peer support worker Change hosted a pre-conference panel at ACON (a position which no longer exists). Vivienne was a wonderful discussion on 17 July 2014 entitled: advocate to ensure women living with HIV had a voice in the AIDS dialogue. ‘Let’s Talk: Sexual Rights, HIV and In the nineties, Vivienne was the Asia-Pacific regional representative for ICW (International Community for Women Living with HIV/AIDS). In this role, Vivienne Development’. The purpose of the worked tirelessly by providing peer support and training for women living with HIV evening was to encourage discussion and was a great advocate for the rights of women. between the HIV and development Vivienne’s legacy will live on. She will be sadly missed by her children, family friends sectors about the growing global and colleagues. I, for one, will miss her as we often worked together locally, regionally polarisation around sexual rights, in and internationally, where we inspired each other as well as having fun. Her motivation particular the growing persecution was always for the care and support of others, particularly women living with HIV. of people in many parts of the world Bye Vivienne, you were a true hero. on the basis of their sexuality or — Bev Greet gender identity. Vivienne Munro was involved in the response to HIV since the 1980s. One of the first women in NSW to be open about her HIV status, she played a key We need further opportunities role in the ACON HIV Support Project and the early years of what was then such as this for strategic reflection PWA(NSW) (which became PLWHA (NSW)) and then Positive Life NSW. on the best way to promote greater Vivienne was involved in setting up HIV support and networks for women in NSW. She acceptance of sexual diversity in a also got involved in the international HIV movement, and for a period was involved world where too often sexuality has with the Global Network of People Living with HIV/AIDS. She was on the committee become a touchstone for fear, prejudice of Positive Life a number of times, serving as Co-Convener and Secretary and contributed to some of its working groups in particular the Talkabout Editorial Group. and hatred. Vivienne’s partner died of HIV before effective treatments arrived. She has two Dennis Altman is a Professorial children – Tasman and Larna. Vivienne has been living on the NSW Central Coast Fellow in the Institute for Human for a number of years. A tireless and energetic advocate of people living with HIV, Security at La Trobe University. Vivienne made a major contribution to the Australian response to HIV and the support of women living with HIV. This article was originally published The staff and board of Positive Life NSW extend our condolences to Vivienne’s on ABC’s The Drum family and loved ones, and our sincere gratitude for her work. (www.abc.net.au/news/thedrum). – Positive Live NSW The original version of the article The first time I saw Vivienne was in a poster she was part of with five other is available at: www.abc.net.au/ women and the caption said, ‘Some of us are HIV-positive’ with a tag line, news/2014-03-28/altman-how- ‘HIV-positive women are women like you’. It was a promotion for the HIV Women’s Project in NSW at ACON. to-spread-gay-rights-beyond-the- Then I met Viv and many other women like Bev and Amelia, and it was a turning west/5351556 point for me and had a huge impact on how I took on my new peer support role in SA back in 1998. I commenced my journey of challenging HIV-related stigma and the courage came from their first steps. — Katherine Leane

More tributes to Vivienne Munro are included on the AFAO blog at http://afaotalks.blogspot.com.au

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Developing the narrative of HIV-related stigma and discrimination in Papua New Guinea By Dr John Rule and Annie McPherson

This article reports on the experience of This article provides some background information for program planning Igat Hope, the organisation representing to the project, and reports briefly on its and interventions in response to people living with HIV (PLHIV) findings. In the context of uncertain HIV-related stigma in PNG. in Papua New Guinea (PNG), in funding support in PNG, we also note 2. To provide additional data furthering the understanding of HIV- some hopes for the future with regard about the ways that stigma and related stigma and discrimination in to this project. discrimination creates barriers to PNG. We describe this process as The PNG Stigma Index is significant accessing services and impedes ‘developing a narrative’ because some of because it is a project owned by the scaling up of delivery of this work has already been completed, Igat Hope and its membership. In antiretroviral therapy in PNG. some work is currently being done PNG the project has been largely 3. To describe the levels of stigma (the research on which we report) managed by HIV-positive people and discrimination faced by people and more work is required into the within the organisation. The project is living with HIV in different future. Some of this narrative has been building community knowledge and provinces. discussed many times before, and some engagement of people living with HIV 4. To describe the differing is still being written. Other people as it proceeds, and is directing attention experiences of people living with are also contributing to the ongoing to the ways in which stigma is being HIV according to gender, sexuality, development this narrative, of course; experienced by HIV-positive people sexual expression or gender here we report only on the work that we in a range of contexts. Sadly, two Igat identity. have been part of. Hope staff members, who were openly 5. To determine the situations Phase one of the PNG Stigma Index HIV-positive and took carriage of work creating heightened risks for project, supported by funding from the within the organisation, have died. Ms people living with HIV and to National AIDS Council (NAC) and Helen Samilo, who attended trainings identify policy and program the Joint United Nations Programme on the implementation of the People responses to reduce this risk. on HIV/AIDS (UNAIDS) in PNG, Living With HIV Stigma Index died in 6. To determine the ways in which has been conducted in the Western August 2013; Don Liriope who was the persistence of stigma and Highlands and Simbu provinces. the Co-Principal Investigator on the discrimination inhibits and The PNG NAC provided funding project died in March this year. Their undermines effective prevention support to the Igat Hope secretariat deaths are very sad losses. strategies. and for other associated research Project aims costs; UNAIDS supported the project HIV-related stigma and through funding the training programs 1. To provide additional data to that discrimination in PNG of the group of people living with HIV which is currently available in It is widely acknowledged that HIV- who conducted the interviews. PNG and provide evidence-based related stigma and discrimination remain barriers to effective prevention, The PNG Stigma Index is significant because it is a project treatment, care and support programs in PNG. There is ample anecdotal owned by Igat Hope and its membership. In PNG the project evidence that the experience of stigma has been largely managed by HIV-positive people within the and discrimination discourages people organisation. The project is building community knowledge from presenting for testing, or upon and engagement of people living with HIV as it proceeds, and diagnosis not returning for follow- up; stigma and discrimination creates is directing attention to the ways in which stigma is being barriers to accessing health services. experienced by HIV-positive people in a range of contexts. The Systematic Literature Review of HIV and AIDS Research in PNG (2007–2008) noted that there is

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significant reporting of the ways in which people living with HIV have been violently mistreated and shamed, but there were few studies that focused on this experience from the point of view of people living with HIV. The Systematic Literature Review identified studies that reported on stigma and discrimination – where the perspective was that of the health care workers or study respondents, looking at attitudes towards people living with HIV. Few studies sought to examine mistreatment and shaming from the perspective of people living with HIV themselves.1 One large-scale study on the experiences of people living with HIV showed that there is limited support for those experiencing stigma and discrimination to pursue their legal rights and that, although there have been some changes in community Don Liriope, far left, Co-principle Investigator on the PNG HIV stigma project, with other members of Igat Hope research team out collecting data in and around Mt. Hagen, PNG. attitudes, there are still unacceptable Photo: John Rule. percentages of people living with HIV – especially women – reporting In memoriam verbal and physical abuse. This study identified that there is research in Don Liriope died in Port Moresby General Hospital on 18 March other countries in the region in relation 2014, due to tuberculosis of the liver. Don had lived openly as an to stigma and challenges for people HIV-positive person for many years. living with HIV, but the data that Don was a passionate advocate for the rights of people living with HIV, is available in PNG needs to be gay men, men who have sex with men (MSM), and transgender people in further developed.2 Papua New Guinea (PNG). Don was employed by Igat Hope, PNG’s national organisation representing Various PNG UNGASS (United people living with HIV, as the Stigma and Discrimination Project Officer. Nations General and Special Assembly) He was also a founding member and Vice President of Kapul Champions, Country Progress Reports, successive a community-based organisation established by MSM and transgender National HIV Strategies and the people in PNG to represent community interests and contribute to PNG’s Report of the Commission on AIDS in national HIV response. Don’s colleagues loved working with him. He was the Pacific 2009 have all noted that energetic, passionate and he was able to stand up for what he believed in stigma and discrimination impact and was always keen to communicate to others what he felt was right. negatively on controlling the spread of Don spoke very clearly about the rights of communities to participate in HIV. 3 The PNG Independent Review research and he understood the benefits that research would bring in Group on HIV/AIDS heard stories of helping to manage the HIV epidemic in PNG. He understood that people living with HIV needed respect and dignity. He wanted the voices heard. stigma against HIV-positive people, He was not afraid – he would speak directly and convincingly to everyone indicating that stigma continues to be 4 about his concerns. This meant that Don was known to many people in a real barrier to HIV prevention. The PNG beyond the HIV sector, and to people in other Pacific Island countries report prepared by the review group and territories, and in Australia for his advocacy efforts on behalf of people said that the implementation of the living with HIV. International People Living With HIV Don had a great sense of humour, was fun to be with and was able to 5 Stigma Index needed to be finalised relate to people of many different levels. Don was savvy. His death is a and implemented with speed so that great loss. We will all miss him. findings could be incorporated into program responses. — John Rule

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Using the International Stigma percentage said that they belong to the Dr John Rule is a Conjoint Associate Lecturer, School of Public Health Index tool group men who have sex with men, or and Community Medicine, Faculty of identified as gay. Over 70% said that The potential use of the Stigma Index Medicine, UNSW and the Principal tool was discussed at the first national they had been physically assaulted in Investigator on the National AIDS conference for people living with HIV the previous twelve months because of Council approved study: HIV-related in PNG in 2009. Helen Samilo, a their HIV status. Over 50% said they Stigma and Discrimination and staff member of Igat Hope, attended had not attended social gatherings Human Rights in PNG (ref: RES10- a meeting in Bangkok about the because of their HIV status. Being 014). Ms Annie McPherson is the Executive Director of Igat Hope, the international efforts to implement the gossiped about was identified as the national organisation representing Stigma Index. The Igat Hope Board major problem and nearly 50% of the respondents said they had feelings people living with HIV across PNG. supported the creation of a special Annie has been working with Igat position within the National Secretariat of being ashamed, guilty or blamed themselves because of their HIV status. Hope for over five years, and has specifically to implement the Stigma provided management oversight Index in PNG; Don Liriope was From the interview data it can be said for this project within her role as employed in this position. In 2010, the that stigma and discrimination are Executive Director. second national conference for people found in the following settings: n living with HIV in PNG endorsed family and clan References n efforts to implement the index in community and peer networks 1 King, E., Lupiwa, T. (2007). A Systematic n PNG. John Rule was invited by Igat workplaces and health care Literature Review of HIV and AIDS Hope to be the Principal Investigator settings. Research in Papua New Guinea, 2007– and to assist in developing the study 2008. National Aids Council of Papua New Recommendations are tentative, being Guinea, Waigani. proposal and ethics application for 2 Kelly, A., Frankland, A., Kupul, M., Kepa, based on two provinces only, but areas the National AIDS Council Research K., Cangah, B., Nosi, S., et al. (2009). Advisory Committee. identified where action can be taken The art of living: the social experience of include: treatments for people living with HIV in The international People Living With n Papua New Guinea. Papua New Guinea PLHIV networks and support HIV Stigma Index was seen as a useful Institute of Medical Research, Goroka, the group relationships with instrument to try and apply in the University of New South Wales, Sydney. communities Retrieved from: https://sphcm.med.unsw. PNG context, although it has always n PLHIV network building and peer edu.au/sites/default/files/sphcm/Centres_ been the view of Igat Hope that the and_Units/Art_Living.pdf interaction index would need to be adapted and n 3 For example see: Port Moresby, capacity building in health care National AIDS Council Secretariat and amended for the PNG context. This settings Partners. (2011). The UNGASS 2010 adaptation was not just to be a matter n Country Report Papua New Guinea. of translation into relevant language, further engagement with the legal Retrieved from: http://www.unaids.org/ but would also take into consideration and para-legal practitioners en/dataanalysis/knowyourresponse/ n the preparedness of the local improving stakeholder countryprogressreports/2010countri relationships with HIV-positive es/papuanewguinea_2010_country_ communities of people living with HIV progress_report_en.pdf to work with the survey instrument. communities. 4 Aggleton, P., Bharat, S., Coutinho, A., Dobunaba, F., Drew, R., Saidel, T. (2011). The implementation of the Stigma Igat Hope will continue to take the Index in PNG is also a way of enabling Independent Review Group on HIV/AIDS. lead on this project, as outlined in the Report from an assessment visit, 28 people living with HIV to take a more PNG National HIV Strategy. Problems April–13 May 2011. National AIDS Council active role in responding to the HIV using the Stigma Index tool were Secretariat, Port Moresby. Retrieved from: http://www.aidsdatahub.org/sites/default/ epidemic by managing a significant identified by the research team (e.g. the national research project. files/documents/Independent_Review_ instrument only asked questions about Group_on_HIV_AIDS_2011_2nd_Mission. events in the previous 12 months). pdf Outcomes from phase one The application of the index as the 5 The People Living with HIV Stigma Index is data collection in the Western a joint initiative that has been developed, correct tool to use, in the PNG context, Highlands and Simbu implemented by, and for people living with may be reviewed. Igat Hope aims to HIV. Those involved in the design and Eighty interviews were conducted. continue with the project and, through development of the survey tool included Seventy-five respondents indicated that discussion with funders such as the the Global Network of People Living with HIV/AIDS (GNP+); the International National AIDS Council and UNAIDS they are sexually active although only Community of Women Living with HIV/ twenty of the respondents said they are in PNG, to determine the best AIDS(ICW); the International Planned married or co-habiting with a partner. approach to develop understanding of Parenthood Federation (IPPF); and the Over 10% identified as belonging to and response to HIV-related stigma Joint United National Programme on HIV/ AIDS (UNAIDS). the category of sex worker and a small and discrimination in PNG.

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Walk with me: creating an enabling environment for men of diverse sexualities and transgender people in Papua New Guinea By Finn O’Keefe and James Malar

In Papua New Guinea (PNG), sex In the weeks leading up to IDAHOT The poster was linked to social media between men is criminalised. Many 2014, Kapul Champions launched Walk to increase the campaign’s visibility and people in the community hold strong With Me – Together We Are PNG, a reach. The campaign uses Facebook views against homosexuality1 and acts campaign promoting acceptance and to create a space for people to express of violence against sexually diverse men celebration of the diversity of sexual support for the campaign and for and transgender people are common2. orientation and gender identity in diversity in PNG. The campaign One recent study examining gender- PNG. The campaign was designed to invites participation by encouraging based violence in PNG and Bangladesh fight stigma and discrimination, and community members, government indicated that police and health care launched to become the country’s first representatives and other development providers were two key sources of ever coordinated IDAHOT activity. partner stakeholders to share a photo violence towards sexual minorities.3 of themselves on Facebook posing with ‘Kapul Champions is proud to be the campaign poster, accompanied by The threat of criminal sanctions, representing Papua New Guinea in a short message of support. This could combined with repressive societal the global IDAHOT conversation be a simple statement such as ‘I do norms and religious beliefs, creates an promoting human rights, social inclusion not discriminate’. environment where men who have sex and the freedom from discrimination with men and transgender people are and stigma, as well as raising awareness The online component of the campaign highly stigmatised. This results in a level of about repression and violence toward has helped to spread the central secrecy around sex which heightens HIV men of diverse sexualities and message of support and inclusion. 4 risk and hinders HIV prevention efforts. transgender people,’ said Manu Peni, By May 17, when IDAHOT 2014 Advocating for change President of Kapul Champions. was held, the PNG Walk With Me Facebook page had 130 members, and Kapul Champions, the national ‘I do not discriminate’ numerous photos and messages had network for men of diverse sexualities The Walk With Me – Together We been uploaded to the site. Photos were and transgender people, is working to Are PNG campaign, centers around a submitted by community members and effect change in PNG. With funding poster featuring a Kapul Champions community leaders, as well as members of parliament, police officials, United from the Australian Government’s aid Board member walking hand-in-hand program, and technical support from Nations and development partners’ with fellow Papua New Guineans the Australian Federation of AIDS staff, National AIDS Council staff, to illustrate that all PNG citizens Organisations (AFAO) and Igat Hope community-based organisations and deserve an equal place in PNG society (the national network of people living regional and international supporters. and community, irrespective of their with HIV in PNG), Kapul Champions sexuality or gender. The poster was are advocating for law reform, ‘We are walking with you’ distributed at community meeting supporting community mobilisation and spots, sports clubs, police stations, Importantly, many messages of support promoting initiatives to increase access non-government organisations and have come from ‘every day’ people. to health and HIV services in PNG. government agencies, clinics and Posts on the Facebook page include a Saturday 17 May, 2014 marked the hospitals across PNG. hotel chef photographed on his ‘day 10th annual International Day Against Homophobia and Transphobia (IDAHOT 2014). For the first time, through an initiative coordinated by The Walk With Me – Together We Are PNG campaign, centers Kapul Champions, PNG joined with other countries participating in this around a poster featuring a Kapul Champions Board member global day of action in support of lesbian, walking hand-in-hand with fellow Papua New Guineans to illustrate gay, bisexual, transgender and intersex that all PNG citizens deserve an equal place in PNG society and (LGBTI) human rights and freedom community, irrespective of their sexuality or gender. of expression.

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off ’, a librarian from the Institute of National Affairs, police officers, taxi drivers, and tradespeople, all proudly voicing support for diversity and inclusion. Messages of support on the Facebook page include: ‘We are walking with you’ ‘We don’t hate, We Love’ ‘I do not discriminate’ ‘We Air Con Technicians, we do not discriminate!’ ‘Great to be apart of this. one love, one heart. lets walk together.’ ‘A great initiative from Kapul Champions, I support #WalkWithMePNG’. These contributions combine to make a strong statement that community support for diversity does exist, and this support can be found among people from all walks of life in the PNG community. Chris Connelly, AFAO International Program Manager says that this is the first time Kapul Champions has done a public campaign. ‘Conversations on sexual orientation and gender identity can be challenging in PNG’, he explains. ‘With the campaign Kapul Champions has found many willing supporters for the principles of ‘Walk With Me – Together We Are PNG’. Above: The Walk With Me – Together We Are PNG campaign poster depicts a Kapul Nick Morea-Evera, Senior Program Champions Board member walking hand-in-hand with fellow Papua New Guineans. Officer from Kapul Champions, expressed a great sense of sense of achievement in launching the Finn O’Keefe is Communications Sexual Health (APCOM). (2010). Laws campaign: ‘2014 is the first year PNG Officer at AFAO and an editor of affecting HIV responses among men who have sex with men and transgender joined the global IDAHOT activities, HIV Australia. James Malar is the Engagement and Communications people in Asia and the Pacific: an agenda and it is great for PNG to be among for action. Draft paper, 17 May 2010. Advisor at AFAO International the other 120 countries marking this Retrieved from: http://www.law.hku.hk/ Program in Bangkok. important day!’ hrportal/wp-content/uploads/file/MSM- Legal-study-Discussion-Draft-13 May- Kapul Champions invite you to 2010.pdf References 3 Wong, C., Noriega, S, et al.; FHI 360. show your support by ‘liking’ the 1 Kindu Dbe, C. (2009). Addressing Legal (2013). Exploring gender-based violence Walk With Me – Together We Issues Preventing Comprehensive among men who have sex with men, male Are PNG Facebook page, and by Prevention among MSM PNG case sex worker and transgender communities study. (Presentation slides). Retrieved following the campaign on Twitter. in Bangladesh and Papua New Guinea. from: http://apcom.org/tl_files/resources/ Results and recommendations. FHI 360. Add your comments on Facebook, presentations/Carol_Kidu_DBE_MP_ Retrieved from: http://www.fhi360.org/ and on Twitter @KapulChampions presentations.pdf sites/default/files/media/documents/GBV #WalkWithMePNG to support and 2 United Nations Development Programme Study report_Final.pdf (UNDP), Asia Pacific Coalition on Male celebrate diversity in PNG! 4 Kindu Dbe, C. (2009). op cit.

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Australian support for community HIV responses in PNG: what works, how do we show it, and who will fund it anyway? By Tim Leach and Dr John Rule

The National Association of This article draws from the insights their claims of being disproportionately People Living with HIV Australia shared at the forum but the views impacted need to be strengthened by (NAPWHA), the Australian Federation expressed here are those of the authors. reference to other knowledge. of AIDS Organisations (AFAO) Current debates around language and Scarlet Alliance have conducted Language matters (as if we in PNG aren’t restricted to the ways partnerships programs in Papua New needed more proof) in which people describe the epidemic. Guinea (PNG). NAPWHA has worked Pretty much every story about PNG They also rage about how those with Igat Hope, PNG’s People Living mentions it is known as the land of communities significantly affected by With HIV (PLHIV) organisation the unexpected. And so, as we might HIV are to be described. It is common for over a decade. Scarlet Alliance is have guessed, the epidemic in PNG to talk of Most At Risk Populations currently working in partnership with has involved a few surprises. What (MARPs) in PNG, but marginalised Friends Frangipani, PNG’s national began as a generalised epidemic – groups don’t like being described as sex worker group, and AFAO has been feared capable of matching the worst MARPs, and have said so repeatedly working closely with Kapul Champions, of Africa’s – suddenly morphed into a and formally. Not only is the language the recently established network concentrated epidemic. Or did it? inaccurate, but it is also experienced representing men of diverse sexualities as deeply offensive. There is widespread Despite an at times unseemly scramble and transgender people. acknowledgement that MARPs is a to convert the PNG response into donor-driven notion, yet it does But these are challenging times for one that addresses a concentrated indeed drive funding decisions so the community response in PNG. The epidemic, more recent discussions the national organisations will need Department of Foreign Affairs and suggest that the epidemic is neither language around their risk relative to Trade (DFAT) is refocusing its work general nor concentrated. It is complex. other communities. away from service delivery in PNG and It is varied depending on location. It is its work in HIV is increasingly absorbed geographically varied. It is changeable Kapul Champions and Friends into a more generalised health program, over time as circumstances change. It Frangipani both refer to higher rates of reducing the national focus on HIV. can be impacted by local customs or infection within their constituencies, At the same time we hear much from local events. In fact, it might be said implying some degree of identify that Canberra about the need for Australian there are multiple epidemics. is related to marginalisation and risk aid to align more closely with Australia’s of HIV. They say quite often that The national organisations – Igat strategic interests, to prioritise initiatives they have heightened vulnerability to Hope, Friends Frangipani and that stimulate economic activity and HIV, and Igat Hope rightly claims Kapul Champions – will need some that deliver results that can be easily its constituents are at heightened risk language around this. They stake a demonstrated and measured against of the negative impacts of HIV – claim to further financial support benchmarks. So where does this leave indeed this has been proven through – most significantly from DFAT – these three community collaborations? Igat Hope research on HIV-related partly because the epidemic is not a stigma and discrimination. These A NAPWHA-sponsored forum was general one, but one with particular notions then of heightened risk and/ held recently in Sydney to consider implications for their constituencies. or vulnerability to HIV and its impacts these related issues. Representatives Friends Frangipani and Kapul are important to the organisations and from Australian HIV organisations, Champions both say from time to they infer some notion of there being a development workers from a range of time that there are higher rates of HIV concentrated epidemic. Australian agencies, and a few interested within their communities, but neither individuals, tried to work out how the has language around the complexity So in rejecting the term MARPs how community HIV response in PNG of the epidemic. Hard data relevant to do the constituencies of the three might be best protected and supported. their communities is very limited, so national organisations want to describe

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their relationship with HIV? Would being provided by a range of people appropriate form of support for Friends they be content to describe themselves via a range of mediums, perhaps Frangipani. NAPWHA has also as key affected populations (another simultaneously. expressed reservations. The process to popular descriptor in PNG)? As replace NAPWHA’s technical input This is not a defence of the FIFO marginalised? As vulnerable? with a volunteer in the Igat Hope model. Most people see its weaknesses, office began over twelve months ago. including NAPWHA, Scarlet Alliance The fly-in/fly-out model of To date, there has been no replacement and AFAO. But in determining what support organised by Australian Aid (formerly the national organisations need, we AusAID) or DFAT. AFAO has had The fly in/fly out (FIFO) model of will need a more sophisticated analysis good experiences with volunteers in its development support has few friends. of the various modalities of providing other international work but wonders It is considered neither cost-effective technical assistance than ‘FIFO doesn’t how this will translate to PNG. And all nor sustainable. But we need a more work’. We need to be able to say what this is occurring against the backdrop sophisticated position than ‘fly in/fly does work. out doesn’t work’. Leaving aside the of a broader national debate in PNG Already we can say things about pejorative nature of the description around the role and meaning of how important it is to be able to do – which reduces ongoing support to volunteering. Clearly, if the volunteer long-term planning, to build up work in-country events – FIFO actually does placement program is to proceed, it over long periods. We can say very work in some ways for some things. should be carefully evaluated. positive things about the value of NAPWHA has compiled a thorough peer-to-peer support. Everybody loves advocacy, report that reflects on a decade of but … We need to call for proper evaluation collaboration with Igat Hope. The 1 of the community partnership model. What do we mean by advocacy in report indicates that Igat Hope would NAPWHA has already carried out a the current context? Where there have preferred a more permanent substantial evaluative process, including is no hope of legal reform, as is the NAPWHA presence in PNG, yet report writing and iterative discussion case currently in PNG, what are we despite this, Igat Hope valued many of with Igat Hope and key stakeholders in suggesting the organisations actually NAPWHA’s efforts, even though they PNG. NAPWHA’s work to date gives advocate for? There are, currently, few were significantly of a FIFO nature. us reason to believe that the evaluation champions of law reform in PNG Scarlet Alliance has stories about how will show community partnerships to in positions of power. Indeed only a FIFO has actually helped establish be effective, and cost effective. single MP (from East New Britain) Friends Frangipani in ways other has made recent statements likely to models of support could not. If Scarlet In recent times, DFAT PNG give any heart at all to the national Alliance were present in PNG all the has moved away from funding organisations. time it would risk becoming the default the Australian CBOs to provide decision-maker for all things related to partnership support. Instead DFAT We say the organisations should be sex work; its absence makes agencies has shown an interest in funding advocating for ‘a seat at the table’, but is and organisations in PNG deal with international volunteers to work with there even a table in PNG? The abject Friends Frangipani and encourages the national organisations. While lots failure of the National AIDS Council Friends Frangipani to make decisions of people can tell stories of amazing and the government to create these without constant reference to Scarlet volunteers in PNG, there is scepticism collaborative decision-making forums Alliance. Australian community-based around the proposed international causes us to wonder at what table we organisations (CBOs) have also warned volunteers as a replacement for support want the organisations to get a place. against thinking that supports are only from Australian CBOs. Scarlet Scarlet Alliance has some stories of being provided during an in-country Alliance and Friends Frangipani have successful local-level advocacy and it is technical visit: they may be ongoing, expressed the view that it is not an important that these be collected and shared. Perhaps we need to shift our advocacy focus towards these smaller, more local goals. They need to take account of the inadequacy of the national And expectations around the advocacy health system, and acknowledge that many of those leading the capacity of the national organisations advocacy efforts of the national organisations will experience ill need always to be grounded in an health and poor care. understanding of the abject poverty characterising the lives of so many of the organisations’ volunteers and constituents. They need to take account

36 | HIV Australia, Volume 12, No. 2 AIDS 2014 SPECIAL EDITION

of the inadequacy of the national Population’s (KAPs) response is Port Moresby and then to Friends health system, and acknowledge that similarly fragile. To protect DFAT’s Frangipani once they move to the many of those leading the advocacy past investment in this KAPs response, Highlands. n efforts of the national organisations it will need to keep funding the Something new. No one is will experience ill health and poor care. national organisations, and it will need asking for the continuation of to do so generously. the status quo. The national The place of the national organisations want to create organisations But in all likelihood the national organisations will need more resources something new that builds on There is general acceptance within than DFAT plans to provide. And it is the learnings from the past and PNG of the need for the national not about just giving more money to prepares marginalised communities organisations. But beyond this, what the national organisations – some are for the challenges ahead. level of support exists? arguably not ready for this – it is about As a priority, work must be done to When NAPWHA’s activities in funding the support these organisations initiate these conversations in Port PNG were defunded, it asked DFAT need in order to survive and, ultimately, Moresby, where decisions about to give these resources directly to thrive. This support does not need to be funding the national organisations will Igat Hope, so that Igat Hope could provided by the Australian community- be made. But these conversations might source its own technical advice. DFAT based organisations (CBOs) – although also be usefully conducted in Canberra. instead sought to replace NAPWHA a case can be made for this to occur – DFAT has a range of commitments with an international volunteer. Yet but it does need to be provided and policy positions seen as conducive NAPWHA’s program concluded in by someone. to ongoing support of the national organisations, and we should encourage 2012 and there is still no volunteer. It is not just about money. It is about DFAT Canberra to make sure all posts That’s about $200,000 and counting the capacity of the organisations to are applying these approaches. that hasn’t gone to Igat Hope as function effectively. NAPWHA’s technical assistance. In view of this work with Igat Hope shows that the Tim Leach is a development lack of follow-up by DFAT in-country, organisations can function effectively practitioner who works a lot in NAPWHA is seriously concerned for in-country, but need resourcing and PNG. He has worked for many years the viability of the organisation. support to do this. with Igat Hope, PNG’s national The commitment to the volunteer organisation for people living with So what is needed? program is, happily, an indication that HIV, under a technical support program conducted by NAPWHA. DFAT will continue to support the The national organisations need to He has also been a part of the national organisations. There have been work together. There is significant AFAO team providing support to other welcome indications as well, and crossover amongst constituencies and Kapul Champions, the national these are all extremely important, as of multiple shared goals. Together they organisation for men with diverse all the donor agencies in PNG, DFAT need to engage with DFAT, but the sexualities and transgender people has been the national organisations’ conversation needs to be a new one. It in PNG. Dr John Rule is a Conjoint most reliable and generous funder. needs to be about: Associate Lecturer, School of Public n DFAT is likely to remain critically The importance of safe spaces for Health and Community Medicine, Faculty of Medicine, UNSW and important. There is no chance that marginalised communities, and the the Principal Investigator on the the government of PNG will fund critical health education that can the national organisations. There is National AIDS Council approved occur only in these spaces. study: HIV-related Stigma and next to no chance that other donors n An acknowledgement that Discrimination and Human Rights in will fund the organisations in the way constituencies are significantly PNG (ref: RES10-014). they need to be funded. Donors love a shared, and that the three flashy project, but no agency other than organisations want services to be Reference DFAT has shown a preparedness to shaped around what individuals 1 Leach, T., Rule, J. (Dr). (2013). The Practice fund the core costs these organisations may need at different times of Partnerships – Reflections on a decade must meet if they are to function rather than the notion of strict of partnership between the National effectively. Association of People With HIV Australia institutional integrity. A person and Igat Hope, the national association DFAT PNG will need to be supported may seek services from Igat Hope for people living with HIV in PNG. National here as it argues for continued at some point and, at another, Association of People Living with HIV support of the national organisations. from Friends Frangipani. A person Australia (NAPWHA), Sydney. The national organisations are very might be connected to Kapul precarious, and the Key Affected Champions while living in

HIV Australia, Volume 12, No. 2 | 37 AIDS 2014 SPECIAL EDITION

The Pacific Sexual Diversity Network: Strengthening enabling environments in the Pacific though capacity building and regional partnerships

By Ken Moala1

The Pacific Sexual Diversity which are also PSDN primary program (NGOs). The SFA has been the lead Network: an overview participants. advocate for HIV and STI issues The Pacific Sexual Diversity Network in Samoa with assistance from key Tonga Leitis’ Association (TLA): (PSDN) is a network that has been stakeholders such as PSDN, Samoa Tonga (158 members) representing the interests of men Red Cross, Ministry of Health and Ministry for Women. who have sex with men (MSM) and Tonga Leitis’ Association (TLA) is an transgender people (TG) in the Pacific organisation that advocates to reduce Rainbow Pride Foundation region since 2007. The PSDN is a discrimination and prevent HIV and (RFP) (formerly MENFiji): Fiji region-wide network of MSM and STI for leitis 2 and vulnerable groups in Rainbow Pride Foundation (RPF) TG community organisations and Tonga. TLA holds annual awareness is a not-for-profit community-based projects and was formed in recognition programs to raise awareness for network that was formerly known as of the need to develop a more effective condom use and human rights issues the Males Empowerment Network regional response to the actual and for the Tongan community and leitis Fiji (MENFiji). The change in name potential threat that HIV and AIDS and other minority groups. The TLA took place in 2012, prompted by the poses to MSM and TG across the has established a focal point office expansion of its networks, membership, Pacific. and drop-in centre where they hold and mandate to holistically address the meetings, workshops and training on Currently the PSDN includes development needs of Fijian people issues including human rights, health, representation from Samoa, Papua with diverse sexual orientation, gender and stigma and discrimination. New Guinea, Fiji, Tonga, Vanuatu and identities and gender expressions. This the Cook Islands with growing ties Samoa Faafafine Association includes but is not limited to lesbian, with Kiribati and the North Pacific (SFA): Samoa (200 members) gay, bisexual, transgender, intersex (Guam and the Federated States of and queer (LGBTIQ) communities. Micronesia). PSDN has ongoing The Samoa Faafafine Association 3 The current focus of RPF work is on partnerships with HIVOS, New works for the equality of fa’afafine advocating for the sexual health and Zealand AIDS Foundation (NZAF), and other sexual minority groups. The rights of the Fijian people with diverse ACON, Australian Federation of organisation has two key objectives: sexual orientation, gender identities AIDS Organisations (AFAO), and to promote the universal respect for and gender expression, building on the memberships with the International and observance of human rights and work that was done by MENFiji since Gay & Lesbian Association (ILGA), fundamental freedoms, including 2009 in the area of HIV prevention, Asia Pacific Transgender Network the elimination of all forms of treatment, care and support. (APTN) and Asia Pacific Coalition on discrimination; and to advocate for Male Sexual Health (APCOM). legal and social recognition of fa’afafine Fiji Network Plus (FJN+): Fiji and other sexual minority groups in PSDN has a strategic plan for 2014– Fiji Network Plus (FJN+) works with order to properly fit in with society. 2019 to which future programs will over 60 communities around Fiji, be aligned. PSDN is incorporated in SFA works closely with government reaching over 80,000 people with Samoa and its Secretariat is based in ministries, such as the Ministry for information about HIV, decreasing the Kingdom of Tonga. It is governed Women, the Ministry of Health and stigma and discrimination, promoting by a Board with representation from the the Ministry of Justice, and with Voluntary Confidential Counselling various country networks, listed below, Samoan non-government organisations and Testing, and encouraging

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Above: PSDN representatives join together for a training workshop in Auckland, New Zealand.

support for people living with HIV. PSDN to develop local approaches Kapul Champions: Papua New FJN+ engages in advocacy activities, for implementing HIV and STI Guinea including taking a prominent role in all awareness programs. In 2013, at the Kapul Champions is the national HIV-related events in the country. 11th International Congress on AIDS network for men of diverse sexualities in Asia and the Pacific (ICAAP FJN+ also provides care and support (MDS) and transgender people in 11) in Bangkok, the Cook Islands for people living with HIV through a PNG, and is based in the capital Minister for Health launched the number of mechanisms: peer support, Port Moresby. Kapul Champions PSDN Strategic Plan as a step for the liaising with health services for represents men of diverse sexualities Cook Islands Government to address improved continuum of care, finding and transgender people in national LGBTIQ issues. accommodation for people living with policy and health discussions. The HIV who are homeless because of their organisation aims to raise the voices HIV status, mediation, support from Solidarity: Vanuatu and concerns of MDS and TG through participation in the planning and church leaders, reconciliation of HIV- Solidarity supports men who have implementation of HIV services, as positive people with their families and sex with men and the transgender well as to promote the protection of communities, and assisting members community in Vanuatu, and partners human rights for MDS and TG. to access financial and housing social with Wan Smol Bag Theatre – a welfare support. community-based organisation which Kapul Champions was launched Te Tiare Association (TTA): implements HIV awareness programs in 2012 by the PNG Minister of Cook Islands (40 members) using dramatic arts and a network of Health, Mr Michael Malabag. The peer educators who provide information organisation operates with funding Founded in 2008, Te Tiare Association about sexual health, distribute condoms from the Australian Department of (TTA) focuses on LGBTIQ issues in bars and nightclubs and encourage Foreign Affairs and Trade (DFAT) in the Cook Islands. TTA partners MSM and TG to visit the Wan and receives technical support from with the Cook Islands Red Cross and Smolbag reproductive health clinic. AFAO and Igat Hope (the national

HIV Australia, Volume 12, No. 2 | 39 AIDS 2014 SPECIAL EDITION

HIV-positive organisation in PNG). Kapul Champions works closely with Friends Frangipani (PNG’s national sex worker network), UNAIDS in PNG and PNG Development Law Association. Kapul Champions is advocating to change laws in PNG that criminalise sex between men. Section 210 (‘Unnatural Offences’) applies criminal sanctions of up to 14 years imprisonment for the act of ‘sexually penetrating any person against the order of nature’ or who any person who ‘permits a male person to sexually penetrate him or her against the order of nature’4. Section 212

(‘Indecent Practices Between Males’) Above: Ken Moala, representing Samoa and the Pacific Sexual Diversity Network at a global imposes a charge of up to three UN forum. years’ imprisonment for acts of ‘gross indecency’ between males5. orientation, gender identities, fact that they hold the keys to Kiribati and Tuvalu preferences and behaviours in avert the development of HIV Pacific Island contexts and sub- among these communities. This Kiribati and Tuvalu, island nations optimal utilisation of community is due to inadequate capacity located in the Pacific Ocean, currently knowledge and networks for in administrative and technical do not have MSM and TG networks prevention skills of the community-based established, however there are n organisations currently involved in initial programs that will support the lag between the publication the response, the often informal basic training of these communities of information and data and its nature of these organisations and and establishment of community utilisation for programming and networks, as well as the lack of organisations. monitoring n investment in these structures persistence of considerable service beyond program funding. Key issues access barriers for MSM and TG (including entrenched institutional Despite mounting evidence of the Ken Moala is Technical Advisor/ discrimination in health, education multi-layered determinants of HIV risk Co-Founder of the Pacific Sexual among men who have sex with men and employment sectors), and little Diversity Network. and transgender people in the Pacific in-depth understanding of these region, there are very few strategic barriers References n interventions that specifically address a predominantly ministry of 1 The author acknowledges and thanks the the needs of these populations outside health-led bio-medical approach PSDN Secretariat, PSDN chairperson, the French territories and Guam. to HIV programming at national PSDN Board members and their respective organisations, Ferdinand level, leading to an undue focus This lack of specific programming can Strobel and the UNDP Pacific Centre for on quantifying and addressing be attributed to a number of factors their assistance and input into this article. the proximate factors of HIV risk 2 Leiti is a local cultural term which is that include: relating to HIV awareness, risk inclusive of men who have sex with men, n transgender people, gay and bisexual men uncertain epidemiology and lack perception and sexual behaviour, and non-identifying men who have sex of data regarding MSM and TG rather than the underlying causes with men. populations and HIV rates amidst unequal social structures, 3 Fa’afafine is a cultural identity that n laws criminalising homosexuality, inadequate legal frameworks and encompasses and reflects the cultural context of sexual and gender diversity in often violent intimate relationships which exist in nine countries in the the Samoan society. 6 n Pacific/Oceanic region weak engagement of key 4 See: http://antigaylaws.wordpress.com/ n little consideration or populations as central actors regional/pacificoceania/ 5 ibid. in the response at national understanding of the diversity 6 ibid. of MSM and TG sexual and regional levels, despite the

40 | HIV Australia, Volume 12, No. 2 AIDS 2014 SPECIAL EDITION

Comparing Pacific and Australian approaches to gay men’s health: reflections on the 2014 AFAO National Gay Men’s HIV Health Promotion Conference

By Isikeli Vulavou

The AFAO National Gay Men’s HIV Health Promotion Conference is held The different scope of HIV programs every two years. The conference is an opportunity for HIV health workers, for gay men and other men who have policy makers and researchers to network, highlight best-practice, and sex with men (MSM) in affluent discuss practical and strategic health promotion responses to emerging countries compared to resource limited issues in the HIV epidemic in Australia. It also provides opportunities for settings like Fiji was immediately others working in our region to network, share information and ideas, and to obvious. Most of the target audience learn from each other. in Australia and New Zealand owns Isikeli Vulavou, the founding Director and President of the Rainbow Pride a smart phone and has easy access Foundation (formerly MENFiji) and current Fijian representative to the to the internet, which is not the case Pacific Sexual and Diversity Network (PSDN), was one of 110 delegates for similar target audiences in Fiji who attended the 2014 conference, held 7–10 April in Sydney. In this and the Pacific. Discussions in the article, Isikeli reflects on his experiences at the conference, and shares workshop even covered using different some insights about differing approaches to gay men’s health in Fiji mobile applications to reach different and Australia. segments of the target population – at this point I was totally lost!! However, I first received notification about the under the Pacific Healthcare Workers the two days that followed were very call for scholarships for the AFAO Support project in which MENFiji informative and gave some insights National Gay Men’s HIV Health (now Rainbow Pride Foundation) was into the respective differences in HIV Promotion Conference in January when a collaborating partner. responses to address the epidemics in the PSDN secretariat circulated a call Australia and in Fiji. to all its board members. It instantly I arrived in Manly, Sydney Australia on Fiji is classified as a low prevalence grabbed my attention, as there has never 7 April, not sure what to expect. I was country, with estimates from UNAIDS been an opportunity in Fiji nor in the both excited and anxious about all the and World Health Organization Pacific region (excluding Australia and new things I would learn during the (WHO) indicating the number of New Zealand) for a conference solely three-day conference. people living with HIV in 2012 to focused on Gay Men’s Health. After The vast difference between the be around 1000, and a prevalence reading the background information I HIV response in developing countries rate of HIV among 15–20 year olds became keener to participate and wrote 1 and developed nations like Australia at approximately 0.2%. Although to the conference secretariat to see if was clearly evident during the first there has been no epidemiological the conference was open to participants afternoon’s information sharing session. HIV sero-surveys conducted for the from outside Australia – the Pacific in I joined a group workshop reviewing general population, the number of cases particular – and to see if scholarships health promotion campaigns and identified among HIV tests undertaken were available. social media strategies currently used annually supports these estimates. In The initial reply was that scholarships in Australia and New Zealand to 2012 and 2013, the total number of were open to the Pacific, but I would advocate for and mobilise communities, new HIV infections identified was 62 have to to pay some costs. I approached impart knowledge and influence and 64 respectively.2 Unlike the picture two UN organisations based in Suva for behaviour change. In these discussions, in Asia, where HIV transmission is assistance but this was declined due to several health promotion staff shared largely among men who have sex with unavailability of such funds. However, examples of Australian and New men, sex workers and people who inject two days later I received good news that Zealand health promotion programs drugs, the same cannot be said about the conference organisers would cover using mobile and internet technologies the Pacific and Fiji. The main mode registration, and that the Albion Centre to increase coverage and mobilise of transmission in Fiji is primarily could cover travel and accommodation target populations. heterosexual followed by perinatal,

HIV Australia, Volume 12, No. 2 | 41 AIDS 2014 SPECIAL EDITION

homosexual and bisexual, and one case issues of gay men and men who The three main takeaways for me related to injecting drug use, noted have sex with men living with HIV from the conference were: 1) how to some years back. In 2013 we saw an were raised frequently, and the use effectively use social media to reach equal distribution of male and female of treatment as prevention and pre- a target audience and disseminate cases, where previously the majority of exposure prophylaxis was covered. information; 2) methods to mobilise the cases were among men.3 target communities and advocate for Most of these terms I heard I had come behaviour change; and 3) opportunities In Fiji, the low prevalence rate among across before, but never understood to advocate with the Ministry of gay men and other men who have sex their meaning, nor made an effort to Health back in Fiji for introduction of with men results in the response and understand them, as they were seldom rapid HIV testing and use of treatment strategies used for these men focusing used in strategy discussions for HIV as prevention strategies. on conventional preventative strategies responses for men who have sex with such as safe sex promotion, mainly men or transgender people back home. Thank you to AFAO and the Albion through condom use. Currently, peer I learnt how numerous HIV programs Centre for the funding support that education is the main approach used targeting gay men in Australia were ensured my participation in this very to promote safe sex among men who using rapid testing, while testing in Fiji important conference. I hope that more have sex with men and transgender is very low across the board – those opportunities will be afforded to other people in Fiji. Given our strong oral who do get tested are often tested participants from Fiji and the Pacific in cultural traditions, where interpersonal through opportunistic events, and the future. communication tends to appeal then often do not return to the clinics more, face-to-face communication to collect the results. The conference Isikeli Vulavou is the President with peers is both low-cost and illustrated to me how rapid testing can of Rainbow Pride Foundation effective. MENFiji has also organised increase testing uptake, and would be a (formerly MENFiji), a MSM and TG organisation in Fiji and a board event-based safe sex campaigns useful tool to advocate for in Fiji. member of Pacific Sexual Diversity with Information Education and There seems to be ongoing discussions Network (PSDN). Communications (IEC) materials like within the Fiji Ministry of Health on rapid testing, but a limiting factor has posters, drop down banners and t-shirts References been funding. distributed to disseminate key messages 1 See: UNAIDS (2012). HIV and AIDS on safe sex. At the 2014 International At some points in the discussion I felt Estimates (2012). Retrieved from: http:// AIDS Conference I will share a poster the conference was only focused on www.unaids.org/en/regionscountries/ countries/fiji/ outlining the Condomising Suva gay men living with HIV, but I soon 2 Ministry of Health – Fiji Islands. (2014). Hotspots project, where MENFiji realised this was due to the nature of Global AIDS Progress Report 2013. Fiji partnered with five nightclubs to Australia’s HIV epidemic, which is Islands. Report submitted to UNAIDS 31 distribute condoms supplied free of concentrated among gay men. March. 6. charge by UNFPA (United Nations 3 ibid. The use of treatment as prevention Population Fund). was another interesting discussion At the AFAO conference, a range of given the challenges in translating additional approaches were discussed knowledge and education into action – I found myself listening and and behaviour change, as evidenced in participating in discussions where the the results of the MENFiji Integrated prefix sero- was frequently mentioned, Behavioural and Biological Survey.

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42 | HIV Australia, Volume 12, No. 2 AIDS 2014 SPECIAL EDITION

Above: Also known as ‘The Tree of Life’, the Baobab tree is found in 32 countries across Africa as well as in Australia and is an enduring symbol of positivity and growth, thriving in conditions where little can survive. AIDS 2014: Under the Baobab Tree By Jill Sergeant and Finn O’Keefe

The African Diaspora Networking Zone at AIDS 2014 in Melbourne has ABD populations to the fore throughout been organised by the Multicultural Health and Support Service (MHSS) in the entire conference. collaboration with the African Black Diaspora Global Network on HIV/AIDS (ABDGN) and the Australian Federation of AIDS Organisation’s (AFAO’s) ‘My hope is that the recognition of African Reference Group. ABD as a key vulnerable population is a common thread throughout the Kwaku Adomaku, the Manager of the ABDGN and representative on sessions and activities. This recognition the African Diaspora Networking Zone working group, has coordinated is critical in supporting improved health ABDGN’s activities at the last three International AIDS conferences; in surveillance, more enabling social and Mexico city (2008), Vienna (2010) and Washington (2012). Kwaku spoke to legal environments for ABD, greater HIV Australia about his hopes for this important space at AIDS 2014. protection of human rights, and reduced vulnerabilities across the determinants of health.’ ‘This networking zone is going to be a The networking zone will include hub of activity and knowledge-sharing speakers from the Caribbean, USA, In addition to participating in the focused on African and Black diaspora Canada, European Union, New Zealand, activities taking place in the networking (ABD) populations locally and around and Australia, discussing a wide range zone, ABDGN is also leading the the globe,’ Kwaku Adomako explains. of issues including treatment advocacy, coordination of the ABD Regional ‘The local energy and excitement of community HIV testing initiatives, and Session – Stepping Up from Vulnerability the Global Village will also result in youth prevention initiatives. to Opportunity: HIV and AIDS in the spontaneous and unplanned experiences Kwaku says that the zone will provide Global Context of African and Black and connections that will inspire and a much-needed space for the global Migrant and Diaspora Populations, recharge our commitment to ensuring the ABD community to come together to taking place on Tuesday 22 July from disproportionate impact of HIV/AIDS on highlight issues relevant to communities 11–12.30pm. Kwaku says that this will ABD populations is recognised as a global and their local context, which will help be a key session bringing issues affecting issue that requires immediate action.’ bring a broad range of issues affecting African Black Diaspora populations

HIV Australia, Volume 12, No. 2 | 43 AIDS 2014 SPECIAL EDITION

to the forefront of the global dialogues taking place at AIDS 2014. HIV and African communities and HIV in Australia ‘We are very excited to be coordinating this for a second time and we intend Between 2009 and 2011, AFAO engaged in a series of consultations with African community leaders, influential stakeholders, HIV sector agencies (both culturally and to ensure that this regional session, linguistically diverse and mainstream organisations) and HIV-positive African people. which began at AIDS 2012, becomes a The consultations presented information JUNE 2014 permanent feature of the International about the HIV response in Australia and DISCUSSION PAPER NOt fOR gENERAl DIStRIbUtION AIDS Conferences,’ Kwaku says. data on HIV diagnoses among African- HIV and sub-Saharan African born people, and invited participants to communities in Australia Prepared by Jill Sergeant ‘We are also excited to share our plans for Project Officer, Australian Federation of AIDS Organisations 1 identify key issues of concern in relation a Diaspora Declaration , a unifying call to HIV and their communities. The to action that brings together the most consultations were followed in 2011 and recent evidenced-based knowledge and 2012 by two national forums which aimed resources to inform the development of to further support and develop the African a global ABD framework that provides community response to HIV in Australia. A new AFAO discussion paper, HIV recommendations for research, policy, AfRICAN COmmUNIty and sub-Saharan African Communities lEADERS hAvE ExPRESSED advocacy and programming that is A StRONg DESIRE tO in Australia (right), draws upon the ADDRESS thE ImPACt Of integrated, grassroots, adaptable and hIv IN thEIR COmmUNItIES consultations and forums, as well as wIthIN thE CONtExt Of sustainable. Activities related to the published research and interviews AUStRAlIA’S hIv PARtNERShIP. declaration will be highlighted at the with HIV service providers and key Regional Session.’ stakeholders, to set out and analyse key HIV-related issues for African communities. ‘This year’s conference theme, Stepping While this discussion paper is not up the Pace, for me means that we Produced by the Australian Federation of AIDS Organisations (AFAO), PO Box 51, Newtown, New South Wales 2042 Australia available for general distribution, AFAO Telephone +61 2 9557 9399 Facsimile +61 2 9557 9867 Email [email protected] www.afao.org.au can no longer be complacent. While has developed a set of briefing papers African DP PRESS.indd 1 2/06/14 10:19 AM migration and population mobility which summarise the main issues raised are international issues, there is a local in the discussion paper. The papers n dimension too. In the context of HIV/ address the following topics: Criminalisation n Prevention and awareness AIDS our communities often remain n An overview n n Stigma. under-serviced, under-resourced, and Men n Women The briefing papers are available for unheard. We are at a crossroads, where n Young people download at www.afao.org.au, and three – we can combine our individual efforts n Gay men and other men who have An overview, Young people and Stigma – to galvanise a global movement that sex with men are also available in French. recognises that despite the disparities between us, we share (many) strengths. The best way to effect change now is to step up our pace, and in solidarity show the global community that we are engaged, passionate and eager to make a real difference in changing the epidemic.’

Jill Sergeant is Project Officer at AFAO. Finn O’Keefe is Communications Officer at AFAO and an editor of HIV Australia.

Reference 1 The Diaspora Declaration: A Global HIV/AIDS Agenda for African/Black/ Caribbean Diaspora Populations is a project bringing together Canadian and international researchers, community members, advocates and programmatic specialists to develop an HIV/AIDS Diaspora Declaration (DD) for African/ Black/Caribbean Diaspora and migrant Above: Sem Mabuwa (consultant), Elizabeth Mlambo (Kirby Institute), Jill Sergeant (AFAO) populations. and Kudakwashe Tuwe (New Zealand AIDS Foundation) at the inaugural AFAO National Forum on HIV and African Communities, May 2011, Sydney.

44 | HIV Australia, Volume 12, No. 2 AIDS 2014 SPECIAL EDITION

HIV and sexuality: why are people with disabilities left behind?

By Suzanne Lau Gooey and Dr Paul Chappell

The prognosis and progress for Health Organization in 2011, nearly Prominent socio-medical discourses in people living with HIV (PLHIV) one billion people, or 15% of the most societies construct people with have been extraordinary over the last world’s population, are living with a physical or sensory impairments as two decades. Most HIV-positive disability.1 The prevalence of disability incapable of experiencing sex, romantic people who access antiretroviral therapy is also growing due to population love, or relationships. In addition to (ART) now live with a manageable ageing and the global increase in being described as asexual, common chronic illness, instead of facing an chronic health conditions, including public perceptions view those with ugly, premature death. HIV and AIDS. In addition to these intellectual impairments or mental high prevalence rates, increasing illness as indistinct, over-sexed and The catastrophic scale of the AIDS evidence also suggests that people with unable to control their sexual desires. pandemic drove enormous changes physical, intellectual2, cognitive, sensory in health services, education, socio- These misconceptions surrounding or mental health disabilities are at cultural and economic development. sexuality and disability have not only equal, if not increased risk to all known HIV and AIDS was not only a medical drawn attention away from the sexual HIV risk factors. For example, poor crisis, but also a product of poverty, agency of disabled people, but also access to information on sexual and power, gender and marginalisation. from the socio-cultural meanings of reproductive health on HIV/AIDS; HIV required new paradigms of disability and desirability. In addition, poor access to health care, including infectious disease control – prevention these misconceptions portray people HIV/AIDS services; poverty and through caring for HIV-positive people with disabilities as one homogenous marginalisation; and higher rates of and those most at risk, rather than group, failing to recognise that they sexual abuse and exploitation than their punishment through quarantine and also form part of other key populations non-disabled peers. fear-based awareness campaigns. at risk of HIV exposure, such as men Despite these increased risk factors, who have sex with men, sex workers Effective responses to HIV have also people with disabilities are rarely and people who inject drugs. As a been based on protecting the human included in HIV and AIDS policies result, very few countries around rights of the most vulnerable and and programs because they are often the globe consider disability when marginalised groups – gay, lesbian, not perceived as being at-risk of collecting HIV prevalence data.3 bisexual, transgender, queer (GLBTQ) acquiring HIV. One of the underlying communities, women, young people, Unfortunately, although the global reasons for this is due to some widely sex workers, people who inject drugs, disability movement has made great held misconceptions about the migrants, and people from culturally strides in promoting disability rights, sexualities of people with disabilities. and linguistically diverse (CALD) they have been slow to recognise backgrounds; however, one group has sexuality as a matter of human rights. been left behind. Why aren’t people As summed up by Ann Finger, a with disabilities included? prominent disability activist: HIV and AIDS has forced us to speak ‘Sexuality is often the source of our openly about what used to be hidden deepest oppression; it is also often and taboo subjects, such as sexuality, the source of our deepest pain. sexual health and sexual practice, and to It’s easier for us to talk about – and provide HIV information and sexuality formulate strategies for changing education for many target groups – what about the needs of people ‘Sexuality is often the source of our deepest oppression; it is also with disabilities? often the source of our deepest pain.’ According to the first ever World Report on Disability, published by the World — Ann Finger, Disability Activist

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– discrimination in employment, persons with disabilities who are of education, and housing than to talk marriageable age to marry and to found about our exclusion from sexuality a family on the basis of free and full and reproduction’.4 consent of the intending spouses is recognized; b) The rights of persons The perception of people with with disabilities to decide freely disabilities as non-sexual routinely and responsibly on the number and results in the suppression of sexuality, spacing of their children and to have notably affecting young people. access to age-appropriate information, Young people with disabilities are for educators who teach sexuality reproductive and family planning generally discouraged from engaging education to learners with disabilities education are recognized, and the in discussions around sexuality. in South Africa’s Life Orientation means necessary to enable them to Furthermore, combined with poor lessons. Likewise, Disability, HIV exercise these rights are provided.’9 access to education due to physical and and AIDS Trust (DHAT)5, a regional attitudinal barriers, young people who People living with HIV have disabled people’s organisation (DPO) have a disability often receive little demanded their human rights and has been established in Zimbabwe formal sexuality education, since it is those of other vulnerable groups to promote the rights of people with believed that they do not need such be protected and upheld, as the disabilities living with or affected by knowledge or will become promiscuous foundation of effective responses to the HIV, AIDS, tuberculosis, cervical if it is provided. HIV pandemic. HIV is recognised as a cancer, and including sexual and disability under anti-discrimination Outside of school, parents of children reproductive health rights. law and the UNCRPD. But where with disabilities are also often reluctant The United Nations Convention on is the HIV community’s advocacy, to discuss sexuality and HIV with the Rights of Persons with Disabilities support and solidarity with the their children, perhaps in the belief (UNCRPD)6 was conceived because disability community? that by not talking about sex they are all existing UN conventions had failed protecting their children from future People living with HIV (PLHIV) to protect persons with disabilities rejection and vulnerability to sexual and people with disabilities (PWD) (PWDs). The UNCRPD came into abuse. Although similar behaviours share similar experiences of stigma, force in 2008, and so far, has been occur among parents of children discrimination, devaluation and ratified by 147 countries.7 But how far without disabilities, this silence exclusion. Neither people living with have people with disabilities come as surrounding sex and sexuality is felt HIV nor people living with disabilities a result? more acutely among young people are regarded as ‘normal’ sexual beings. growing up with a disability, because Article 25 (a) of the UNCRPD states Considered unworthy of motherhood, it is commonly believed that sex will that governments: ‘shall provide women with disabilities and HIV- never be part of their lives. persons with disabilities with the same positive women still routinely undergo range, quality and standard of free or forced sterilisations and abortions in Despite these misconceptions, there affordable health care and programmes many parts of the world. However, is a growing awareness of the need as provided to other persons, including neither the PWD nor the PLHIV to include children and adults with in the area of sexual and reproductive movement regard people living with disabilities in sexuality and HIV health and population-based public HIV as having a disability, despite the services. For example, in South Africa, health programmes.’8 fact that both groups experience the the Health Economics and HIV and debilitating effects of stigma, and have AIDS Research Division (HEARD), Article 23 states that governments: increased care and support needs. has developed an intervention toolkit ‘shall ensure that :a) The right of all Both the HIV and disability communities demand meaningful involvement and equal partnerships, People living with HIV (PLHIV) and people with disabilities and reject charity or medical models, (PWD) share similar experiences of stigma, discrimination, that devalue or disempower them as devaluation and exclusion. Neither people living with HIV nor patients or weak, dependent welfare recipients. People with disabilities have people living with disabilities are regarded as ‘normal’ sexual called for ‘Nothing about us without beings. Considered unworthy of motherhood, women with us’ since the 1980s, and the early AIDS disabilities and HIV-positive women still routinely undergo activists also supported the Americans with Disabilities Act.10 The GIPA forced sterilisations and abortions in many parts of the world. principle of meaningful involvement

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of people living with or affected by with a disability, not even the 2014 http://www.who.int/disabilities/world_ 13 report/2011/en/ HIV was formalised by 42 countries plenary titled ‘No one left behind’. 2 Intellectual disability originates before 11 at the Paris AIDS Summit in 1994. Similarly, the AIDS 2014 Melbourne adulthood. Some countries use the term Both movements desire genuine Declaration: Nobody Left Behind14 ‘learning disability’ or ‘developmental social inclusion, where they live with fails to name people with disabilities as delay’. 3 Groce, N., Rohleder, P., Eide, A., dignity and are valued participants and a key affected population. MacLachlan, M., Mall. S., Swartz, L. contributors in society. Urgent action is needed now, as HIV (2013). HIV Issues and people with disabilities: a review and agenda for Individual disability activists and responses are scaled-up, to ensure that research. Social Science and Medicine, people living with HIV have people with disabilities are included, 77, 31–40. called unsuccessfully for coalitions not only as service users, but also as 4 Finger, A. (1992). Forbidden fruit: why between PLHIV and PWD since leaders and partners in better HIV shouldn’t disabled people have sex or 12 become parents? New Internationalist, the mid-2000s. Both movements programs. There can never be an 233, 8. Retrieved from: http://newint.org/ have different strengths and can AIDS-free generation if we continue features/1992/07/05/fruit/ complement and learn from each other. to leave behind 15% of the world’s 5 The Disability, HIV and AIDS Trust website People with disabilities and people population – people with disabilities. is available at: www.dhatregional.org 6 United Nations (UN).(2008). Convention with HIV both need to break down The Disability Networking Zone on the Rights of Persons with Disabilities their beliefs based on stigmatising and Optional Protocol (GA resolution A/ (DNZ) will be located in the Global stereotypes about each other and RES/61/106). UN, Geneva. Village at the 20th International focus together on their common 7 For information about ratifications and AIDS Conference in Melbourne. The signatories of the Convention and its goals of access, equity and genuine Global Village offers free admission Optional Protocol See: United Nations social inclusion. Enable website. Latest Developments. to the public and the DNZ will also Retrieved from: http://www.un.org/ Australia’s successful HIV strategies be running a program throughout the disabilities/latest.asp?id=169 have incorporated partnerships with conference, with Auslan interpreters 8 ibid. Article 25 – Health. Retrieved from: key communities, but its domestic available for most presentations. http://www.un.org/disabilities/default. and international HIV programs asp?id=285 9 ibid. Article 23 – Respect for home and the in treatment services and capacity Details of the DNZ program (including some conference sessions) family. Retrieved from: http://www.un.org/ building of PLHIV organisations disabilities/default.asp?id=283 are available at: www.addc.org. have not linked with people with 10 Shapiro, J. (1993). No Pity: People with disabilities and DPOs. The National au/events/disability-networking- Disabilities Forging a New Civil Rights Association of People with HIV zone/99/ Movement. Times Books/Random House, New York, 127. Australia (NAPWHA) was a member The DNZ’s theme of Leave No One 11 UNAIDS. (1999). From Principle to of the peak Australian Federation of Behind aims to promote awareness Practice: Greater Involvement of People Disability Organisations in 2004–2013, of the need for HIV programs to Living with or Affected by HIV/AIDS. but withdrew to focus on wellbeing Retrieved from: http://data.unaids.org/ be inclusive of people with disabilities Publications/IRC-pub01/JC252-GIPA-i_ instead of disability. and provide opportunities for en.pdf An urgent alliance is needed between people with disabilities to participate 12 Tataryn, M. (2004, May). Bridging the and network. gap: a call for cooperation between HIV/ people living with HIV, HIV and AIDS activists and the global disability development practitioners and people Suzanne Lau Gooey is a former movement. Presentation delivered at the with disabilities, DPOs, disability chair of Positive Women Victoria, Canadian Disability Studies Association, practitioners and donors. HIV is not and a member of the Disability Winnipeg, Manitoba, Canada. Retrieved from: http://www.aidsfreeworld. only a risk to people with disabilities Reference group at the Victorian org/OurIssues/Disability/~/media/ in Africa, but also to other regions, Equal Opportunity and Human B758E3CDA2864779A364CBCF0B6BC especially in Asia which is home to Rights Commission since 2010. 135.pdf two-thirds of the world’s population. Dr Paul Chappell is a Postdoctoral 13 Conference Coordinating Committee. (2014). AIDS 2014 list of sessions. HIV, development and gender violence Research Fellow at the University of Johannesburg, South Africa, and Wednesday 23 July: No one left behind. programs must also encompass also a Co-chair of the International Retrieved from: http://www.aids2014.org/ disabled people. WebContent/File/AIDS2014_Current_ Disability and Development Programme_April2014.pdf The 20th International AIDS Consortium (IDDC) HIV and 14 International AIDS Society (IAS). (2014). Conference (IAC) being held in Disability Task Group. AIDS 2014 Melbourne Declaration: Melbourne is themed ‘Stepping up Nobody Left Behind. IAS, Geneva. References Retrieved from: http://www.aids2014.org/ the Pace’, to reflect the urgent need declaration.aspx to reverse the trajectory of the HIV 1 World Health Organization (WHO), The epidemic. However, no IAC plenary World Bank. (2011). World report on Disability. WHO, Geneva. Retrieved from: session has ever included a person

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Learn from the past, live in the present, dream for the future: Melbourne Youth Force stepping up the pace

By Alex Mindel, Karen Salter, Kristine Squire, Naveen Tenneti and Nitasha Kumar

Since the beginning of the HIV Since the 2002 International AIDS and bring this information back to local epidemic, young people in Australia Conference (IAC) in Barcelona, young communities. By participating in the have played a vital role in shaping the people have come together to collectively IAC, young people are also able to share HIV/AIDS response. By helping to to form YouthForce – a platform for stories with other conference delegates deliver crucial services and providing youth voice and visibility at the IAC. about what life is like for young people indispensable support, young people The YouthForce presence at the past six living with HIV across the globe. have made an invaluable contribution International AIDS Conferences has Sanele is from a province that has to Australia’s strategies and action ensured young people’s voices are heard high rates of poverty and few job and on HIV. and has created increased opportunities educational opportunities. He is a for young people to contribute to the Thirty years of Australia’s investment in volunteer Youth Engagement Officer program and learn from the wealth of research and advocacy have resulted in at the local drop-in centre and a knowledge gathered. many benefits. There are now 26 drugs leader in his community. He coaches available to HIV patients and treatment Made up of members from 26 youth- soccer, teaches computer workshops is personalised around the individual; oriented partner organisations from and provides HIV education to other however, the hardship of frontier around the world, the 2014 Melbourne young people. This year he will leave his treatment days still linger as a poignant Youth Force (MYF) is a platform to hometown for the first time to attend reminder. José Machado, who has been unite young people and those who the IAC, where he will present two HIV-positive for 24 years, recalls, ‘It was support a global agenda, which places videos he created about the experience very frightening. It was something you young people at the centre of the global of being HIV-positive in his community had to deal with many hours per day HIV response. The MYF is a global and his community’s knowledge of HIV. network of young people committed to because, basically, some of the treatments Since last October, MYF volunteers shaping the next generation’s response involved taking large doses of pills have been working tirelessly to develop to HIV in the world. at certain times of the day, at certain an effective platform for young people intervals. Very complex treatments, but MYF member and the founder of attending the conference to network, also very severe on your system.’ partner organisation LetsStopAIDS, exchange ideas, advocate for change, Across Asia and the Pacific, Shamin Mohammed Jr. from Canada, learn new skills and, in the process, build approximately five million people are has been participating in IAC events lasting and effective partnerships. since 2006. As a 14-year-old he was living with HIV. Young people carry The MYF’s Melbourne 2014 Youth much of this burden; half of all new given the opportunity to ask Bill Clinton a question on ‘how youth can Pre-Conference will be held at the infections in the region are among people Victorian State Library on 18–19 July. under 25. While HIV prevalence in commence leadership and inspiration around the world’, highlighting the The two day youth pre-conference Australia remains comparatively low, in opportunities that youth are offered has been designed to bring together 2012 Australia’s rate of newly diagnosed at IACs to voice their concerns and 200 of the world’s young leaders in HIV infections rose by 10% – the largest questions to a global audience. the global AIDS response to provide increase in 20 years. a forum to build on the latest global At AIDS 2014, the 70 strong MYF core youth campaign and programs, build YouthForce planning for team presence promises to be bigger and the future tangible skills and debate and learn better than ever, with the team focused from the experiences and successes of As young people from key affected on leveraging the presence of global young people from around the world. populations around the world converge leaders and ensuring the needs of young Technical sessions will be delivered people continue to be a key focus at on Melbourne this July, the 20th by a range of local and global leaders AIDS 2014 and beyond. International AIDS Conference (AIDS in the HIV sector, including sessions 2014) provides a vital opportunity to For many young people, like 21-year- run by UNAIDS, UNFPA (United highlight the current situation, both old Sanele Ntobela from Dududu in Nations Population Fund), Restless locally and regionally, and form a South Africa, AIDS 2014 provides the Development, Youth Rise, Global Youth concrete action plan for the future. opportunity to learn more about HIV Coalition on HIV/AIDS (GYCA) and

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Above: The world’s largest World AIDS Day sign by YEAH! (Youth Empowerment Against HIV/AIDS) for World AIDS Day 2013. Photo: Andrew Henshaw.

Advocates for Youth. Sessions will focus away and not turned into action, In keeping with past IACs, the Global on the post-2015 development agenda, especially at a time when we have Village will once again house the new funding mechanisms, adolescent such great opportunity to really drive Youth Pavilion, a space where young access to treatment, age of consent, harm forward a powerful and committed people can meet, exchange ideas, relax, reduction and peer education models. response to HIV that builds on all our participate in informal workshops and past learnings of our failures and listen to informative youth-focused Youth Action Plan our successes’. presentations. The Youth Pavilion is open to the public and provides an In the lead up to and during the youth The Melbourne Youth Force Youth exciting opportunity for non-delegates pre-conference, the MYF will develop Action Plan will be formally presented to also get involved in AIDS 2014. the Youth Action Plan (YAP). The to UNAIDS Executive Director Michel Sidibé, at the AIDS 2014 High Level The diversity of young people in the decision to move away from developing MYF provides a great opportunity for a youth declaration, as has been the Youth Symposium. The plan will ensure that both the young leaders attending knowledge transfer and skill building Youth Force tradition, was a focus to across the HIV sector. shift thinking towards the need for AIDS 2014 and the thousands an action-based plan set against clear connecting via social media are actively Twenty-four-year-old Alyce Vella from time-bound goals and clear indicators involved in shaping the future direction Melbourne has been working at the of HIV youth advocacy. so progress can be measured. As Alischa Burnet Institute for a few years, and wanted to expand her skill set. Ross, who has been involved with In addition to the pre-conference, the Youth Forces for many years reflects: MYF will host a youth reception and a ‘I joined the MYF after doing some ‘We know that we cannot afford number of other youth-related events in volunteer work with YEAH! (Youth to continue to produce well crafted the lead-up to and throughout the week Empowerment Against HIV/AIDS) declarations that are too easily filed of AIDS 2014. – the MYF lead Australian partner’

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says Alyce. ‘I really wanted to be more involved on a community level, so I thought the MYF would be a fantastic opportunity to meet other like-minded young people who work in the sector’. This seems to have worked: ‘My experience so far has been amazing’, she says. ‘I’ve been able to meet new people from all over the country (and world!) and strengthen connections I already had with other organisations in Melbourne’. Beyond just building connections, Alyce says that being involved has helped build her skills too, ‘I’ve gained new skills in writing funding proposals as well as engaging with people I wouldn’t normally come across in my day-to-day research work.’ Since last October, members of the MYF have been utilising various forms of technology and digital communication to work together and across international boundaries on projects that have tangible outcomes. The opportunities the MYF provides for young people at AIDS 2014 to connect and learn from each other, and to strengthen their collective voice, will have an impact far beyond July. Throughout this process, the diversity and richness of the partner organisations has resulted in MYF members learning from each other, effectively using resources and increasing their organisational capacity. The real beauty of the MYF is the ability for those involved to transfer their new Above: World AIDS Day 2013 in Melbourne. Photo: Andrew Henshaw. knowledge and skills back to their own local communities and organisations – a true and powerful example of young the lead up to and during AIDS 2014 Toronto, Canada. Naveen Tenneti is leaders in action and the power of the Chair of the Australian Medical on our social media channels connecting like-minded individuals. Students’ Association’s Global www.facebook.com/youthaids2014 Health Committee and Co-Chair of As Alyce says, ‘AIDS 2014 is shaping and @youthaids2014. up to be a very memorable event, and the Youth Pavilion Sub-committee for AIDS2014. Karen Salter is the I can’t wait to celebrate the hard work We hope to see you there! Co-Chair of the Melbourne Youth of the MYF with my new international Alex Mindel is the Communications and Membership Services Officer at Force Media and Communications and local friends!’ The National Association of People Sub-committee and works at You can read more about the with HIV Australia (NAPWHA) and SA Health in Adelaide, South Melbourne Youth Force, our activities part of the Melbourne Youth Force Australia. Nitasha Kumar is part of and incredible partner organisations at Media and Communications the Melbourne Youth Force Pre- www.aids2014community.org/youth Sub-committee. Kristine Conference Sub-committee and We’ll also be posting more information Squire is the Vice President of is completing her PhD at Monash University, Melbourne, Victoria. and opportunities to be involved in Communications at LetsStopAIDS in

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Community-based responses to HIV in developed Asia: challenges and approaches for lesbian, gay, bisexual and transgender (LGBT) people1 By Laurindo Garcia and Jane Koerner

Introduction we acknowledge that for many of on transgender people, HIV prevalence 4,5 Developed Asia is a sub-region within these people, these identities may be is significantly higher. Modeling Asia, and has been referred to by the irrelevant to their lived experience. by the Commission on AIDS in Asia-Pacific Coalition on Male Sexual Despite the recognition by UNAIDS Asia predicted by 2020, 50% of new that human rights for lesbians, gay infections in Asia would be among Health (APCOM) in its regional 6 strategy and response to HIV among men, bisexual and transgender people MSM and transgender people and gay men, other men who have sex (LGBT), access to LGBT friendly this trajectory was confirmed in the health services, and protection from UNAIDS Global report 2013 data on with men (MSM) and transgender 7 people since its inception in 2007. The discrimination are critical enablers in HIV in Asia and the Pacific . any effective HIV response2,3 – it is countries/territories of developed Asia In most low and middle income Asian clear that these elements are missing in include Hong Kong, Japan, Macau, countries there is now reasonably developed Asia and the rights of people Singapore, South Korea and Taiwan robust epidemiology on HIV from sexual and gender minorities – settings with similar characteristics prevalence, risk behaviours and HIV including LGBT are far from assured. including relative socio-economic prevention program coverage, with prosperity, rapid uptake of internet and This paper will outline the most research funded by international other technologies, and high rates of epidemiology and response to HIV donors. Despite having relative wealth, regional travel. in developed Asia in relation to gay developed Asia lacks nationally While a basic level of universal health men, other MSM and transgender coordinated data on HIV prevalence care is provided by governments people; identify barriers to scaling-up and incidence, rates of HIV testing and across developed Asia, free access to testing and treatment; and present condom use, and on the percentage treatment for people living with HIV some examples of community-based of gay men and other MSM reached is not necessarily a given. In addition, responses. Finally, we give suggestions by prevention activities. Virtually no recent prevention options such as on what is needed for an effective data is available on transgender people post-exposure prophylaxis (PEP) response to HIV among gay men, in these countries/territories. While and pre-exposure prophylaxis (PrEP) other MSM and transgender people in HIV prevalence rates among MSM are not available in developed Asia developed Asia. in developed Asia are low by global comparisons with prevalence ranging and there is little open debate about Epidemiology and response their implementation, indicating the from 3.1% to 5.8%, the numbers difficulties in getting HIV prevention In Asia, the HIV epidemic of annual infections are increasing 8 for gay men and MSM on the public disproportionately affects men who steadily. The few behavioural studies health agenda in this sub-region. have sex with men. Where data exists among MSM in developed Asia point Consistent with many countries in Asia, strong cultural taboos exist in Despite having relative wealth, developed Asia lacks nationally relation to homosexuality and sexuality in general, and many gay men, MSM coordinated data on HIV prevalence and incidence, rates of HIV and transgender people are not openly testing and condom use, and on the percentage of gay men and visible in society. Although we use the other MSM reached by prevention activities. Virtually no data is terms gay and bisexual, MSM and transgender throughout this paper, available on transgender people in these countries/territories.

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to low rates of condom use and HIV 30.8% in 2007. This was mirrored in and forced rehabilitation of testing, high rates of regional travel Taiwan, when between 2005 and 2010 people who use drugs, including and high numbers of sexual partners HIV prevalence among gay men and non-injecting drug users, in all enabled by the internet, as well as drug- other MSM increased from 17% to countries/territories. 15,16,17 n use during sex as implicated in HIV 71%. In the Philippines, HIV Institutionalised discrimination 9–13 transmission. diagnosis among MSM increased by against people living with and 114% and 214% respectively between Low levels of advocacy to address most-affected by HIV – for 2003 and 2008.18 These rapid increases HIV among gay men, other MSM and example: travel restrictions on show the importance of adequate transgender people are reflected in the foreigners living with HIV to enter monitoring of HIV prevalence, fact that few countries/territories in Singapore; forced deportation incidence and sexual behaviours as well developed Asia have national AIDS of migrants living with HIV in the necessity to increase community- plans, and HIV activities focus on Singapore and Taiwan; cases of based programs targeting MSM and general heterosexual transmission denial of employment and/or transgender people. even though HIV transmission insurance for people living with rates in heterosexual populations are or affected by HIV in Singapore, comparably low. The poor visibility of Barriers to scaling-up testing South Korea and Taiwan; and these groups is evident in a lack of risk and treatment restrictions that prevent positive assessments in national epidemics, and portrayals of same-sex attracted Increasing infection rates indicate people in Singaporean media, low levels of funding and political will an inadequate response to date, to affect a community-level response. this entrenching intolerance and and government policies as well as stigmatisation against these groups. Community-based organisations prevailing cultural and social norms n Inadequate investment, capacity- exist but their scope and number are have been barriers to scaling-up HIV building and leadership for nowhere near sufficient to reach the testing and treatment. These include: recommended 80% of MSM to affect a n advocacy and support services Criminalisation of people living reduction in HIV infections (including for people living with HIV and with and most-affected by HIV, condom use during anal sex, and people most-affected by HIV, which discourages people from regular HIV and STI testing).14 which has inhibited meaningful key affected populations from participation in policy debates The situation faced by MSM in engaging with government health about access to treatment, Taiwan, Bangkok and Manila in services. Policies requiring reform government subsidies for testing the 2000s shows how rapidly HIV include: 377A of the Singaporean and sexual health services, and the infections among MSM can increase Penal Code, which criminalises quality of health services. in the face of poor epidemiological sex between men; criminalisation n Cultural taboos and stigma, surveillance, inadequate funding of of HIV transmission in Singapore which make public discourse community responses, and inadequate and Taiwan; criminalisation of about sex, drug use, safer sex, government leadership, investment and non-disclosure of HIV status to risk reduction, harm reduction action. In Thailand, HIV prevalence sexual partners deemed high-risk and positive portrayals of sexual increased from 17.3% in 2003 to in Singapore; and criminalisation minorities problematic and difficult to scale-up. n Poor visibility and advocacy of transgender communities in all countries in developed Asia, which is facilitated by a poor The situation faced by MSM in Taiwan, Bangkok and Manila in the understanding of the complexitites 2000s shows how rapidly HIV infections among MSM can increase of transgender and intersex identities which render many in the face of poor epidemiological surveillance, inadequate funding people invisible. n of community responses, and inadequate government leadership, The conflation of gay and bisexual investment and action. In Thailand, HIV prevalence increased from men and transgender populations 17.3% in 2003 to 30.8% in 2007. despite their distinct health issues. There is a need to increase accessibility to gay, MSM and transgender-friendly HIV, STI and sexual health services.

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n Lack of a multisectoral entry-point for LGBT community community-based HIV prevention, response. In East and South East groups to work in partnership to care, treatment and support. Links Asian countries, international raise the issues they face, private need to be strengthened between development assistance builds sector engagement is not without its organisations, local health providers capacity for community-based challenges. These include difficulties and other government agencies to service-providers. Strengthening in engaging business leaders, and the facilitate dialogue on the problems community systems is lack of discourse on HIV care and and challenges faced by LGBT people acknowledged as an essential support for people living with HIV in order to increase inclusiveness of activity by the Global Fund to and reduction of HIV-related stigma existing programs and reduce stigma. Fight AIDS, TB and Malaria and and discrimination within current Increased efforts are needed to share the US Government’s PEPFAR ‘diversity and inclusion’ activities. This data and monitor prevalence and program. Strong community private sector support is commendable, incidence among gay men, other MSM systems are also acknowledged but it cannot be relied on to fund and transgender people. as critical enablers in achieving national-scale prevention programs and In order to reduce HIV infections Millennium Development Goals treatment and support for gay men, among gay men and other MSM (MDGs) by UNAIDS in its other MSM and transgender people. and a relatively unknown epidemic investment framework guidance to Significant resources, planning and among transgender people, increased domestic governments. coordination is needed in order to have community-based capacity is needed a significant and lasting impact on Community level approaches to: increase access to and promote the HIV incidence in key populations. use of condoms with lubricant; provide Despite the barriers identified above, LGBT-friendly harm reduction there are groups mobilising to increase Where to from here? services for people who use alcohol the visibility of LGBT issues and affect While the community responses to and drugs; offer reliable HIV testing a response to HIV in developed Asia. HIV in developed Asia are nascent, and treatment; and offer general For sexual minorities stigmatised there is growing interest and potential to mental health support for an often within Asian societies, the internet increase organisation on LGBT health marginalised community. Invisible plays a valuable role in helping LGBT and human rights. Initiatives such as populations such as non-gay identified people to meet and access HIV and DAN (Developed Asia Network on MSM and transgender people are in sexual health information, while also Sexual Diversity and HIV) and others urgent need of tailored interventions. serving as a source of LGBT news. that actively transfer good practice (see Furthermore, new prevention methods There are a number of LGBT portal breakout box overleaf ) are a valuable including rapid HIV testing, PEP sites in developed Asia; examples source of innovation and support and PrEP need to be investigated for include Fridae (www.fridae.asia), for groups concerned with LGBT implementation within developed Asia. Utopia Asia (www.utopia-asia. health and should be replicated across The steady increase in annual HIV com), and Gay Star News (www. developed Asia. gaystarnews.com). While the internet infections among gay and bisexual has been identified as a possible The pressing need is to increase men underscores the urgent need for facilitator of risk, in that higher funding and political commitment to action. The failure of most developed frequency of meeting sexual contacts by internet may be related to higher rates of unprotected anal sex, it also has significant potential to provide information on HIV prevention and treatment, and facilitate organisation of In order to reduce HIV infections among gay men and other MSM networks for care and support. and a relatively unknown epidemic among transgender people, Due to the lack of government support, community-based groups in increased community-based capacity is needed to: increase access developed Asia have had to be creative to and promote the use of condoms with lubricant; provide LGBT- in instigating support and sponsorship friendly harm reduction services for people who use alcohol and from private and corporate donors. Often the sources of these have been drugs; offer reliable HIV testing and treatment; and offer general companies and individuals from LGBT mental health support for an often marginalised community. communities. While private sector engagement provides a significant

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Community-based responses to HIV in Asia

Examples of community-based responses that are working to effect a health and human rights response for gay men, other MSM and transgender people in developed Asia include:

Information sharing and networking n DAN (Developed Asia Network on Sexual Diversity and HIV) In 2010, a community-led network was formed among civil society organisations from five countries/territories as a result of the 1st Developed Asia Regional Consultation on HIV in MSM and Transgender People, held in Singapore in December 2010. The Developed Asia Network on Sexual Diversity and HIV, which was formed from this meeting and has focused on building the capacity of community actors in each of the countries to advance advocacy and social justice on issues related to HIV and sexual and gender minorities. In 2014, the DAN secretariat hopes to embark on a regional capacity-building program to improve the skills of member community advocates to develop long-range advocacy strategies, mobilise resources and engage stakeholders more effectively.

Improving the visibility of transgender communities n Asia Pacific Transgender Network The Asia Pacific ransgenderT Network (APTN) provides a platform to enable transgender women and men in the Asia and Pacific region to organise and advocate for the improvement to their health, protection of legal, social and human rights, and enhancement of their social wellbeing and quality of life. APTN recognises HIV issues affecting transgender people, and advocates for improved access to appropriate prevention, treatment and care services as for HIV and other sexually transmissible infections. The Network has published several key policy and technical reports, and has developed recommendations on the protection and promotion of transgender rights that can be used by governments and partner organisations in national and other action plans. n Transgender Resource Center, Hong Kong Hong Kong’s Transgender Resource Center (TRC) is one of the few community-based organisations in developed Asia that provides support, educational material and advocacy specific to issues facing transgender people. The work of TRC is indicative of increasing momentum across Asia for community-level advocacy on transgender issues. Much of this movement has been catalysed by the regional HIV response.

Addressing HIV stigma and raising visibility of people living with HIV n Living Together Living Together started as a project to raise the visibility of people living with HIV within the gay community and wider population in Japan, but has since been adapted to other settings including Mongolia. A number of HIV community groups and support groups for people with HIV collaborated to produce ‘Living Together’ stories by people living with and affected by HIV. The stories are about being diagnosed, the everyday experience of living with HIV, having a friend or partner with HIV, getting tested, and experiences of risky and safer sex. The Living Together materials have been used in various events including photo exhibitions, radio programs, and music events with public readings accompanied by DJ or live music. The stories and readers’ impressions enable the Living Together message to be personalised creating a powerful tool in combating HIV-related stigma. n Taiwan Lourdes Association and the Positive Alliance, Taiwan Taiwan Lourdes Association aims to improve the quality of life for people with HIV through care and support programs. It works with the Positive Alliance of Taiwan who engages with decision-makers to improve access to HIV treatment. The need for direct community advocacy has become more urgent in recent years as the Taiwanese government has considered rolling back the government subsidy of HIV treatment17 despite global calls to increase HIV treatment access. These cuts would potentially undermine the recent progress made in Taiwan’s HIV response. n PLUS: B-Change Foundation PLUS is a web-app which uses social networking to enhance connections between gay men and other MSM living with HIV so that they can help each other and understand they are not alone, and to find local services to support their health. The platform has been built for HIV-positive MSM in Bangkok, Kuala Lumpur, Jakarta, Manila and Singapore using the languages native to these cities. All registered members have full control over their privacy settings in order to create and maintain a safer space for users. PLUS will be released in a public beta-version in June 2014.

Addressing diversity and inclusion of LGBT people in the community n Pink Dot Pink Dot started in Singapore in 2009 but has been adopted in other places such as Hong Kong and Japan and has been an enormously successful campaign that raises the visibility of LGBT people. Pink Dot has become synonymous with tactical social media-based advocacy (including YouTube videos) that mobilises followers towards a day of action where people are rallied together dressed in pink to show their support for the LGBT community. The last Pink Dot in Singapore attracted over 21,000 people. n Out On The Street Community Business, a Hong Kong-based NGO, provides technical assistance for multinational corporations interested in diversity and inclusion in the workplace, including resources for business leaders and human resource managers. The engagement work conducted by community stakeholders, LGBT employee groups (in particular Asia’s Interbank Forum) and collaboration with Community Business resulted in an executive commitment to diverse and inclusive workplaces at the Out On The Street Asia event in 2013. A follow-up event is scheduled for late 2014.

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Asian governments to sufficiently UNAIDS, Geneva. Dependence, 120, 246–249. 3 Schwartländer, B., Stover, J., Hallett, 14 Chen, Y., Lin, Y., Huang, S., et al. (2011). allocate HIV expenditure toward T., Atun, R., Avila, C., Gouws, E.,, et al. Risk factors for HIV-1 seroconversion evidence-based inventions alongside (2011). Towards an improved investment among Taiwanese men visiting gay saunas policies that enable communities is, approach for an effective response to HIV/ who have sex with men. BMC Infectious ironically, contributing to an expansion AIDS. Lancet, 377(9782), 2013–2041. Diseases, 11, 334. 4 van Griensven, F., van Wijngaarden, J. 15 Low-Beer, D., Sarkar, S. (2008). Catalyzing of concentrated HIV epidemics among (2010). A review of the epidemiology of HIV prevention in Asia: from individual to their citizens who are gay, MSM or HIV and prevention responses among population level impact. AIDS, 24(Supp 3), transgender. Considering that the MSM in Asia. AIDS, 24(Suppl 3), S30-S40. S12–S19. cost of antiretroviral HIV therapy 5 United Nations Development Programme 16 van Griensven, F., Thanprasertsuk, S., (UNDP). (2012). Lost in transition: Jommaroeng, R., Mansergh, G., Naorat, in this region are among the world’s Transgender people, rights and HIV S., Jenkins, R., et al. (2005). Evidence of highest – due to a lack of access to vulnerability in the Asia-Pacific region. a previously undocumented epidemic of generic medicines – the cost of HIV UNDP Asia-Pacific Regional Centre, HIV infection among men who have sex treatment significantly outweighs the Thailand. with men in Bangkok Thailand. AIDS, 19(5) 6 Commission on AIDS in Asia. (2008). 521–526. cost of prevention. These costs are Redefining AIDS in Asia: Crafting an 17 Farr, A., Wilson, D. (2010). An HIV largely avoidable – but the failure to effective response. Commission on AIDS epidemic is ready to emerge in the invest in strengthening and sustaining in Asia, New Dehli. Philippines. Journal of the International a community-based response leaves 7 UNAIDS (Joint United Nations Programme AIDS Society, 13, 16. doi: 10.1186/1758- on HIV/AIDS). (2013). HIV in Asia and the 2652-13-16 developed Asia lagging behind its low Pacific in UNAIDS Global Report 2013, 18 See: and middle income neighbours. UNAIDS, Geneva: 33-41. (AIDS coalition pushes civil interests in 8 Onitsuka, T., Koerner, J., Kaneko, N., amendment of AIDS law). TSSD News/ A paradigm shift towards more regular Tsuji,H., Cho, Y., Shiono, S., et al. (2009). Yahoo. Retrieved from http://bit.ly/TqQkiR HIV testing, earlier initiation of HIV infection rates, risk and preventive treatment, the use of new prevention behaviours of MSM in Asia: How does Laurindo Garcia is a civil society technologies and increased funding Japan compare? 9th International and social justice advocate based Congress on AIDS in Asia and the Pacific, between the Philippines and for community-based approaches Bali Indonesia, 9–13 August 2009. that serve key populations has gained Retrieved from: http://www.msm-japan. Singapore, who is often called traction in the emerging economies com/report/wp-content/uploads/2010/08/ to give a perspective of people of the world. It is high time that Bali-ICAAP-poster-NE-Asian-MSM-.pdf living with or affected by HIV 9 Hidaka, Y., Kimura H., Ichikawa S. (2008). in the Asia-Pacific region. He developed Asia matches its economic Internet survey into HIV risk and preventive is coordinator for two regional success with comparable public health factors among MSM – REACH Online community networks, including the outcomes for all its citizens. 2008. In Hidaka, Y. (Ed.) Monitoring HIV prevention among internet users – 2009 Developed Asia Network for Sexual Diversity, and founded a regional Acknowledgements Research Report. Department of Health, Labour and Welfare AIDS Research Grant, tech-based, social enterprise group The authors would like to thank Tokyo, 7–33. (In Japanese) called B-Change. Jane Koerner 10 Lau, J., Wong, W. (2000). Behavioural Dennis Altman, Don Baxter, Seiichi started working with HIV-related surveillance of sexually-related risk community-based organisations Ichikawa and Joe Wong for their behaviours for the cross-border traveller in Australia in 1989. She has been comments on an earlier version of this population in Hong Kong: the evaluation a research associate with the paper, and acknowledge any omissions of the overall effectiveness of relevant prevention programmes by comparing Japanese Ministry of Health, Labour or errors as our own. the results of two surveillance surveys. and Welfare funded ‘Study group International Journal of STD & AIDS, on the development of community- References 11(11), 719–27. based prevention interventions 11 Lee, S., Ma, E., Tam, D. (2007). Report 1 We use the terms ‘lesbian, gay, bisexual, for men who have sex with men’ transgender’ (LGBT) to describe what is on the assessment of recently acquired at Nagoya City University since actually a much wider range of identities HIV infection in men who have sex with and sexualities, and also acknowledge men in Hong Kong. Stanly Ho Centre for 2005 and currently works at the that such terms may not be relevant to Emerging Infectious Diseases, Chinese Australian Catholic University the lived experience of many people in University of Hong Kong. in Canberra as a public health developed Asia. Many LGBT groups in 12 Wei, C., Lim, S., Guardamuz, T., Koe, researcher. developed Asia are conscious of the S. (2012). HIV disclosure and sexual labelling problems associated with the transmission behaviors among an internet use of foreign and local terms and some sample of HIV-positive men who have use language and imagery to show sex with men in Asia: Implications for inclusiveness which would be difficult to prevention with positives. AIDS and adequately describe in the scope of this Behavior, 16(7), 1970–1978. paper. 13 Wei, C., Guardamuz, T., Lim, S., Huang, 2 UNAIDS. (2012). Investing for results. Y., Koe, S. (2012). Patterns and levels Results for people: A people-centred of illicit drug use among men who have investment tool towards ending AIDS. sex with men in Asia. Drug and Alcohol

HIV Australia, Volume 12, No. 2 | 55 AIDS 2014 SPECIAL EDITION

Enhancing partnerships across the region: Australia Awards Fellowships

By James Malar

Introduction links between Australian organisations AFAO will be working in conjunction The Australian Federation of AIDS and partner organisations in Asia and with ASHM, who will facilitate Organisations (AFAO) International the Pacific. The program’s goal is to a twelve-month mentoring and Program is working to enhance develop the skills and knowledge of leadership program for the AAF partnerships across Asia and the Pacific. current and aspiring leaders in priority participants on several AAF programs. One way that this work is continuing areas to provide support in advancing The ASHM leadership and mentoring is through a project that is engaging key regional policy objectives and program will be particularly important directly with HIV/AIDS and men increase institutional capacity of in assisting this new network of who have sex with men (MSM) and partner countries. AAF projects are community leaders to continue to transgender (TG) organisations across designed to complement individual develop, enhancing the HIV/AIDS the region as part of the Australia bilateral country programs by offering and MSM and TG response for their Awards Fellowships (AAF) program. flexible learning opportunities that local community and strengthening the address current and emerging needs community networks across the region. AFAO is partnering with the Asia at the country, sub-regional and Details about the two AFAO AAF Pacific Council of AIDS Service regional levels. Organisations (APCASO) and the programs are below. Asia Pacific Coalition On Male The AFAO AAF programs AAF Program 1: Strengthening Sexual Health (APCOM) to bring HIV/AIDS civil society policy together participants from HIV/AIDS The AFAO AAF initiative is split into and advocacy capacity in Asia and MSM and TG organisations two groups, involving 25 participants and the Pacific in Cambodia, Myanmar, Vietnam, each. One program focuses on Laos PDR, Indonesia, Timor Leste, strengthening HIV/AIDS civil society This capacity development program Philippines, Cook Islands, Fiji, Samoa, policy and advocacy capacity in Asia aims to strengthen community-based Tonga and Vanuatu. and the Pacific, while the other aims to capacity for advocacy to promote The program will see a total of strengthen MSM and TG policy and sustained investment for HIV 50 advocates and leaders from advocacy capacity among regional and responses, political commitments community organisations, representing sub-regional networks in Asia and and investment in HIV responses for 13 countries, each participating in one the Pacific. HIV based on relevant context and evidence. This program particularly of two month-long training programs These two programs, running in targets APCASO and its members, being held in Australia. The training has tandem, will provide representatives as they play a lead role in facilitating been timed to coincide with the 2014 from Asia and the Pacific with community systems strengthening International AIDS Conference (IAC) opportunities to build skills and around policy and advocacy for HIV and will continue after the conference in capacity in advocacy, leadership, legal responses in Asia and the Pacific. the form of a twelve-month mentoring frameworks, social research and policy and leadership program, facilitated development; and also give participants As many countries in the region move by the Australasian Society for HIV the unique opportunity to experience into middle income status and the Medicine (ASHM). and participate in an international HIV sustainability of funding is questioned conference (an opportunity that will due to withdrawal of international What are the Australia Awards no doubt ensure the voice of Asia and donors and uncertainty over domestic Fellowships? the Pacific will be strongly represented governments commitments, the Administered by the Australian at AIDS 2014). It is envisaged that role of civil society to conduct Government Department of Foreign the two programs will empower and advocacy around HIV financing and Affairs and Trade (DFAT), the AAF equip HIV/AIDS and MSM and TG hold governments accountable to program aims to develop leadership, networks across Asia and the Pacific to their political commitments and to address priority regional development continue to expand their influence and providing programs to address key issues, and build partnerships and effectiveness over the coming years. populations is crucial.

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This AAF program will provide The Asia Pacific Coalition on Male keep our rights-based and evidenced- advocacy and policy skills and Sexual Health (APCOM) works to based programming to be responsive knowledge on HIV financing to steer respond to this huge gap in funding, to the current needs of the changing APCASO and representatives from research, and human rights protection socialisation of our communities in its members in Cambodia, Indonesia, for MSM and TG and is AFAO’s a highly digitalised and globalised Laos and Vietnam through challenging partner for this program. The AAF will world, and also the challenges that we advocacy environments, to supported support APCOM members to respond continue to face for our communities to sustained funding for community- with increased advocacy and leadership be an equal partner in the response.’ based HIV organisations and key to the MSM and TG epidemics in populations, within the post-2015 Asia. Strengthened strategic planning Conclusion landscape following expiration of the and leadership skills, will contribute International organisations, community Millennium Development Goals. The to APCOM and members capacity to organisations and governments have program will enable APCASO to function as peak advocacy bodies for continually highlighted the importance gather updates from the International MSM and TG in Asia and Pacific. The of civil society and community AIDS Conference, and learning to AAF will also provide more focused engagement in achieving broader social support human rights advocacy and learning on building specific skills and economic development outcomes strengthen policy analysis capacity for in advocacy, human rights and social for the HIV/AIDS response. Given engagement in national, regional and media focused on MSM and TG that Asia and the Pacific constitutes global policy discussions. community issues. the world’s most populous region, Rodelyn (RD) Marte from APCASO The AAF will strengthen the skills and given significant economic and says that the AFAO/APCASO of key MSM and TG advocates social changes in the region, AFAO AAF partnership presents a unique and networks in Asia and Pacific, to commends DFAT and the Australian opportunity for APCASO and be able to engage more effectively Government for their ongoing support its members to focus on skills and knowledgeably with national of HIV/AIDS and MSM and TG development, away from the day-to- government, health service providers community organisations across day pressures of carrying out the work: and other stakeholders. This will the region. AFAO, APCASO and ‘In the course of implementing our support the scale-up and accessibility APCOM look forward to enhanced work, the daily pressure to implement of services for MSM and TG around working relationships between all many things well and on time often HIV and health, as a priority DFAT our member and partners as we leaves little room and energy for much issue. The AAF will also support move forward. needed personal and organisational increased advocacy around human James Malar is the Engagement and reflection and learning. This is why rights protections for MSM and Communications Advisor at AFAO the AAF is so valuable to APCASO TG communities. International Program in Bangkok. fellows – it provides precious time, Midnight Poonkasetwattana from space and resources to dedicate just APCOM emphasises the broad for learning.’ benefits he sees resulting from the AAF, particularly with regard to AAF Program 2: Strengthening the way APCOM will be equipped MSM/TG policy and advocacy to respond to challenges: ‘APCOM capacity among regional and believes in working in partnerships to sub-regional networks in Asia contribute to an effective response to and the Pacific HIV for key populations such as MSM It is well known that countries across and transgender people because an effective response is a well coordinated Asia and the Pacific are experiencing HIV Australia is available escalating rates of HIV transmission response. AFAO provides coordination online with additional content. among men who have sex with men and support to APCOM to jointly Read Moi Lee Liow’s article and transgender people, particularly implement an AAF program aiming An engaged civil society in large urban areas. The 2008 to strengthen civil society-led advocacy underpins the success of and leadership. Commission on AIDS in Asia, Global Fund’s New Funding Multi City Initiative, and the HIV The AAF fits in with one of APCOM’s Model in HIV Australia online. Strategic Assessment each call for four Strategic Results – to build a urgent investment in MSM and cadre of advocates by investing in TG prevention, treatment and emerging leaders and community www.afao.org.au care programs. advocates. This is crucial to be able to

HIV Australia, Volume 12, No. 2 | 57 AIDS 2014 SPECIAL EDITION

Community engagement for improved outcomes for HIV/AIDS in Myanmar By Dr Paul McShane

A program to strengthen the HIV/ targeted, there remains difficulty in AAF program, offer opportunities for AIDS response in Myanmar was financing this plan5, which has already solutions to current health problems recently undertaken by Monash entered its second phase6. The plan is to be developed in a culturally relevant University under the Australian coordinated by the Ministry of Health interdisciplinary environment. Having Government’s Australia Awards and is overseen by a Technical and a mix of government and NGO Fellowships (AAF) program. Twenty Strategy Group on AIDS comprising representatives assisted in bringing senior health professionals from representatives of donors, NGOs, realistic and candid perspectives on Myanmar’s Ministry of Health, UN agencies and the government.7 cultural and social drivers of behaviour Universities and non-government This reflects the multi-sector and on practical cost effective organisations (NGOs) such as approach to funding and ongoing intervention strategies. An open and the United Nations (UN) World efforts of international agencies. The interactive environment with facilitated Food Program and Marie Stopes Monash AAF program emphasised discussion sessions helped with International, worked with Monash community-level approaches and constructive information exchange. academics to explore community sought to complement these multi- In Myanmar, sex work, homosexuality engagement strategies for addressing sectoral efforts directed at health care and use of injection drugs – all HIV/AIDS and maternal health in Myanmar through engagement prominent modes of HIV transmission in Myanmar. Monash brought with key practitioners and their in Myanmar – are currently illegal. interdisciplinary insights including representative agencies. This not only influences behaviour, for contemporary biomedical approaches example by discouraging individuals to community health care and the The Monash Fellowship program from seeking advice or treatment participants from Myanmar brought focused on primary health care through from government health agencies, but knowledge and experience of the social proactive community engagement criminalises many social interactions, and cultural context in which the HIV/ rather than on clinical intervention. It influences power structures and AIDS epidemic is being tackled in their addressed the first strategic priority of creates inequality, particularly among country. There are clear mutual benefits the National Strategic Plan: prevention women. Female sex workers lack power in such programs. of the transmission of HIV through in enforcing the use of a condom unsafe behaviour. The program Total expenditure on health in by their clients. Acting outside the was necessarily interdisciplinary, Myanmar remains low at about 2% of law, sex workers are vulnerable to recognising that community GDP, compared to Australia’s 9.5% HIV infection and other sexually engagement for improved health of GDP.1 Out-of-pocket expenditure transmissible infections (STIs), and outcomes requires understanding of on health ranks among the highest in also to violence and other anti-social the cultural, ethnic, religious, social the world and accounted for 92% of behaviour.11 Male workers from and legal context in which behaviour all health expenditure in 2010.2 Thus, Myanmar migrating temporarily to affecting the health of individuals is typically, it is the poor who lack effective Thailand or China for employment can influenced. Social support networks access to health care. acquire HIV through local sex workers through communities are key vehicles and then pass the virus on to their Rates of HIV infection in Myanmar are to transfer relevant information and partners back home. among the highest in South East Asia. knowledge to develop understanding Myanmar’s epidemic is concentrated in of disease prevention strategies among Continuing poverty reduction efforts select risk groups, including sex workers vulnerable groups and the community will assist in reducing economic and their clients, men who have sex at large.8,9,10 Such issues are well incentives for sex work and migration, with men, people who inject drugs and understood, for example in the African and help reduce gender inequality. the sexual partners of these groups.3,4 contexts cited above, but cultural De-stigmatisation of gay men along In dealing with the HIV epidemic, influences on health-related behaviour with community leadership on social Myanmar has developed a National in Myanmar are not well described justice will also encourage access of Strategic Plan on HIV and AIDS. in the literature. Interactive inter- vulnerable groups to necessary health Although comprehensive and well- country programs, such as the Monash services. Prominent Myanmar pro-

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democracy politician and Nobel Peace prevention and primary health care 3 Auerbach, J., Parkhurst, J., Caceres, C. (2011). Addressing social drivers of Prize Laureate, Aung San Suu Kyi, in Myanmar with the participants’ HIV/AIDS for the long-term response: is the UNAIDS Global Advocate for knowledge and understanding of the conceptual and methodological Zero Discrimination and therefore a cultural, ethnic, social and political considerations. Global Public powerful ally in the battle against HIV- landscape as a vital background. There Health, 6, suppl 3, S293–S309. doi: 10.1080/17441692.2011.594451 related stigma. is now a team of highly motivated 4 Bergenstrom, A., Abdul-Quader, A. (2010). health professionals back in Myanmar With relatively few trained health Injection drug use, HIV and the current ready to further improve the response response in selected low-income and professionals available, particularly to HIV/AIDS, and strong personal middle-income countries. AIDS, 24, s20– in regional areas of Myanmar, there s29. and institutional relationships between is a reliance on informal health 5 Saw, Y., et al., (2013), op. cit. 12 Australia and Myanmar to draw on in services. Community health workers 6 Myanmar National Strategic Plan and the future. Operational Plan on HIV and AIDS and volunteer health workers play 2011–2015, available at: http://www. important roles, engaging members nationalplanningcycles.org/sites/default/ Acknowledgements of the community and influencing files/country_docs/Myanmar/myanmar_ national_strategic_plan_on_hiv_and_ behaviour both positively and Funding support through the 13,14 aids_2011-2015.pdf negatively. In some cases, traditional Australian Government’s Department 7 ibid. norms may be inconsistent with of Foreign Affairs and Trade through 8 Airhihenbuwa, C., Obregon, R. (2000). A necessary interventions. In particular, the Australia Awards Fellowships critical assessment of Theories/Models linking evidence-based approaches to used in health communication for HIV/ (AAF) program is gratefully AIDS. Journal of Health Communication, community health to the traditional acknowledged. Comments and 5, 5–15. care-giving provided by community suggestions by Dr Miranda Smith, Dr 9 Airhihenbuwa, C., De Witt Webster, J. health workers is vital to improving Tina Kalivas, and by participants in the (2004). Culture and African contexts of health outcomes. HIV/AIDS prevention, care and support. AAF program were gratefully received. Journal of Social Aspects of HIV/AIDS Developing capacity among community Dr Paul McShane is Chief Research Research Alliance, 1, 4–13. 10 Auerbach, J., et al., (2011), op. cit. health workers who understand Officer at the Monash Sustainability Institute, Monash University 11 Talikowski, L., Gillieatt, S. (2005). Female customary norms and cultural drivers of sex work in Yangon. Sexual Health, 2(3), behaviour formed a critical component 193–202. of the Monash program. This strategy References 12 Tin, N., Lwin, S., Kyaing, N., Htay, T., Grundy, J., Skold, M., O’Connell, T., represents a conduit for promoting 1 Australian Institute of Health and Welfare Nirupam, S. (2009). An approach to health the importance of incorporating (AIHW). (2013). Health expenditure Australia 2011–12. Health and welfare system strengthening in the Union of evidence-based approaches to primary expenditure series 50. Cat. no. HWE 59. Myanmar. Health Policy, 95(2–3), 95–102. health care, awareness-raising among AIHW, Canberra. 13 ibid. 14 Thomas-Slayter, B., and Fisher, W. the community harnessing trusted 2 Saw, Y., Win, K., Shiao, L., Thandar, M., (2011). Social capital and AIDS- relationships, and adoption of practices Amiya, R., Shibanuma, A., et al. (2013). Taking stock of Myanmar’s progress resilient communities: strengthening which prevent HIV infection among toward the health-related Millennium the AIDS response. Global Public community members. The Monash Development Goals: current roadblocks, Health, 6, S323–S343. doi: 10.1080/17441692.2011.617380. program enabled an exploration of paths ahead. International Journal for evidence-based approaches to HIV Equity in Health, 12, 78.

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HIV Australia, Volume 12, No. 2 | 59 AIDS 2014 SPECIAL EDITION

‘Using the heart’: law enforcement and people who use drugs in Asia

By Fifa Rahman, Hong Reaksmey, Pham Hoi Thanh and Olga Golichenko

1 ‘These addicts, actually they are patients!’ a ‘police talking to police about HIV prevention’ approach, working in countries through experienced police In countless countries around the world in Kuala Lumpur do not know focal points. LEAHN also champions law enforcement officials continue to that needle and syringe exchange the Statement of Support by Law be at the forefront of the failing war on programs reduce the risk not only of Enforcement Agents for Harm Reduction drugs and can be a major obstacle when HIV infection but also of hepatitis C. and Related Policies for HIV Prevention, it comes to implementing evidence- The police authorities there tend which has been signed by more than based HIV prevention and treatment to challenge the scientific evidence 5,000 police officers worldwide and an interventions. It’s not all doom and relating to the efficacy of methadone. increasing number of police agencies. gloom, however, and thanks to the Police organisations in Victoria care Following the study visits, country energy of progressive champions within about the levels of public confidence in 7 cooperation platforms among police the police and cooperation with civil their work as well as being concerned and civil society are in the process society, the police are changing from the with the public health needs of of being established in Malaysia and inside in some places. people who use drugs. Deprivation of Cambodia. In this article we describe medication in detention is considered a our main learnings from the study visit Learning from the Australian disciplinary offence in Victoria. experience to Victoria and next steps. Police officials together with Australia, particularly law enforcement community advocates from Cambodia Malaysia: police support for in the state of Victoria, is at the (KHANA8), Malaysia (Malaysian health services in detention forefront of such changes and is AIDS Council [MAC]) and Vietnam stimulating similar developments in (Supporting Community Development In Malaysia, healthcare services are not other countries, most notably in parts Initiatives [SCDI]) visited Victoria available for people who use drugs in of Asia. It’s one of the few countries in and New South Wales in Australia pre-trial detention. According to Ng the world where civil penalty schemes last summer to find out more about Soon Wah, Assistant Superintendent in allow the police to issue fines for minor law enforcement practices with a the Royal Malaysian Police’s Narcotic drug offences2; the police can exercise view to increasing political support Crimes Investigation Department, who the discretion to be able to divert people of a harm reduction approach among took part in the study visit: who use drugs towards the health police officials in each country. The ‘The most interesting point was the system (before or after arrest); and study visits were organised as part of health management services provided individuals in police custody are allowed the Asia Action on Harm Reduction by Victoria Police at the police remand access to HIV medicines, methadone program9 which is coordinated by the centre. Victoria Police have their own and medical services.3 Police officers in International HIV/AIDS Alliance doctors, pharmacists and nurses to Victoria have a good understanding of with support from the European check and take care of detainees under public health and harm reduction.4 For Union, and in partnership with the police custody, including patients example, they do not park patrol cars in Australian Police Leadership program living with HIV. This practice should front of or in close proximity to a needle run by the Law Enforcement and HIV be implemented in Malaysia.’ and syringe exchange site because this Network (LEAHN) with support from 10 The study visit report and the might scare people off from accessing the Australian government. fostering of close relations with the the services.5 Working with the Melbourne and police officials who participated have By comparison, our research in Bishkek-based LEAHN global helped MAC to get police buy-in for Malaysia6 shows that the police lack network of police and health the introduction of medical services information about the links between professionals provided participants for those detained in holding cells. harm reduction and public health. For with considerable food for thought, With support from key champions example, law enforcement members not least because the network practises in the police, a committee has been

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established under the auspices of the its communication officer to the AIDS the development of harm reduction Ministry of Home Affairs to discuss Secretariat to help inform the PCPI and community-based rehabilitation a pilot project to introduce healthcare training. Some 200 police officers services in Bac Giang province. services in detention settings, starting have already participated, together with the police custody system at with 150 commune council members, Where to from here Jinjang integrated lockup centre. drug users’ representatives and other In many countries in Asia, such as Drawing on the experiences of local stakeholders. Indonesia, Malaysia, China and India, multiple stakeholders’ forums in Dr Hy Someth is program manager there are some progressive policies in Australia, MAC now convenes the with the AIDS Secretariat and took place that allow the implementation of Kuala Lumpur Health and Drugs part in the study visit to Australia. harm reduction services and diversion Forum which brings together different ‘After the harm reduction training, the from arrests to treatment. However stakeholders, including the Royal police will use not only their heads and they are not being implemented Malaysian Police, to look at HIV hands but also their hearts to support properly because of law enforcement and drug issues. A commitment has people who use drugs,’ he said. As policies such as police arrest quotas, also been received from the Royal well as applying his experiences from which lead to the arrest and harassment Malaysian Police to introduce the Australia to the PCPI training, Dr of outreach workers and people concept of harm reduction to the Someth is also supportive of KHANA’s who use drugs. In such cases police training curriculum for police cadets. advocacy efforts to extend methadone leadership and collaboration is required maintenance therapy (MMT) services to ensure an effective implementation Cambodia: a ‘softer’ to prisons and to offer MMT takeaway of drug and harm reduction policies. implementation of the Village/ doses to current patients. ‘Once a drug Commune Safety Policy In Indonesia for example, the diversion user is sent to prison, the police are no policy outlined in Narcotics Law #35, The Village/Commune Safety longer responsible but we acknowledge which seeks to divert people suspected Policy was launched by Cambodia’s that MMT substitutes heroin and of drug use and possession for personal Ministry of Interior in 2010 and normalises drug users’ behaviour use to treatment and harm reduction due to a priority focus on ‘cleaning towards stopping using illegal drugs,’ services instead of the criminal justice the streets’, has driven people who Dr Someth said. process and potentially prison, can inject drugs underground. This has only work if police officials (as well as created significant difficulties for HIV Vietnam: gaining police prosecutors and judges) are aware of prevention programs but unfortunately support for harm reduction the policy – and willing to implement the popularity of the policy among it. Last October the People’s Police the public and politicians leaves little Academy, jointly with LEAHN and This year the Asia Action on Harm opportunity to advocate for changes. SCDI, organised a meeting about Reduction program will support police However, local police forces are able harm reduction between officials from officials and community advocates from to apply a certain level of discretion Vietnam’s Ministry of Public Security Indonesia to learn from the Australian to implement the policy in a ‘softer’ and civil society representatives. It model. The study tour will include a way, for example by referring people was the first time such a dialogue had visit to Harm Reduction Victoria, a who inject drugs to harm reduction occurred. The ongoing collaboration peer-based organisation of people who programs instead of arresting them. between the People’s Police Academy use drugs. Participants hope to learn Since last year, KHANA, jointly and SCDI includes research about about various strategies to engage with the Ministry of Interior’s AIDS the effects of relapse on drug use and with people who use drugs and the Secretariat, has been implementing the associated risk of criminal activity. support services they provide to their the Police–Community Partnership SCDI is also working closely with members. There will be discussions Initiative (PCPI), which builds the police to gain their support for about how to work with police and police awareness of harm reduction through training. It also develops police platforms on harm reduction ‘The police have the authority to divert people who use drugs in at a district and community level Indonesia from prison towards treatment but this is not happening in Phnom Penh together with local community participation. To because of a number of structural barriers. I hope to learn from encourage international best practice the police in Australia to help us to improve the implementation of and create stronger linkages between Narcotics Law #35.’ the Ministry of Interior and other — Policy Manager, Ardhany Suryadarma stakeholders, KHANA has seconded

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government to develop policies that recognised the importance of civil society collaborating with the criminal justice system. Policy manager Ardhany Suryadarma already knows the change he wants to see: ‘The police have the authority to divert people who use drugs in Indonesia from prison towards treatment but this is not happening because of a number of structural barriers. I hope to learn from the police in Australia to help us to improve the implementation of Narcotics Law #35.’ In the majority of countries in Asia, policies on drug use and harm reduction need to be amended and introduced first before, or at the same time as, asking for police leadership and collaboration. Improving relationships with law enforcement Above: Malaysian police at a training session to raise awareness of harm reduction approaches. Photo: Fifa Rahman for the Malaysian AIDS Council. officials and understanding harm reduction through their ‘lens’ is critical. The study visits to Victoria have Asia Action on Harm Reduction is Conference of the International Society helped build trust and partnership for the Study of Drug Policy Conference, between community advocates and a European Union funded program Rome, 21–23 May, 2014. police officials. As well as creating which enables civil society advocates 2 Stoicescu, C. (ed.) (2012). The Global State of Harm Reduction 2012: Towards harm reduction champions within in China, India, Malaysia, Indonesia, Cambodia and Vietnam to advocate an integrated response. Harm Reduction law enforcement sectors, the visits are International, London. 159. Retrieved from: contributing to in-country changes for harm reduction. This is done http://www.ihra.net/files/2012/07/24/ where both police and community through creating evidence-based GlobalState2012_Web.pdf advocates work together. In Malaysia, advocacy calls, and by improving 3 Rahman, F. (2013). Police Leadership in knowledge and building support Public Health. Study Tour to Melbourne, for example, law enforcement members Australia. Malaysian AIDS Council. who participated in the trip are now for harm reduction among policy Retrieved from: http://www.mac.org.my/ facilitating police training and high makers. The contents of this article v3/?page_id=367 level briefings on HIV/AIDS and are the sole responsibility of the 4 ibid. 5 Mike Anderson, quoted in ibid. harm reduction. International HIV/AIDS Alliance 6 Poster presentation. (2014). Harm and do not necessarily reflect the According to Professor Nick Crofts Reduction Services and Police opinion of the European Union. Involvement in Malaysia. Poster presented from LEAHN: ‘Together with other at the Eighth Annual Conference of the stakeholders, LEAHN focal points Fifa Rahman is Policy Manager at International Society for the Study of Drug are building police leadership in harm the Malaysian AIDS Council. Hong Policy Conference, Rome, 21–23 May, 2014. reduction in countries following the Reaksmey is Policy Manager at study visits. What we need is the 7 Public confidence is one of the indicators KHANA. Pham Hoi Thanh is Policy of the police work performance and is political support from governments Manager at Supporting Community reported to the public in the Victoria Police and resources from donors to Development Initiatives, Vietnam. Annual Report 2012–2013. Retrieved institutionalise this leadership’. Olga Golichenko is Senior Advisor: from: http://www.police.vic.gov.au/ Harm Reduction Advocacy at the annualreports/ebooks/2013/index.html It’s imperative that key donors, 8 KHANA is the largest national NGO International HIV/AIDS Alliance. particularly the Global Fund to Fight providing integrated HIV prevention, care HIV/AIDS, Tuberculosis and Malaria, and support services at the community as well as governments in Asia, fund References level in Cambodia. See: http://www.khana. org.kh 1 Source: Corporal of the Narcotics interventions that will build support 9 For further information see: http://www. Department in the state of Pahang, aidsalliance.org/Pagedetails.aspx?Id=543 of harm reduction approaches within Malaysia (where police practice towards 10 Rahman, F. (2013). op cit. the law enforcement sector. This will people who use drugs is considered to help create an enabling environment be less repressive) during an interview for harm reduction services at a with the Malaysian AIDS Council. community level. Research presented at the Eighth Annual

62 | HIV Australia, Volume 12, No. 2 AIDS 2014 SPECIAL EDITION

Learning from each other: the Australian-Asian partnership experience By Ele Morrison

This article presents some case studies of successful partnerships between They were using it to show other the Australian Injecting and Illicit Drug Users League (AIVL) and networks of organisations what they wanted to people who use drugs in Asia, reflecting on some challenges experienced achieve, and were already receiving by these networks, both in Australia and across the region. other support from stakeholders in Vietnam. Since then, we have worked with VNPUD in several different ways. We have provided workshops, support Case study one four day period were all five people for their launch, shared resources, in the room, and at no time was I I first met the Coordinating Committee brought them to international and told who I could expect to be there. of the Vietnamese Network of People regional events, and worked with them who Use Drugs (VNPUD) in March, One woman missed two-and-a-half to develop relationships with other 2010. This group of five people had been days because she was worried about stakeholders. Their membership has introduced to me through a Vietnamese her chickens, and spent most of the more than doubled. Their Coordinating time she was there on the phone. non-government organisation (NGO) Committee has changed. The Another person left a day early and which provides support for the group. President, the petite woman from my others missed periods of time to attend They had only formed a few months first meeting, is still fearlessly leading meetings with other organisations. before and already had over twenty them all. They still face serious barriers They were eager to start early, but member groups at local levels around to their ability to legally register the forgot to tell me and after the first day, Vietnam, despite very few of them organisation, and they still don’t have most of them were late. They weren’t ever having had any funding or much core funding. They have received so eager to stay late. But when they support. I wanted to meet with them funding for some activities and training were there, they were some of the most and was going to Vietnam anyway, so over the years, all of which they use to enthusiastic and motivated people I’ve organised through the NGO to have help them navigate their next steps and worked with. They obviously liked each a meeting with the President. A few develop the capacity of their members. other, enjoyed each other’s company, days before I arrived I was asked to the many organisations and relevant and really wanted me to be happy. And provide a workshop. It sounds crazy government departments in Vietnam the President was a tiny woman who now, but as probably the first peer- know who they are. They stand up and had more charisma than most of us based organisation of people who use advocate for change whenever they can. have in our left elbow. drugs (PUD) to ever receive funding They are extremely passionate about to work with other PUD organisations At the time we thought AIVL was issues like compulsory drug detention in developing countries, it was an at the end of its work in Asia. The centres and the human rights of people opportunity we didn’t want to miss. program was supposed to end a few who use drugs. months later and we didn’t believe I delivered VNPUD’s first organisational Case study two there would be any more funding. development workshop on developing A couple of months later, against Recently I worked with the a mission statement, designing a the odds, we were asked to submit Coordinating Committee and a few constitution, basic strategic planning a proposal for another two years of key leaders from their member groups and some very basic ideas for funding and we decided to include in another workshop. This time, I was communication within the network. The supporting the development of co-facilitating with someone from one idea was that these things could help VNPUD in our proposal. It was only of the most successful and established them start to develop the structure and then that I found out the results of PUD networks in Asia, the Indonesian governance of their organisation and our hastily developed and slightly Drug Users Network, PKNI. The start advocating for support from other chaotic workshop. VNPUD had workshop focused on training the organisations within Vietnam. taken everything we had talked about participants to provide training on The workshop was like no other I had and developed a brilliant Mission blood borne viruses, particularly HIV delivered during the course of my Statement and Constitution that and hepatitis C, to their peers in the international career. At no time in the reflected their objectives perfectly. network. Over three days they learnt

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the basics, as well as more in-depth knowledge about HIV and hepatitis C. The Indonesian facilitator and I were surprised to find out the extent to which a person’s right to health has been ignored in Vietnam. Many of the participants in the workshop were HIV-positive, but none knew the results of their viral load or CD4 tests. They had never been told why they had been started on antiretroviral treatment (ART) when they were, and nor were they educated about the Vietnamese standards for antiretroviral medication. Some thought they were positive for hepatitis C as well, but few had voluntarily Above: Out on the road in Vietnam with VNPUD project outreach workers. Photo: Ele Morrison. accessed a hepatitis C test, they just knew they had been given a hepatitis C test at some point. It was most likely an We talk to each other about things social and political battles, similar to antibody test, which would only have we can’t easily talk about with people many of the battles we continue to face told them if they’d been exposed to the who don’t share our experiences. This in Australia. Over the three years or so virus, not whether they had developed workshop, attended by people from I’ve known them, VNPUD have stayed chronic hepatitis C. And they weren’t three different countries, including the same in many important ways such told the results of those tests either, two lower income countries, revealed as their commitment and their passion. they just made assumptions based on the ease with which those similar They have also significantly changed. the way they were treated afterwards. experiences can bring out and translate The amount they have grown and They learnt a lot from hearing the into useful information across cultures. learnt in this relatively short period experience of the Indonesian facilitator, The Australian experience is relevant of time is incredible, and they have and everyone agreed people have the in many ways, but there are ways where achieved this with very little resourcing. right to know their own health status. it isn’t as relevant, or isn’t perceived to The partnerships we have developed be as relevant. In particular, Australians with these different networks reveals Our similarities and differences: who inject drugs don’t have a shared something to us in Australia about some reflections history of high rates of hepatitis C and where we have come from, and where HIV co-infection. In the middle was our peers in other countries could The workshop was also revealing in the Indonesian experience, where harm be heading. At the same time, our other ways. My experience in countries reduction and the capacity of PUD different experiences show that we all around Asia is that there are many networks have come a long way in have things to learn from each other. things we share with our peers in comparison to Vietnam. other countries. We tend to quickly develop trusting relationships over PUD networks and organisations in Ele Morrison is International Program Manager at AIVL cigarettes and stories about drugs. Asia are all fighting a lot of personal,

Read Brenton Geyer’s article, ‘ENUF: social action to resist HIV stigma and promote resilience’, about an Australian anti-stigma and discrimination campaign HIV Australia is available produced by Living Positive Victoria. online with additional content. Pictured: Jai Wallace, an ambassador for the ENUF campaign (enuf.org.au) www.afao.org.au

64 | HIV Australia, Volume 12, No. 2 AIDS 2014 SPECIAL EDITION

Successful funding mechanisms to foster civil society: which way forward in China? Experiences from the CHAIN, APCASO and AFAO Community Advocacy Initiative on the Investment Framework program in China

By Cai Lingping, Li Yue, RD Marte and Chris Connelly

China is at a cross road in its The crucial role of Chinese civil workshops to develop the capacity of HIV response – a transition from society and CBOs is recognised by the Chinese civil society and CBO partners international funding towards a fully Chinese government, with the Chinese to critically engage with and use the domestically funded response. How premier Le Kiqiang in November 2012, Investment Framework to advocate for this transition is managed, and the publicly declaring the government’s more effective financing of the HIV models of funding that are developed commitment to funding civil society response in the country. to support civil society, will determine and CBO involvement as a critical part Since the Chinese government has the continuity of existing civil society of the HIV response. However from now taken over funding the HIV organisations and the overall future that public statement to the present, response from external donors, effective effectiveness of the response. the government has been stalled in developing a viable funding mechanism engagement between civil society Over the past ten years, China has made to operationalise its commitment. At and CBOs is crucial. The Investment significant progress in scaling-up its the same time, international funding Framework has galvanised civil society HIV response. The central government sources are withdrawing from China, and CBO dialogue, advocacy and has moved to strengthen coordination making it increasingly difficult for strategising around ensuring that the among HIV-related ministries and many civil society and community- Chinese government effectively : 1) issue policies to support effective based networks and organisations to funds CBOs in sufficient amounts and implementation of the National AIDS secure funding to continue their work in a transparent and accessible manner; Strategic Plan. Government funding and sustain established networks. 2) funds civil society work on critical at all levels for the response has also enablers; and 3) supports synergies Civil society was in urgent need of increased significantly, with central between health and HIV departments a platform to discuss China’s HIV funding increasing from RMB 120 and broader development ministries funding situation and the role of million (USD 19.35 M) in 2002, to and sectors. RMB 2.06 billion (USD 323.5 M) in civil society in the HIV response. 2010, 2.2 billion (USD 354.8 million) The DFAT-supported Community A notable aspect of this phase of in 2011, and an estimated RMB 2.8 Advocacy Initiative on the Investment the program was the readiness with billion (USD 451.6 million) in 2012.1,2,3 Framework (CAI-IF) program aimed which civil society took on Investment This means that China is one of very few to provide this platform. Implemented Framework thinking and approaches, countries in Asia that domestically funds by a collaboration of China HIV/AIDS and adapted these to their own HIV the majority of its HIV response. As of Information Network (CHAIN), funding situation. 2012, 88% of China’s HIV funding is Asia Pacific Council of AIDS Service 4 Under the CAI-IF program, reported to be domestically sourced. Organisations (APCASO) and the CHAIN also led a nationwide Australian Federation of AIDS Chinese civil society and community- survey of civil society to explore Organisations (AFAO), the program based organisations (CBOs) play and document Chinese CBO worked to enable Chinese civil society significant roles in the country’s HIV perspectives on HIV funding. The and CBOs to take stock of their response. Under external funding survey was a collaboration of almost country’s HIV funding scenario – from the Global Fund and Gates 100 representative civil society and particularly regarding community Foundation, civil society has been able community networks from all over mobilisation, identify challenges and to grow in China in an unprecedented the country, and represents a bottlenecks, and plan strategies together way. Numbers of community-based significant achievement for civil to begin advocacy on funding issues. organisations across the country have society in China itself. Civil society multiplied, providing different models From late 2012 to early 2014, organisations contributed their for community engagement in various CHAIN, with support from APCASO perspectives and experiences to aspects of the response. and AFAO, conducted a series of provide clear recommendations for

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the Chinese government, international need to continue funding for civil society to receive government donors, and civil society. Chinese CBOs in areas of capacity funding. In partnership with UNAIDS building and in areas of critical enablers China Country Office and the Advocacy under the CAI-IF program and synergies with the development National AIDS Commission, CHAIN culminated in a national CBO- sector – areas that may be difficult for continues to work to feed the CBO government-development partners Chinese government to support – as recommendations to higher levels of workshop in May 2014, titled well as continued encouragement and government to influence decisions on ‘Investing in CBOs Towards a More assistance to Chinese government to future Chinese HIV funding. Effective HIV Response in China: practise transparency in HIV funding An HIV Investment Framework and support CBO institutional Cai Lingping is Manager at the China from Community Perspectives.’ This development. HIV/AIDS Information Network workshop was significant for being the (CHAIN). Li Yue Project Officer at first CBO initiated meeting between The Community Advocacy Initiative the China HIV/AIDS Information Chinese government and Chinese on the Investment Framework, and the Network (CHAIN). RD Marte is CBOs at the national level on work of CHAIN, APCASO, AFAO the Program Manager at Asia HIV issues. and all the civil society partners in Pacific Council of AIDS Service Organisations – APCASO.Chris Key findings and recommendations China is considered by many in- country partners to be ground-breaking Connelly is International Programs from the survey of Chinese CBO and Policy Manager at AFAO perspectives on HIV funding presented as the start of a new way for CBOs and government to work together. to government in the workshop References included the need to: This work provides a platform for civil n society and CBOs to mobilise and 1 The current exchange rate is around USD develop clear policies and systems, 1 = RMB 6.2 rally around the issue of the country’s via consultation with CBOs, to 2 Ministry of Health of the People’s Republic HIV funding. It also facilitates a ensure that government invests of China. (2012). 2012 China AIDS nationwide collaboration of civil society Response Progress Report. in CBOs, establishes systems to to articulate and document funding 3 China Daily, Wen Jiabao, speech at the support CBOs involvement in the HIV/AIDS work meeting on 20 November experiences and recommendations. HIV response and makes CBOs 2012 The recommendations were put to involvement a standard policy 4 HIV Expenditure from Domestic Public n government representatives at the first Sources: Asia and the Pacific. Latest develop clear policy guidelines civil society/CBO-initiated meeting, Available Data slide 7 of HIV and AIDS and a CBO service list on key Data Hub for Asia-Pacific Review in where these representatives listened Slides: ‘HIV Expenditure’. Retrieved government HIV investment areas to community recommendations on from: http://www.slideboom.com/ n invest in CBOs to work HIV funding, and heard about positive presentations/856026/HIV-expenditure on developing an enabling experiences of civil society participation environment, including on anti- and leadership in China. discrimination, gender equality, livelihoods, advocacy, legal aid and The program has facilitated clear monitoring articulation of civil society and CBO n issues via the survey and national set up a government information workshop, enabling community disclosure system at central and perspectives on HIV funding to local levels to ensure CBO access reach relevant decision-makers. Key to information. messages from the community can Recommendations to international hopefully be incorporated into the development partners included the development of the mechanism for

HIV Australia is available online with additional content. “The consultation has been a good method and platform to For information about the improve our communication with CBOs. The CBOs suggestions CAI-IF program activities in Vietnam, see ‘How do we for fund allocation are useful, and we may also consider inviting make change happen’ CBOs to discuss fund allocation policy in the future.“ in HIV Australia online. — Representative of the local China Center for Disease Control (CDC) who attended the CAI-IF meeting. www.afao.org.au

66 | HIV Australia, Volume 12, No. 2 AIDS 2014 SPECIAL EDITION

For the community, by the community: strengthening effective responses to HIV By Inad Rendon

Men who have sex with men (MSM) Pacific. The MSM/TG Initiative aims and strategic information. APCOM and transgender (TG) people are two to support networks and organisations and AFAO engage each community populations disproportionately affected through the provision of technical network in conversations that encourage by HIV across Asia and the Pacific. and advocacy support and assistance them to reflect on daily achievements In recognition of the fact that urgent to foster coordinated approaches to and progress, as well as areas where investment is required to strengthen the advocacy and communications among improvement is needed. Through this capacity of MSM and TG communities network members. process, APCOM and AFAO can and their organisations to participate Under the project, APCOM and identify any gaps where additional in HIV responses at the local, national AFAO forged partnerships with a technical and advocacy support for each and regional level, Asia Pacific Coalition range of national, regional and sub- network may be required, at the same on Male Sexual Health (APCOM), regional networks and organisations, time as areas where additional capacity in partnership with the Australian each working to fight HIV epidemics development is required. Federation of AIDS Organisations in-country and across the region. The A regional analysis report presenting (AFAO), implemented a project entitled networks involved are: Youth Voices some of the findings of this work will the MSM and TG Networks Capacity Count (YVC), Asia Pacific Transgender be published and launched during the Strengthening Initiative (MSM and Network (APTN), Islands of 2014 International AIDS Conference. TG Initiative). Southeast Asian Network on Male and The report summarises and analyses the The project recognises two key elements Transgender Sexual Health (ISEAN), common organisational strengths and that are essential for fostering effective Pacific Sexual Diversity Network weaknesses and puts emphasis on which responses to HIV. The first is the (PSDN), Purple Sky Network (PSN), programmatic areas the organisations meaningful involvement of communities Myanmar MSM Network (MMN), and should focus on. most affected; the second is effective Viet Community Development Ltd. One of the strengths presented is that community-led advocacy driven (VCDL). the networks have a good representation by a thorough and well-articulated The MSM/TG Initiative also promotes of key affected populations including understanding of local HIV epidemics. collaboration among the networks MSM and TG people – as both There remains a lot of work to be by creating a mechanism to share members and board representatives. done, particularly at the regional level, information from the region with the One of the needs found was a lack to use this evidence to build effective sub-region and, ultimately, with the of capacity within the networks to prevention, care and support programs country and community level, and mobilise and apply for the resources for MSM and TG communities. vice versa. This includes the sharing of that are crucial to accomplish the This article looks at some of the ways information such as policies, guidelines, goals of any advocacy organisation. that the MSM and TG Initiative is media releases, and the documentation A tool that proved extremely useful helping to remove barriers that hinder of successful approaches. in assisting network communications effective engagement and advocacy is the Dissemination Plan Template among regional, sub-regional and Reporting and communications (D-Plate), designed to assist the national MSM and TG organisations tools networks, organisations and individual advocates to strategically and effectively by providing support and capacity One of the key elements of this project communicate information to their development tools to empower is the Rapid Assessment Apparatus partners, target audiences and other communities to lead effective responses (‘Rapid App’). This is a reporting stakeholders. The D-Plate template to local and regional HIV epidemics. tool which assesses the strengths assists advocates to successfully identify and needs of the networks against Building capacity and deliver key messages that are eleven essential criteria: governance; consistent with sub-regional, national Since its inception, Asia Pacific finance and administration; staffing; or local issues that they wish to address Coalition on Male Sexual Health resource mobilisation; partnerships and through their organisational work. (APCOM) has been working towards networking; membership; program the improved sexual health and services design and management; technical Using the D-Plate template, the for the community in Asia and the capacity; advocacy; communication; networks involve members and staff

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in a discussion to agree on one or Myanmar Youth Stars (MYS) is one More than partnerships more advocacy messages that they of the country networks in Myanmar The success of the project to date is wish to pursue. Being inclusive from that will disseminate the APCOM evident in the strong linkages and the beginning of the process, the Policy Briefs. ‘Hurray! Burmese!’ was pathways that have formed among dissemination activity promotes co- the excited remark of recognition the regional and sub-regional as operation within the network. Through from one of the MYS members when well as the in-country networks. these discussions a range of strategic the Burmese translated Policy Briefs By regularly sharing feedback on decisions are made, such as identifying were delivered to them during the first strategic methodologies and action the most appropriate individuals to City-Based Hidden/Positive MSM plans, channels for open and effective deliver particular advocacy messages Consultation in Yangon, Myanmar. communication between network and designing the best dissemination The Headlight series members have been established. This activity for this specific audience. includes information flow between Knowledge of the relevant issues for city-based networks and sub-regional Improving access to HIV testing, prevention, treatment, and regional networks, in a process information care and support programs is essential which sees diverse community groups Translating key documents role for development of effective working together. responses in the region, sub-region An example is the Hidden/Positive Another way that APCOM is assisting and in-country. Apart from translating Consultation in Yangon, Myanmar, to build an enabling environment that key documents in full, the project where a number of networks of men assists the sub-regional and in-country also developed ‘bite-size’ summaries who have sex with men, gay, lesbian networks to build capacity and increase of key materials (Headlight: Bite Size and transgender communities are the effectiveness of their advocacy Briefs) to further enhance networks’ working together towards evaluating initiatives is to make key documents and advocates’ understanding about the HIV response of the city, each about HIV in the region more particular subjects to improve their providing recommendations and accessible by translating them into local advocacy skills. filling in knowledge gaps. It was community languages. TheHeadlight: Bite Size Brief series also an opportunity for the regional English is the main language used in presents high-level documents in networks such as APN+ and YVC to cross-country discussions and in the simplified format, using easy-to- collaborate with their country networks development of high-level policy and understand language summarising by providing useful information on research materials on HIV in the region, discussions and analysis on issues people living with HIV and young men but it is not the primary language used affecting the rights and health of key who have sex with men, and for the by most of the countries in Asia and affected population across Asia and the consultation formats. the Pacific. To increase access to these Pacific. Making data and research on A noticeable effect of this environment key sources of information, a range local HIV epidemics more accessible of open communication between of documents – including APCOM creates opportunities for communities what can be at times quite disparate policy briefs, country snapshots and to use the evidence-based approaches community groups, is the improved multi-city reports - were selected by in their advocacy efforts. The Bite- confidence in dealing with each other. APCOM and AFAO to be translated Size Briefs form part of APCOM’s This environment allows for the free into 11 different community languages: ‘Light Series’, which also includes exchange of ideas and feedback, and Burmese; Chinese; Khmer; Lao; Spotlight (which highlights community increased level of coordination, towards Thai and Vietnamese for the Greater organisations and their responses to achieving effective results. Mekong Sub-Region; Bahasa, Cebuano HIV), Limelight (which features specific and Tetum for the ISEAN Sub-Region; individuals and their advocacy work) The knowledge transfer from regional French and Pidgin for the Pacific and Highlight (which profiles advocacy to sub-regional and/or regional/sub- Sub-Region. work on a specific issue). regional to national level improves the capacity of the networks in the areas of policy analysis, advocacy and A regional analysis report presenting some of the findings effective representation. This facilitates the engagement of the networks in the of this work will be published and launched during the regional and national responses to HIV. 2014 International AIDS Conference. The report summarises The knowledge and capacity provided and analyses the common organisational strengths and are essential elements in effective participation and representation. weaknesses and puts emphasis on which programmatic areas Inad Rendon is Advocacy Capacity the organisations should focus on. Development Officer at APCOM.

68 | HIV Australia, Volume 12, No. 2 AIDS 2014 SPECIAL EDITION

Mobilising men who have sex with men for HIV counselling and testing

By Matthew Vaughan

Matthew Vaughan looks at an innovative pilot project that aims to increase Guidelines, ensuring that the voices demand for HIV counselling and testing among regional networks of men and experiences from grassroots who have sex with men. organisations are present in this key global document.

n HIV testing is a critical component Although current approaches such Generating demand for testing of any successful response to the HIV as direct and indirect models of Mobilising the MSM community and epidemic. Throughout Asia and the outreach, HCT service provision, generating demand for HIV testing, Pacific, evidence shows that many client retention, support networks as well as increasing existing testing people do not undergo HIV testing and strategic partnerships have rates has been a great challenge for 1 for fear of stigma and discrimination. been very successful, scale-up the region, and APCOM is looking at Disclosure of a person’s HIV status of services is urgently needed to an innovative ways to increase testing can negatively impact many areas of a achieve comprehensive service rates through targeted messaging person’s life, such as family relationships, provision in the region. using platforms that are currently n status in the community and livelihood. The success of HCT and underutilised. In some settings in the region, testing comprehensive service provision Building on from the 2010 Multi- is only available through government is dependent on the visibility, services such as public hospitals or city MSM and Transgender (TG) availability, accessibility, Initiative, which had identified the public sanitation clinics. This can be confidentiality and affordability of problematic for men who have sex need for city-based responses and services. Dependable partnerships increased data on younger MSM at with men (MSM) and transgender and collaborations with public women who fear disclosure of their much higher risk to HIV but less and private organisations that likely to access services, an innovative identity, or have concerns about effectively offer effective treatment, discrimination. Community-based campaign was developed which could care and adherence to antiretroviral be replicated and adapted to other testing and counselling programs therapy (ART) support also add to clearly demonstrate that community- cities in the region – including the the success of HCT services. cities from the Initiative: Bangkok, based approaches help reduce stigma n and discrimination, encourage greater Creative and innovative outreach Chengdu, Ho Chi Minh City, Jakarta, up-take of services, and ensure greater messages are required to attract Manila and Yangon. protection of human rights.2 MSM to HCT services. These targeted messages need to be TestXXX At the Melbourne International AIDS supported by the continuous The TestXXX campaign is a regional Conference, Asia Pacific Coalition on upgrading of skills among non- campaign targeting young MSM Male Sexual Health (APCOM) will government and community-based through social media to encourage launch a regional report, MSM and staff/volunteers in areas including them to access HIV testing. HIV Counselling and Testing (HCT) in professionalism and empathy, as Asia and the Pacific. The report details well as technical skills. To date, Bangkok has never seen a HCT activities in the region that n large-scale, well-coordinated MSM For comprehensive service target men who have sex with men. HIV testing campaign. Until recently, provision to be offered, the The report is based on inputs from key traditional prevention campaigns have availability of funding from local informants in Australia, Bangladesh, focused on venue outreach for condom governments and international Cambodia, China, Hong Kong, distribution and other behaviour organisations must be made a India, Indonesia, Lao PDR, Malaysia, change interventions using the peer priority. Mongolia, New Zealand, Pakistan, the face-to-face method in locations Philippines, Singapore, Thailand, Tonga The report findings were fed into perceived to be ‘high risk hot spots’ and Vietnam, and puts forward the the development of the WHO such as bars, clubs, sex-on-premises following key findings: Consolidated Key Population venues and massage parlours.

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Test BKK – the pilot project focused on the key elements of HIV between 500,000 to 1,000,000 times. The first phase of this campaign is testing including ‘where to go’, ‘what to Given their experience and the shared TestBKK – a pilot based in Bangkok. expect’, ‘the results’, and ‘staying safe’. target audience, their involvement was It was important that TestBKK Further information was provided via critical to the success of TestBKK. links to existing services. complement the already existing Maximising visibility services in Bangkok. As a regional Having a clearly defined target Serendipitously, as we were preparing organisation, APCOM’s role is not population to replicate existing local services, to launch the campaign, it was drawing including those online. Thailand Given the concentration of the HIV close to April and the Thai New Year, already had a popular website used by infections in young MSM, and the Songkran, was just around the corner. MSM called Adam’s Love. There were target groups of already existing peer This is a festive time for all of Thailand, also many community organisations outreach services, we decided to target and has become a key event on the working on peer-led outreach services, young gay men (18–24 years) that social calendar of the gay community including the Rainbow Sky Association regularly seek out male sexual partners also, with the gay centres of Bangkok of Thailand, Bangkok Rainbow, and for online. Therefore, we wanted a message like Silom, Ratchada and Or-Tor-Gor HIV-positive MSM, the Poz Home that was considered edgy and relevant being packed for the three nights of Centre Foundation. Our aim for the to our target audience; it needed to be the festival, attracting crowds of up to campaign was to, where possible, short, sharp and simple. After several 20,000 people. At this time, Bangkok encourage MSM to visit one of the trial slogans and utilising focus group also becomes home to the well- existing MSM friendly clinics or discussions with the target group, known gCircuit parties, which attract services for additional information and we were able to refine the campaign approximately 10,000 to 15,000 gay to provide follow up for treatment, care title to something that was catchy men from all over Asia. and support. and appealing to our target audience: This made for the perfect time to TestBKK explicitly promotes four SUCK. F*#K. TEST. REPEAT. launch our campaign. We approached ‘premium testing services’. These During the planning and discussions, the party promoters, who couldn’t services were identified during the we were trying to think of concepts have been more willing to support the focus group discussions as friendly or that would make TestBKK attractive campaign activities such as condom sensitive towards gay men and MSM. to young Thai MSM. Obviously provision, posters in high-visibility They include two main clinical testing it had to be sexy; that was a given. areas, and an information booth where services, Thai Red Cross Anonymous However, considering we had a party-goers could access additional Clinic and the Silom Community limited advertising budget, we wanted condoms or information about Clinic @ Tropical Medicine, along with to ensure that it was a message that emergency testing facilities over the two community-based testing services, would be widely shared through social Songkran period. Rainbow Sky Community Health media. At the launch of this campaign, These community outreach messages Clinic (the National MSM Network’s APCOM – a regional health and were coordinated with online new community based testing facility) advocacy organisation – had limited messaging through Facebook, and SWING Outreach Clinic (for recognition and reputation within generating social interest by posting male service workers in Bangkok). the MSM community of Bangkok. pictures of evening events, people Another part of the rationale for Careful consideration had to be given receiving TestBKK branded condom this approach was that the specific to how to establish the TestBKK brand packages and engaging with the messaging within the campaign within the community. We partnered TestBKK campaign. Alongside testing could be tightly focused on HIV with a well-known group in Thailand, promotion messages and banner testing. Information did not need to TRASHER, which hosts a monthly advertising on mobile applications be included on every topic, and the dance party that attracts between Grindr and Hornet, we reinforced the TestBKK website was able to offer 700–1200 young people, mostly gay campaign slogan, drawing people back specific information designed to be men. They are also quite well-known to the campaign website. quickly viewed and digested by our for their music parody videos, each of readers. The information we offered which has been viewed on YouTube With the support of the National MSM Network, we were also able to mobilise a community outreach team. Teams of 8–10 people visited During the planning and discussions, we were trying to think of key community hotspots, wearing the concepts that would make TestBKK attractive to young Thai MSM. campaign merchandise, and handing Obviously it had to be sexy; that was a given. out free water-proof bags, temporary tattoos, condoms and information.

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During the launch of the campaign, received notification from the clinics The campaign was not a one-off over a period of three days, the team they have seen an increase in numbers activity and needed to be sustained handed out more than 50,000 units of of MSM testing within the services over a period of time to build the brand campaign materials. This was certainly offered by TestBKK. recognition and trust. This sustained the biggest coordinated response that The success of the TestBKK pilot – effort needs adequate investment in all the Bangkok gay community had seen which will hopefully see the campaign these areas to achieve a best result. for many years. rollout in other cities – really depends Matthew Vaughan is Senior on how successfully the target audience Results Programme Officer at APCOM. engage with the campaign and share With a successful launch and messages on social media with their References community mobilisation we had peers. The involvement of the service generated significant interest in the 1 Berry, S., Escobar, M., Pitorak, H. (2012). providers to ensure quality and stigma- Rapid Testing–Rapid Results: Scaling campaign; in less than a month the free services is also essential. The aim Up HIV Rapid Testing with Same-Day campaign website had attracted is to create an environment where Results in the Asia-Pacific Region. USAID’s approximately 35,000 page views. The young people will feel confident about AIDS Support and Technical Assistance four videos released on YouTube ticked Resources, AIDSTAR-One, Task Order 1, accessing testing – and when they do Arlington. over 500,000 views and people were test, ensuring that their first time testing 2 World Health Organization (WHO). starting to engage with the campaign. experience will be a positive one. (2013, June). Consolidated guidelines The videos releases by TestBKK have on the use of antiretroviral drugs for In the longer term the campaign received national and international treating and preventing HIV infection: will also need to be sustained by the Recommendations for a public health media attention from nineteen different involvement of the local community approach, WHO, Geneva. news outlets including the Huffington organisations, as well as private sector Post, The Gaily Grind and Queerty. partnerships in order to reach other While it is early days for the first young people who may not already be phase of the campaign, already we have connected to the HIV organisations.

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A Papua New Guinea–Australia HIV Research Partnership: generating new knowledge, building capacity and forging new friendships By Clement Manineng1, Dr David MacLaren2, Michelle Redman-MacLaren2, Rachael Tommbe3, Dr Tracie Mafile’o3

1 Divine Word University, Papua New Guinea; 2 James Cook University, Australia; and 3 Pacific Adventist University, Papua New Guinea

Partnerships of mutual benefit are these findings, the World Health collection techniques and improve often forged to confront a common Organization recommended that data collection skills. In addition, our challenge. One such challenge is how male circumcision be scaled-up in team was aware that language can be to address HIV in Australia’s nearest countries with high rates of HIV a daunting challenge for non-Papua neighbour, Papua New Guinea (PNG). transmission among heterosexuals7, New Guineans. The official language With a wide range of cultures, a largely and where the majority of men remain in PNG is English but the common, rural population and a host of other uncircumcised8,9,10. These findings everyday language is Tok-Pisin and development issues, PNG is a tough and the recommendation to scale- each of the 800 different cultural environment in which to conduct public up circumcision rates sparked great groups that make up PNG has their health research. In order to overcome interest in PNG, given its high rates of own language. The JCU researchers some of these obstacles, researchers HIV primarily among the heterosexual needed to be able to understand the formed a collaboration between three population, limited traditional male meaning of conversations, and know universities: James Cook University in circumcision practices and the lack what is the acceptable form of greeting Australia, and the faith-based Papua of any national medical male and so on. New Guinean Universities of Pacific circumcision program. Apart from language, a mixture of Adventist University and Divine Word In the planning phase, this project religious backgrounds and diversities University. This article describes that carefully considered the challenges in geography, culture and beliefs adds partnership, outlines our research of conducting research into male to the complexities of public health capacity building activities and describes circumcision for HIV prevention in research in PNG. In addition to that, how colleagues become friends while PNG and decided that collaboration the different rates of HIV across the contributing to the national and regional was the best approach. Researchers country and limited health services HIV response. from James Cook University ( JCU) means that any HIV prevention PNG has over 90% of the Pacific in Australia had more experience campaign involving male circumcision region’s HIV cases. The first case and expertise in study design, data would need to be informed by local of HIV was identified in 1987 and, management and publication while evidence. We therefore wanted to until recently, rates of HIV have researchers from PNG had more know how PNG people felt about male been increasing rapidly.1,2 A range of experience and expertise in interacting circumcision. Did they know that male intervention measures have been sought with local cultures, the logistics of circumcision had health benefits and by both Australia and PNG, to help data collection and local interpretation could help prevent HIV? What were control rates of HIV in PNG. of study results. As found in other women’s views and what were men’s health research in the Pacific, the views? Do the views differ by religion In addition to increasing testing, collaborative blending of these skills or geographic region? We wanted to improving HIV treatment and making was fundamental to the success of have answers to these questions and condoms more available, another the program.11 at the same time, we wanted to boost approach being considered in PNG the capacity of PNG academics to be is male circumcision. Between 2005 The sensitive nature of HIV and independent researchers. and 2007, a number of international male circumcision was an obstacle studies showed that the risk of HIV in itself. Papua New Guineans do While PNG academics were keen to transmission during heterosexual sex not talk openly about sex and so in undertake research, their experience was reduced by 50–60% when men initial stages, desensitising workshops with large HIV studies was limited. were circumcised.3,4,5,6 Following were organised to practise data Apart from a few senior leaders, most

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Above: HIV researchers from Divine Word University, Pacific Adventist University, National Department of Health of Papua New Guinea and James Cook University at the ‘Technical Data Analysis and Writing Workshop’, James Cook University, November 2012, funded by an Australian Leadership Award. academics in PNG are not trained publication, presentation at scientific explore the research topic. We went on or sufficiently qualified to undertake meetings and participation at a national to present results in numerous local, independent research. Therefore, in policy forum. national and international conferences addition to contributing towards HIV and forums12–19 and produced a Several PNG researchers from our response in PNG, our project had a comprehensive paper published group are now undergoing masters and key focus on research capacity building by BMC Public Health, Foreskin doctoral level studies at universities in and supporting PNG researchers to cutting beliefs and practices and the PNG, Philippines and across Australia. attain higher qualifications. This allows acceptability of male circumcision skilled and qualified PNG researchers This improvement in research for HIV prevention in Papua New to not only lead local and regional HIV capacity is one step in the process of Guinea20. We also published a paper research but also contribute to quality enabling PNG to improve the search on the processes we used to conduct of teaching and learning at PNG for workable solutions to the HIV the research together, Researching universities. epidemic and other development issues. male circumcision for HIV prevention in Papua New Guinea: a process that A ‘learn by doing’ approach was taken Our study needed to progress within incorporates science, faith and culture.21 to build research capacity. Potential a ‘give and take’ setting – an avenue lead researchers at PNG universities for mutual benefit. JCU researchers Looking back, the collaboration has were identified and given lead roles led the team in study design and been a huge success. Involvement early in the collaboration. Many capacity building and PNG researchers of PNG researchers, some of whom other potential PNG researchers were provided the enabling environment had lead roles, was a winning factor involved and most of them participated for data collection and to make data in recruiting study participants, in various capacity building activities. understandable. All three collaborating collecting and analysing data and These included workshops on data universities hosted workshops to writing for publication. Additionally, collection, data analysis and writing for improve research capacity and to the opportunity for capacity building

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provided by the study was a rare response and other development issues 12 MacLaren, D., Tommbe, R., Mafile’o, T., Redman-MacLaren, M., Browne, K., achievement for a research project. Less for PNG, Australia and surrounding McBride, W. (2011). I was circmcised in experienced researchers were up-skilled Pacific island nations. my uncle’s coconut plantation’: location to conduct research independently. Two and techniques of penile cutting in Papua of the PNG academics are currently New Guinea, in 20th World Congress for References Sexual Health.12–16 June 2011, Glasgow. lead investigators on a number of HIV 1 National AIDS Council. (2006). Papua New 13 MacLaren, D., Tommbe, R., Mafile’o, research projects in PNG. A JCU Guinea National Strategic Plan on HIV/ T., Redman-MacLaren, M., Browne, K., member of the team has also enhanced AIDS 2006–2010. Government of Papua McBride, W. (2011a). ‘My brother told her research skills and is currently in New Guinea, Port Moresby. me it was for my own good’ - reasons 2 New Guinea National AIDS Council for penile cutting in Papua New Guinea. the final stages of her doctoral studies Secretariat. (2013). Papua New Guinea Journal of Sexual Medicine, 8(1), 229. 22 about women and HIV in PNG. HIV Prevalence: 2012 Estimates. Papua 14 MacLaren, D., et al. (2011). Stronger New Guinea National AIDS Council or tougher: reasons for penile cutting in While this partnership received its Secretariat, Port Moresby. Papua New Guinea. Presentation delivered share of positive comments, one most 3 Auvert, B., Taljaard, D., Lagarde,E., at the Australasian HIV/AIDS Conference notable was a remark uttered by a Sobngwi-Tambekou, J., Sitta, R., Puren, 2011, 26–28 September 2011, Canberra. A. (2005). Randomized, Controlled respected senior academic from one 15 MacLaren, D., Tommbe, R., Redman- Intervention Trial of Male Circumcision for MacLaren, M., Browne, K., Mafile’o, T., of the collaborating PNG universities. Reduction of HIV Infection Risk: The ANRS Manineng, C., and McBride, W. (2011). In his comments during a feedback 1265 Trial. PLoS Medicine, 2(11), e298. ‘I was cut under the plantation palms’: presentation, he mentioned that 4 Bailey, R., Moses, S., Parker, C., Agot, K., techniques and locations of penile Maclean, I., Krieger, J. , et al. (2007). Male this project was one of very few that cutting in Papua New guinea, in ASHM Circumcision for HIV prevention in young Conference. Presentation delivered at the not only included capacity building men in Kisumu, Kenya: a randomised Australasian HIV/AIDS Conference 2011, as a vital component of its research controlled trial. The Lancet, 369(9562), 26–28 September 2011, Canberra. activities but actually fulfilled those 643–656. 16 Tommbe, R., Asugeni, L., MacLaren, 5 Gray, R.,Kigozi, G., Serwadda, D., capacity building plans. He reiterated D., Redman-MacLaren, M., Mafile’o, T. Makumbi, F.,Watya, S.,Nalugoda, F., (2012). What can be Learned about Male that future research in PNG would et al.(2007). Male Circumcision for HIV Circumcision and HIV Prevention from a do well to follow the same lines with prevention in men in Rakai, Uganda: a Cohort of Students and Staff at a Papua emphasis on capacity building. randomised trial. The Lancet, 369(9562), New Guinea University: research report. 657–666. Pacific Adventist University, Port Moresby. On a people-to-people level, 6 World Health Organization (WHO). (2014). 17 MacLaren, D., Tommbe, R., Mafile’o, T., something else eventuated that is Male Circumcision for HIV prevention. Redman-MacLaren, M., Browne, K., and Retrieved from: http://www.who.int/hiv/ McBride, W. (2011). Implications of Male important to mention. Over the life topics/malecircumcision/en/ Circumcision for HIV Prevention in Papua of the project, lasting friendships were 7 In recognition of the fact that male new Guinea: Possibilities and Challenges. formed between researchers. While circumcision only provides partial Journal of Sexual Medicine, 8, 230–230. our initial four year study (2010–2013) protection from HIV transmission, WHO 18 MacLaren, D., et al. (2011). Implications recommends that circumcision be used of male circumcision for HIV prevention to investigate the acceptability and in combination with other prevention in Papua New Guinea: possibilities and feasibility of male circumcision for strategies, such as HIV testing and challenges. Presentation delivered at the HIV Prevention in PNG has ended, we counselling and the promotion of safer sex 20th World Congress for Sexual Health, continue to collaborate across a number practices. See: WHO, (2014), op cit. 12–16 June, 2011, Glasgow. 8 World Health Organization (WHO). (2014). 19 Tommbe,R. , MacLaren, D., Redman- of follow-up studies that have emerged. Male Circumcision for HIV prevention. MacLaren, M., Mafile’o, T., Asugeni, L., Work on these studies will further Retrieved from: http://www.who.int/hiv/ McBride, W. (2013). Researching male strengthen existing relationships. The topics/malecircumcision/en/ circumcision for HIV prevention in Papua collaborating researchers, especially the 9 World Health Organization (WHO), New Guinea: a process that incorporates Department of Reproductive Health science, faith and culture. Health research lead partners do not see themselves as and Research and Joint United Nations policy and systems/BioMed Central, 11(1), being mere colleagues; they have gone Programme on HIV/AIDS (UNAIDS). 44–44. beyond that, seeing themselves now (2014). Male Circumcision: Global trends 20 Tommbe,R. , MacLaren, D., Redman- as friends. One would frequently hear and determinants of prevalence, safety MacLaren, M., Mafile’o, T., Manineng, C., and acceptability. WHO, UNAIDS, Fregonese, F., Redman-MacLaren, M., collaborators offer to their travelling Geneva. Retrieved from: www.who. et al. (2013). Foreskin cutting beliefs and colleagues to, ‘come and stay with us int/reproductivehealth/publications/ practices and the acceptability of male at our house’. That kind of offer comes rtis/9789241596169/en/ circumcision for HIV prevention in Papua from relationships that have grown 10 Redman-MacLaren, M., MacLaren, D., New Guinea. BMC Public Health, 13, 818. Harrington, H., Asugeni, R., Timothy- 21 Tommbe,R., et al. , (2013), op. cit. roots, relationships that will care for Harrington, R., Kekeubata, E., et al. 22 Redman-MacLaren, M., Mills, J., Tommbe, the shortcomings and triumphs of its (2012). Mutual research capacity R., MacLaren, D., Speare, R., McBride, partners in the years to come. strengthening: a qualitative study of W. (2013). Women and HIV in a moderate two-way partnerships in public health prevalence setting: an integrative review. The direct consequence of links like research. Biomed Central, 11(79). doi: BMC Public Health, 13(1), 552–552. these is a solid regional partnership 10.1186/1475-9276-11-79 that can help improve the HIV 11 ibid.

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Sex worker organisations’ partnerships and collaborations for capacity development By Maria McMahon

Scarlet Alliance, the Australian Sex The centrality of sex workers within Scarlet Alliance works in capacity Workers Association, is the national the HIV response is imperative and development partnerships in the peak body representing sex workers and includes activities to support and Asia and Pacific regions, including sex worker organisations in Australia. strengthen sex workers’ organisational partnerships with Friends Frangipani Formed in 1989, Scarlet Alliance is a capacity, leadership and advocacy. Just in Papua New Guinea, and with $carlet community-based organisation. Through as the Australian response has included Timor Collective in Timor Leste. In its objectives, policies and programs, sex workers within the partnership addition, the project brings the partners Scarlet Alliance aims to achieve equality, addressing HIV, so too should sex together for strategic partnership social, legal, political, cultural, health and workers be included in the design and building activities around international economic justice for past and present delivery of responses in our region. forums such as the International sex workers. Congress on AIDS in Asia and the Scarlet Alliance has 25 years’ Pacific (ICAAP) and International Within the global HIV epidemic, sex experience within the Australian AIDS Society (IAS) conferences. workers are defined as a key affected HIV response of significant program population. The majority of HIV design, implementation and evaluation The capacity building approach infections are sexually transmitted, experience, as well as advocacy for sex is unique, involving a mentoring putting sex workers and their clients at worker rights. The Regional HIV/AIDS partnership between our peer sex heightened risk of acquiring HIV. Sex Capacity Building Program, funded by worker organisations. This approach workers not only experience the impacts Australian Aid, links nine Australian varies dramatically from provision of HIV, but also experience increased organisations with counterparts in the of technical advice or short-term stigma and discrimination on the basis Asia and Pacific regions to develop training. The approach is a long- of their occupation and real or perceived the capacity of the most affected term commitment to ensuring the HIV status, reduced human rights and a communities and their peer-based sustainable development of a sex worker organisation with the capacity lack of access to health services. organisations to actively participate in national and regional responses to to govern, consult and represent sex The Joint United Nations Programme workers and work within the unique HIV. Scarlet Alliance’s project titled Sex on HIV/AIDS (UNAIDS) states: set of barriers that affect sex worker Worker Organisations’ Collaboration for organisations. The approach brings with ‘To date, the HIV response has devoted Strengthened Advocacy and Partnerships it a network of support as sex workers insufficient attention and resources to includes activities to support and are linked into national, regional and efforts to address HIV and sex work, strengthen sex workers organisational international sex worker networks. with less than 1% of global funding capacity, leadership and advocacy. for HIV prevention being spent on ‘The networking of sex worker groups HIV and sex work. The epidemiological In a project evaluation report, one sex from different countries empowers us. data on HIV infection rates among sex worker organisation said: We have common ground, common 4 workers and their clients reflects the ‘HIV has been with us for 30 years problems, and a common destination.’ failure to adequately respond to their already. Social and legal changes Scarlet Alliance adopts an approach human rights and public health needs. are not short-term projects but are that includes ‘learning by doing’. Recent studies continue to confirm a long journey. Leadership on this Capacity is built and held by the that in many countries sex workers journey is not static but is more like individuals, the sex worker community experience higher rates of HIV infection a relay where the task to reform and thus the organisation on an than in most other population groups.’1 must continually be passed along to emerging leaders. The Capacity accumulative experiential basis, and UNAIDS also says in Principles of Building Program with Scarlet retained within the guiding documents, Effective HIV Prevention: ‘Community Alliance is one avenue where policies, records and systems. Rather participation of those for whom HIV emerging and young sex worker than developing a dependent prevention, treatment, care and support leaders can be mentored and given relationship, the organisation knows programmes are planned is critical for opportunities to stand up. Without its capacity and genuine potential at their impact.’2 Sex workers need to be support how can we grow new any time, as a function of this lived central within a strong HIV response. leadership and continue the journey?’ 3 experience and retained infrastructure.

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Project partners note that leadership Sex worker advocacy actions were government because we have been growth takes time to achieve, yet cohesive and delivered messages on members of international events.’ 12 all report a boost in confidence and enabling legal frameworks, including Sex workers in the region continue to competence as a result of project the call to decriminalise sex work, that build their presence and effectiveness activities, as illustrated in these quotes were highly visible within regional at national and international levels, and from project participants: forums and related media. Sex worker are clearly taking their place within representatives clearly identified issues ‘The forum really built my capacity the response. Sex workers within the and our organisation as well, we and called for specific changes through partnerships have gained a stronger practiced chairing meetings, taking their advocacy work, and connected voice in the national HIV response, minutes – it had a different feel about with key stakeholders through and within regional and international it, a good feeling, gave me confidence regional forums. The key message that forums. The capacity building work is to stand up and talk, especially in decriminalisation will best support 5 now more important as countries realise international groups.’ sex workers responses to HIV, has that sex workers need to be at the table, ‘Now I have the guts to talk for reached non-government organisations, advocating on their issues and needs in my fellow sex workers and talk for governments, the World Health 6 order to have an effective HIV response. their rights.’ Organization (WHO), UNAIDS and ‘I stood up; I had the confidence to the United Nations Population Fund Maria McMahon is International speak with donors. We need our voice (UNFPA)and is now consolidated into Program Manager at Scarlet to be heard, we face it, we feel it, we national, regional and international Alliance. know what it’s like. It gave me the strategies and policies. courage and confidence to stand up References 7 Regional forums are where significant strong and talk public.’ progress in terms of sex worker 1 Joint United Nations Programme on HIV/ The activities create a rare space AIDS (UNAIDS). UNAIDS Guidance Note advocates participating effectively on HIV and Sex Work. UNAIDS, Geneva, 2. for sex workers to drive their own takes place. Scarlet Alliance 2 UNAIDS. (2005). Intensifying HIV agenda, bring a boost in confidence, provides support and mentoring Prevention. UNAIDS policy position paper. competence and self-determination. for partner organisations to engage UNAIDS, Geneva. Retrieved from: UNAIDS Intensifying HIV Prevention, UNAIDS Policy The skill sharing within a sex worker in opportunities, select and prepare only setting is invaluable, and project Position Paper, 2005, data.unaids.org/ representatives, develop activity publications/irc-pub06/jc1165-intensif_hiv- partners are encouraged to articulate proposals, develop advocacy, travel newstyle_en.pdf p17 and advocate their agenda. and participate. The international 3 Submission to the Independent Project Review, 2014. ‘We can share the (sex worker) language conferences provide sites for key between us, ideas, feel comfortable to 4 Program Component Final Report learnings and collaborations. 2008–2011. talk out and share. If other stakeholders 5 ibid. attended this meeting, we would not Importantly, the project enables 6 ibid. feel good to share.’ 8 feedback from international events by 7 ibid. 8 ibid. ‘Because of our partnership with sex worker advocates to the sex worker community and other stakeholders 9 ibid. Scarlet Alliance, how to develop/ 10 ibid. create our capacity to raise awareness in-country. This can reorientate key 11 Evaluation feedback, 2014. of our problems we face every day as stakeholders as they see sex worker 12 Program Component Final Report sex workers, our human rights, sexual issues’ profile raised and understand 2008–2011. op cit. abuse, violation, because we understand better how sex workers national our rights, we are more confident. It demands fit within the global HIV means we can meet with stakeholders response. There is more leveraging 9 and go into a relationship with them.’ possible given the “match” between The Project strengthens regional national and international advocacy networking and relationships, enhances messages and policy environments. sex worker organisations’ day-to-day ‘I was invited to a civil education efforts to champion sex worker rights, workshop to talk a little bit about and contributes to community solidarity ICAAP. I was confident to share with and collaboration across the region. my community the purpose of it and it was an eye opener for them since they ‘It is helping us to stand up strong and 11 talk out. We are feeling strong to fight didn’t know about it.’ for our rights too – we see other sex work ‘ ... we became members of National organisations can do this in another AIDS Commission; we have more country, and this strengthens us.’ 10 recognition of our position from

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LOW VITAMIN D After controlling for country and CONCENTRATIONS HIV treatment regimen, the factors ASSOCIATED WITH POOR TREATMENT BRIEFS CLINICAL AND VIROLOGICAL significantly associated with low OUTCOMES AMONG PEOPLE vitamin D were race, season of STARTING HIV THERAPY sampling (winter/spring), high or low SEMINAL US REPORT ON body mass index (BMI) and lower HIV TREATMENT STRATEGIES FOR ow vitamin D concentrations are viral load. OLDER HIV PATIENTS UPDATED associated with an increased risk ON HIV-AGE.ORG The investigators cite other studies Lof HIV disease progression among showing it is ‘biologically plausible’ that people starting antiretroviral therapy, n May 28, 2014 the American low vitamin levels would increase the investigators report in the online Academy of HIV Medicine risk of poor clinical outcomes. O(AAHIVM), the AIDS edition of The Journal of Infectious Low vitamin D at baseline more than Community Research Initiative of Diseases. Virological failure also had doubled the risk of virological failure. America (ACRIA) and the American an association with low vitamin D The authors note that theirs is the first Geriatrics Society (AGS) released levels at the start of therapy, and there study to identify vitamin D as a factor a revised version of the report, was evidence suggesting a relationship in the virological outcomes of therapy. Recommended Treatment Strategies for with between vitamin D levels and Clinicians Managing Older Patients with immunological outcomes. The study There was also evidence suggesting HIV.1 Originally published in 2011, the was conducted in eight low-and that low vitamin D increased the risk report is a key resource for managing middle-income countries and the of a poor CD4 response to treatment. HIV in older patients. Almost half of the US. The authors believe that studies However, there were too few cases for report’s chapters have been updated, and exploring the impact of vitamin D this to be proved. supplementation on HIV treatment are accessible via an interactive website ‘The associations found in this paper outcomes are warranted. at: http://hiv-age.org raise questions of reverse causation: The report and website form part of Concentrations of vitamin D are related does advanced HIV disease cause the HIV and Aging Consensus Project, to exposure to sunlight, latitude, season low [vitamin D] concentrations; or, developed to assess how the presence and skin pigmentation. The vitamin is is low [vitamin D] concentration of both HIV and common age- important to a healthy immune system. a general marker for poor health,’ associated diseases alter the optimal Several studies involving people living write the authors. ‘The fact that this treatment of HIV, as well as other co- with HIV have shown a high prevalence was prospective and that severely ill existing medical conditions. of low vitamin D concentrations. persons were excluded from the study ‘We are learning more and more everyday However, few studies have examined makes this unlikely. Also, [vitamin D] about how to best treat HIV in aging the relationship between low vitamin concentrations were comparable to patients,’ said Jonathan Appelbaum, D concentrations at the initiation those found in studies of non-HIV Medical Director of the HIV and Aging of antiretroviral therapy and infected persons in similar populations.’ Consensus Project. ‘As new research clinical outcomes. The connection The investigators believe their findings and clinical studies emerge, we are between baseline vitamin D levels support the concept of vitamin D committed to reflecting those learnings and virological and immunological supplementation as an adjunct to HIV in our treatment strategies to ensure best outcomes is unexplored. therapy, concluding ‘a well-designed practices among all HIV care providers. Data collected during the PEARL clinical trial is needed.’ In Australia, ASHM provides a (Prospective Evaluation of commentary on the several international Antiretrovirals in Resource Limited Reference antiretroviral guidelines (including those Settings) study provided information Havers. F., Smeaton, L., Gupte, N., Detrick, for investigators to explore the B., Bollinger, R., Hakim, J, et al. (2014). produced by the DHHS). This resource 25-hydroxyvitamin D insufficiency is associated may be a useful supportive text for use in relationship between low baseline with HIV disease progression and virological the Australian context. vitamin D levels and treatment failure post-antiretroviral therapy initiation in outcomes. diverse multinational settings. J Infect Dis, Reference online edition. 1 American Academy of HIV Medicine (AAHIVM), Almost half (49%) of all participants AIDS Community Research Initiative of America in the study had low vitamin D Michael Carter (ACRIA), American Geriatrics Society (AGS). concentrations at baseline. Prevalence Adapted from aidsmap.com (2011). Treatment Strategies for Older HIV of low vitamin D varied between Published: 19 May 2014 Patients. AAHIVM, ACRIA and AGS. Retrieved from: http://www.aahivm.org/Upload_Module/ countries, ranging from 27% in Brazil upload/HIV%20and%20Aging/Aging%20 to 78% in Thailand and 72% in India. report%20working%20document%20 Prevalence was 92% among African- FINAL%2012.1.pdf Americans in the US.

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