In July 2023, delegates at the International AIDS Conference in the Australian city of Brisbane heard that that Sydney, and Australia as a whole, is on track to becoming the first place in the world to virtually eliminate the transmission of HIV.

Australia’s HIV response strategy has been characterised by longstanding bipartisanship and community engagement since the 1980s and is now close to meeting the Joint United Nations Programme on HIV and AIDS (UNAID)’s ’95-95-95’ AIDS targets, which aim for 95 percent of all persons living with HIV knowing their status, of whom 95 percent would be on antiretroviral therapy, with 95 percent of achieving viral suppression. In 2022, Australia achieved an estimated 96 percent, 92 percent and 98 percent against these targets. The news was greeted with excitement and validated Australia’s collaborative approach.

However, closer analysis indicates a worrying gap: much of the steep decline of new HIV notifications is concentrated among Australian-born men living in inner-city locations. Notifications of HIV infection have not declined as quickly—and in some cases for have been increasing—in the outer suburbs, which have a high concentration of immigrants, including LGBTQ+ immigrants of Asian backgrounds.

What does the data show?

We are the lead researchers on the Gay Asian Men’s Survey (GAMS), a cross-sectional survey on the sexual health and wellbeing of Asian gay, bisexual and other men who have sex with men (GBM) in Sydney. It began in 1999 and has been conducted biennially since 2015. The survey is administered by the Centre for Social Research in Health at the University of New South Wales in Sydney, with collaborators from government, local health districts and community groups. It is primarily completed online through an anonymous questionnaire that takes 20 minutes to complete. In the last round of the survey in 2021, participants were recruited through social media and gay dating apps, and at gay community events and sex-on-premises venues. The 2023 survey, launched in mid-October, appears in English, Simplified and Traditional Chinese and Thai, based on the historical uptake of translated versions in the context of limited resources and time.

HIV medicine has evolved rapidly since the survey first started, and there now exist prophylaxis and treatment regimens that are effective, affordable and easy to use. Australia has the world’s highest number per capita of users of pre-exposure prophylaxis (PrEP), which is preventative antiretroviral medication that protects those who have not contracted HIV but who are at substantial risk of infection. The introduction of oral PrEP globally has become a key tool in preventing HIV transmission, and two other PrEP options are available: the Dapivirine vaginal ring and the Cabotegravir long-acting injectable (CAB-LA),which is currently being assessed for rollout in Australia.

Despite effective biomedical developments, inequalities remain. While PrEP has been subsidised by the federal government through the Pharmaceutical Benefits Scheme (PBS) since 2018, these subsidies are not available to Medicare-ineligible populations, who instead rely on personal networks or generic medication from overseas, or go without it. In addition to access barriers, findings from the GAMS suggest that important health promotion messages have not reached Asian GBM communities, especially those with lower English language proficiency and who are on a temporary visa. For example, most of the survey’s participants who did not live with HIV (73 percent) were unaware that people living with HIV who have achieved a suppressed viral load following effective adherence to antiretroviral therapy have negligible risk of transmitting HIV (with those achieving undetectable viral loads having no transmission risk, i.e., undetectable equals untransmittable, or ‘U=U’). Additionally, participants who reported lower English language proficiency or who were on a bridging visa (as compared to citizens and permanent residents) were significantly less likely to have ever used PrEP, and only 58 percent of all participants had ever tested for sexually transmitted infections.

Low testing rates and continuing HIV transmission among Asian-born immigrants, particularly those on temporary visas, might also be linked with fears over having their visa applications rejected and their employers being notified if they were tested positive for HIV. Despite its robust HIV response, Australia continues to be one of only approximately 40 countries that applies visa restrictions on people living with HIV on the basis that they might present ‘a threat to public health’ and a burden on the taxpayer.  The GAMS results thereby suggest that policy factors, lack of education and difficulties with accessing appropriate care and health promotion messages present health and wellbeing consequences for Asian-born GBM.

The latest national HIV surveillance report, which monitors trends over the period 2012-2019, shows that while the number of HIV notifications decreased by 43 percent among Australian-born GBM and by nine percent among those born outside Australia and Asia, there was a 54 percent increase in HIV notifications among Asian-born GBM in the same period. Notably, people born in Southeast Asia, together with those born in Latin America, make up the largest proportion of undiagnosed people living with HIV in Australia, at 25 percent each. While there was a 35 percent decline in notifications among Asian-born survey respondents between 2019 and 2021, this decrease could reasonably be attributed to strict national border closures implemented due to COVID-19, which prevented international students, workers and others from entering Australia, and many who were in Australia returned to their home countries. Also concerningly, we found that among Asian GBM living with HIV in Sydney, only 72 percent self-reported as having achieved viral suppression, significantly below the UNAIDS 95 percent target and Australia’s national 98 percent suppression rate.

These figures signal widening health inequities between Sydney’s regions and within the GBM community. Health illiteracy and financial precarity, coupled with race-based discrimination (experienced by 91 percent of participants, mainly in the form of sexual racism from other GBM) and visa concerns, complicate overseas-born Asian GBM’s sense of belonging and place them at risk of physical and mental distress. Indeed, a quarter of the GAMS 2021 sample were at risk of serious mental distress, with predictors including low weekly income, lack of LGBTQ+ friends in Australia, experiencing intimate partner violence, and experiencing racism from Australian society. Additional factors that that might increase the number of notifications include the increasing student and employee arrivals following the relaxation of COVID-19 border restrictions, and Sydney’s very high costs of living that might increase the potential for overseas-born GAM in particular to be exploited by employers, landlords and intimate partners. These challenges indicate that coordinated work addressing policy, health education, and stigma and discrimination need to more effectively target overseas-born Asian populations, including gender and sexual diverse international students, in order to more broadly and sustainably eliminate HIV transmission.  

How might we move forward?

Policy shifts

There were several encouraging policy announcements over the past two years aimed at making HIV care in Australia more equitable and acceptable.

One development following the release of GAMS 2021 results was the announcement that HIV antiretroviral treatment will be provided for free at public hospital pharmacies regardless of Medicare status. Since 1 July 2022, Medicare-ineligible people living with HIV have been able to access free HIV treatment at public hospital-based pharmacies. The AU$39 million five-year commitment by the federal government effectively provides HIV treatment access to all, and reduces the reliance of those who are not eligible for Medicare on personal importation or compassionate access to antiretroviral therapy. The news was greeted with enthusiasm from leaders, researchers, community groups and clinicians in Australia’s HIV sector who had long advocated for the change, and who had collaborated on Agenda 2025, a holistic plan to achieve virtual elimination of HIV in Australia by 2025. However, PrEP access remains a barrier ‘especially for international students with limited work rights and relatively low income’, despite evidence that Medicare-ineligible individuals provided with free PrEP demonstrate high PrEP uptake and adherence. In addition to worries about visa consequences and deportation that might make them less inclined to engage with testing and treatment, the GAMS results support the finding that Asian-born GBM who are international students face multiple challenges that might place them at higher risk of contracting HIV or receiving a late diagnosis (i.e., at an advanced stage of HIV) because they might:

• be in a new environment with many opportunities and uncertainties about exploring their intimate options;
• have difficulties with negotiating boundaries around safer sex due to cultural and language factors;
• have financial difficulties that make them dependent on their partners, employers or landlords;
• wrongly view PrEP with suspicion due to doubts over its safety and efficacy; and they might view PrEP as a marker of sexual promiscuity rather than an effective HIV prevention tool.

GAMS data have repeatedly suggested that in order to encourage testing and treatment, HIV restrictions should be removed—as has been done in the USA, UK and New Zealand—and for the elimination of transmission to occur at a wider and more durable scale, PrEP should be made more accessible to Medicare-ineligible populations and so-called ‘key population’ groups: men who have sex with men, transgender  people, sex workers, people who inject drugs, and people in prisons and other closed settings . PrEP has proven to be highly effective at reducing the risk of HIV transmission; the World Health Organization’s (WHO) policy update at the aforementioned International AIDS Conference officially confirmed that people living with HIV who have an undetectable viral load as a result of effective adherence to antiretroviral therapy have ‘zero risk’ of transmitting the virus. The implications of WHO’s statement are broad in terms of destigmatising HIV, encouraging adherence to antiretroviral therapy, and promoting HIV diagnostic viral load testing.

Targeted health education  

GAMS findings indicate that sexual health awareness among Asian GBM—particularly those born overseas—is low, signalling much more effort has to be put into targeted health promotion to ensure that information on testing, treatment, and policies reach these populations.

The population of Asian GBM, like Sydney’s population more broadly, is increasingly culturally and linguistically diverse. Therefore, it is important for health promotion to be culturally informed and accessible to communities in the languages and locations convenient to them. Examples include producing health promotion material in languages such Chinese, Nepali and Thai (three of the top 5 source countries of international students in New South Wales), and developing health services in the areas where many of them live and work, such as in the Greater Western Sydney region, where there been a long-identified lack of LGBTQ-specific sexual health services. Additionally, for many Asian-born GBM, HIV and sexual health remain taboo in their countries of origin, and collaborative health education messaging targeting stigma, testing, early treatment and suppression is therefore crucial to end HIV transmission. Such community-focused messaging should not merely imagine Asian-born GBM as passive recipients of care, but should consult with, and include, them as active participants and collaborators in care. Recognising the urgent need to focus on culturally and linguistically diverse populations outside the inner city, community health organisation ACON, a partner in the GAMS, has over the past two years invested in capacity-building, health promotion and sector-development activities targeting the Western Sydney region; it has partnered with multicultural community groups, public health networks and LGBTQ+ community members in Western Sydney to develop LGBTQ-focused health services programmes, networks and communities of practice. Further, in recognition of the particular needs of the sexual and reproductive health needs of international students, the NSW Government, in collaboration with multicultural, health and educational organisations and practitioners including GAMS investigators and ACON, launched the International Student Health Hub in 2021.

Educational settings are central partners in a coordinated response, notably through simplifying health access routes for students and providing opportunities for engagement on matters relating to belonging, navigating sexual health and wellbeing, and understanding the Australian healthcare system. UNSW’s Health Promotion Unit, for example, launched a suite of programs based on survey and surveillance data and identified needs, which included setting up the award-winning Peers Advocating for Sexual Health (PASH) programme to provide capacity-building training and opportunities for students to learn and talk about sexual health, relationships and consent with their peers. In addition to peer support and organising sexual health testing in colleges and on university campus, PASH peers have been involved in advising the online NSW International Student Health Hub and the implementation of the on-campus CASI computer kiosk that facilitates anonymous STI testing, and are active collaborators on the annual SEXtember festival with a diverse group of stakeholders including students, government and health agencies, community partners, researchers and businesses.

In addition to educating about sexual health and wellbeing, such targeted health education programmes serve to address stigma and discrimination, which we have found to be a significant concern preventing Asian GBM’s access of sexual health services.

Stigma and discrimination

Due to cultural sensitivities, the lack of comprehensive sex and sexuality education in their home countries, and their anxieties with the English language and with their economic and temporary migrant status, many overseas-born GAM remain concerned about being stigmatised and discriminated at various levels: at the immigration, health services, institutional (i.e., school or work), community and peer levels. At the health level, for example, the GAMS found that about a quarter of overseas-born participants did not know how to find an interpreter even if they needed it, and more than 70 percent had not been provided any HIV/sexual health information from health care providers in a language other than English. Therefore, health providers play a key role in ensuring that underserved populations are adequately supported when they present for care, and care should be sensitive to persons of culturally and linguistically diverse backgrounds, and to the different ways sexuality and gender diversity are understood and expressed. Effective access to appropriate interpretation and translation services that support strength-based approaches without reinforcing stigma are needed, and the role of opportunistic screening (testing proactively offered to all patients as part of a routine medical check) should be considered. Due to anticipated legal and social  implications such as homelessness, employment restrictions and legal/visa consequences of a positive HIV diagnosis, medical-legal partnerships—either co-located at health facilities or operating through off-site referrals—should be considered. Such an approach, such as  one explored by the Health+Law initiative in Australia, recognises the importance of combining legal, health, and social care because health problems frequently result from, or are exacerbated by, legal and social barriers.

Conclusion

Sydney has been a global leader in tackling HIV through emphasising community-based health promotion efforts. However, much of Sydney’s HIV response has concentrated on urban inner-city centres, rather than in the Western Sydney suburbs where a significant proportion of culturally and linguistically diverse residents of migrant background live. Expanding coordinated outreach to include Asian-born GBM – in addition to other key populations in the areas they live, work and socialise would further open the benefits of promising new biomedical advancements for HIV prevention and treatment to a significant number of people. The inclusion of marginalised populations as active collaborators in the city’s HIV success story is critical to ensure health equity and justice and to improve lives, promote wellbeing and foster belonging.

Authors: Dr Sujith Kumar Prankumar, Dr Horas TH Wong and A/Professor Limin Mao.

Image credit: Photo by Anna Shvets/Pexels.

Note: The 2023 round of the Gay Asian Men’s Survey is recruiting participants until April 2024. For more information and to participate, please visit https://www.gayams.org.au/.