This presentation was given by Sally Cameron at the AFAO HIV Educators Conference 2010.

1. The National Preventative Health Agenda - HIV and Social Determinants of Health

2. It would be very sad to survive HIV and die of something else that was preventable. Epidemiologist Dr. John T. Brooks referring to obesity Centersfor Disease Control and Prevention, in Alicia Chang, "Obesity a Problem in HIV Population", Associated Press, 4 October 2007.

3. Impact of chronic disease Affluence and ageing significantly contribute to the total burden of disease in Australia Chronic diseases such as cardiovascular disease, diabetes and cancers: • 80% of the burden of disease and injury • 70%of total health care expenditure • 50% of GP consultations • leading causes of disability and death in Australia • 537 000 person years loss of participation in f-time & 47 000 person years in p-time employment/year. The burden of chronic disease is projected to dramatically increase.

4. Timeline - Preventative Health Agenda April 2008 Government announces establishment of National Preventative Health Taskforce Oct 2008 National Preventative Health Taskforce releases Australia: The Healthiest Country by 2020 – a detailed discussion paper Sept 2009 Taskforce delivers Australia: the Healthiest Country by 2020 – National Preventative Health Strategy, and papers addressing obesity, tobacco control and preventing alcohol-related harm May 2010 Government releases Taking Preventative Action: A Response to Australia: The Healthiest Country by 2020

5. Priority Areas Infrastructure Key modifiable factors driving some 30 percent of the burden of disease in Australia - obesity, smoking and excessive alcohol use

6. Social Determinants of Health Social factors influence broader patterns of health and illness within any given population. Those factors include the experience of living with HIV, and being lesbian, gay, bisexual or transgender. While the preventative health discussion paper refers to social determinants and targeting, it does so in a very limited number of instances. People living with HIV, and gay, lesbian, bisexual and transgender people are absent.

7. Impact on HIV and LGBT Need to understand: Obesity Tobacco use Excessive alcohol consumption

10. US Based Findings on HIV & Obesity 2001 High prevalence of obesity amongHIV+ patients: 34% overweight & 9% obese (Hodgson) 2005 58% of HIV+ women and 42% of men either obese or overweight: 31% women and 30% of men obese (Amorosa) obesity more common than wasting amongst HIV-positive people 2006 13% of HIV+ men and 29% women were obese (Hendricks) the prevalence of overweight & obese had increased had over preceding 8 years 2007 63% of HIV+ patients at two hospitals were overweight or obese, including some 30% of people with AIDS (Crum - C) many are prone to the same bad habits as many HIV negative Americans: poor eating choices and lack of exercise

11. US supposition Given the association of AIDS with progressive and dramatic wasting, despite potential morbidities, some HIV-infected patients may favor[stet] maintaining elevated weight to serve as a protective cushion against future wasting or may believe that being overtly overweight masks their disease from friends or acquaintances.

12. Australia Lack of data HIV Futures 6 ... when asked about health management strategies, almost all participants agreed that exercise, healthy eating and an optimistic outlook were important or very important strategies. Notably, those who indicated they exercised and ate well were more likely to agree with the respective statements than those who did not.

13. HIV - Implications of Weight Loss? ... as weight loss is a documentedpredictor of decreased survival of PLHIV, the role of intentional weightloss in overweight and obese HIV infected people also requiresthorough scientific study.

14. LGBT & Obesity Gay men enjoy some statistical privilege Private Lives, 2004: Gay men less likely to be overweight or obese than the Australian average male: 43% to 54% (Pitts) Little Australian data on overweight and obesity among gay men Limited effort to develop means to reach gay men who are overweight.

15. LGBT & Obesity Private Lives, 2004: Lesbian women more likely to be overweight or obese than Australian average female (49% to 38%). W.A, 2007: 23% of lesbian and bisexual women overweight (comp. 26.5% in general pop) 22% of lesbian and bisexual women obese (comp. 18% ) Ate less fresh fruit and vegies Consumed more fast food Significant proportion insufficiently active for health benefit

16. Smoking and HIV HIV Futures 5 - almost half of PLHIV smoke (48%), more than twice the rate of the general Australian population (23%) particularly concerning – many of the conditions associated with smoking are much more likely to occur in people who are HIV positive.

17. Interrelationship – Smoking & HIV HIV+ More likely to develop throat, lung, anal & colon cancers Emphysema likely to occur earlier Smoking: Increases risk of cardiovascular disease, exacerbating the effect of HIV infection and problematising treatments Increases risk of oral health conditions, including Oral Hairy Leukoplakia (Epstein Barr Virus), Oral Candidiasis (Thrush), Mouth Ulcers, and Oral Cancers Compounds issues around diabetes (becoming more common as side effect of ART). Directly affects insulin sensitivity and negatively affects blood sugar metabolism. May also compound the negative impact of HIV infection and treatment on bone mineral density, triggering osteoporosis and osteopenia .

18. Smoking Cessation US study found smoking cessation in symptomatic HIV positive people can significantly improve symptom burden for HIV positive people from as early as three months of cessation. Virrine 2007

19. Smoking and LGBT Communities Numerous studies have documented higher rates of smoking among LGBT communities, particularly lesbians. Murnane 2000 - alcohol and other drug use among LGBT Victorians Level of women’s tobacco use higher than that of men in sample, and both men and women in the Australian National Household Survey. Female respondents expressed concern about the level of tobacco use within the lesbian community.

20. Smoking and LGBT Communities Hillier, 2005 (survey of more than 9000 women) non-heterosexual women were more likely to be current smokers. Pitts, 2006 more than 1/3 of respondents reported using tobacco more than 5times in the previous month (37%) compared to approximately 24% of respondents in the Australian Bureau of Statistics’ National Health Survey. Hyde, 2007 lesbian and bisexual women smoked at a rate (28.1%) nearly double that of the general female population surveyed in the WA Health and Well-Being Surveillance System sample (14.8%).

21. Broad Implications for Targeted QUIT Initiatives Decisions to quit smoking are not made solely by isolated persons, but rather they reflect choices made by groups of people connected to each other both directly and indirectly at up to three degrees of separation. People appeared to act under collective pressures within niches in [a] network. … Network phenomena might be exploited to spread positive health behaviors. Indeed, cessation programs for smoking and for alcohol use that provide peer support — that is, that modify the person’s social network — are more successful than those that do not. Christakis and Fowler, ‘The Collective Dynamics of Smoking in a Large Social Network’, The New England Journal of Medicine, 22 May 2008,

22. Alcohol Consumption and HIV Alcohol consumption impacts HIV in terms of risk practices, access to treatments and disease progression.

23. Alcohol & Risk Behaviours Some studies have sought to establish an association between alcohol, drug use and unsafe sex, however, a causal link remains disputed. Newman - barriers and incentives to HIV treatment uptake among Aboriginal people in WA found alcohol ‘featured in the accounts of many participants, as a key element of the risk context in which they acquired HIV’. Tawk - alcohol consumption identified as factor associated with inconsistent condom use among multi-partnered HIV-negative men (7000 Sydney Sexual Health Centre patients surveyed).

24. Alcohol & Risk Behaviours Korner, Hendry and Kippax, 2005 In-depth details of exposures and participants’ understanding of ‘risk’, documenting physical, social and emotional contexts in which unsafe sex occurs. Contexts interact in various ways, and alcohol is just one factor at play . Many participants reported ‘being in control despite being seriously affected by alcohol. Some emphasised that using condoms was a matter of routine, irrespective of drugs and alcohol with the exception of this particular episode. Where unprotected sex occurred in conjunction with drugs and alcohol, drugs and alcohol were not seen as an excuse. Rather, some participants emphasised own role in allowing unsafe sex to happen and insisted that they should have been in control.

25. Access and Adherence to HIV Treatments Newman, 2007 alcohol consumption one of the main barriers to treatment - 11 of 20 Aboriginal participants on ART. alcohol featured … as a perceived factor in the progression of infection. Some had stopped drinking, but those who continued reported difficulties in maintaining treatment regimens. If you've had a hard night out it stops you. But you know, you make it up until … You don't double your dose but you take your one dose again … until you start catching up. Participants expressed a willingness to comply with treatment regimens but adherence was compromised by heavy regular alcohol consumption.

26. Alcohol & Disease Progression Acute and chronic alcohol abuse impairs various functions of the immune system and has been implicated as a cofactor in HIV disease progression. Samet, 1996 examined alcohol use among PLHIV and found heavy drinkers on anti-retroviral therapy were more likely to have higher HIV viral load (after adjustment for medication adherence). In those not on anti-retroviral therapies, heavy drinking was associated with lower CD4 cell counts. Futures 5 77% of respondents had consumed alcohol during the previous 12 months, suggesting a lower percentage of Australian PLHIV consume alcohol than in the general population (some 83%) approximately one in five (19%) respondents felt they drank more alcohol than they would like.

27. Alcohol & LGBT Health Australian research - limited but that which exists suggests patternsand rates of use are different , with ratesof use higher than those of the heterosexual population. Numerous studies have suggested that to some extent at least, drug and alcohol use common to GLBT Australians is the result of their experiences of stigma, discrimination and abuse, internalised homophobia, and also particular mechanisms for socialising (a reliance on ‘bar cultures’).

28. Alcohol & LGBT Health Murnane, 2000 alcohol and drug use 2 to 4 four times higher in Victorian LGBT communities than in Victorian population Gay men and lesbians less likely to abstain from drug and alcohol use, less likely to stop using both illicit drugs and alcohol as they grow older, and there appeared to be less distinction in patterns of use between lesbians and gay men than between heterosexual men and women. Hyde, 2007 Health care providers working with gay men and lesbians reported the prevalence of substance abuse to be 2 to 3 times higher than in heterosexual population. Almost 1/3 of lesbian and bisexual women (31%) exceeded National Alcohol Guidelines but only 7% described themselves as b ‘heavy drinker’, suggesting they were unaware ‘their consumption patterns were potentially harmful, and that heavy drinking may be a normalised behaviour.

29. Alcohol & LGBT Health Hillier, 2005 Evidence that young GLBT people’s experiences of homophobia and transphobia lead to higher rates of drug and alcohol use, compared to exclusively heterosexual youth. Data on young Australian women aged 22 to 27 years found they consumed alcohol at high risk levels (7% compared to 4% of the general population). Consequence of ‘a serious lack’ of drug and alcohol-free forums in which to interact.

30. Time to gear up

31. Fit with the National HIV Strategy? specific expertise of the HIV community sector in developing and delivering targeted programs to HIV-affected communities, especially gay communities little attempt to consider how the HIV response, and particularly the National HIV Strategy, might ‘fit’ with or link to wider preventative health strategies vital that issues are not siloed, duplicated or overlooked potential for consultation fatigue and frustration stemming from having to frequently reiterate the same policy arguments in different, unlinked forums

32. Targeting HIV and LGBT Populations Impact HIV and LGBT omission as the preventative health framework is rolled out, and strategies are designed in detail. National Men’s Health Policy - cause for optimism. Includes men who identify as gay, bisexual, transgender or from intersex groups, as priority groups. Lists gay, bisexual and transgender males as communities impacted by social determinants of health; as examples of communities to be targeted, for example, in health promotion; and as communities requiring targeted health care services.

34. How can we impact those with values outside ‘mainstream, eg, gay men who have railed against dominant messages about ‘perfect’ bodies?

35. How do definitions of ‘health’ correlate to a sense of ‘wellbeing’?

36. How do descriptions of HIV as a ‘chronic disease’ fit within this new preventative health framework?