Community-based approaches to HIV prevention & priorities and strategies

of the Preventative Health Taskforce

Graham Brown

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Community-based approaches to HIV prevention & priorities and strategies of the Preventative Health Taskforce

Foundations within the HIV community response

Preventative Health Agenda Reflecting on strategic directions of PHTF Implications to and from HIV and affected

communities

What needs to be engaged and advocated

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Community response to HIV

Building on a range of human, gender and social rights and justice movements, HIV brought a revolution in the way affected communities participated at all levels of public health initiatives

eg The “Denver Principles” in 1983 Positive activists announced a set of principles that would

revolutionise responses to self-empowerment in a health crisis.

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Community response to HIV

Building on a range of human, gender and social rights and justice movements, HIV brought a revolution in the way affected communities participated at all levels of public health initiatives

Innovative approaches developed by affected communities and activists.

It was later that the influence of a formalised health promotion frameworks and social research became more significant

Australia’s relative success in HIV demonstrated that an integrated, participatory, pragmatic and community driven response does work, and works better

(Lowe and Nutbeam, 1999,, Feachem, 1995, Nutbeam, 1998, Brown 2006).

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Core principles of HIV response have included…

Human rights principles and the Ottawa Charter.

Partnership of affected communities, PLHIV, Government, researchers, health professionals.

Strong and visible leadership by both Government and community.

An enabling environment with bi-partisan support.

Commitment to harm reduction principles.

Legislation and public policy reform to support healthy behaviours, protect those who are vulnerable or marginalised.

A resourced community and research sector, ensuring a community driven and evidence based foundation.

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Preventative Health Agenda

Australia: the healthiest country by 2020 and the Government Response

driven by evidence based contemporary practice, much which is consistent with the evidence that HIV response has provided

Highlights the success of HIV

However does not articulate: How the methods used in HIV might be applied as a model for the

development of strategies regarding obesity, alcohol and tobacco

How the approaches of the Preventative Health Framework could enhance areas outside of Alcohol, Tobacco and Obesity or with communities not identified in the high level reports

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7 strategic directions from the NPHTF

1. Shared responsibility and strategic partnerships 2. Act throughout life 3. Engage communities where they are4. Influence markets and coherent connected policies5. Reduce inequity through targeting disadvantage 6. Indigenous Australians and ‘Close the Gap’7. Refocus primary healthcare towards prevention

Reflect on a some of these

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Engage communities …inform, enable and support people to make healthy choices

In HIV affected communities led the debates in deciding and developing what the ‘healthy choices’ would be. Using condoms was not the first or only option presented to gay

men in the early 80s by public health Communities most affected by HIV, particularly gay men and sex

workers, invented the concept of ‘safe sex’.

What does community participation and control mean for Obesity, Tobacco and Alcohol initiatives? Clear principles with our Indigenous communities – others? Who are the communities in a generalised epidemic? Who decides the healthy choices? Is participation just “people living with weight” being on

committees?

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Engage communities …inform, enable and support people to make healthy choices

Broad based HIV social marketing did not start on the right footing – utilising stigmatising fear based approach

I think to a large extent the taskforce has started from a much more informed place There is a momentum in Australia to still go down the

fear and blame path This is a joint challenge of HIV, HepC and NPA

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Reduce inequity through targeting disadvantage Expertise on the taskforce ensured that social determinants of

health was recognised as a major factor

Stigma and discrimination has been one of the largest social barriers to the response in HIV. HIV and affected communities long standing historical and cultural stigma and discrimination at the

personal, social, legal and structural level.

Health and social inequalities between LGBTI communities and rest of the community Higher alcohol and tobacco consumption higher within these groups?

History of poor treatment from health professionals, educators, and authorities.

While things have changed a lot, for many of our community members these experiences are recent, and much has yet to change.

(Paul Martin speaking later today)

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Reduce inequity through targeting disadvantage

There are important groups not identified within preventative health agenda strategies

As with any marginalised affected community – there can be resistance when: messages seen as “health enforcement”, an assumption that absence of disease is the priority goal, culturally irrelevant or inaccurate, or omits their community’s existence.

In HIV we have had to grapple with “At what point does social and peer influence become stigmatising, discriminatory and exclusionary influence?”

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Indigenous Australians

– contribute to ‘Close the Gap’ Currently there is little gap epidemiologically in HIV – suggesting

non priority within Indigenous health.

However Indigenous communities may be our most vulnerable. Social determinants and cultural contexts eg. For many Indigenous communities sharing is a core characteristic of

the culture. Promotion of non-sharing injecting equipment can conflict the way culture is expressed.

We have seen in Australia what happens when investment and leadership in HIV prevention is reduced – resulting in major increases in HIV transmission.

Danger of an unstrategic focus on only the “gaps”, and a reduction in the community mobilised HIV responses.

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Influence markets and develop coherent and connected policies

Similar to sex - eating is a natural function of life, full of emotion, culture, meaning and pleasure, power, regret, guilt and fantasy.

Similar to injecting - Alcohol and Tobacco is full of personal and peer expectations, cultural meaning and ritual, and social constructions and judgements.

Result: Moralising, stigma, and belief systems can compete against having evidence based coherent and connected policies (eg expansion of NSP, sex work law reform)

National Prevention Agency will be in a strong position to mobilise the translation of evidence into policy and practice with implications across many health areas.

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Refocus primary healthcare towards prevention As indicated by WHO – the majority of the factors that

determine people’s health are outside the control of the health sector

Much of the Taking Preventative Action report is more health service focused than broader health promotion.

Complexity of treatment as prevention, and the individualised focus, is as much a challenge for Obesity, Tobacco, Alcohol as it is for HIV

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What needs to be engaged with and advocated?

When I lay back and think of core mobilisers in the gay community, who rallied against dogma, stigma and the early oppressive responses to HIV – what do I see?

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…big, drinking, smoking, bears!

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What needs to be engaged with and advocated? Reaction against dogma or dominant culture or can be part

of a marginalised group’s empowered identity. What if “health”, as presented, is rejected

“How can we impact gay men who have railed against dominant messages about ‘perfect’ gay body type, lesbians rejecting patriarchal objectification of women’s bodies, or men who have lived long-term with HIV who consider the notion of ‘getting on a treadmill’ an anathema?” (Cameron, AFAO Briefing paper)

Issue of health promotion verses health enforcement 90’s backlash response in USA

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What needs to be engaged with and advocated? For HIV - great opportunities in, but not a straight

forward fit with, wider preventative health strategies: Community participation and control, Stigma/Discrimination Harm reduction, Use of evidence and policy, Generalised and concentrated targeted approaches

Alcohol, tobacco and obesity are critical health issues impacting directly on PLHIV and LGBT communities

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What needs to be engaged with and advocated? There is much that we can (and do) learn from the

experiences and successes of other community interventions and responses outside for HIV. From reducing social and structural stigma to self management

of chronic conditions

There are common challenges and goals for both HIV partnership and the NPA Key opportunities to collaborate and partner

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What needs to be engaged with and advocated? Need to share more effectively and with greater

influence the real lessons we have learnt in HIV – its successes and failures.

Need to ensure our communities achieve improved health benefits from the NPA agenda

Need to ensure broader health agendas and reforms enhance and support our work in HIV prevention without: Losing the strengths and principles our non conforming LGBT,

sex worker and IDU communities have built; or Reducing the momentum we have built in HIV prevention and

support

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Complementary Reading:

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Strategic Partnerships

HIV partnership and the role of affected communities has been at the core of the HIV response from the beginning,

Probably the largest difference between Australia’s response and the response of many other countries.

But partnerships do not just happen

Need all partners to have the capacity to play their full role

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Act throughout life – working with individuals, families and communities

Healthy weight and chronic conditions, alcohol and tobacco have been significant issues within LGBT communities and PLHIV.

Tobacco, Alcohol, Nutrition and Physical activity these are all influenced by social networks GLBTI networks are likely to have higher proportions of members who

smoke, drink at harmful levels, and have cultures with them that affirm larger body sizes as a social and political response

Difference between concentrated and generalised responses – and the importance of targeting.