Understanding the health care needs of transgender and gender diverse people engaging with rural Australian sexual health centres: a qualitative interview study.

BACKGROUND: Although there is a presumption that LGBTQ+ people living in rural Australia will have poorer health outcomes than those living in metropolitan areas, minimal research has focused specifically on the perspectives of transgender and gender diverse (henceforth referred to as 'trans') people living in these regions. The purpose of this study was to understand what health and wellbeing means to trans people in a regional or rural community and identify their health needs and experiences. METHODS: A total of 21 trans people were recruited through two regional sexual health centres (SHC) and interviewed between April and August 2021. Data were analysed via reflexive thematic analysis. This paper focuses on participants' accounts of health and wellbeing regarding gender affirmation, the experience of rural living, respectful holistic care, safety in rural communities, isolation, loneliness, and employment. RESULTS: The experience of living rurally can have both positive and negative impacts on the experiences of trans people. Participants reported experiences of stigma and discrimination, reduced employment opportunities and limited social interactions, which led to feelings of isolation and loneliness; however, they also reported high quality of care, particularly with the specific SHCs which supported this research. CONCLUSION: Living rurally can impact both positively and negatively on the health and wellbeing of trans peoples, and the experiences of living in this environment are diverse. Our findings challenge the perception that rural trans people experience only poor health outcomes and shows the difference that key health services such as SHCs can make in supporting trans health.

Optimising community health services in Australia for populations affected by stigmatised infections: What do service users want?

Stigma in health services undermines diagnosis, treatment and successful health outcomes for all communities, but especially for those affected by blood-borne viruses and sexually transmitted infections (STIs). This study sought to examine experiences in accessing and receiving health services, including what characteristics promoted better health, safety and well-being for people with blood-borne viruses or STIss. It conducted 46 in-depth interviews with people who inject drugs, gay men and other men who have sex with men, sex workers, people in custodial settings, culturally and linguistically diverse people, Indigenous Australians and young people in one Australian urban community setting. Findings reveal that stigma persists in the provision of healthcare services, and that previous experiences of discrimination or fear of mistreatment may result in a reluctance to continue to access services. On-going staff training and education are important to ensure healthcare environments are welcoming and inclusive. Specialised services and services that employed peers were seen as favourable. Attending different services for different health needs created particular access challenges and undermined participant ability to engage in more holistic healthcare. The fragmented structure of health services was thus seen as a barrier to accessing health services, and stronger collaboration between health services is recommended.

Integrating testing for sexually transmissible infections into routine primary care for Aboriginal young people: a strengths-based qualitative analysis.

OBJECTIVES: This paper examines factors that enabled successful integration of testing for sexually transmissible infections into routine care in Aboriginal Community Controlled Health Services. METHODS: This paper reports analysis of qualitative interview data recorded with 19 purposively sampled key informants in New South Wales, Australia, representing six Aboriginal Community Controlled Health Services and five government health bodies supporting those services. The analysis explicitly adopted a strengths-based approach. RESULTS: Participants reported a strong belief that routine screening overcomes shame and increases engagement with sexual health screening. Incorporating sexual health screening into general medical consultations increases the capture of asymptomatic cases. The Medicare Benefits Schedule 715 Adult Health Check was highlighted as an ideal lever for effective integration into routine care. CONCLUSION: Integration of testing for sexually transmissible infections into routine care is widely perceived as best practice by senior stakeholders in Aboriginal healthcare in NSW. Findings support continued work to optimise the MBS 715 as a lever to increase testing. IMPLICATIONS FOR PUBLIC HEALTH: Identifying accessible strategies to increase testing for sexually transmissible infections in Aboriginal Community Controlled Health Services can reduce disparities in notifications affecting Aboriginal young people.

Challenges of providing HIV pre-exposure prophylaxis across Australian clinics: qualitative insights of clinicians.

Background HIV pre-exposure prophylaxis (PrEP) has been rapidly implemented in Australia, initially through restricted access in demonstration studies, and then through prescribing across sexual health clinics and general practice settings. In 2018, PrEP was publicly subsidised for people with Medicare (universal health insurance for citizens, permanent residents and those from countries with reciprocal arrangements). There is little research examining the experiences of PrEP providers in Australia, and existing research has been primarily conducted before public subsidy. METHODS: In this qualitative study, we examine the challenges that have emerged for PrEP-providing clinicians after public subsidy for PrEP was introduced. We conducted 28 semi-structured interviews in 2019-20 with PrEP providers in two Australian states, and analysed data thematically. Participants included general practitioners (GPs), sexual health nurses and sexual health physicians. RESULTS: Sexual health services have been reconfigured to meet changing patient demand, with an emphasis on ensuring equitable financial access to PrEP. Restrictions to nurse-led PrEP frustrated some participants, given that nurses had demonstrated competence during trials. GPs were believed to be less effective at prescribing PrEP, but GP participants themselves indicated that PrEP was an easy intervention, but difficult to integrate into general practice. Participants expressed discomfort with on-demand PrEP. CONCLUSIONS: Our findings indicate that supporting ways for patients without Medicare to access PrEP inexpensively, advocating for nurse-led PrEP, and developing guidelines adapted to general practice consultations could ensure that PrEP is delivered more effectively and equitably. Additionally, PrEP providers require encouragement to build confidence in providing on-demand PrEP.

'Everything is okay': the influence of neoliberal discourse on the reported experiences of Aboriginal people in Western Australia who are HIV-positive.

While Australian Aboriginal conceptions of health have been described as holistic and collective, contemporary approaches to health services and health research are often premised on the rational, reflexive subject of neoliberal discourse. This paper considers how neoliberal conceptions of health and subjectivity arose and were negotiated in the context of a qualitative research project on Aboriginal experiences of HIV in Western Australia. Questions about 'coping', 'future' and 'life changes' stood out in the interview transcripts as examples of neoliberal discourse. This paper explores the reflexive, contextual and deflective responses to these questions and suggests they demonstrate how neoliberal discourse can produce the impression that 'everything is okay' despite the difficult social and economic conditions of everyday life experienced by many Aboriginal people. Aboriginal people with a chronic and serious infectious disease such as HIV may utilise the language of self-management and responsibility when talking about HIV with a non-Aboriginal researcher for pragmatic and utilitarian reasons. In this way, the responses of the Aboriginal participants in this study provide a valuable opportunity for exploring new approaches to both research methodology and health service delivery.

Barriers and incentives to HIV treatment uptake among Aboriginal people in Western Australia.

OBJECTIVE: To examine the barriers and incentives to HIV treatment uptake among Aboriginal people in Western Australia. METHODS: In-depth, semi-structured interviews were conducted between February and September 2003 with 20 Aboriginal people who were HIV-positive; almost half the total number of Aboriginal people known to be living with HIV in Western Australia at that time. RESULTS: Despite having access to treatments in both urban and rural areas, only 11 of the 20 participants were on antiretroviral treatment at the time of interview. Four of the women had been prescribed treatment during pregnancy only. The main barriers to treatment uptake were fear of disclosure and discrimination, heavy alcohol consumption and poverty. The incentives were pregnancy and access to services whose approach can be described as broad-based and holistic, i.e. supporting people in the context of their everyday lives by providing psychosocial and welfare support as well as healthcare. CONCLUSION: For many Aboriginal people, maintaining social relationships, everyday routines and the respect of friends, families and community is a greater priority than individual health per se. Treatment regimens must be tailored to fit the logistical, social and cultural context of everyday life, and be delivered within the context of broad-based health services, in order to be feasible and sustainable.