A journey to HIV prevention research: From social psychology to social health via multidisciplinarity.

This is a personal account of my research in HIV prevention from 1984 to the present day. It demonstrates my disquiet with the individualism of psychology as a way of thinking about what was needed to prevent HIV transmission. HIV prevention requires social transformation which is produced via changes in social practices and norms of communities and networks rather than by changes in behaviours of individuals. My colleagues and I developed a 'social health' model of social transformation that involves enabling communities to modify their social practices by building on emergent community responses, responses that were identified by the use of a reflexive research methodology.

Awareness and knowledge of HIV pre-exposure prophylaxis among Australian gay and bisexual men: results of a national, online survey.

Background: Expanded access to HIV pre-exposure prophylaxis (PrEP) is being actively debated in Australia. Awareness and knowledge of this HIV-prevention method have not been assessed in detail in the primary affected population, gay and bisexual men. Methods: Awareness and knowledge of PrEP were assessed among Australian gay and bisexual men, who were asked to complete a national, anonymous, online survey in 2015. Associations with PrEP awareness were identified with multivariate logistic regression and associations with PrEP knowledge were identified using multivariate linear regression. Results: Among 1251 participants, 954 (77%) were aware of PrEP. The most common sources of information were gay community media, Australian websites and friends. Awareness of PrEP was independently associated with older age, living in a capital city, having a university degree, being tested for HIV, being HIV-positive, having condomless anal intercourse with regular male partners, and ever having taken post-exposure prophylaxis. Men in monogamous relationships were less likely to be aware of PrEP. Among men who were aware of PrEP, the mean PrEP knowledge score was 6.8 out of 13. Relatively few participants knew that taking PrEP involved regular clinical monitoring and that in Australia PrEP was only recommended for people at risk of HIV. Better knowledge was independently associated with living in a capital city, having a university degree, being in full-time employment, being HIV-positive, and ever having taken post-exposure prophylaxis or PrEP. Conclusions: To assist in appropriate PrEP uptake, we recommend educating gay and bisexual men about current Australian prescribing guidelines and how PrEP is accessed in Australia.

Evolving views and practices of antiretroviral treatment prescribers in Australia.

OBJECTIVE: To examine whether there have been recent changes in Australian antiretroviral treatment (ART) prescribers' perceptions and practices relating to early ART initiation, which was defined as commencing ART when a patient's CD4+ T-cell count approaches 500 cells/mm3 or immediately after a patient is diagnosed with HIV. DESIGN, PARTICIPANTS AND SETTING: Self-completed, anonymous, cross-sectional surveys, targeting all ART prescribers in Australia, were conducted online in 2012 and 2013. The surveys included questions on prescriber factors, CD4+ T-cell count at which prescribers would most strongly recommend ART initiation, and perceived patient characteristics that could change prescribers' practices of early initiation of ART. MAIN OUTCOME MEASURES: Proportions of ART prescribers recommending early ART initiation. RESULTS: We analysed responses from 108 participants in 2012 and 82 participants in 2013. In both years, more male than female prescribers participated. The median age of participants was 49 years in 2012 and 50 years in 2013. In both rounds, over 60% had more than 10 years' experience in treating HIV-positive patients. More prescribers in 2013 stated that they would most strongly recommend early ART initiation compared with those in 2012 (50.0% [95% CI, 38.7%-61.3%] v 26.9% [95% CI, 18.8%-36.2%]; P=0.001). The prescribers' primary concern was more about individual patient than public health benefit. Out of 824 patients for whom ART was initiated, as reported by prescribers in 2013, only 108 (13.1% [95% CI, 10.9%-15.6%]) were given ART primarily to prevent onward HIV transmission. The number of patients for whom ART was initiated was significantly associated with prescribers' HIV caseload even after adjusting for prescriber type (adjusted odds ratio, 1.73 [95% CI, 1.47-2.03]; P<0.001); of the 37 who had initiated ART for 10 or more patients, 29 had a high HIV caseload. In 2013, 60 prescribers (73.2% [95% CI, 62.2%-82.4%]) reported that they routinely recommended ART to treatment-naive, asymptomatic patients with a CD4+ T-cell count of 350-500 cells/mm3. CONCLUSION: Our findings show increasing acceptance of and support for early ART initiation primarily as treatment and not as prevention.

Interest in using rectal microbicides among Australian gay men is associated with perceived HIV vulnerability and engaging in condomless sex with casual partners: results from a national survey.

OBJECTIVE: We assessed interest in using rectal microbicides to prevent HIV transmission among gay men in Australia. METHODS: A national online survey was conducted in 2013. Interest in using rectal microbicides was measured on a seven-item scale (α=0.81). Factors independently associated with greater interest in using a microbicide were identified using multivariate logistic regression. RESULTS: Data were collected from 1223 HIV-negative and untested men. Mean age was 31.3 years (SD=10.8, range 18-65); 77% were born in Australia and 25% reported any condomless anal sex with a casual partner in the previous 6 months. Overall, there was moderate interest in using rectal microbicides (M=3.33, range 1-5). In multivariate analysis, greater interest in using microbicides was independently associated with being born outside Australia (adjusted OR (AOR)=1.59; p=0.009), greater self-perceived likelihood of becoming HIV positive (AOR=3.40; p<0.001), less uncertainty about the efficacy of microbicides (AOR=0.65; p=0.009), any condomless anal sex with casual partners in the previous 6 months (AOR=1.78; p=0.03) and ever having received postexposure prophylaxis (AOR=1.53; p=0.04). Interest in using microbicides was not associated with age, number of male sex partners or the HIV status of regular male partners. CONCLUSIONS: Interest in using rectal microbicides was associated with self-perceived vulnerability to HIV, engaging in sexual practices that increase the risk of HIV acquisition and less uncertainty about the efficacy of microbicides. There appears to be a group of men who would benefit from, and are highly motivated to use, a rectal microbicide product.

Australian gay and bisexual men's attitudes to HIV treatment as prevention in repeated, national surveys, 2011-2013.

OBJECTIVE: Assess the acceptability of HIV treatment as prevention and early antiretroviral treatment among gay and bisexual men in Australia and any changes in attitudes over time. METHODS: National, online, cross-sectional surveys of gay and bisexual men were repeated in 2011 and 2013. Changes in attitudes to HIV treatment over time were assessed with multivariate analysis of variance. The characteristics of men who agreed that HIV treatment prevented transmission and thought that early treatment was necessary were identified with multivariate logistic regression. RESULTS: In total, 2599 HIV-negative, untested and HIV-positive men participated (n = 1283 in 2011 and n = 1316 in 2013). Attitudes changed little between 2011 and 2013; most participants remained sceptical about the preventative benefits of HIV treatment. In 2013, only 2.6% of men agreed that HIV treatment prevented transmission; agreement was associated with being HIV-positive, having an HIV-positive regular partner, and having received HIV post-exposure prophylaxis. In contrast, 71.8% agreed that early antiretroviral treatment is necessary; younger men were more likely and HIV-positive men and participants with HIV-positive partners were much less likely to agree with this. CONCLUSIONS: Promoting the individual health benefits of HIV treatment rather than its preventative benefits remains more acceptable to Australian gay and bisexual men.

Willingness to use HIV pre-exposure prophylaxis has declined among australian gay and bisexual men: results from repeated national surveys, 2011-2013.

We surveyed willingness to use pre-exposure prophylaxis (PrEP) and the likelihood of decreased condom use among Australian gay and bisexual men in 2011 and 2013 (n = 2384). Willingness to use PrEP declined from 28.2% to 23.3% [adjusted odds ratio = 0.83, 95% confidence interval (CI): 0.68 to 1.00, P = 0.050]. Willingness to use PrEP was the greatest among men with HIV-positive partners and among those who had taken HIV postexposure prophylaxis. Among men willing to use PrEP, the likelihood of decreased condom use remained stable between 2011 and 2013 (8.0% vs. 11.9%; adjusted odds ratio = 1.40, 95% CI: 0.80 to 2.45, P = 0.23). A minority of men remain willing to use PrEP and appear to be appropriate candidates for it.

Expert perspectives on the contribution of HIV general practice nursing to the 'extraordinary story' of HIV medicine in Australia.

AIM: This paper explores cultural and professional dynamics of HIV general practice nursing in Australia. It highlights specific contributions that HIV general practice nurses make to HIV medicine and considers how nurses' clinical practice has been shaped by past experiences of the AIDS crisis and subsequent developments in HIV medicine. BACKGROUND: In international contexts, nurses in HIV medicine commonly work as part of shared-care teams. In recent years, HIV general practice nursing has become a prioritised area for primary health care in Australia. METHODS: Data for this analysis were drawn from 45 in-depth, semi-structured interviews conducted with nurses and general practitioners (GPs) who provide HIV care in general practice, and key informants who work in policy, advocacy or education and training of the HIV general practice workforce. FINDINGS: Viewed through a socio-ecological framework of social capital, descriptive content analysis highlights a unique and strong HIV health professional identity, which emerged out of the adverse conditions experienced by nurses, GPs and allied health professionals during the 1980s AIDS crisis. Participants reported that today, HIV general practice nursing includes information provision, HIV treatment side-effect management, teaching patients methods to increase adherence to HIV treatments and capacity building with allied health professionals. Participants reported that HIV general practice nurses can reduce the clinical burden on GPs, ameliorate patients' exposure to HIV health care-related stigma and discrimination and facilitate the emergence of a comprehensive and personalised model of shared primary health care based on trust and rapport, which is desired by people with HIV. This study's findings support the future expansion of the role of HIV general practice nurses in Australia and internationally. General practice nursing will become increasingly important in the scaling up of HIV testing and in caring for increasing numbers of people living with HIV.

No ordinary mainstream illness: how HIV doctors perceive the virus.

Research has shown that social representations of HIV can constitute barriers to health workers' willingness to provide HIV care. Considering a growing shortage in the HIV primary workforce in Western countries, we examine how HIV is perceived today by doctors involved in its care. In 1989 Sontag predicted that once the virus became better understood and treatable, the dehumanizing meanings that defined the early epidemic would vanish and HIV would turn into an ordinary illness. However, research shows that HIV still carries stigma, including in the health care sector. Drawing on qualitative interviews, we found that HIV doctors in Australia perceived HIV as a far-from-ordinary chronic illness because of its extraordinary history and its capacity to extend in multiple clinical and social directions. These rarely explored perspectives can contribute to the social reframing of HIV and to strategies to build a dedicated HIV workforce in Australia and elsewhere.

Between individual agency and structure in HIV prevention: understanding the middle ground of social practice.

When HIV prevention targets risk and vulnerability, it focuses on individual agency and social structures, ignoring the centrality of community in effective HIV prevention. The neoliberal concept of risk assumes individuals are rational agents who act on information provided to them regarding HIV transmission. This individualistic framework does not recognize the communities in which people act and connect. The concept of vulnerability on the other hand acknowledges the social world, but mainly as social barriers that make it difficult for individuals to act. Neither approach to HIV prevention offers understanding of community practices or collective agency, both central to success in HIV prevention to date. Drawing on examples of the social transformation achieved by community action in Australia and Brazil, this article focuses on this middle ground and its role in effective HIV prevention.

Engaging non HIV specialist general practitioners with new priorities in HIV prevention and treatment: qualitative insights from those working in the field.

BACKGROUND: The science of HIV prevention and treatment is evolving rapidly, resulting in renewed calls to increase rates of HIV testing and, in particular, facilitate the timely and possibly earlier initiation of treatment, as this has the potential to dramatically reduce new infections. Little is known about how to engage non HIV specialist Australian general practitioners (GPs) with these new priorities. METHODS: Content related to the engagement of non HIV specialist GPs in the HIV response was identified within the transcripts of in-depth interviews with policy key informants (n=24) and general practice clinicians (n=47) engaged with HIV medicine. A qualitative analysis of the semantic meaning of this content identified three categories of 'issues' described by participants. RESULTS: Educational issues referred to a lack of attention to HIV in medical curricula, a perception that HIV care is only provided by HIV-specialist GPs, a need to make HIV testing more 'routine' in GP education and a need to strengthen GP awareness of referral options. Organisational issues encompassed time pressures in general practice, and a need for general practice nurses and for rapid testing to become available, as well as formalised peer mentoring and comanagement opportunities. Societal issues included the changing dynamics of HIV transmission and a need to reconnect GPs with the Australian HIV response. CONCLUSIONS: To successfully engage non HIV specialist GPs in the promotion of regular HIV testing and timely initiation of treatment, challenging issues affecting their capacity and willingness must be urgently addressed.

At the coalface and the cutting edge: general practitioners' accounts of the rewards of engaging with HIV medicine.

BACKGROUND: HIV has become a chronic manageable infection in the developed world, and early and lifelong treatment has the potential to significantly reduce transmission rates in the community. A skilled and motivated HIV medical workforce will be required to achieve these health management and prevention outcomes, but concerns have been noted in a number of settings about the challenges of recruiting a new generation of clinicians to HIV medicine. METHODS: As part of a larger qualitative study of the HIV general practice workforce in Australia, in-depth interviews were conducted with 31 general practitioners accredited to prescribe HIV medications in community settings. A thematic analysis was conducted of the de-identified transcripts, and this paper describes and interprets accounts of the rewards of pursuing and sustaining an engagement with HIV medicine in general practice settings. RESULTS: The rewards of initially becoming involved in providing care to people living with HIV were described as interest and inspiration, community calling and right place, right time. The rewards which then supported and sustained that engagement over time were described as challenge and change, making a difference and enhanced professional identity. Participants viewed the role of primary care doctor with special expertise in HIV as occupying an ideal interface between the 'coalface' and the 'cutting edge', and offering a unique opportunity for general practitioners to feel intimately connected to both community needs and scientific change. CONCLUSIONS: Approaches to recruiting and retaining the HIV medical workforce should build upon the intellectual and social rewards of this work, as well as the sense of professional belonging and connection which is imbued between both doctors and patients and across the global and national networks of HIV clinicians. Insights regarding the rewards of engaging with HIV medicine may also be useful in enhancing the prospect of general practice as a career, and strengthening retention and job satisfaction among the existing general practice workforce.

Women hold up half the sky - and half the burden of the HIV epidemic.

It has been said that women hold up half the sky. In the HIV epidemic, women carry half the burden of the epidemic, perhaps even more. The HIV burden on women is dramatically higher in some regions, certain age groups and among marginalized groups, such as female sex workers. Women's vulnerability to HIV is exacerbated by gender inequality and domestic violence. The global effort towards elimination of paediatric HIV and keeping mothers alive deserves applause. However, the needs of women go beyond their child-bearing age or potentials and/or reproductive desires and must be recognized in the global HIV agenda. In particular, more female-controlled prevention tools are urgently required to allow women to protect themselves. It is time to turn the tide through promoting gender equality and genuinely committing to gender-responsive policies and programmes, and encouraging a more gender-aware research agenda that can generate necessary evidence. In recognition of International Women's Day, the Journal of the International AIDS Society is pleased to launch a thematic series to highlight articles that address the different dimensions of HIV as they relate to women.

Australian prescribers' perspectives on ART initiation in the era of "treatment as prevention".

This study explores Australian prescribers' attitudes towards Treatment as Prevention (TasP) and their practices around initiating combination antiretroviral treatment (cART) for HIV. A brief online survey was conducted nationally amongst antiretroviral treatment (ART) prescribers in Australia. The sample broadly represented ART prescribers in Australia (N = 108), with 40.7% general practitioners (GPs), 25.9% sexual health clinic-based physicians and 21.3% hospital-based infectious diseases physicians. About 60% of respondents had been treating HIV-positive patients for more than 10 years. Respondents estimated that about 70-80% of all their HIV-positive patients were receiving ART. Over half of the prescribers agreed very strongly that their primary concern in recommending cART initiation was clinical benefit to individual patients rather than any population benefit. A majority of the prescribers (68.5%) strongly endorsed cART initiation before CD4+ T-cell count drops below 350 cells/mm(3), and a further 22.2% strongly endorsed cART initiation before CD4+ T-cell count drops below 500 cells/mm(3). Regarding the optimal timing of cART initiation, this study shows that prescribers in Australia in 2012 focus primarily on the benefits for their individual patients. Prescribers may need more convincing evidence of individual health benefits or increased knowledge about the population health benefits for a TasP approach to be effective in Australia.