EIGHTH

National
HIV Strategy

2018–20221

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Foreword

Australia has continued to make significant
progress in addressing blood-borne viruses (BBV)and sexually transmissible infections (STI) overthe period of the previous national strategies.
The National BBV and STI Strategies for 2018-2022
set the direction for Australia’s continuing response.
Together they outline a framework for a high-quality
and coordinated national response.
The national strategies are endorsed by all Australian
Health Ministers. The ambitious targets and goals
outlined in the national strategies will continue toguide Australia’s efforts to significantly reduce thetransmission of BBV and STI, and improve rates
of diagnosis and treatment. Importantly, they will
also focus actions on improving the quality of life
for people with BBV and/or STI and addressing thestigma people still experience.
The national strategies capitalise on thesignificant headway that has been made in recent
years in our response to BBV and STI. This includes
the listing of Pre-Exposure Prophylaxis (PrEP) for
HIV prevention, additional HIV treatment medicines,
and ensuring the broadest possible access to new
direct acting antiviral treatments for hepatitis C on
the Pharmaceutical Benefits Scheme. Maintaining
our momentum is essential—we now have thepotential to considerably advance our response
across some critical areas.

The success of these strategies relies oncontinuing to build a strong evidence base to better
inform our responses, evaluating our approaches
to identify what is most effective, and further
strengthening our workforce, partnerships andconnections to priority populations.
These national strategies recognise the considerable
work already being progressed collaboratively bygovernments, community-based organisations,researchers, health professionals and communities.
Despite our efforts, the strategies identify trends ofconcern and gaps in our response. The developmentof these strategies has highlighted the significant
collegiality and commitment of stakeholders tostrengthening our BBV and STI response. With thisfoundation, Australia can continue to strive toachieve great things, building on our reputation
as a world leading model of best-practice.

The Hon Greg Hunt MP
Minister for Health

Eighth National HIV Strategy 2018–2022

3

Contents
1

Introduction

05

2

Guiding principles

083

Snapshot of HIV in Australia

104About this strategy

125

Measuring progress

16

6

Priority populations and settings

18

7

Priority areas for action

24

8Implementing this strategy

34

Appendix A: References

4

36

1.
Introduction
Since the first cases of AIDS and the discovery of
HIV 35 years ago, Australia has made a concerted
and sustained effort to respond to the virus.
Australia’s domestic response to HIV is regarded
internationally as a world-leading model of bestpractice. Australia has a national HIV incidence
lower than many other comparable high-income
countries1 .
Despite Australia’s success, there is a need tobolster and realign efforts in response to thechanges of HIV incidence within priority populations
and the changing contribution of risk exposures.
Gay men and other men who have sex with men(MSM) continue to bear a high burden of HIV inAustralia, and our response needs to maintain astrong focus on this priority population. However,achieving and maintaining low rates of HIV inother populations is also of critical importance.
This includes responding to increases in HIV
transmission among Aboriginal and Torres Strait
Islander people and among heterosexuals.
Protecting Australia’s achievements in the virtual
elimination of HIV among sex workers, mother tochild transmission and in people who inject drugs2
is also essential. Ensuring all people with HIV andthose at risk are linked to quality prevention, testing,treatment, care and support services is a priority
for Australia, as is addressing HIV-related stigma
and discrimination.

Australia’s response to HIV needs to capitaliseon the promise offered by new technologies andadvancements. Medical advances in the treatment
of HIV include the availability of more potent,
convenient and well-tolerated antiretroviraltreatments that allow people with HIV to begin
treatment immediately and improve both short-and
long-term health outcomes. Research to date has
found that people with HIV who take antiretroviraltreatment daily as prescribed and achieve andmaintain sustained viral suppressiona haveeffectively no risk of sexually transmitting thevirus to a HIV-negative partner.3,4,5,6 This is known
as undetectable equals untransmittable (U=U)
and Treatment as Prevention (TasP).
Australia has made significant steps towards
providing equitable access to pre-exposure
prophylaxis for people at medium and high risk.
This, combined with high rates of testing andtreatment, has the potential to considerably
advance our response to HIV.
Meeting and exceeding international HIV obligations
and targets is a critical part of Australia’s response.
Internationally, Australia supports the 2016 United
Nations Political Declaration on HIV and AIDS:
On the Fast-Track to Accelerating the Fight against
HIV and to Ending the AIDS Epidemic by 2030,7
which provides a global framework for action on HIV.
The declaration endorses the UNAIDS 90–90–90
HIV treatment targets.8
Currently defined as a sustained viral loadof less than 200 copies/mL.

a

Eighth National HIV Strategy 2018–2022

5

The aim of these targets is that, by 2020, 90 per
cent of all people with HIV will know their HIV
status, 90 per cent of all people with diagnosed
HIV infection will receive sustained antiretroviraltherapy (treatment coverage) and 90 per cent of all
people receiving antiretroviral therapy will have viral
suppression. Australia is on track to achieving thesetargets ahead of 2020, and sights are now set on
achieving the UNAIDS Fast-Track 95–95–95 global
targets to end the HIV epidemic.9
However, we need to do more than achieve theseinternational targets if we are to reach our goal ofvirtual elimination of HIV transmission, achieve
longer and healthier lives for people with HIV andeliminate stigma and discrimination. A concerted
effort is needed by all Australian governments,
clinicians, researchers, community and professionalorganisations, and individuals, to support action in
key areas and accelerate an effective and equitable
response to HIV. The meaningful involvement ofpeople with HIV and all priority populations is criticalto ensuring our efforts are inclusive, responsive andconnected to the needs and concerns ofthese communities.
Since the first national HIV strategy in 1989,
Australia’s response has been underpinned bya partnership approach between the AustralianGovernment, state and territory governments,
people with and affected by HIV, community
organisations, researchers and clinicians.
The Australian Government acknowledges thesignificant contribution of people with HIV and thenational community and health peak organisations,and other organisations, representing communities
and the clinical workforce over the course of theprevious HIV strategies. These organisations,
including the Australian Federation of AIDS
Organisations; the National Association of People
with HIV Australia; the Australian Injecting

6

and Illicit Drug Users League;
Scarlet Alliance, Australian Sex Workers’
Association; and the Australasian Society for HIV,
Viral Hepatitis and Sexual Health Medicine haveplayed a critical role in the success of Australia’s
response to HIV. This strong foundation and thecommitment and work of all partners meansthat Australia remains well placed to build on the
successes of the Seventh National HIV Strategy
2014–2017, realise gains for all priority populations,and achieve the goal of becoming one of the first
countries to virtually eliminate new
HIV transmissions.

Gratitude is expressed to those
who participated in the stakeholder
consultations and contributed tothe strategy development process—in particular, the members andorganisations represented on the
Blood Borne Viruses and Sexually
Transmissible Infections Standing
Committee (see Figure 1).

Figure 1:
Blood Borne Viruses and Sexually
Transmissible Infections Standing
Committee (BBVSS)

Peak organisations

State and territory governments

Australian Federation of AIDS Organisations(AFAO)ACT Health

Australian Indigenous Doctors’ Association (AIDA)
Australian Injecting & Illicit Drug Users League(AIVL)
Australasian Society for HIV, Viral Hepatitis andSexual Health Medicine (ASHM)
Hepatitis Australia
National Association of People with HIV Australia(NAPWHA)
Scarlet Alliance, Australian Sex Workers
Association

NSW Ministry of Health
NT Department of HealthQueensland Health
SA Department for Health and Wellbeing
Tasmanian Department of Health and Human
Services
Victorian Department of Health and Human
Services
WA Department of Health
Australian Government Department of Health

BBVSS is a key advisory body reporting to the Australian Health Ministers’ Advisory Council through theAustralian Health Protection Principal Committee on strategic policy, programs, social issues and activities
related to HIV, viral hepatitis and sexually transmissible infections (STI).

Eighth National HIV Strategy 2018–20227

2.
Guidingprinciples
The Eighth National HIV Strategy
2018–2022 includes guiding
principles to support a high-quality,
evidence-based and equitable
response to HIV. These are includedin each of the blood borne viruses(BBV) and sexually transmissible
infections (STI) strategies and are
drawn from Australia’s efforts overtime to respond to the challenges,
threats and impacts of HIV,viral hepatitis and STI. Perhaps
most critical is the ongoing andmeaningful participation of people
with HIV and affected communities
in all aspects of the response.
This is central to the partnershipapproach and is key to the successof this strategy.

1. Centrality of people with HIV and meaningful
involvement of priority populationsb
The centrality of people with HIV in accordancewith the MIPA/GIPA principle and their meaningful
participation along with other priority populations
is essential to the development, implementation,
monitoring and evaluation of effective programs
and policies.
2. Human rights
People with HIV have a right to participate fully
in society, without experience of stigma or
discrimination. They have the same rights tocomprehensive and appropriate information andhealth care as other members of the community,
including the right to the confidential and sensitive
handling of personal and medical information.
3. Access and equity
Health and community care in Australia shouldbe accessible to all, based on need. The multiple
dimensions of inequality should be addressed,
whether related to gender, sexuality, disease status,
drug use, occupation, socio-economic status,
migration status, language, religion, culture or
geographic location, including custodial settings.
Special attention needs to be given to working with
Aboriginal and Torres Strait Islander people to close
the gap between Aboriginal and Torres Strait Islander
health status and that of other Australians.
4. Health promotion
The Ottawa Charter for Health Promotion provides
the framework for effective action under thisstrategy. It facilitates the active participation ofaffected communities and individuals to increase
their influence over the determinants of their healthand the formulation and application of laws andpublic policies to support and encourage healthy
behaviours and respect for human rights.

8

5. Prevention
The transmission of HIV can be reduced throughthe appropriate combination of evidence-based
biomedical, behavioural and social approaches
within a supportive enabling environment.
Education and prevention programs, together withaccess to the means of prevention, are prerequisites
for adopting and applying prevention measures.
6. Quality health services
A strong multidisciplinary workforce of motivated,trained and regularly updated health professionals,
community and peer-based workers from, and who
work with, priority populations are vital to delivering
culturally appropriate, high-quality services acrossAustralia. Coordination and integration of healthservices across a number of settings is essential inorder to respond to new technologies, best practice,and to best support people with or at risk of HIV tomake informed choices about their treatment andprevention.
7. Harm reduction
Harm reduction approaches underpin effective
measures to prevent transmission of HIV.
Approaches include needle and syringe programs,
alcohol and other drug treatment programs,
counselling and mental health support, andmeasures to address social determinants of health.

9. Commitment to evidence-based
policy and programs
The national response to HIV has at its foundation
an evidence base built on high-quality researchand surveillance, monitoring and evaluation.
A strong and constantly refining evidence base isessential to meet new challenges, evaluate current
and new interventions and develop effective social
policy. The development and dissemination ofevidence-based national clinical guidelines andother information resources on testing, treatment,
care and support is critical.
10. Partnership
Effective partnerships exist between affected
communities, national peak organisations
representing the interest of communities,
and the clinical workforce, government andresearchers. These relationships are characterisedby consultation, cooperative effort, clear roles
and responsibilities, meaningful contributions,empowerment, respectful dialogue and appropriate
resourcing to achieve the goals of the strategies.
It includes leadership from the Australian, state
and territory governments and the full cooperative
efforts of all members of the partnership toimplement agreed directions.

8. Shared responsibility
Individuals and communities share responsibility
to prevent themselves and others from becoming
infected and to inform efforts that addresseducation and support needs. Governments andcommunity organisations have a responsibility toprovide the necessary information, resources andsupportive environments for prevention.

b
The MIPA/GIPA Principle (Greater Involvement of PLHIV) is fromthe Paris AIDS Summit Declaration in 1994, endorsed by Australia
and 42 other countries. Available at: http://data.unaids.org/pub/briefingnote/2007/jc1299_policy_brief_gipa.pdf

Eighth National HIV Strategy 2018–20229

3.
Snapshotof HIV in Australia
Figure 2: Snapshot of HIV in Australia 2,3,4,5,6,10,11,12

What is HIV

What health issues does it cause?

Human immunodeficiency virus (HIV) is a virus that
impairs the body’s immune system by reducing
CD4 T cells. Acquired Immune Deficiency Syndrome(AIDS) is the late stage of HIV infection. Progression
to AIDS is rare in Australia.

Without treatment, HIV damages the immune
system which can lead to serious infections andcancers over time.

Routes of transmission
HIV is transmissible by sexual and blood contact
as well as from mother to child during child birthor through breastfeeding. The main route of HIV
transmission in Australia continues to be sexual
contact between men.

10

With treatment, people with HIV who are diagnosed
early can experience normal life expectancy andnot develop AIDS. However, people with HIV may
experience comorbidities such as cardiovasculardisease, kidney disease, various cancers.
Stigma and discrimination in relation to HIV
can have significant impacts on health outcomes
and can lead to social isolation and poorer
mental health.
Discriminatory or unfair treatment increases
the negative impact on the health status of people
with HIV. Stigma and discrimination have beencorrelated with poor access to health care andcan create barriers to services and support.

How is it managed?

Prevention

There is currently no effective cure for HIV.
Antiretroviral treatment (ART) can suppress
the virus to undetectable levels, which prevents
disease progression and makes onward
transmission rare. Managing comorbidities andimproving quality of life for people with HIV are
essential components of HIV management.

Prevention strategies include: condoms andother safe sex practices; Treatment as Prevention(TasP); safer injecting drug use practices;increasing testing rates; reducing time between
infection and diagnosis; early and sustained
treatment to achieve undetectable viral load;
retention in care; raising community awarenessthrough effective prevention messages; peer
education; pre-exposure prophylaxis (PrEP)
and post-exposure prophylaxis (PEP).

New diagnoses
The number of HIV notifications newly
diagnosed in Australia has remained stable from2012—2016, with 1013 new diagnoses in 2016.

Prevalence
26 444 (0.1% of total population) people with
HIV in 2016.
Estimated 7.3% prevalence among gay andbisexual men.*
Estimated 1.4% prevalence among people
who inject drugs.

Testing and care
Of the estimated 26 444 people living with
HIV in 2016:•

89% were diagnosed by the end of 2016

People with HIV have an important role toplay in HIV prevention, including through theirknowledge and experience of treatment, as
community educators and in preventing onward
HIV transmission. Research to date has foundthat people with HIV who take ART and achieve
and maintain sustained viral suppression# haveeffectively no risk of sexually transmitting thevirus to an HIV-negative partner. This iscommonly referred to as undetectable =untransmittable or U=U.
PrEP is an antiretroviral treatment thatallows people who do not have HIV but who
are at medium or high risk of being infected,
to prevent infection by taking a daily
pre-exposure prophylaxis.
PEP is an ART that can be taken after being
potentially exposed to HIV, in order to prevent
becoming infected.
There is currently no vaccine for HIV.

And of those diagnosed:•

95% were retained in care
As defined by the Gay Community Periodic Surveys
Currently defined as a sustained viral load of less than
200 copies/mL*• 86% were receiving ART, and of those on ART,
93% had achieved viral suppression.

#

Eighth National HIV Strategy 2018–2022

11

4.
About thisstrategy

It is one of five national strategies that, together,outline a framework for a high-quality andcoordinated national response to BBV and STI inAustralia. These five strategies are:

The Eighth National HIV Strategy
sets the direction for Australia’s
continuing response to HIV for 2018
to 2022. It builds on achievements
and lessons learned from previous
strategies.

2. Fifth National Hepatitis C Strategy
2018–2022

1. Third National Hepatitis B Strategy
2018–2022

3. Eighth National HIV Strategy 2018–2022(this strategy)
4. Fourth National Sexually Transmissible
Infections Strategy 2018–2022
5. Fifth National Aboriginal and Torres Strait
Islander Blood Borne Viruses and Sexually
Transmissible Infections Strategy 2018–2022.
Each strategy has a specific focus but sharessome structural elements, including guiding
principles, goals, targets, priority areas (seeSection 5, ‘Measuring progress’) and definedpriority populations. Also, all five national BBV andSTI strategies have key priority areas for action,
including education and prevention, testing,treatment and management, equitable access andcoordination of care, workforce, improving data andsurveillance, and stigma and discrimination.
The Eighth National HIV Strategy aims to provide
a framework for the efforts of all partners in the
response to HIV, guide resourcing decisions andmonitor progress. It is informed by progress
made under the Seventh National HIV Strategy
2014–2017; the effectiveness of current and past
responses to HIV in Australia and internationally;
the identification of gaps and opportunities;
and consultation with governments, community
organisations, researchers, health professionals andother stakeholders across the country. This strategy
is also informed by, and responds to, a range ofsurveillance data and research on HIV in Australia
and its impact on priority populations.

12This strategy complements other jurisdictional,
national and international policy documentsthat contribute to the HIV response and supports
the achievement of existing commitments.
These include:•

state and territory HIV strategies• Australian Health Ministers AIDS 2014
Legacy Statement• National Strategic Framework for Aboriginal andTorres Strait Health Plan 2013–2023•

This strategy acknowledges that some states andterritories have set or may set different targets todrive progress and that the goals and targets ofthis strategy are intended to facilitate jurisdictional
efforts. Wherever possible, jurisdictions areencouraged to match or exceed the targets ofthis strategy.
Further detail on the implementation of thisstrategy, including the associated action plan, is
provided in Section 8, ‘Implementing this strategy’.

National Drug Strategy 2017–2026• Action Plan: Enhanced response to addressing
sexually transmissible infections (and blood borne
viruses) in Indigenous populations•

Aged Care Diversity Framework• World Health Organization (WHO) Global Health
Sector Strategy on HIV 2016–2021• 2016 United Nations Political Declaration on
HIV and AIDS: On the Fast-Track to Accelerating theFight against HIV and to Ending the AIDS Epidemic
by 2030• Regional Action Plan on the Triple Eliminationof Mother-to-Child Transmission of HIV, Hepatitis B
and Syphilis.
This strategy also supports progress towards
Sustainable Development Goal 3 (‘Ensure healthy
lives and promote well-being for all at all ages’)of the United Nations 2030 Agenda for
Sustainable Development.

Eighth National HIV Strategy 2018–2022

13

Progress under the Seventh National
HIV Strategy 2014–2017
Progress under the Seventh National HIV
Strategy 2014–2017 provides a context for theachievements in Australia to date (see Figure 3).
These achievements reflect the joint efforts ofgovernments, community organisations, affected
communities, researchers and clinicians throughthe partnership approach.

Figure 3: Key achievements under theSeventh National HIV Strategy 2014–2017 2
Highly successful needle andsyringe programs coupled withservices provided by peer-basedorganisations have ensured low
prevalence amongst people who
inject drugs

A broad community and clinicaleffort to expand testing coverage,
including through making testingeasier and more accessible, has
increased testing rates for gay
and bisexual menc

Continued health promotion andprevention efforts of peer-based sex
worker organisations have sustained
the low prevalence of HIV amongsex workers

By the end of 2017, approximately
15 351 people who are at higher
risk of acquiring HIV were enrolled in
pre-exposure prophylaxis (PrEP)
trials conducted by states andterritories, and this has continued
to grow. The impact of these trials
on national HIV transmission rates
is expected to be observed over the
coming years.

High quality antenatal care hassustained the virtual elimination of
mother-to-child transmission
Community mobilisation andcommunity-led education programs
among gay men have continued tocontribute to the stabilisation in
HIV notifications from 2012
to 2016

14

An increase in treatment uptake,with an estimated 86% of people
diagnosed with HIV receiving
antiretroviral therapy and 93% of
people on ART having a suppressedviral load in 2016

While progress under the Seventh National HIV
Strategy 2014–2017 has been notable in someareas, there are challenges remaining that need
to be overcome.
Overall, Australia’s HIV prevalence among thegeneral population remains one of the lowest amongdeveloped countries. There are approximately
26 000 people estimated to currently be living with
HIV.2 The number of new HIV cases diagnosed eachyear has remained stable at around 1000 people
over the past five years.2
Australia has made significant gains in a numberof areas. It has sustained the virtual elimination of
mother to child HIV transmission and low rates of
HIV amongst sex workers and people who injectdrugs; it has significantly increased treatment
uptake by people diagnosed with HIV; and it has
effectively maintained prevention programs forpriority populations.
The following summarises progress in relation to thespecific targets set under the previous strategy:• Australia has sustained the virtual elimination of
HIV among sex workers, among people who injectdrugs and mother-to child transmission in linewith the targets of the previous strategy. This has
been partly a result of the maintenance of effective
prevention programs targeting sex workers andpeople who inject drugs, which was also a targetof the previous strategy.
• Treatment coverage of people with HIV was
86 per cent in 2016.2 It is likely that in the near
future, Australia will achieve the target of 90
per cent of people diagnosed with HIV being on
treatment, which was a target of the previous
strategy and is also an agreed UNAIDS target.
• Sexual transmission (both male-to-male andheterosexual) remained static between 2012 and2016, and the target of a 50 per cent reduction
in sexual transmission of HIV by 2015 was
not achieved.2• The rate of newly diagnosed HIV among
Aboriginal and Torres Strait Islander people
increased by 30 per cent between 2012 and 2016.
Rates of diagnoses more than doubled in the period
since 2008 (from 19 in 2008 to 46 in 2016).13
The previous strategy’s target of sustaining low
general population rates of HIV in Aboriginal andTorres Strait Islander people and communities was
not achieved. This is of great concern.
Gay men and other MSM continue to be the mostcommonly reported population group exposed toHIV. Nationally, 70 per cent (712) of cases in 2016
were attributed to this priority population.2 There
are also increasing rates of transmission amonggay men and other MSM from Asia2—an issue that
requires specific attention.
Further detail about the epidemiology of HIV in
specific priority populations is provided in Section 6,‘Priority populations’.
During the period of the previous strategy, workcommenced on the development of an indicator
to measure progress in achieving the objectiveof eliminating the ‘negative impact of stigma,
discrimination, and legal and human rights issues
on people’s health’. This indicator will be used tomeasure progress under this strategy.
The limited progress demonstrated against sometargets of the previous national strategy, including
an increase in rates of HIV among Aboriginal andTorres Strait Islander people and the stabilisationof sexual transmission, indicate that a revitalised
response to these challenges is needed.

Where the term ‘gay and bisexual men’ is used in the document,
this is a reflection of the methodology utilised for the dataset
described—notably, the data collected by the AustralianCollaboration for Coordinated Enhanced Sentinel Surveillance(ACCESS). For the purposes of this strategy, the terminology
used elsewhere is ‘gay men and other men who have sex withmen (MSM)’.

c

Eighth National HIV Strategy 2018–2022

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5.
Measuring
progress
This strategy has overarching goals,
targets and priority areas which will
guide the national response to HIV
for 2018–2022. Indicators andassociated data sources formeasuring progress towards eachtarget are included in the Surveillanceand Monitoring Plan for the fivenational BBV and STI strategies.

16

Goals
• Virtually eliminate HIV transmissionin Australia within the life of this strategy• Sustain the virtual elimination of
HIV transmission among people who
inject drugs, among sex workers andfrom mother to child• Reduce mortality and morbidity
related to HIV• Eliminate the negative impact ofstigma, discrimination, and legal andhuman rights issues on people’s health• Minimise the personal and social
impact of HIV

Targets• Increase knowledge of treatment as prevention
for individuals at risk of HIV

By the end of 2022:• Improve the frequency, regularity and targetingof access to testing for priority populations anddecrease rate of late diagnoses

1. Increase the proportion of people with HIV(in all priority populations) who are diagnosed
to 95 per cent
2. Increase the proportion of people diagnosed
with HIV on treatment to 95 per cent
3. Increase the proportion of those on treatment
with an undetectable viral load to 95 per cent
4. Reduce the incidence of HIV transmissions
in men who have sex with mend

• Improve early uptake and sustained treatment
to improve quality of life for people with HIV andprevent transmission• Ensure health care and support services areaccessible, coordinated and skilled to meet therange of needs of people with HIV, particularly as
they age

5. Reduce the incidence of HIV transmission inother priority populationsd• Ensure people with HIV are engaged in thedevelopment, delivery and evaluation of theservices they use

6. Sustain the virtual elimination of HIV amongsex workers, among people who inject drugs andfrom mother to child through the maintenance ofeffective prevention programs• Facilitate a highly skilled, multidisciplinary
workforce that is respectful of and responsive
to the needs of people with HIV and otherpriority populations

7. Increase the proportion of eligible people who
are on PrEP, in combination with STI prevention
and testing to 75 per cent

• Implement a range of initiatives to address
stigma and discrimination and minimise theimpact on people’s health-seeking behaviourand health outcomes

8. 75 per cent of people with HIV report goodquality of life
9. Reduce by 75 per cent the reported experienceof stigma among people with HIV, and expressionof stigma, in relation to HIV statuse

Priority areas f• Maintain focus on health promotion,
prevention and peer education to improveknowledge and awareness of HIV in priority
populations and reduce risk behaviours
associated with the transmission of HIV• Continue to work towards addressing
the legal, regulatory and policy barriers which
affect priority populations and influence theirhealth-seeking behaviours• Strengthen and enhance partnerships andconnections to priority populations, including
the meaningful engagement and participationof people with HIV• Continue to build a strong evidence basefor responding to HIV in Australia, informed byhigh-quality, timely data and surveillance systems• Ensure priority populations have accessto the means of prevention• Increase knowledge of, and access to,treatment as prevention for individuals with HIV

dCompared with 2016 data.

eCompared with 2018 data.

Links to Section 7, ‘Priority areas for action’.
Priority population and priority settings are describedin Section 6, ‘Priority populations and settings’.

fEighth National HIV Strategy 2018–2022

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6.
Priority
populations
and settings
In our response to HIV it is importantto prioritise emerging populations
at elevated risk and vulnerability
as well as those populations thatare impacted historically and areat continued risk.

HIV disproportionately impacts a number ofkey populations. This strategy identifies priority
populations and settings (see Figure 4) andacknowledges that many individuals may identify
with multiple priority populations and settings.
This results in a diverse variety of intersecting
characteristics and risk factors unique to eachindividual. In accordance with the guiding principleof access and equity, the unique challenges andexperiences within all priority populations need
to be considered in the response. This includes,
but is not limited to, all gender expressions andexperiences, disabilities, cultural and ethnic
identities, different geographic settings, sexual
orientations and religious affiliations.
While women are not represented here as a distinct
priority population, women are recognised acrossmost other priority populations. Women, boththose with HIV and those at risk of HIV, have uniquechallenges and experiences that are not easily
addressed solely on the basis of risk. It is important
to apply a gender lens to all aspects of the HIV
response to ensure women’s needs are considered
and addressed.

18

Figure 4:
Priority populations for the Eighth National HIV Strategy 2018-2022

Priority populations

Trans and gender diverse people

People in custodial settings

People who inject drugs

People with HIV

Gay men and other men
who have sex with men

Aboriginal and Torres
Strait Islander people

Culturally and linguistically diverse
people from high HIV prevalencecountries, people who travel to thesecountries, and their partners

Sex workers

Priority settings
Geographic locations withhigh prevalence and/or
incidence of HIV
Community, primary health andother health services, including
Aboriginal Community
Controlled Health Services/Aboriginal Medical Services

Custodial settings

Other services that support
priority populations, including
peer-based services, needle
and syringe programs,
homelessness services, andmental health services

Places where priority
populations live, workand socialise
Aged Care settings

Note: This graphic is not intended to reflect equal priority or prevalence among groups

Eighth National HIV Strategy 2018–2022

19

People with HIV
In Australia, accessible and effective antiretroviraltreatment has significantly improved the livesof people with HIV. Early detection, treatment
adherence and a focus on retention in care supports
the achievement of an undetectable viral load. An
undetectable viral load improves health outcomesand quality of life and, if sustained,g results in there
being effectively no risk of onward transmission of
HIV through sexual contact. Despite the availabilityof effective antiretroviral treatments, people withHIV also experience comorbidities and other healthissues associated with HIV infection.
Poorer mental health outcomes in people withHIV have been linked to stigma, discriminationand the lack of an enabling environment. 14,15,16,53,54
Due to shared modes of transmission and otherrisk factors, people with HIV are also more likely
to self-report key comorbidities and drug use;
have high rates of certain STI; and have co-infection
with syphilis, hepatitis B and hepatitis C whencompared with people from a similar demographic
who do not have HIV.17,18,19,20,21,22
The proportion of people with HIV in older
age groups is growing, and this has important
implications for the healthcare system and agedcare services.23,24 Like the general ageing population,
people with HIV will experience health conditions
more common with age. However, they are also
more likely to experience complex age-relatedcomorbidities and chronic illnesses—for example,
cardiovascular disease25—than age-matched
populations.
In relation to mother-to-child transmission, among
223 women with HIV who gave birth in the five-year
period from 2012 to 2016, the transmission rate
to newborns was 2 per cent compared with 39 percent in the period from 1985 to 1991 and 28 per centfrom 1992 to 1996.2 There were no cases notified
in 2016.2 It is important that high-quality antenatal
care and education is provided to all women in orderto sustain this achievement.26

Currently defined as a sustained
viral load of less than 200 copies/mL.

g

20

The meaningful participation of people with HIV inthe development, implementation, monitoring andevaluation of HIV programs and policies is central
to the partnership approach and the success of
this strategy.
Within the population of people with HIV, tailoredapproaches are needed, including for people withcomorbidities, older people, people with complex
needs, Aboriginal and Torres Strait Islander
people, women with HIV, people from culturally
and linguistically diverse (CALD) backgrounds andpeople who are ineligible for subsidised health careand medicines.

Gay men and other men who havesex with men
HIV in Australia remains concentrated amonggay men and other MSM (70 per cent of new
notifications in 2016).2 However, over the past five
years, HIV testing among gay and bisexual men has
continued to increase, with the proportion having a
repeat HIV test within six months of a previous test
at 43 participating sexual health clinics increasingfrom 37 per cent in 2012 to 50 per cent in 2016.2
Increases in HIV testing also occurred in gay andbisexual men attending high-caseload generalpractice clinics—from 22 per cent in 2013 to 33
per cent in 2016.2
Alongside TasP, the listing of PrEP on the
Pharmaceutical Benefits Scheme (PBS) provides anopportunity to significantly reduce HIV transmission
among gay men and other MSM. However,consistent condom use with casual partners
has been declining over the past five years.2 It istherefore important that the increased availabilityof PrEP is accompanied by STI prevention
education, regular and comprehensive HIV andSTI testing, and ongoing commitment to partner
notification after STI diagnosis. Addressing thechallenges in access to PrEP and other preventative
treatments for those individuals not eligible for
Medicare is also important.
As noted earlier, the increasing rates oftransmission among gay men and other MSM from
Asia2 is an issue that requires specific attention in
the response.

Aboriginal and Torres Strait
Islander people
Within the priority population of Aboriginal andTorres Strait Islander people, gay men and other
MSM remain the group at greatest risk of HIV.
However, in the period from 2012 to 2016, Aboriginal
and Torres Strait Islander people were more likely toacquire HIV from heterosexual contact (20 per centof new notifications) and needle and syringe sharing(14 per cent) when compared with non-Indigenous
populations—at 15 per cent and 3 per centrespectively.13 The higher prevalence of other
STI also contributes to the increased risk of HIV
transmission.27,28
While the prevalence of HIV remains low among
Aboriginal and Torres Strait Islander people, newnotifications of HIV in Aboriginal and Torres Strait
Islander people have steadily increased since 2007.
Notification rates are over two times higher thanthe Australian-born non-Indigenous population(6.4 per 100 000 versus 2.9 per 100 000).13
There has been a 52 per cent increase in thenumber of new notifications in men since 2012,
while the number of new notifications in women
has remained fairly stable over this period.
In 2016, rates of receptive needle and syringe
sharing were greater amongst Aboriginal and Torres
Strait Islander respondents to the Australian Needle
and Syringe Program Survey when compared with
the non-Indigenous population.29 Between 2007
and 2011, there were higher levels of condomlessanal intercourse among Aboriginal and Torres Strait
Islander gay and bisexual men when comparedwith non-Indigenous gay and bisexual men.30
Within this population, tailored, culturally inclusive
and safe approaches are needed for people fromremote, regional and urban areas; women; people
who are highly mobile; people who inject drugs;
people with complex needs; and people incustodial settings.

Epidemiology, policy context and priority areas
for action in relation to HIV in Aboriginal andTorres Strait Islander people are more specificallyaddressed in the Fifth National Aboriginal and Torres
Strait Islander Blood Borne Viruses and Sexually
Transmissible Infections Strategy 2018–2022.

Culturally and linguistically diverse
people from high HIV prevalencecountries, people who travel tohigh-prevalence countries, andtheir partners
New HIV diagnoses have increased for people
from high HIV prevalence countries and theirpartners—they accounted for over one-third of
the cases of heterosexual transmission of HIV
in 2016 in Australia.2
In 2016, the Australian national notification rate
was 4.2 per 100 000 population, while the rate inpeople born in Australia was slightly less, at 3.4
per 100 000.2 This compares with a notification
rate of 17.3 per 100 000 for people born in theAmericas (North and South America); 17.1 per
100 000 for people born in South-East Asia; and10.9 per 100 000 for those born in sub-SaharanAfrica. From 2012 to 2016, the highest proportionof late diagnoses was in people born in Central
America, Sub-Saharan Africa and South-East Asia.2
Of the women who reported heterosexual sex as
their risk exposure, 28 per cent were born in ahigh-prevalence country and 4 per cent had sex
with a person from a high-prevalence country.2
Tailored approaches that effectively address
cultural, language and gender issues across all
aspects of the response to HIV are needed forseveral sub-populations, including gay men andother MSM, people who inject drugs, international
students, people who are ineligible for subsidised
health care, refugees, humanitarian entrants andwomen. Specific messaging for people who travel tohigh-prevalence countries about the risks of HIV andprevention strategies is also important.

Eighth National HIV Strategy 2018–2022

21

Sex workers
Sex workers are a priority population due to thepotential higher exposure risk associated with
sex work. Continued prevention efforts led by sex
workers and their organisations ensure that HIV
prevalence among Australian sex workers remains
among the lowest in the world.
Sex workers experience barriers to accessing
health services including stigma and discrimination.
They also face a range of regulatory and legal issues
including criminalisation, licensing, registrationand mandatory testing in some jurisdictions.31
These barriers create a complex system of
impediments to evidence-based prevention, accessto testing and healthcare services. They can resultin increased risk of BBVs and STIs, loss of livelihood,and risk to personal and physical safety. Evidence
that has emerged since the previous strategy
definitively shows that decriminalisation of sex work
is linked to the reduction of HIV risk and rates.32
Within this population, tailored approaches areneeded for sub-populations of sex workers,
including street-based sex workers, sex workers
who work in isolation, sex workers in rural andremote areas, migrant and CALD sex workers,
Aboriginal and Torres Strait Islander sex workers,
male sex workers, trans and gender-diverse sex
workers, sex workers with HIV, people with complex
needs and people from other priority populations.
Tailored approaches that address stigma anddiscrimination and the regulatory and legal barriers
experienced by sex workers are required.

People who inject drugs
Australia’s highly successful needle and syringe
programs coupled with services provided bypeer-based organisations have maintained low
HIV infection rates among people who inject drugs.
However, this population remains a priority due tothe potential risks associated with receptive needle
and syringe sharing.
Between 2012 and 2016, the proportion of people
who injected drugs and attended needle and syringe
programs reporting receptive needle and syringe
sharing in the last month increased from 16 per

22cent to 19 per cent.29 These rates were similar inmen and women. Rates of HIV are influenced by
the availability of injecting equipment. Access toinjecting equipment in rural, regional and remote
Australia requires particular consideration within
this context.
Within this population of people who inject drugs,
tailored approaches are needed for people withcomplex needs and people from other priority
populations, particularly Aboriginal and Torres Strait
Islander people, gay men and other MSM. People
experiencing mental illness or homelessness arealso important sub-populations identified as beingat higher risk, and they need to be specificallyconsidered in the response.2,16,17,33,34 Aboriginal
and Torres Strait Islander people are more likely
to acquire HIV from and participate in receptive
needle and syringe sharing when compared with
the non-Indigenous population. This indicates thatan individual approach targeting promotion of andaccess to sterile injecting equipment is needed
for this population. This is further explored anddefined in the Fifth National Aboriginal and Torres
Strait Islander Blood Borne Viruses and Sexually
Transmissible Infections Strategy.
There are also broader issues in relation to
non-injecting drug use that may also require
attention. This includes recreational drug use
among MSM, particularly when used to enhancesexual experiences.35 Numerous studies have foundthat HIV and other STI are more likely to occur ingay men and other MSM who use recreational drugs
than those who do not, although the causal natureof this requires further investigation.36

People in custodial settings
People in custodial settings are at risk of HIV
transmission through shared use of injecting
equipment, unsafe tattooing and condomless sex.
The National Prison Entrants’ Bloodborne Virus andRisk Behaviour Survey Report, which provides dataon the prevalence of HIV and other BBV and STI
among Australian prison entrants, found no newcases of HIV among the 431 people entering into
custodial settings who were voluntarily screened(out of a possible 862) in 2016.38 In addition, theprevalence of HIV among people entering custodial
settings has remained low over the past five years.38
However, the risk of transmission in thecontext of undiagnosed HIV or detectableviral load is significant given the nature of risk
exposures occurring in custodial settings.37,38,39
Barriers to HIV prevention include a lack of accessto sterile injecting equipment, sterile tattooing
equipment, PrEP, post-exposure prophylaxis(PEP), TasP, health promotion and condoms; andhigh levels of stigma and discrimination, which
also impact on access to HIV prevention, testing
and treatment. Limited data are available ondischarges from custodial settings. While data on
the percentage tested for BBV and STI on leaving
the prison system are available, the results of thesetests are not available.40 This highlights a significant
gap in our understanding of HIV and other BBV
and STI in custodial settings. Care coordination /through-care for men and women living with HIV,ensuring continuity of access to medication, andengagement with medical care and community
supports are crucial to reduce transmission risk
after release from custody.

and care that need to be taken into consideration in
the response to HIV.
Increased community engagement with trans andgender-diverse people, alongside improved data
and research, is needed to better understand how
HIV impacts this population. Inclusion of trans andgender-diverse people in the HIV response is apriority for all stakeholders.
Improved access to HIV prevention, testing andtreatment will require improving the levels ofliteracy about gender diversity in the broader healthworkforce. Healthcare settings will require support
to provide appropriate and sensitive sexual healthcare to trans and gender-diverse people.
Within this population, tailored approaches areneeded for Aboriginal and Torres Strait Islander
people, including Sistagirls/Sistergirls,
Brotherboys and other two-spirit people.

Effective HIV prevention, testing andtreatment for this population requires a strong,whole-of-government partnership approach
involving those concerned with juvenile detention
centres as well as adult prisons.

Trans and gender-diverse people
HIV prevalence among trans and gender-diverse
people is unknown in Australia due to a paucity
of data. However, international studies in lowand high-income countries have found that HIV
prevalence among trans and gender-diverse people
is many times that of the general population.41,42
Many trans and gender-diverse people are alreadypart of existing priority populations, such as trans
MSM, trans men, trans women and non-binary sex
workers, people who inject drugs, and others, andthey may share some of the same risk exposuresof other priority populations. However, trans andgender-diverse people may also have specific sexual
health needs and barriers to prevention, treatment

Eighth National HIV Strategy 2018–2022

23

7.
Priority areas
for action
This strategy includes a set ofpriority areas for action designed
to support the achievement of thegoals and targets. Each priority area
for action relates to one or more of
the targets. It is the interaction ofthese actions as a whole which isessential to the achievement of
the strategy.

Australia’s response to HIV builds on theachievements and lessons learned over the
past 30 years and is shaped by a number of key
challenges and opportunities. Some of these havebeen around for some time and others are new
and reflect ongoing changes in the epidemiology ofHIV, biomedical prevention technologies and otheraspects of the response.
Some of the key challenges and opportunities
include the high numbers of late diagnoses inparticular population groups; access to preventative
measures and diagnostic technologies, including
PrEP, PEP, TasP, HIV rapid testing and needle andsyringe programs; maintaining and improving thegains made in treatment coverage; and improving
the quality of life for people with HIV. This strategy
is designed to address these while recognising theneed to maintain key aspects of the response thatremain pivotal to its success and respond flexibility
to other issues as they arise.

Education and prevention• Maintain focus on health promotion, prevention
and peer education to improve knowledge andawareness of HIV in priority populations and reducerisk behaviours associated with HIV transmission• Ensure priority populations have access to themeans of prevention• Increase knowledge of, and access to, treatment
as prevention for individuals with HIV• Increase knowledge of treatment as prevention
for those individual at risk of HIV
Effective HIV prevention relies upon readyaccess to the means of prevention, including
HIV treatment, PEP, PrEP, condoms and sterile
injecting equipment, together with a strong enabling
environment to support access and use. This needs
to be combined with sustained, community-led
prevention education programs for people at riskof HIV to improve health literacy and empower
priority populations.

24

It is important that priority populations areprovided with tailored education, including correctand consistent condom use, safe sex practices,
community mobilisation, peer education andoutreach, health promotion, capacity development,
harm reduction approaches, needle and syringe
programs, increased testing (including making
it easier for people to ask for and to be offeredtesting), and promotion of early HIV treatment.
Prevention approaches that have worked well inAustralia’s response to date, including peer andcommunity-led prevention and education for people
with HIV, gay men and other MSM, sex workers andpeople who inject drugs, need to be strengthened
and considered for other priority populations.
Collaboration with priority populations andcommunity-led programming are important
to ensure that initiatives are appropriately
targeted, culturally sensitive, gender sensitive,
age appropriate and tailored to local contexts.
TasP plays a central role in HIV prevention.
Education for health professionals and people at riskof or with HIV should outline the benefits of having
an undetectable viral load, including through its role
as a prevention method and in improving the healthand wellbeing of people with HIV. Raising awarenessof the significance of having an undetectable viralload may also assist in addressing HIV-related
stigma, such as alleviating fear of infection, andsupport greater efforts in critical aspects of the
HIV response, including the importance of regulartesting and early treatment.
Another significant development in HIV prevention
is the subsidisation of PrEP through the PBS asof 1 April 2018 for people at medium and high riskof HIVh. Current evidence demonstrates that, forgay men and other MSM, PrEP makes a significant
impact on HIV transmissions if implemented
rapidly alongside high rates of HIV testing andtreatment.43,44 Early evidence from Australian PrEP
access trials indicates that PrEP, combined withhigh rates of testing and treatment and TaSP, canlead to a reduction in rates of HIV transmission.45

To reap the full benefits of PrEP in appropriate
priority populations, it is essential to address theremaining barriers to access, including a lack ofawareness in relevant priority populations and nothaving a general practitioner or other clinician who
is familiar with PrEP. PrEP needs to be combinedwith regular testing for STI, timely treatment andprevention education (particularly in relation to
the importance of condom use for STI prevention),along with current clinical guidelines to support
provider decision-making. STI surveillance
and monitoring is an important part of PrEP
implementation to measure any changes indisease prevalence.
It is important to also recognise the role of PEP in
the prevention ‘toolbox’ for individuals who havebeen exposed (or suspect they have been exposed)
to HIV, including in both non-occupational andoccupational settings.46,47 Continued awareness andaccessibility to this medication for the purposesof PEP is essential.
A combination prevention approach comprisingmultiple methods and interventions is critical forachieving effective prevention and for meetingthe specific needs of priority populations andindividuals.

h
As defined in the PrEP guidelines published by the AustralasianSociety for HIV, Viral Hepatitis and Sexual Health Medicine.
Available at: http://viruseradication.com/journal-details/
Australasian_Society_for_HIV,_Viral_Hepatitis_and_Sexual_
Health_Medicine_HIV_pre-exposure_prophylaxis:_clinical_
guidelines/

Eighth National HIV Strategy 2018–2022

25

KEY AREAS FOR ACTION

Testing, treatment and management

1. Maintain and implement targeted programs,
including community-led and peer-based
approaches, which improve HIV-related knowledge,
reinforce prevention and promote safe behavioursin priority populations• Improve the frequency, regularity and targetingof testing for priority populations and decrease ratesof late diagnosis

2. Promote the availability and effectivenessof PEP and PrEP and facilitate rapid, widespreadand equitable access to PEP and PrEP acrossthe country
3. Ensure clinical prevention approaches aredelivered in combination with education on STI
prevention and regular STI testing
4. Increase the knowledge and awareness of
HIV among general practitioners / primary care
professionals in relation to the suite of available
prevention methods, including TasP, PEP and
PrEP; how to support priority populations; and theavailability and effectiveness of HIV treatment, witha particular focus in areas of high need
5. Support and prioritise TasP by increasingawareness of HIV treatment; promoting the benefitsof having an undetectable viral load; and supporting
access, uptake and adherence to antiretroviraltreatment immediately after diagnosis
6. Ensure the wide distribution and availabilityof sterile injecting equipment and safer injecting
education among people who inject drugs, including
a focus on priority populations and people living inregional, rural and remote areas
7. Improve surveillance and research on priority
populations, including through improved
data collections and greater granularity of
epidemiological data, and use these data to inform
approaches

26• Improve early uptake of sustained treatment
to improve quality of life for people with HIV andprevent transmission
Regular frequent testing in accordance with risk
enables people to know their status and adopt
safe behaviours. It also supports early treatmentcommencement and adherence. Successful
long-term treatment adherence, connection tocare, effective management of comorbidities andside effects, connection to peers, an enabling
environment and building resilience to challenge
stigma are all important in securing an improved
quality of life for people with HIV.
While HIV testing rates have increased in Australia,
the proportion of new HIV cases diagnosed late hasremained stable, and some priority populations
are over-represented in late diagnosis data. These
include people born in high-prevalence countries,
heterosexual people, Aboriginal and Torres Strait
Islander people, and women. In particular, of womenreporting heterosexual sex as an exposure risk from2012 to 2016, the groups with the highest proportionof late diagnoses were those in the age groups of 30
to 39 years and 50 years and older and those bornin South-East Asia and sub-Saharan Africa.2 People
who are diagnosed with HIV late are more likely toexperience comorbidities, and having untreated HIV
increases the risk of onward HIV transmission.
Efforts to increase the frequency of testing for
all people at risk of HIV must be based on theprinciples of voluntary testing, informed consent
and confidentiality which have underpinned theimprovements in testing coverage achieved inAustralia to date. Continued efforts to expand
testing coverage are important. They need to besupported through improved ability to recogniserisk factors and by ensuring a mix of testing options,such as rapid testing in community and after-hours
clinics, are available. Efforts to expand testing
coverage must also be supported by improved
community education, availability and accessibilityof testing services and initiatives to build linkages
between peer educators and testing services.

Testing options that support early diagnosis need
to be linked to the provision of early treatment andcare. Timely patient follow-up is needed to minimise
the time between diagnosis and commencement oftreatment, support patient adherence to treatment,
and support the achievement and maintenance ofsustained viral suppression. This is important for
all priority populations and is already recognised as
an integral component of antenatal care in order toprevent mother-to-child transmission of HIV.
The achievement of the 95–95–95 targets relies
on rapid, affordable and continued access toantiretroviral therapy for all people with HIV andtheir ongoing clinical management in communitybased settings by well-trained and accreditedprescribers. Increasingly, new HIV diagnoses arebeing made in general practice settings.48 Generalpractitioners may require additional support andtraining to be able to provide appropriate ongoingcare to their patients.

KEY AREAS FOR ACTION
8. Expand the use and accessibility of a range of
HIV and STI testing technologies and options andtailor testing approaches to the needs of priority
populations and sub-populations, particularly where
there is a need to improve early diagnosis
9. Improve the knowledge and awareness of healthprofessionals and community-based health workers
of indications for HIV testing, including, for healthprofessionals, the investigation of non-specificsymptoms without identifiable risk factors
10. Ensure that people diagnosed with HIV arepromptly linked to treatment, ongoing care and peer
support using approaches that address the specificbarriers experienced by priority populations andsub-populations across priority settings
11. Promote the use of evidence-based clinicalguidelines and resources
12. Investigate a sustainable model for access totreatment for people with HIV who are ineligiblefor Medicare

Eighth National HIV Strategy 2018–202227

Equitable access to and coordinationof care• Ensure healthcare and support services areaccessible, coordinated and skilled to meet the rangeof needs of people with HIV, particularly as they age• Ensure people with HIV are engaged in thedevelopment, delivery and evaluation of the services
they use
Healthcare and support services need to becoordinated and staff must be appropriately skilled
to meet the range of needs of people with HIV
across the continuum of their care. People withHIV have a unique knowledge of their own treatment
and management and need to be actively engaged
as equal participants in the planning and deliveryof their own care.
The provision of care requires a team-based,
multidisciplinary approach tailored to the needs ofthe individual. Clear protocols and pathways are
essential to ensure that comprehensive care andsupport is delivered in a cohesive way across a
range of medical and community-based settings.
Models and approaches need to facilitate
early referral to treatment services, retain
newly diagnosed patients in care, and maintain(or re-establish) links to services for people with
HIV. Approaches need to be culturally acceptable;
address the specific barriers experienced bypriority populations, including those in regional,
rural and remote communities and with gender andcultural diversity; and take into account the rangeof healthcare and other settings commonly used bypriority populations to maximise their engagement.
The ageing population of people with HIV inAustralia is a key issue to be considered in the
response. Effective treatment has greatly improved
life expectancy and quality of life for people with
HIV, with approximately 40 per cent of people withHIV now aged over 50. This proportion is expected
to continue to increase. Older people with HIV
in Australia are likely to require special care andsupport, including access to high-quality agedcare services, the management of comorbidities,
assistance with treatment adherence,28

and other issues related to ageing.18,19 Stigma anddiscrimination is a central concern for many people
ageing with HIV who may require healthand social services outside of their regular HIV
care and support providers with whom they
have an established relationship.44
There are additional sub-populations in thecommunity, such as people experiencing
homelessness or mental health issues that require
more intensive support and coordination, including
through outreach and district nursing services.

KEY AREAS FOR ACTION
13. Improve the integration of care provided topeople with HIV, including by general practitioners,
sexual health physicians, psychosocial support
services, community pharmacies, communitybased nursing, other health services and specialists,
and aged care services, particularly in rural andremote locations
14. Identify, implement and evaluate models of carethat meet the needs of people with HIV who areageing and ensure quality of care across services
15. Increase capacity for HIV treatment andcare in those health services providing culturally
appropriate care to Aboriginal and Torres Strait
Islander people and culturally and linguisticallydiverse populations
16. Increase HIV awareness, capability andcollaboration of service providers to support people
with HIV, including in settings such as drug andalcohol, mental health, aged care, disability, housing,
employment, child and family, and justice andcorrective services

Workforce• Facilitate a highly skilled multidisciplinary
workforce that is respectful of and responsive tothe needs of people with HIV and other priority
populations
A strong multidisciplinary workforce of motivatedand trained health professionals and community
health, aged care, and peer-based workers who are
from, and who work with, priority populations is vitalto delivering best-practice, culturally appropriate,high-quality services across Australia.
Primary health services, including generalpractice, Aboriginal Community Controlled HealthServices (ACCHS) and Aboriginal Medical Services(AMS), remain priority settings for the delivery of
prevention, testing and treatment services for HIV,in collaboration with specialist care as necessary.
Sexual health clinics and peer-based organisations
involved in health service delivery play an importantrole in providing culturally and age-appropriate
services to priority populations and people whoare not accessing mainstream primary healthservices. Other health services, including specialist,
antenatal, alcohol and other drug and mental healthservices and treatment programs and needle andsyringe programs, are also important settings in the
response to HIV.
Evidence-based, responsive and accessible clinicalguidelines and tools play an essential role insupporting the provision of effective HIV prevention
and care in Australia. These guidelines must be
updated at regular intervals and coupled witheducation and training to build workforce capacity
and capability. This is particularly important insupporting the management of patients withcomplex needs in community-based settings.
Specific education, professional development
and specialisation opportunities need to be madeavailable to support the development of essential
knowledge and skills across the workforce.
Hybrid approaches of online learning, web-based
resources and mobile applications, as well as
face-to-face learning opportunities, should betailored to specific workforce needs and locations(including urban, regional, rural and remote).

Comprehensive guidance for the workforce that
supports professionals in providing advice topatients, including on legal and policy issues inrelation to HIV transmission and undetectable viralload, would better support people with HIV to makeinformed decisions about prevention and treatment
adherence. Education to reduce and address
stigma and discrimination should be included intraining programs for staff of all specialist, primary
healthcare and community service providers.
Issues in relation to recruitment and retention ofstaff need to be addressed, particularly in rural andremote areas, to ensure that the required expertise,capability and capacity exists in all areas. Innovativemodels adapted to local contexts can assist in
addressing such challenges by utilising the skills ofother appropriately trained health professionals.
Shared care models involving general practitioners,
medical specialists, nursing professionals,
Aboriginal and Torres Strait Islander Health Workers,
community-based workers, and other healthprofessionals will assist in decreasing the burden on
sexual health services. Less experienced diagnosing
clinicians need strong links with specialist providers
in providing an HIV diagnosis and enablingtreatment, ongoing care and other support
services in the community.
As the accessibility of PrEP is increased, prescribers
need to be more closely linked to HIV services
and sexual health services and/or able to provide
those services in primary healthcare settings.
PrEP-related education for primary care should be
informed by caseload, the priority populations being
cared for and the past community experiences ofaccessing such services. Enhanced roles for nursing
professionals that facilitate access to preventive
measures, including PrEP, early treatment andmonitoring for priority populations, should befurther explored and developed.

Eighth National HIV Strategy 2018–2022

29

KEY AREAS FOR ACTION
17. Continue to regularly update, maintain, andmake accessible evidence-based clinical guidelines,
tools and support for prevention, testing andmanagement of HIV and related comorbidities
18. Ensure that access to PrEP, TasP and otherprevention methods are supported by consistentand targeted information and messaging
for health professionals
19. Continue to explore and share experiencesof innovative multidisciplinary models of care for
HIV prevention and management, particularly
models for rural and remote areas and areas ofworkforce shortage
20. Develop knowledge and awareness of HIV
across the multidisciplinary workforce to facilitate
the delivery of appropriate services and address theongoing care and support needs of people with HIV
21. Support the capacity and role of community
organisations to provide education, prevention,
support and advocacy services topriority populations

Addressing stigma and creating
an enabling environment• Implement a range of initiatives to address
stigma and discrimination and minimise theimpact on people’s health-seeking behaviourand health outcomes• Continue to work towards addressing
the legal, regulatory and policy barriers which
affect priority populations and influence theirhealth-seeking behaviours• Strengthen and enhance partnerships andconnections to priority populations, including
the meaningful engagement and participationof people with HIV
Stigma is widely recognised as one of the mostsignificant barriers to an effective HIV response. It
can have a significant impact on health outcomesas well as relationships and employment prospects
and can lead to social isolation and mental ill health.

30

The experience and anticipation of discriminatory or
unfair treatment increases the negative impact on
the health status of people with HIV and can reduce
access to care. Stigma and discrimination havebeen correlated with poor access to health care, andthey create barriers to services and support.
While stigma and discrimination have reduced
somewhat over the last 30 years, it continues tobe reported by people with HIV and by lesbian, gay,bisexual, trans and gender-diverse, and/or intersex
populations, sex workers, people who use drugs,
Aboriginal and Torres Strait Islander people and
CALD populations. In a 2016 online survey completed
by 181 people with HIV, nearly three-quarters of
respondents (74 per cent) reported stigma related
to their HIV status and approximately half of
respondents (52 per cent) reported experiencing
negative or different treatment by health workers.49
The stigma and discrimination experienced bypeople with HIV and other priority populations canalso be influenced by intersecting characteristics
and the stigma and discrimination associated withthose. This includes sexual orientation, gender andgender identity, cultural background, migrant or
refugee status, disability, or being a sex worker or
person in a custodial setting. Strategies to address
stigma and discrimination must acknowledge andaccount for this.
There is an ongoing need for Australian
governments to continue to review and work
towards removing barriers to access to HIV
prevention, management, care and support;
promote and protect the human rights of people
with HIV and people among affected communities;
and break down the stigma and discrimination
associated with HIV.
Increased efforts are needed to address stigma
and support people with HIV and priority
populations to challenge stigma and build resilience.
The meaningful involvement of people with HIV
and affected communities in all aspects of the
HIV response play an important role in addressing
stigma and discrimination. It enables individuals
and communities to draw on their lived experiences
and be meaningfully involved in the design,
implementation and evaluation of HIV interventions.

Efforts are also needed to increase the awarenessof health professionals and community healthworkers, particularly those on the front line of HIV
diagnosis and treatment, in relation to stigma
and discrimination. This is an important part oftraining programs for staff of all specialist, primary
healthcare and community-based service providers.
The training needs to highlight the essential role
they play in removing stigma and discrimination
as a barrier for priority populations in accessing
prevention, testing, treatment, care and support.
It is important to ensure that healthcare
professionals are well-informed about how tomost effectively engage with and support priority
populations is important, and this must be
underpinned by comprehensive and transparent
health service quality standards, including
standards that address privacy, confidentiality
and patient rights.

responsibility of the health system—for example,
criminalisation impacts on priority populations
by perpetuating isolation and marginalisation andlimiting their ability to seek information, supportand health care. It is important that effective andmeaningful dialogue is maintained across sectors
and jurisdictions to support knowledge translation(for example, current HIV-related clinical evidence)and to discuss the potential impacts of any wider
decisions on the health of priority populations.

Overall Australia has a strong enabling environment,
including regulation of needle and syringe programs
and strong anti-discrimination legislation for some
populations. However there are some key legal,
regulatory, policy, social, cultural and economic
barriers that impact on HIV prevention and accessto HIV services. These barriers include the cost ofservices; challenges with service delivery in regionaland remote areas; language and cultural barriers;
a lack of culturally appropriate health services;and laws and regulations in relation to sex work,
drug use, peer distribution of injecting equipment,
and non-disclosure, exposure and transmission of
HIV.31 Studies have found that the removal of suchbarriers, and reduction in stigma and discrimination,
increased the rates of testing and treatment andcontributed to a decrease in the incidence andprevalence of various BBV and STI.31,50 Approaches
to addressing barriers in Australia need to be
informed by the national and international evidencebase in relation to the impact on HIV transmission
and public health outcomes, and they need to beconsidered in the Australian context.
The implementation of this strategy rests within
the health sector. However, many of the barriers
to access and equitable treatment of affectedindividuals and communities fall outside of theEighth National HIV Strategy 2018–2022

31

KEY AREAS FOR ACTION
22. Implement initiatives to reduce stigma anddiscrimination across priority settings, including
education which incorporates messaging tocounteract stigma
23. Implement initiatives that assist people
with, and at risk of, HIV to challenge stigma
and build resilience
24. Maintain and develop peer support models
appropriate for priority populations and maintainsupport for people with HIV as peer navigators indiagnosis, treatment and care
25. Monitor laws, policies, stigma anddiscrimination which impact on health-seeking
behaviour among priority populations and theiraccess to testing and services; and work toameliorate legal, regulatory and policy barriers to an
appropriate and evidence-based response
26. Review and address institutional, regulatory andsystem policies which create barriers to equality of
prevention, testing, treatment and care and support
for people with HIV and affected communities
27. Engage in dialogue with other government
sectors to promote the use of up-to-date HIVrelated science to improve policies affecting people
with HIV and to discuss the impacts of wider public
policy decisions on the health of priority populations

Data, surveillance, research andevaluation• Continue to build a strong evidence base forresponding to HIV in Australia that is informed byhigh-quality, timely data and surveillance systems
Continuous improvement of data collections andsystems is important to support a comprehensive
understanding of HIV in Australia. However,this must be appropriately targeted to avoid
unnecessary burden for health services andfrontline staff and to ensure effective patient
privacy and confidentiality.

32

Opportunities to improve the level of detail incollected data to better identify trends andissues of concern in relation to specific priority
and sub-populations, including trans andgender-diverse people and women, need to
be explored. Improvements in the reporting of
Aboriginal and Torres Strait Islander status inclinical and pathology settings also need to be
implemented. There is a need for data on stigma
and discrimination, both in relation to HIV itself andin relation to a variety of other factors, with a focus
on gender and sexuality and sex work, and on thequality of life for people with HIV. There is also aneed to improve the timeliness and consistency ofdata collection across Australia to better supportcompleteness and comparability. Potential areasfor greater involvement of community andpeer-based organisations in surveillance alsoneed to be identified, given their strong knowledgeof priority populations.
Rates of HIV drug resistance require ongoing
monitoring. While cases of treatment failure arerare in Australia, active and accurate monitoring isrequired to detect any increase. This is important,as drug resistance can result in adverse healthoutcomes and transmission of drug-resistant HIV.
Social, behavioural, epidemiological, clinical andbasic research is essential in developing a strong
evidence base for managing and preventing HIV
in the community. This research identifies andexamines key changes in the epidemiology andbehaviours of priority populations; emerging issues
and concerns; and influences on people’s decisions
in regard to risk taking and seeking testing, careand treatment. It also assists to inform targeted
responses in priority populations and settings.
Partnerships between research institutes, clinicians
and community and peer based organisations
are valuable, as community and peer-basedorganisations (and clinicians) are often the first to
identify changes in behaviours, social interactions
and demographics of priority populations.51,52
Maintaining a strong research agenda and programthat informs and responds to the priority actionsof the strategy ensures that implementation is
supported by a strong, relevant evidence base.

The National BBV and STI Surveillance andMonitoring Plan 2018–2022 will be developed
to measure and monitor the implementationof this strategy through the identification anddevelopment of indicators to measure progress
towards achieving the strategy’s targets.
The evaluation of existing HIV activities andprograms, and development of new ones, will
aim to maximise their alignment with the priority
areas for action set out in this strategy.

KEY AREAS FOR ACTION
28. Identify gaps in surveillance data formeasuring and monitoring the implementationof this strategy and prioritise these for action
29. Identify opportunities to improve thetimeliness and consistency of data collection
30. Improve surveillance of issues impacting on
people with HIV, including morbidity and mortality,
stigma and discrimination, quality of life measures,the availability of new biomedical interventionsand HIV drug resistance
31. Build on the existing strong evidence baseto effectively inform the implementation of thepriority actions of this strategy
32. Ensure current and future programs andactivities are evaluated to ensure linkage andalignment to the priority areas of this strategy
33. Explore opportunities for assessing theimpact of legislation and regulation on barriers toequal access to health care

Eighth National HIV Strategy 2018–2022

33

8.
Implementing
this strategy
Leadership, partnership andconnections to community
Australia’s response to HIV is built on amodel of partnership between government,
community-based organisations, researchers,
health professionals and priority populations.
The partnership approach depends on clear
leadership roles and accountability for all involved.
The Australian Government is committed toproviding strong national leadership by working
across portfolios and jurisdictions to achieve thegoals of this strategy. The Australian Government
Department of Health leads the coordination of
the national response to HIV under the National
HIV Strategy. However, the success of this strategy
is contingent on productive partnerships between
Australian, state and territory governments andpartners, including peak bodies representing
communities, health professionals, researchersand others. In the case of research on BBV and
STI, it is imperative that this is conducted inpartnership with communities and aligned withthe priorities of the five national strategies.
National community and health peakorganisations, and other organisations,representing communities and the clinicalworkforce remain at the forefront of the HIV
response in Australia. Organisations including theAustralian Federation of AIDS Organisations; theNational Association of People with HIV Australia;
the Australian Injecting and Illicit Drug Users
League; Scarlet Alliance, Australian Sex Workers’
Association; and the Australasian Society for HIV,
Viral Hepatitis and Sexual Health Medicine, andthe relationship these organisations havewith their members, have a critical role to playin the implementation of this strategy.

34

Action plan
The National BBV and STI Strategies Action
Plan 2018–2022 provides the detail of specificactions for governments and partners. The action
plan outlines the roles and responsibilities ofgovernments and partners and the time frames
for implementation of the actions. Indicatorsfor measuring the progress towards achievementof the strategies’ targets will also be developed.
The action plan will be reviewed as required during
the lifetime of the strategies.
The five national BBV and STI strategies
share a number of key actions related toareas such as workforce, improving data andsurveillance, education programs, and stigma
and discrimination. The action plan will focus
on encouraging connections between existing
programs and policies, and adapting lessons
from previously successful approaches, tominimise duplication of effort. It will also look foropportunities to learn from and adapt responses
used for other diseases where relevant.

Governance, reportingand evaluation
The five national BBV and STI strategies areendorsed by Australia’s Health Ministers andgoverned through relevant committees of theAustralian Health Ministers’ Advisory Council(AHMAC). The Blood Borne Viruses and Sexually
Transmissible Infections Standing Committee(BBVSS) coordinates implementation efforts
across jurisdictions and reports to the Australian
Health Protection Principal Committee (AHPPC)on progress in the implementation of the national
strategies. BBVSS and the Communicable
Diseases Network Australia (CDNA) will jointly
monitor progress towards the targets of eachstrategy and identify emerging issues andopportunities for action.

Surveillance and monitoring plan
The National BBV and STI Surveillance andMonitoring Plan 2018–2022 supports the fivenational BBV and STI strategies and informs
and monitors progress on achieving the goals
and targets of each strategy. A subcommitteeof the CDNA is responsible for overseeing thesurveillance and monitoring plan and reportingon progress to the CDNA and BBVSS.

Eighth National HIV Strategy 2018–2022

35

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22

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24

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Ward, J., L. Crooks, and D. Russell. (2016). High level summit on rising HIV, sexuallytransmissible infections (STI) and viral hepatitis in Aboriginal and Torres Strait Islander
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29

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30

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2018–2022