It was 1985 and HIV/Aids had exploded in Australia.
Working as a social employee counselling weak homosexual males in Sydney’s Kings Cross, I noticed first hand the human price of this brutal epidemic.
In the shadow of the now infamous Grim Reaper adverts, it was a group gripped by worry and stigmatised into isolation.
As a homosexual man myself, it hit far too near house. I misplaced buddies to Aids. I watched households flip their backs on family members.
When the disaster peaked in 1994, nearly 800 Australians had been dying annually from Aids-related diseases.
Since then, the advances in prevention and remedy have been exceptional. Today, the variety of new diagnoses is so low specialists have declared that Aids is now not a public health issue.
But while HIV infections have significantly dropped, every year around 1,000 Australians are diagnosed with a virus that can pose significant health complications and requires constant management.
It’s therefore no surprise that a pill which could put Australia on track to ending HIV transmission altogether has been hailed as a “game changer”.
On 1 April 2018, after successful trials in Victoria and New South Wales, the pre-exposure prophylaxis (PrEP) Truvada, was listed on the Pharmaceutical Benefits Scheme.
Taken daily, it is up to 99% effective in stopping the spread of HIV in the body.
This is great news and will help the Australian government reach its pledge to end all new transmissions by 2020.
But we can’t afford to be complacent. There are already early signs that this “wonder drug” may have unintended consequences that pose a significant public health challenge.
While PrEP can protect against HIV, it is no barrier to debilitating diseases such as syphilis, chlamydia, gonorrhea and shigella.
Within our North Western Melbourne Primary Health Network – which has one of the highest STIs rates in Victoria – sexual health clinicians are reporting a worrying trend.
After decades of anxiety about HIV infection, understandably many gay men are enjoying the liberation that comes from taking a drug which all but removes that risk, and are using condoms less frequently.
This mirrors the results of Australia’s first PrEP study, which found a significant reduction in condom use and a rise in STIs during the first year of taking the drug.
Exposure to STIs is linked to serious long-term health consequences. Syphilis can cause brain infections, meningitis blindness, deafness and dementia while infertility is among the myriad complications of gonorrhea and chlamydia.
One senior clinician told me recently that many of the men he sees on PrEP don’t fear these infections because a “cure” is just a course of antibiotics away.
But just last week, Victoria’s acting chief health officer, Brett Sutton, issued an alert that two new cases of multi-drug resistant gonorrhea have been detected in Australia.
Sutton warned that the emergence of a strain that is resistant to all antibiotics is a “major public health concern.”
This over-reliance on drugs has already been blamed for the rise of antibiotic-resistant strains of “super-gonorrhea” in the United Kingdom and the United States.
We must be vigilant. Even before PrEP hit the scene, sexually transmitted infections were rising steeply across all populations in Australia for more than a decade.
In Melbourne, syphilis transmissions are at their highest rate since the second world war. Gonorrhea rates are at similar levels to before the peak of the HIV epidemic.
Against this backdrop, we simply can’t afford a further upsurge. Without action, this is a public health disaster in the making.
Perhaps of greatest concern is the people who are not being seen in sexual health clinics. Left untreated, a sexually transmitted infection can be a health ticking time bomb.
While participants in the successful Victorian and New South Wales PrEP trials were required to undergo regular sexual health screening and treatment to gain access to the drug, there is no such obligation now it is freely available to any at-risk person with a Medicare card.
Testing for sexually transmitted infections will now be up to individual patients and their GP.
Community activists and health workers in the HIV/Aids sector are working hard to ensure that the enthusiasm for PrEP is matched with promotion around condom use and STI screening but they can’t go it alone.
We need increased government funding for awareness campaigns to ensure the reduction in HIV transmission does not come at the cost of an outbreak of sexual health superbugs.
And we need investment in training for GPs for STIs – work we have already begun at North Western Melbourne Primary Health Network but needs to be extended nationwide.
As health professionals, we must work to get better at talking about safe sex. In an era of hook-up apps, sexual fluidity and liberated attitudes to casual sex, it’s important we do not shame or stigmatise people for living their lives.
But we must ensure that while we respect people’s free agency, we also arm them with the facts and the best preventative tools to keep them safe. I have no doubt that PrEP will change and save lives.
Our challenge is to make sure that this “game changer” does not shift the goalposts in ways we did not expect.
- Chris Carter is chief executive officer of North Western Melbourne Primary Health Network
Chris Carter from theguardian.com