HIV prevention failing to reach Asian-born gay and bisexual men in Australia

HIV diagnoses are going up in gay and bisexual men born in Asia who have recently arrived in Australia, while they are falling in Australian-born men. The disparity may be fuelled by exclusion from government-subsidised healthcare, including HIV treatment and pre-exposure prophylaxis (PrEP), researchers warn.

The most recent annual surveillance report for Australia, published by the Kirby Institute, shows different rates of HIV diagnoses for people born in different parts of the world, with increases seen in people born in Asia. Over the ten years from 2008 to 2017, across the population, the diagnosis rate per 100,000 people born in Australia remained steady, fluctuating between 3.5 and 3.2, while in people born in south-east Asia, it rose from 9.1 to 14.0. In 2017, the rate for men born in north-east Asia (which includes China and Korea) was 4.8 and for men born in southern and central Asia (which includes India) it was 4.4.

Turning specifically to absolute numbers of HIV diagnoses attributed to sex between men, they fell in Australian-born men from 407 to 319 diagnoses over the decade, while rising from 50 to 128 in Asian-born men. They remained steady in men born in other parts of the world (between 103 and 116 diagnoses annually).

Three leading sexual health clinics in Sydney and Melbourne have looked in more detail at the profile of newly diagnosed men who were born in Asia and had arrived in Australia in the previous four years. Compared to 209 newly diagnosed Australian men, the 111 Asian men were:

• Younger (27 vs 32 years)
• Less likely to report risky behaviour, including large numbers of partners, inconsistent condom use and injecting drug use
• More likely to have never previously tested (29% vs 11%)
• More likely to be diagnosed late (median CD4 count at diagnosis 326 cells/mm3 vs 520 cells/mm3; with diagnosis below 200 cells/mm3 for 16% vs 5%).

It is inherently challenging to determine when and where someone acquired HIV, but based on reported behaviour and testing history, the researchers estimate that 25% of the Asian men probably acquired HIV in Australia and 32% did so overseas, but the location couldn’t be determined for the remainder. Consistent with this, 29% had HIV subtype B (predominant in Australia) and 55% had subtype CRF01-AE (predominant in south-east Asia but also found in some Australian communities).

Eighty per cent of the Asian men had a visa and 61% were international students. Most spoke a language in addition to English, including Mandarin (35%), Thai (14%), Korean (5%), Indonesian (5%) and Vietnamese (5%).

Only 10% had access to Australia’s universal healthcare system, Medicare.

Exclusion from biomedical prevention

A separate analysis, published last year, examined testing episodes at the Melbourne Sexual Heath Centre, which is one of the sexual health clinics included above. Between 2013 and 2017, 1047 gay and bisexual men born in Asia (who had arrived in Australia in the previous four years) took HIV tests at the centre, while 11,133 other gay and bisexual men did so, with multiple testing episodes recorded for many individuals.

The proportion of non-Asian born men tested who were diagnosed with a recent HIV infection fell from 0.83% to 0.38% over the four years of the study (p = 0.01). But in Asian men, it did not change significantly, varying between 1.18% and 1.56%.

As in the last study, Asian men were less likely to have multiple partners. Also, over the four years of the study, consistent condom use fell dramatically in non-Asian men (from 53% to 38%), but only slightly in Asian-born men (from 57% to 52%). In 2017, 11% of non-Asian men were using PrEP, compared to 6.8% of Asian men.

The researchers note that in the era of biomedical HIV prevention, the risk of HIV infection in gay and bisexual men is determined by whether a person is taking PrEP and by the prevalence of untreated and undiagnosed HIV infection among his sexual partners.

However, Medicare is not available to temporary migrants and international students. While people who do not have Medicare coverage can access HIV testing, it is a requirement for HIV treatment, PrEP, STI testing and STI treatment in most settings. Even if there are some exceptions and loopholes, considerable barriers exist to migrant populations’ access to healthcare.

“Limited access to biomedical interventions in newly-arrived Asian-born MSM [men who have sex with men] is explaining the observed disparity in HIV incidence,” say the authors. While lack of access to PrEP is one of the factors, the limited number of PrEP users in this data set suggest that it is not the whole explanation. It is more likely that earlier diagnosis and prompt initiation of HIV treatment is having an impact in the wider population, but less so in communities and networks of Asian migrants. Sexual mixing patterns are a factor, with other data showing that Asian men often have other Asian men as sexual partners.

Failing to address inequalities in access to care for newly arrived Asian-born MSM may lead to ongoing high rates of HIV transmission in this sub-population, undermining the overall impact of biomedical prevention, Nicholas Medland and colleagues warn. “It is recommended that provision of sexual health and HIV medicine services free of charge, including HIV testing, antiretroviral therapy and pre-exposure prophylaxis is expanded to cover patients who are not eligible for Medicare.”