Denying the Grim Reaper

When the first case of AIDS was reported in Australia 20 years ago, health experts braced themselves for a morbidity rate to rival World War II. In 1987, the Grim Reaper advertisements announced that 50,000 Australians might already be infected and this figure would continue to rise. Due to Australia’s pragmatic and innovative response, the rate of new HIV infections fell from approximately 2500 per year in the mid-1980s to less than 500 per year within a decade. Australia’s response represents a success story; one
frequently cited by the World Health Organisation as a model for other countries.

‘Gays cause AIDS’

The first case of AIDS in Australia was diagnosed by Professor Ronald Penny, an immunologist at Sydney’s St Vincent’s Hospital, in November 1982. His patient was a 27-year-old New York City resident visiting Sydney. The case was reported six months later in the Medical Journal of Australia, by which time the first Australian had been diagnosed with AIDS. The early news reports of these cases were announced in a tone that bordered on hysteria. The public was left in no doubt about who was harbouring the fugitive, as media reports emphasised that all of the cases involved homosexual males and that this group in the US was in the middle of an epidemic. Even doctors lent support to the opinion that gays were responsible for exposing Australians to a malicious new killer.

The public’s anxiety about AIDS soon manifested in discrimination against homosexuals. A Sydney dentist banned homosexual patients from his surgery, and numerous gay men were evicted from their homes or denied accommodation. Sydney Telecom engineers refused to carry out repairs at the Pitt Street mail exchange because, they claimed, it was staffed by a large number of homosexual telephone operators ‘who probably had AIDS’. News that three Queensland babies had died from AIDS as a result of receiving HIV-contaminated blood donated by a homosexual prompted a gang of men to roam Sydney’s gay strip looking for poofters to punish.

Such responses continued even after the viral origin of AIDS had been established. In November 1984, New South Wales police called for a halt on random breath testing, and then insisted on being issued with plastic gloves, because they believed that HIV could be transmitted via the saliva of motorists. (This caused one commentator to ponder which part of the policeman’s apparatus the subject was required to blow.) Seven months later, Ansett and TAA airlines banned HIV-positive individuals from travelling on their planes as a means of protecting their staff. The Australian Flight Attendants’ Association re-jected the bans. A spokesman wryly noted that if anyone managed to have mid-flight sex with an HIV-positive passenger—one of the few ways of transmitting the virus—they should be given ‘points for enterprise’. No-one was laughing, however, when three-year-old Eve van Grafhorst was prohibited from attending pre-school in July 1985 after parents, fearing contagion, threatened to withdraw their children from her class.

Given the hostility towards homosexuals, and the public’s fear of those afflicted by HIV, it seemed likely that Australian  governments would be persuaded to enact a range of coercive public health measures in an effort to contain the spread of AIDS. Opinion polls in 1986 and 1987 suggested that 25 per cent and 50 per cent of the population favoured the quarantine of infected individuals and universal screening of the entire population for HIV antibodies respectively. An even greater number supported mandatory testing of ‘high risk’ groups, such as gay men, injecting drug users and sex workers. Advocates of this ‘traditional’ approach to the control of infectious disease also called on the government to close gay bathhouses and other venues where disease might be spread. In addition, they asked for funds to be channelled into research institutions and clinical facilities in the hope that a cure for AIDS might be found and widespread HIV antibody testing programs implemented.

Gay AIDS organisations, which emerged spontaneously within Australia’s gay communities in order to educate their members about AIDS prevention and care for the sick, also asked for funding and to be a part of the policy-making process. This looked unlikely while medical experts dismissed their claims for legitimacy and homosexuals were still perceived to be the cause of the problem. Australian governments looking to the US for guidance would have noticed that most federal and state authorities in that country were refusing to fund gay community-based organisations, preferring to support programs devised by public health authorities. Facing the prospect of mandatory testing, the destruction of community institutions, and the possible identification and isolation of HIV-positive individuals, gay men prepared themselves to fight again for the rights and public acceptance they had slowly gained over the previous 20 years. As the Victorian AIDS Action Committee’s Adam Carr warned in December 1984:
The community’s tolerance for our existence, and its respect for our rights, have always been fragile at best, and are now rapidly eroding … Unscrupulous politicians, extreme right wing fringe groups, powerful religious bigots and a sensation-hungry media will combine to exploit public fear and channel ignorance into bigotry and the search for a scapegoat … [T]here is no doubt that we will have a real fight on our hands to defend our rights, our freedoms and even our personal safety.

The expected backlash against the homosexual community did not eventuate. Australian state and federal governments—with the exception of Queensland and Tasmania—deviated from the US model and chose to incorporate representatives of the communities most affected by AIDS into a partnership with government and medical experts. This decision was made in order to gain their expertise in communicating with, and educating, people at risk. The result was an approach to AIDS prevention that stressed community participation and education rather than targeting infected individuals
through testing and the curtailment of their activities through coercive laws. Instead of promoting abstinence and relying on prohibition, Australian public health authorities sought to inculcate an understanding that everybody was at risk from AIDS, but that this risk could be minimised by the adoption of safe sexual and drug use practices.

Thus by the end of 1987, the Commonwealth and state governments were funding targeted education campaigns that extolled the virtues of (safe) anal intercourse in glossy posters and pamphlets and supported the promotion of condom use on prime time television. Comprehensive sex and AIDS education courses were introduced in state (and most private) secondary schools, and nearly all of the Australian states established needle exchange programs. Sex worker organisations and collectives of current and former drug users were also funded to provide education and outreach support.

These initiatives proved extremely successful in preventing the spread of HIV. After peaking at approximately 2500 in 1984, the number of new HIV infections fell to less than 500 per year within a decade, and has remained relatively stable ever since. Fortified by the partnership between doctors, the government, and ‘a bunch of poofters, junkies and whores’, as they are often pejoratively called, Australia effectively ducked the ‘second wave’ of HIV infection that crashed on the shores of North America and Europe in the early 1980s, infecting drug users and their sexual partners, heterosexual men, women and their babies.

Learning to trust Australia’s approach to AIDS  prevention became recognised as one of the most innovative and successful in the world. This was because politicians such as Neal Blewett, key doctors and the first National Advisory Committee on AIDS (NACAIDS), chaired by Ita Buttrose, trusted and empowered gay men, sex workers and injecting drug users to care for themselves and for others. They were persuaded to do so because these maligned social groups proved themselves to be responsible and committed to the fight against AIDS. They raised funds, devised educational materials, held forums and workshops and sought alliances with sympathetic medical professionals and politicians. They angrily refuted the notion that they were recklessly spreading disease and deliberately poisoning the blood supply, and proved themselves to be caring and committed lovers and friends. Their actions defied representations of them as hedonistic, selfish and irresponsible pleasure seekers.

As the epidemic in Australia effectively  began 18 months after that in the US, gay men and sex worker organisations had time to understand what was required of them and to plan HIV-prevention strategies. Governments also benefited from this window of opportunity, through which they observed the mistakes made by civic leaders in the US. During a research trip to the United States in January 1985, Neal Blewett, the Commonwealth Minister for Health from 1983 to 1990, was able to witness the effect of the Reagan administration’s reluctance to speak frankly about safe sex or finance AIDS prevention initiatives within the homosexual community. Touring an AIDS ward of a public hospital, and listening to frustrated doctors and AIDS workers, he glimpsed the consequences of HIV prevention policies constrained by moralism. Similarly, Australian AIDS advisory committees were able to read reports of HIV spreading rapidly through injecting drug-using populations in the US and Scotland before they had to deal with this reality in Australia. They became convinced that an innovative approach to HIV prevention, using the communication skills and energy of community-based organisations, was required to combat AIDS.

There was also an element of pragmatism. Politicians and public health authorities were eventually convinced that HIV posed an exceptional problem as it predominantly affected marginalised individuals and communities who had little faith in doctors and legislators, and who demonstrated a reluctance to alter their behaviour regardless of laws requiring them to do so. As High Court Justice Michael Kirby stated, ‘Law and the risk of punishment are usually the last things on the minds of people in the critical moment of pleasure’. Politicians and public health authorities also came to accept that there was little incentive for ‘high risk’ individuals to contact doctors, given that there was neither a cure for AIDS nor (until the late 1980s) drugs to delay the onset of the syndrome. Moreover, there was a significant disincentive to be identified as ‘at risk’ or ‘infected’ as it carried the possibility of discrimination and ostracism.

As Neal Blewett acknowledged, an approach to AIDS control that relied on testing was likely to drive individuals away from health services. Government had to build a partnership of trust between medical professionals and the communities most affected by AIDS, and empower gay men, drug user groups and sex worker organisations to become the vanguard in the fight against AIDS.

The educational materials and safe sex messages devised by community-based organisations were effective because they employed a visual and textual language that was explicit, erotic and subculturally appropriate. In the hands of peer educators and the designers of colourful campaigns that depicted glistening latex-clad bodies in a selection of steamy sexual scenarios, condoms became the hottest sex toys of the 1980s, promising safe sexual pleasure. Large-scale surveys indicate that by the end of the 1980s, 85–90 per cent of gay men were using condoms or having non-penetrative sex with their casual partners—a substantial degree of behavioural change in a population that previously had little reason to use condoms.

AIDS Councils and drug user groups also faced the challenge of educating injecting drug users about using needles and syringes safely. When they pasted posters outlining such information on the doors of public toilets in an effort to reach this transient and nebulous population, they risked being accused of promoting drug use, just as the eroticisation of protected gay sex risked being construed as the promotion of homosexuality. While these risks inhibited many countries from supporting the work of community-based organisations, the Commonwealth and most state governments accepted that gay sexual activity and drug use would continue regardless. They committed themselves to the principle of harm reduction, placing the lives of gay men and injecting drug users ahead of public sensibilities.

Two other examples serve to illustrate Australia’s pragmatic approach to AIDS prevention. The first was the launch—relatively early in Australia’s epidemic and before many heterosexuals had been infected—of a large-scale mass-media education campaign co-ordinated by NACAIDS. The ‘Grim Reaper’ campaign, as it became known, cost over $3.6 million and aimed to inform Australians that HIV did not discriminate between age, sex or gender, and that, in the absence of a cure, prevention was the only method of combating the epidemic. It implored sexually active Australians to have sex with only one partner or, alternatively, to ‘always use condoms’. The campaign was criticised for exaggerating the risk to ‘ordinary’ Australians and frightening children with its macabre images.

Prominent members of the National AIDS Task Force, including David Pennington and Ian Gust, suspected that its message of widespread risk was designed to remove the responsibility of AIDS prevention from gay men, thereby alleviating the compulsion for them to be tested for HIV. These criticisms overlooked the campaign’s other aims which relied on members of the public personally identifying with the epidemic. For example, at a time when the government was curtailing public expenditure in response to economic recession, NACAIDS wanted to promote a sense of public urgency that would compel the Commonwealth and states to fund AIDS programs. It also sought to elicit public and political support for the introduction of comprehensive AIDS and sex education in secondary schools and the establishment of needle exchange programs. The realisation of these goals, and the failure of a second wave of HIV infection to swell within the heterosexual population, vindicated NACAIDS’ decision to spend large sums of money scaring Australians and to speak frankly about safe sex on prime time television.

The establishment of large-scale needle exchange programs in nearly all of the states by 1988 represents another example of Australia’s commitment to harm reduction. Despite initial opposition, Australia’s needle exchange program became the largest and most comprehensive in the world. Originally conducted by health professionals and pharmacists, community-based organisations were also funded to distribute sterile injecting equipment, puncture-proof disposable containers,  condoms and safe sex information. Their success in preventing the widespread transmission of HIV among injecting drug users was demonstrated in studies that found a large discrepancy between the rates of HIV infection in cities with, and without, needle exchange programs. Success was also reflected in the continued low level of HIV infection among injecting drug users in Australia in the 1990s—they now account for about four per cent of all HIV infections, as opposed to 50–60 per cent in other parts of the world. In real terms, lives have been saved. A recent evaluation estimated that Australia’s needle and syringe program prevented approximately 25,000 HIV infections between 1988 and 2000.

The establishment of needle exchange outlets was, in part, born of the acceptance that education alone would not result in behavioural change among people who lacked the resources or power to act on the information. Drug addicts without access to sterile needles, or the means to purchase them, would continue to share equipment regardless of their understanding of the risks involved. AIDS prevention workers also recognised that prostitutes, although fully informed of the consequences of unsafe sex, would find it difficult to insist that clients wear condoms when forced to work, without peer support, at the mercy of their clients, on the streets and from the back seats of cars. Equally, there was little prospect of gay men taking pride in their health while they were humiliated or bashed at school, vilified in the community or rejected by their families. Economic, legal and psychological factors conspired to make it more difficult for some to make healthy life choices.

Australia’s success in preventing the spread of AIDS relied on countering these impediments. Governments funded AIDS Councils to offer workshops promoting self-esteem within the gay community. Comprehensive needle and syringe exchange schemes were established. And one state legalised prostitution in brothels as a means of providing a safe working environment where condom use could be enforced and prostitutes could be trained in safe sex techniques and negotiation.

This model of disease prevention, which recognised the need to educate and empower those most at risk, was very  different from a traditional medical model that viewed disease prevention as a fight in which only doctors and medical researchers could engage. It challenged the validity of traditional measures of infectious disease control that focused on identifying and restraining infected individuals on the assumption that these people were autonomous agents capable of behaving ‘rationally’ once they were informed of their HIV-status or were faced with the prospect of imprisonment if they ‘wilfully’ endangered the lives of other people. It also contradicted the idea that some people with AIDS were deserving of their plight because they became infected through unsafe practices despite being aware of the risks.

Not all states and territories embraced the principles of explicit education, harm reduction and community empowerment, and none was willing to act upon all of the recommendations of the AIDS Councils and the Commonwealth’s chief advisory committee. Queensland refused to distribute
NACAIDS-approved educational materials or have contact with its AIDS Council until the end of 1987, forcing the Commonwealth to channel funds to this organisation through the Catholic Sisters of Mercy, whom Neal Blewett described as ‘the most cheerful and altruistic of money launderers’.

Queensland also baulked at the establishment of a needle exchange scheme until 1990, and Tasmania resisted until 1993. All of the states enacted laws against the ‘reckless’ and ‘knowing’ transmission of HIV, and New South Wales displayed little hesitancy in detaining a ‘recalcitrant’ HIV-positive prostitute in a hospital against her will. Brothels remained illegal in most states but escort agencies were tolerated, despite the fact that they do not provide a place for prostitutes to gather or receive training from sex worker organisations.

Similarly, laws were changed to allow for the possession and exchange of condoms and needles on the street—previously they had been used by police as evidence of sex work or drug use. Yet neither condoms nor sterile injection equipment was made available in prisons despite strong evidence that drug use and anal sex frequently occur between prisoners.

Finally, Tasmania refused to repeal laws that criminalised homosexual sexual activity, making it difficult for AIDS educators in that state to contact homosexuals (the laws were finally changed in 1997). Western Australia refused to lower the age of consent for homosexuals to match that of heterosexual adolescents. It was therefore difficult for AIDS organisations to target young gays in safe sex campaigns without appearing to condone unlawful sexual activity. Such restrictions contravened the principles of Australia’s approach to AIDS prevention and remain challenges for AIDS prevention workers today.

While these are significant shortcomings, Australia’s political response to AIDS was quick, innovative
and humane, and defined by its trust in the communities most affected by AIDS to behave responsibly.
Countries such as Russia and the Ukraine, without explicit safe sex education or needle exchange programs and now experiencing the fastest growth in new HIV infections in the world, have much to learn from Australia’s pragmatic approach. Australia’s success should also prove illuminating to those public policy-makers and community leaders who scorn ‘harm reduction’ approaches to social and health problems such as drug use, and who are still reluctant to trust and empower marginalised communities to care for themselves. 

Paul Sendziuk is a Postdoctoral Fellow in the School of Historical Studies at Monash University. His book Learning to Trust: Australian Responses to AIDS, will be published by UNSW Press in November.



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