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Redefining negotiated safety: Gay, bisexual and queer men adapting to HIV pre-exposure prophylaxis in intimate relationships(2022) MacGibbon, JamesThesisHIV pre-exposure prophylaxis (PrEP) is a recent, yet significant, development in HIV prevention. This mixed-methods research followed PrEP’s introduction in Australia, and examined how gay, bisexual and queer (GBQ) men in relationships have adapted to and incorporated PrEP in their sex practices, relationships, and everyday lives. As PrEP raises the prospect of having condomless sex both within and outside primary relationships without risking HIV infection, this research revisited the concept of negotiated safety (Kippax et al., 1997) to explore how HIV-negative GBQ men practice and negotiate safe sex in the era of biomedical HIV prevention. Quantitative data were collected in two national cross-sectional survey projects, The Gay Community Periodic Surveys (GCPS; 2013–2018) and the PrEPARE Project (2013–2021). The GCPS analysis showed a rapid shift away from relationship agreements in which condomless sex is only sanctioned between regular partners. The PrEPARE Project analysis found that men in relationships who used PrEP were more likely to have spoken and non-monogamous agreements, and to have partners that also used PrEP, compared to men in relationships who did not use PrEP. Qualitative data were generated using semi-structured, in-depth interviews conducted between January and August 2019 with 26 GBQ men in Sydney, Melbourne and Perth. Thematic analysis of these data identified new shared meanings and social practices that were enabled or mediated by PrEP, with an analytic focus on complexity, situatedness, contingency and relationality. Participant accounts illustrated diverse sexual practices and views about risk, but most participants adopted PrEP due to perceived HIV risk from casual sex rather than sex with their primary partners. PrEP complicated views about what counted as ‘safe sex’ and revealed changing understandings and practices of intimacy, pleasure, trust and risk. There was, however, an enduring narrative of individual responsibility to practice effective HIV prevention. Participants diverged in how they discussed and disclosed sexual practices with their primary and casual partners, revealing tensions about what disclosures were believed to be necessary or expected. Together, these quantitative and qualitative data collected as PrEP use became more common refocus attention on the practicality and complexity of relationship agreements among GBQ men.
Cognitive aging in people living with HIV: concept development and empirical evidence from several longitudinal cohorts in Australia and beyond(2022) Aung, Htein LinnThesisWith widespread access to combination anti-retroviral therapy (cART) and HIV suppression, life expectancy among people living with HIV (PLHIV) is increasing more than ever. According to UNAIDS, there were 8.1 million older PLHIV (i.e., 50 years of age and over) in 2020 globally. Although HIV-associated dementia has become rare in the cART era, mild neurocognitive impairments remain prevalent among PLHIV (~30% in virally suppressed). With aging, there is an increasing concern that HIV may precipitate neurocognitive abnormal aging because HIV is associated with increased markers of aging (e.g., immunosenescence and hyper-coagulopathy) and multiple age and HIV-related comorbidities (e.g., cardiovascular diseases). Importantly, these comorbidities occur at an earlier age and at a higher rate among PLHIV compared to age-matched HIV-negative persons. Earlier, more severe and more rapidly progressing neurocognitive impairment would have major public health consequences for the millions of PLHIV and the healthcare system. The overarching aim of this PhD thesis is to determine whether having chronic stable HIV infection and suppressive ART is associated with abnormal cognitive aging including premature cognitive aging (HIV and age synergistically/addictively lead to much lower cognitive performance at a younger age compared to controls), accentuated cognitive aging (HIV and age synergistically/addictively lead to much greater prevalence and severity of neurocognitive impairment), and/or accelerated cognitive aging (HIV and age synergistically/ addictively lead to much more rapid progression of neurocognitive impairment). To address these questions, we used a range of scientific methodologies including a systematic review, and several types of advanced statistical analyses using national and international longitudinal cohort data. First, to contextualise the potential public health consequences of cognitive aging in PLHIV, we conducted a narrative review of the burden of established dementia risk factors among PLHIV. We identified that the burden of several major dementia risk factors is much greater among PLHIV than in the general population. Second, we conducted the first-ever systematic review evaluating the current evidence for premature, accentuated and accelerated cognitive aging among PLHIV. We determined moderate evidence for premature cognitive aging and strong evidence for accelerated cognitive aging, while accentuated cognitive aging had not been optimally assessed. Lastly, addressing the previous literature major limitations (low sample size, cross-sectional study design, low proportion of older PLHIV, and inadequate controls/norms), we quantified the profiles of cognitive aging in four longitudinal studies of PLHIV. We demonstrated robust trends for premature cognitive aging among PLHIV compared to age-matched HIV-negative persons. We also demonstrated that older PLHIV had a higher risk for both neurocognitive impairment and neurocognitive decline compared to younger PLHIV, while controlling for normative age effect. These results are indicative of both accentuated and accelerated aging, although our research identified the need for longer-term studies using very large sample size to assess these trends especially in PLHIV older than 70+. Based on these findings, we discussed implications for clinical practice and future research directions.
(2022) Smith, AnthonyThesisHIV pre-exposure prophylaxis (PrEP) is a highly effective strategy for preventing new HIV infections. Since 2015, PrEP has been rapidly implemented with gay and bisexual men in Australia. While there is recognition of the importance of optimising the clinical delivery of PrEP, there has been scarce empirical research in Australia documenting how clinicians engage with prescribing PrEP, and minimal international social science research considering how PrEP has (re)shaped clinical practice. In this thesis I explore the role of clinicians in delivering PrEP in Australia. Drawing on the sociology of prescribing, I approach PrEP prescribing as a social practice, and attend to how clinicians anticipate and imagine patients, and how they think and feel about PrEP. This study draws on qualitative methodologies, including findings from semi-structured interviews conducted with clinicians who provide PrEP in New South Wales and Western Australia between 2019 and 2020, and with HIV expert stakeholders across Australia in 2017. Through empirical findings, I consider debates about which types of clinicians are best suited to prescribing PrEP and workforce challenges for providing PrEP in different clinical settings. I analyse clinician imaginaries of PrEP users and broader patient collectives, as well as clinicians’ views on providing PrEP to alleviate different types of ‘HIV anxiety’. I also examine prescribing as an affective clinical practice. I identify recommendations for supporting clinical workforces to improve the implementation of PrEP across Australian communities. This thesis demonstrates how PrEP has transformed HIV prevention for clinicians, requiring them to adapt to new ways of approaching HIV and sexual health. Clinicians develop expertise through routine opportunities to prescribe, and they develop imaginaries about patients and communities through consultations that shape their future interactions with patients. Conversely, a lack of patient demand makes it challenging for general practitioners to develop confidence and competence with PrEP prescribing. Providing PrEP involves the complexity of discussing sex and managing ideas about risk and responsibility, which are persistent challenges for both HIV-experienced and inexperienced clinicians. I argue for the value of sociological perspectives on clinical workforces to support and sustain effective HIV prevention.
Understanding HIV risk and engagement with harm reduction and HIV services: the lived experiences of women and men who inject drugs in Jakarta, Indonesia(2022) Sudewo, AninditaThesisIn recent years, major changes have affected the national response to HIV with people who inject drugs in Indonesia. These include changes in international HIV funding, the dissolution of the National AIDS commission, and a “war on drugs” declared by the Indonesian president in 2015. Set in this national context, this thesis examines the production of HIV risk for men and women who inject drugs in Indonesia; the factors that influence their engagement in harm reduction and HIV testing, treatment and care services; and the everyday strategies and actions instigated by people who inject drugs to enhance health and wellbeing. This study adopted a qualitative study design, and involved in-depth interviews with 36 men and women who inject drugs, and 10 key informants in community-based organisations (CBOs) and government health services. Key findings pertain to the production of HIV risk for people who inject drugs within micro-level social and physical spaces, influenced by macro-level stigmatising community values and criminalising policies; socio-ecological influences that inhibit their engagement in harm reduction and HIV services, including insular lifestyles associated with drug use and stigmatisation within interpersonal relationships with families and friends; the loss of critical community-based support services; and the shift of HIV care to formal government health services perceived as unsafe, with operations constrained by national policies. Yet, people who inject drugs also demonstrate a range of strategies – with support of people in injecting networks, families, CBOs and health services – that enable them to navigate and negotiate restrictive social, physical and policy environments to seek health and wellbeing. This thesis contributes to an emerging scholarship in social science approaches to public health in Indonesia. It draws on an analytic framework that recognises the interpersonal, institutional and contextual influences on people’s health and wellbeing, as well as the important action that HIV affected communities take to enhance their own lives in challenging contexts. The conclusions argue for the adoption of HIV and harm reduction practices and policies that cater to the complex lives of people who use drugs, and help overcome their everyday experiences of criminalisation and stigmatisation that produce risk and inhibit engagement in appropriate support services.