Innovations in HIV treatment and incarcerated fathers' parenting skills
Think:Health cultivates and articulates the best in health research and news.
The following program, which aired on Sunday 6th December 2015, features:
- how treatment for HIV has changed in the last four decades (01:17);
- domestic violence against our ageing population (12:11); and
- a new intervention to help incarcerated fathers become better parents (21:14).
Guests:
- Jason Farley - Adjunct Associate Professor at the UTS Faculty of Health.
- Liz Crock - from the Australian New Zealand Association of Nurses in Aids Care.
- Cathrine Fowler - Tresillian Chair in Child and Health and Professor of Child and Family Health Nursing at UTS.
- Lynn Chenoweth - Professor in Aged and Extended Care Nursing.
Presenter:
- Ellen Leabeater, 2ser
- Jake Morcom, 2ser
Transcript:
[Opening theme]
Ellen Leabeater: Hello and welcome to Think Health, where we cultivate and articulate the best in new health research. I'm Ellen Leabeater and you are tuned in to 2SER 107.3. Today on the show…
Catherine Fowler: Many of them didn't have a father. They were raised by mothers or their grandmothers or in kinship care, aunties and neighbours. So they've never had that opportunity to see what a highly functioning father should look like or act like.
Ellen Leabeater: A new intervention to help incarcerated fathers be better parents and we take a look at domestic violence against our aging population. But first on the program, in 1981 the HIV and aids pandemic attacked in full force killing and affecting millions around the globe. As of 2014 it is estimated that nearly 40 million people have died from aids or aids related illnesses and that over 35 million are currently living with HIV. But in 2015 innovations in both pre and post exposure HIV treatments have meant the virus is no longer the death sentence it used to be.
On Tuesday the world celebrated World Aids Day. A day raising awareness around the many issues related to HIV and aids. Although we've come a long way since the 80s there's still a way to go before reaching the globally recognised target of zero new HIV transmissions. Jake Morcom has this story.
Jason Farley: I think HIV remains concerning in that there's still no cure. Once a person becomes infected they remain so for life.
Jake Morcom: That's Jason Farley. He's an Adjunct Associate Professor in the Faculty of Health at UTS with expertise in the epidemiology of HIV and aids.
Jason Farley: I think the youth of today in particular have - see HIV as a disease that has evolved so much and it's no different than diabetes or high blood pressure or the like and therefore people may not take it as seriously as we did in the early 80s and 90s. If you talked to persons who are living with HIV they will say if they had the choice they would not get the disease. So I really think it's important that we take a step back and really think about how we can prevent HIV infection while still living a very healthy sexually robust life that prevents us from acquiring HIV and potentially other STIs as well.
Jake Morcom: The face of HIV and aids has changed massively since the 1980s. A huge part of this is due to the fact that innovations in treatment can help drastically reduce the rate of HIV becoming aids as well as transmitting the virus to someone else.
Jason Farley: Particularly people who did not live through those earlier days don't see HIV as a death sentence at all and that's great. It helps to reduce our stigma. It helps our patients to be accepted and it really does change the tone of HIV.
In regards to what we can do today for prevention, if a person has been exposed they can seek post-exposure prophylaxis and there are recommended regiments for that that use HIV treatment medications called antiretroviral, they can use those for prevention of infection generally within 48 to 72 hours and generally no longer than that. Some clinicians will allow it to go slightly longer, others have a very strict 48 hour period where they will after exposure give medication to prevent HIV infection.
Jake Morcom: The latest innovation in HIV treatment is something called pre‑exposure prophylaxis otherwise known as PrEP which a HIV negative person can take to reduce their chance of contracting the virus.
Jason Farley: Basically PrEP is a medication called, at this point, Truvada. It is a two combination pill in which you would take prior to any sexual encounter, men or women, and this medication needs to get into your systems basically at the right tissue, right point making sure it's there before sex and then after that is there and at appropriate levels it has been shown for people who are really adherent to be up to 99% effective at preventing HIV infection.
That's really important and really cool but it also provides us with this opportunity to sit back and say, wow, how do we as sexually active individuals and, for example, myself as a gay man, how do I now look at sex with PrEP because so much of sexual decision making was made utilising an HIV paradigm. Utilising saying, well this is the biggest thing I have to worry about and the risk that I'm concerned about and therefore you change your sexual practices and change your behaviours.
Now people with PrEP can re-engage in a sexual decision making process that is less about fear and more about pleasure.
Jake Morcom: Although PrEP may drastically diminish the chance of contracting the HIV virus, Jason makes one important note. Being on PrEP doesn't make you exempt from other sexually transmitted diseases or infections.
Jason Farley: So our biggest concerns, particularly among young gay men and when I say young that's generally in the range of 13 to 24, in the States at least that's what we're talking about when we say young. The STI incidents, so the number of new cases among young MSM regardless of PrEP has been on the rise for years. What many gay men don't realise is that unlike HIV which doesn't transmit very well orally, syphilis, chlamydia and gonorrhoea transmits very easily through oral sex.
So we screen, as part of a PrEP program, the oropharynx or the back of the throat. We screen the urine which will give us obviously what's happening in the penis. We screen if you're female obviously the vaginal screening and then we also do rectal screening in anyone who participates in anal intercourse both men or women for chlamydia and gonorrhoea and then we draw blood for syphilis. What we're seeing in our PrEP patients is - and data now from San Francisco has shown and kind of what is similar to my practice as a nurse practitioner that we are seeing increasing STIs but we're also looking in more places for STIs.
So before we would come in and bring a patient into the clinic and we would ask for urine or do a swab of the urethra and that would be it. But now with PrEP because we know better, we do better. As a result we now screen three body sites in men and we're finding more STIs.
Jake Morcom: In Australia PrEP is currently administered under the therapeutic goods administration. However pre-exposure prophylaxis or PrEP isn't. Currently PrEP is only available on a trial basis to a very few selective people. The Australian Government recently announced that 3700 high risk mostly gay and bisexual men would be enrolled in the expanded PrEP implementation in communities trial. However with PrEP previously being trialled on only 300 people widespread accessibility is a continuing issue.
Jason Farley: Accessibility for PrEP is highly varied. If you're well insured or have medical aid of some sort PrEP is generally not about having problems accessing your pill. The pill in the United States is the easiest part to access through either assistance programs from the manufacturer or from the drug company itself or through co-pays that you need to pay through your insurance which are generally small, the pill is the easiest thing. We can get you that pretty simply.
Outside the pill though the PrEP - in order to participate effectively in a prevention program you need to have HIV and STI screenings every 90 days. With my PrEP patients I bring them in, we do the counselling, we do the initial HIV testing and then we do the initials STI screenings for all the necessary STIs and then we talk about sexual health and sexual risk reduction and all those things that makes someone sexually healthy in a very sex positive way. After that I schedule them their next appointment in 90 days and then that process continues every 90 days checking in on their HIV status, their STI status and the like.
Now those visits if you're not insured can be quite costly. Now if you're coming through something like a national health service, those visits would be much cheaper as long as the service covers those prevention activities. If they do not, we would not, in most clinics, have an opportunity to have that free. Some of the public health clinics are presently looking at sliding scale fee models which means you pay based on your income but in private clinics and private settings that's not available and you would pay, depending on what your insurance requirements are, you would pay a pretty substantial fee for the wrap around services in addition to getting the pill.
Jake Morcom: Jason Farley from the Faculty of Health at UTS. Access to PrEP in the western world is one thing but HIV and aids is a global issue. Liz Crock is from the Australian New Zealand Association of Nurses in Aids Care.
Liz Crock: It varies from country to country but you know New Guinea on our doorstep the epidemic's quite large and there's a lot of sexual violence in some countries. So it could be women that may require PrEP more so than gay men in some countries so it depends on the demographic of the epidemic in each country which varies really widely. You know some countries could be injecting drug users who don't have access to clean needles like say in Russia and the Ukraine and places like that.
PrEP hasn't been tested properly in injecting drug users at all in that population. So until the research is done, medical practitioners are always very reluctant to prescribe the drugs.
Jake Morcom: However, for those affected by the virus in the developing world having access to sufficient health services let alone HIV treatments is the next problem to solve.
Liz Crock: It's often around building capacity in those countries, strengthening the health system themselves is key and HIV has actually been quite a catalyst for that in a lot of countries because people have gone in there and HIV workers have been real activists and that includes nurses, doctors and community development workers have been really proactive and very highly political. They've actually managed to integrate HIV treatments into other services, such as for example general sexual health services or maternal and child health services.
Ellen Leabeater: Jake Morcom with that story. Coming up next, how a prison parenting program is helping inmates become better fathers.
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Jake Morcom: You're listening to Think Health on 2SER 107.3.
Ellen Leabeater: Welcome back to Think Health on 2SER, I'm Ellen Leabeater. At any given time in the New South Wales prison system between 13,000 or 14,000 children will have one or both their parents in prison. Corrective Services run a range of rehabilitation programs to equip offenders with skills to help them on the outside. One such problem focuses on parenting. There are programs for both mothers and fathers and Catherine Fowler has been involved with rolling out and studying the impacts of these programs. Catherine is the Tresillian Chair in Child and Health and Professor of Child and Family Health Nursing at UTS.
Catherine joined us to talk about how these programs help Aboriginal fathers in particular.
Catherine Fowler: A lot of the men we interviewed had very little exposure to warm nurturing male role models. Many of them didn't have a father. They were raised by mothers or their grandmothers or in kinship care, aunties and neighbours. Some of them were on the street. So they've never had that opportunity to see what a highly functioning father should look like or act like because many of them if they did have a father he was either in prison himself or on drugs and alcohol.
Not everyone was like that but there were certainly some of fathers that were - some of the men that were like that.
Ellen Leabeater: Obviously you can grow up with a mother and people go on to have great lives…
Catherine Fowler: Certainly.
Ellen Leabeater: …if they've just grown up with a female role model. Is there something in particular that fathers bring to that relationship with a child?
Catherine Fowler: I think there's a lot and it's not so much a father, it's about a male role model. Yeah, a lot of successful single mums there's no problem with their children or with their parenting because they are encased in a family with supportive males. Whether that's a grandfather or an uncle or friends that are male role models that show this child how to nurture.
Ellen Leabeater: So when these fathers who are imprisoned, is it more likely that they don't have that male father figure?
Catherine Fowler: Yeah, it's very much - well they don't have that sort of appropriate, sensitive male figure.
Ellen Leabeater: So how much interaction is there between a parent and child while the parent is incarcerated?
Catherine Fowler: That varies from weekly visits, regular phone calls, letters to being none at all. The men often have sometimes less access to their children than the women do and certainly one of the reasons is because there's multiple partnerings. So a father can have children from three different partners.
Ellen Leabeater: Tell me a little bit about the parenting programs. What's the aim? What do people learn?
Catherine Fowler: Well there is one really major parenting program in the prisons and it's for Aboriginal fathers. It is run by an Aboriginal facilitator who is a very experienced and respected Elder and I think that's really the key to its success. He is trying to provide the men with a different role model of an adult male. In this case an adult Aboriginal male and he talks a lot about culture and what it means to be an Aboriginal male and that's often very different from what these men have experienced.
The thing that, from our experience of working in there, was very much that this facilitator was so respected by the Aboriginal men but he also included non-Aboriginal men if they had Aboriginal children or had access to Aboriginal children.
Ellen Leabeater: You recently did a study that looked at 32 men who had been through this program and 32 men who hadn't, what were some of the main differences?
Catherine Fowler: I think one of the really important things was the ability to be reflective about where they had been and what they were now doing. There was a real depth to it and that surprised me. I must admit I thought that they wouldn't be that reflective but they were able to very critically look at their childhood themselves, at their own parents and to speak about that. They could see the strengths in their appearance, it wasn't all negative but they also could see the things that they wanted to do differently.
When they spoke to us and they described what they wanted for their own children, you wouldn't find any difference from any father in Australia. They want their children to go to university, they wanted their children to be happy and to be healthy and live productive lives. That was a really strong thread through the interviews.
Ellen Leabeater: How long does the program run for?
Catherine Fowler: It runs for about 10 weeks and they come together on a weekly basis but it's really about sitting around and talking. A lot of these men, there was a high - one of the challenges we faced was the level of literacy of the men. So it's around a verbal interaction rather than providing information to them.
Ellen Leabeater: Is it likely that these men go home, well when they are released, go home and use these parenting skills. Can we expect that from a 10 week program?
Catherine Fowler: I don't think you can. I think what any of these programs do is that it puts a crack there. They are starting to see that there's an alternative. Some of the men when they do come back into prison or are in for long periods, they do the program again because they found it so useful. The important thing is that corrective services are trying to provide a range of programs so that they're trying to connect up things like drug and alcohol, rehabilitation programs, anger management programs. You know one program on its own won't do it. It needs to be a suite of programs.
Ellen Leabeater: So what happens to these fathers once they are released? Is there enough support in the community to solidify those skills?
Catherine Fowler: I don't think there is enough support in the community. I think people dismiss them and they also want to disappear and get out of the vision of anybody so that they won't be caught and put back into prison. Unfortunately many of these men will go into hostels, into men's hostels because they don't have permanent accommodation and that was a common thing that they talked about to us was that they just didn't want to bring their children into those places.
So we need to provide fathers with accommodation that is child friendly and child safe. The fathers were very concerned about the safety of their children when they went out into the community. They also need to have jobs. One of the fathers said to me that it was easy for him to get a job, it was just very difficult for him to keep the job. So we need to have much more support as a community about getting these people into, or these fathers into positions where they feel they're productive.
Ellen Leabeater: You mentioned child safety there, I'm assuming a lot of these fathers may have - may be unable to see their children because of things that have happened.
Catherine Fowler: Yes.
Ellen Leabeater: What happens after they've gone through that parenting program? Is there the opportunity for them to see their children again?
Catherine Fowler: Corrective Services are doing lots of innovative things. They're trying very hard. They're doing things like getting the fathers to read to their children and sending tapes. They're getting video conferencing calls to their children so that's really important.
Ellen Leabeater: Catherine Fowler there, Tresillian Chair in Child and Family Health speaking about parenting programs for incarcerated fathers. You're listening to Think Health on 2SER. Coming up the motivators behind domestic violence against the elderly.
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Jake Morcom: You're listening to Think Health on 2SER 107.3.
Ellen Leabeater: Welcome back to Think Health on 2SER, I'm Ellen Leabeater. In recent weeks on Think Health we've been talking a lot about domestic and family violence. Cases of violence in pregnancy, how to screen for abuse and how to respond to ensure the safety of the victim. But one area that is rarely talked about is abuse experienced by the aging population.
Family violence for the older person is often acted out by a child or young relative which can have a huge effect on the older person and the wider family. Lynn Chenoweth is a Professor in Aged and Extended Care Nursing at the University of Technology Sydney. She spoke to Jake Morcom about who in the aging population experiences this violence and how the lack of support services can leave them abandoned.
Lynn Chenoweth: So the violence occurs towards them in all different ways. So it might be psychological abuse where the person is constantly put down, demeaned, told off, not able to make decisions. Their views are criticised. That sort of psychological violence. There's also violence of course in terms of sexual abuse, actual sexual abuse or physical hitting, shoving, pulling, slapping, all of the things that happens in a family that normally occurs for some children and some wives and also some husbands and financial abuse where the person's money is denied them.
So they might have a pension coming in or they might have private income and that money is taken away from them by family members and used - doled out to them according to what the family member things they need or completely denied the use of their money to do what they wish to do with. So there are - all the forms of violence that occur in society for other people occur for older people. But the point is that like children they're much more vulnerable because they don't have the psychological and physical health and also the status in society to actually act out against that and to actually stand up for themselves.
Jake Morcom: Is this a common area of abuse that is overlooked in society?
Lynn Chenoweth: I think it is because somebody might have been married for 60 years or something like that and the husband has always made the decisions about all sorts of things and that continues on into older age and what happens is we find that the person who makes all the decisions continues to do it and often those people are not good decision makers so that the other member of the family has to suffer that. They have learned to be dependent on that other person. So often abuse continues into very old age until somebody picks up on it that this person is quite distressed and it may be that they might be admitted to hospital for treatment or investigation.
The social workers and nurses and doctors discover that this person has been abused for years and nobody in the family has picked up on it. The person is becoming quite anxious, agitated, quite depressed and is fearful of making any decision for themselves.
Jake Morcom: Does this indicate an underlying inequality that as a society we don't justify abuse against the aging population as important?
Lynn Chenoweth: Mm, I think we live in an ageist society in Australia where older people who do not longer continue to work and bring in financial income, they're considered to be redundant and they're not considered with due respect as a citizen who has contributed enormously to society, to building up society and providing the foundations for the society that we enjoy. So I think we are an ageist society and alongside that we're a sexist society where men have dominated and continue to dominate the discourse on who makes decisions, who's in charge, who has the power and control over many of the institutions in society.
So older women, people who actually gave up work when they married because that was expected of them, their husbands usually force them to give up work when they married and had children, they never went back to work or they were forced to stay at home and be a homemaker. Those people, those women gave up all rights in many respects to the normal rights of citizens in this society and because of that they learn to become dependent.
They learn to become helpless and society has supported it and certainly in terms of financial arrangements they don't have equal status because their superannuation accumulation is less because they've gone in and out of work to rear children. So their accumulated wealth is much less than men and their opportunities to grow and develop in the work place are less than men. Their career aspirations are stymied because of that.
So at the end of the day we have more women abused in all sorts of ways than men but there are some men who are abused by women as well and by their children.
Jake Morcom: Do the care and domestic violence services that are out there work in the same way for those or work alongside those who experience domestic violence as they do for younger demographics who experience similar abuse?
Lynn Chenoweth: No, there are no refuges for older women. The refuges exist for younger women and children. Older women who often undergo significant abuse throughout their entire life, there's nothing for them. The only organisations which might try to help might be Carers Australia, Carers New South Wales and they respond to the needs of carers, you know people who are caring for others like caring for elderly people or whatever or Alzheimer's Australia. It actually advocates and tries to support people with dementia and their carers. But if they don't have those conditions then these older people don't get any support.
There is really no organisation that really pays attention to this abuse for older people. It's possible, as I said, that it might be picked up if they go to hospital for treatment or investigation and the social workers and doctors and nurses discover this older person's got bruises. They clearly have been sexually abused. They have no money. Their money has been taken off them and you only discover it in a crisis and usually that crisis is at a point where the person's really lost all rights and their situation is quite dire.
So getting that situation reversed is very difficult. One of the reasons that people end up having to be put into an aged care facility is because they have been abused by family members. They're much safer in an aged care facility where they're protected from any further abuse.
Ellen Leabeater: That's Lynn Chenoweth, Professor in Aged and Extended Care Nursing at UTS, ending that story by Jake Morcom. If this story has raised any issues with you, please call Lifeline on 131114.
If you'd like to find out more about that story or listen to any of our past programs head to our website at 2SER.com/Think Health. This show is produced with the support of the University of Technology Sydney, Faculty of Health. Please remember that you should not consider the contents of this show medical advice and you should consult your physician if you have any concerns.
I'm Ellen Leabeater, this has been Think Health. See you next week for more in health research and news.
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