AIDS and Minorities

A look at some issues for HIV/AIDS education and support programs for ethnic communities in an Australian context.Overview

The needs of people from ethnic communities in respect of HIV/AIDS was recognised from the early days of the development of services for people with HIV/AIDS.

The Australian AIDS Tape, a Commonwealth government produced video intended as a general education resource, was translated into several community languages. Free telephone information lines now operate in 17 languages. A number of specific projects targeted at ethnic communities have been funded. For example, in NSW, the Commonwealth has funded education programs targeted at Arabic speaking people, Viet Namese Youth, and the Viet Namese community more generally. Sacbe was a Commonwealth funded project for Spanish speaking people.

In May 1991, the NSW government funded its Multicultural HIV/AIDS Education and Support Project aimed at reducing the impact of HIV/AIDS among ethnic communities. This project has trained sessional bicultural/bilingual workers to assist other workers – doctor, nurse, social worker, counsellor etc – in providing appropriate service to HIV/AIDS affected people, their family, friends and carers. The workers trained by the program are also involved in developing and conducting HIV/AIDS education programs in ethnic communities.

In November 1989, the AIDS Council of NSW (ACON) began an education program targeted at ethnic gay men, under funding provided by the State government. ACON has also received funding for a program targeted at gay Asian men in Western Sydney and for a support program for positive Asian men. I want to talk about these projects more extensively later. The State government also funds through ACON a worker for the Spanish speaking community.

The Sex Workers Outreach Project (SWOP) in NSW has a half time outreach worker to Thai and Chinese women in the sex industry. Thai women currently make up the bulk of sex workers from ethnic communities. The worker concentrates on doing education and support in the workplace with both the women and with management.

This should not make us feel complacent. While HIV/AIDS and ethnic communities is on the agenda of National and State government strategies, it does not receive the level of attention that the ethnic communities believe it should.

Today, I don’t propose to go group by group and discuss what services are being provided for whom. I don’t have access to all that information, and I’m not sure that that’s what would be most useful to you. What I propose to do is look at what data we have about the incidence of HIV in ethnic communities; consider some general issues that arise across the board in dealing with HIV/AIDS in ethnic communities, looking at both issues for education and issues for care; and then offer an example of a successful education intervention.

Available data on HIV/AIDS and ethnic communities in Australia One of the biggest barriers to effectively addressing the needs of ethnic communities in respect of HIV/AIDS is the paucity of data on its incidence in those communities, data without which it is difficult to argue for adequate resourcing.

The major data collection in Australia on HIV/AIDS is conducted by the National Centre in HIV Epidemiology and Clinical Research. AIDS is a mandatorily notifiable disease nationally. The notification collected by the National Centre includes country of birth. However, the Centre’s regular surveillance reports do not break down its data on this basis. The Centre’s most recent overall review of data, `Estimates and Projections of the HIV Epidemic in Australia, 1981-1984′, does not include country of birth.

Eisenberg, Painter and Todaro, writing in the March 1993 National AIDS Bulletin[1], say that it has been suggested that country of birth data has not been published because of the possibility that it might be used to discriminate against ethnic communities.

There may be some, albeit limited, justification for holding such a view. In the early years of AIDS in the US, Haitians were over-represented in the numbers of people with HIV/AIDS and there was an audible sigh of relief from those who wanted to find some scapegoat, sexual, racial or otherwise, on which to pin the disease. There are still many people who would want to be able to do so. Publishing the rates of infection or illness for particular ethnic communities may lend itself to this even now.

After all, you only have to consider how we still speak of something as commonplace as influenza in terms of its country of origin – the Hong Kong flu this year, the Ugandan flu the next – to see how easily epidemiology, which is after all only the recording of a pattern of transmission, can come close to being causation. History is replete with examples of the xenophobic construction of illness as invasion.

Eisenberg et al argue that the possibility of discrimination in other forms does not prevent the release of HIV/AIDS data by exposure category – homosexual, bisexual, homosexual IDU, heterosexual etc. Gay men have long argued that this is indeed discriminatory and that data should be presented in terms of mode of transmission and not presumed sexual identity, that is, transmission through anal sex or vaginal sex and not homosexual or bisexual.

Eisenberg et al go on to argue that non-publication of the country of origin has functioned to discriminate in that base data which is necessary for the better allocation of resources and the planning of services is unavailable. `Without publicly available data,’ they say, `there is neither public identification of NESB communities as a legitimate group nor validation to argue for funding.

Since 1991, language spoken at home is part of the national data collection of HIV infection. Infection data is a better source of information of the location of the epidemic than is AIDS diagnosis data. There has as yet been no release of information from this data base. Eisenberg, et al are critical, however, of using language spoken at home rather than country of birth as an indicator of ethnicity. People from non-English speaking backgrounds may in fact speak English at home, but this does not necessarily equate with language competence. If the underlying assumption behind using language used in the home as an indicator of ethnicity is that it is a useful indicator of the likelihood of a person accessing necessary services, then we are likely to be getting a false picture.

So, in the absence of any published data on ethnicity what can information to we have of the extent of HIV infection or of AIDS among ethnic communities ?

Eisenberg et al looked at data not publicly available from the Albion Street Clinic in Sydney. The Clinic has been a major site for HIV infection testing since 1985. The Clinic has since that time collected recorded country of birth of those tested at the Clinic. Country of birth is known for 30.4% of those tested between 1985 and 1991.

Of those for whom country of birth was recorded, 11.4% come from ethnic communities. According to the 1986 census, 12.3% of the NSW population was born in a non-English speaking country. In other words, the proportion of those from ethnic communities appearing in the sample of those tested is roughly proportional to their appearance in the State’s population.

More importantly, perhaps, the rate of infection among those from ethnic communities, that is those testing positive, was close to the rate of infection for those from English speaking backgrounds, 18.9% in the former and 23.3 % in the latter.

Looking more closely at the years 1989 and 1990 where country of birth was better known (data available for 74.3% and 70.2% of all clients respectively), again the client proportion and rates of seropositivity are similar to the representation of people from ethnic communities in the State population.

Eisenberg et al don’t break these figures down further into country of birth.

They also looked at the NSW figures for hospital admissions in NSW. Because this is admission data rather than individual patient numbers, large figures don’t necessarily mean a large number of cases. It could simply mean a few cases with multiple admissions. However, it is the relation between those admitted from ethnic communities and those admitted from English backgrounds that we are interested in.

Figures are available for the three years 88/89, 89/90 and 90/91. The overall proportion of admissions from ethnic communities has remained roughly the same over the three years at 9.6%, 12.9% and 11.5% respectively. Again, this is surprisingly similar to the proportion of people from ethnic communities appearing in the 1986 Census.

Those being admitted with ethnic community backgrounds also appeared to be clearly older than those who were Australian born. Available data did not allow for explanations as to why this should be so. It may be that they were presenting later in the course of illness either because they had been supported at home longer, or that they did not present until seriously ill. Whether they presented with different AIDS-related illnesses is not discussed.

Figures from Royal Prince Alfred Hospital show this trend at the level of the individual hospital. Overall, 10% of all patients admitted to RPA are from non-English speaking backgrounds, and this same pattern is reflected in patients admitted to the hospital with HIV-related illnesses.[2]

Are particular ethnic communities represented more than others among those who are HIV infected ? According to Dr Doong, a general practitioner with a large HIV positive caseload interviewed for a documentary on HIV/AIDS affected gay men from ethnic communities[3], the majority come from Spanish-speakers, Italians, ethnic Chinese from Viet Nam, and Thais. Clarita Norman, formerly of the NSW AIDS Bureau, interviewed for the same program, reports on a study she conducted which found Spanish speakers to be the most represented ethnic communities in both those HIV infected and those who had died of AIDS in NSW.

Funding for programs targeted at particular ethnic communities in NSW reflect this pattern of incidence to some extent.

Access to services: more than an issue of language

When the question of access to services by people from ethnic communities in any area of health or welfare delivery is raised, the focus often falls on language skills. The term people from non-English backgrounds, the ubiquitous acronym NESB, in itself points to language as the distinguishing characteristic. In this paper I have consciously only used the term NESB when quoting from others who have used the term. I have used ethnic communities instead.

This has often led to the question of improved access being boiled down to a question of simply translating information into community languages,or of providing for bi-lingual interpreters. So it has been with HIV/AIDS.

Eisenberg et al, looking primarily at education, put the problem this way. `The prevailing assumption has been that if one translates the message of the mainstream into whatever other language, the desired attitude and/or behaviour will result’.

The issue is that ethnicity is not just about language. It is about culture and the meanings culture gives to all aspects of personal and social life.

Take the area of HIV preventative education. Simply translating information developed for an Anglo audience assumes that sexuality and sexual behaviour are consistently defined and understood across different cultures and that simply translating English terms in to community languages will ensure that messages are understood and acted on.

But it’s clear, or it should be clear, that sexuality and sexual behaviour is mediated through a number of means of social organisation – class, race, gender, religion and so on. As a simple example, and one I’ll return to later, the concept of homosexual identity and the formulation of homosexual practice that goes with it is very much an Anglo concept. Men have sex with men in virtually every racial/cultural/ethnic grouping you could differentiate. But not all of it, perhaps very little of it, is understood as homosexual activity.

A man performs oral sex on another man in the back room of a sex shop on Oxford Street. Both those men probably have a similar framework for what they are doing. They will in all likelihood perceive themselves as gay and understand their act as a sexual act. A young boy in the hills of New Guinea fellates his father. The act is the same but the meaning here is very different. It happens that in this community in New Guinea, what we would define as oral sex is a part of a highly complex cosmological and social set of beliefs wherein maleness is passed on through fellatio.

That’s an extreme example of the kind of cultural contextualising that needs to be done when considering how to approach HIV/AIDS in non-Anglo communities.

Not only is the understanding of sexuality and sexual behaviour culturally specific, but the means of delivery of education or support programs will also depend on the particular ethnic community.

For example, an education program targeted for the Arabic speaking community in the course of doing a needs survey identified the importance of constructing safe sex practice messages that could be supported by and disseminated by religious leaders. In practice, this probably means prioritising messages about chastity and monogamy over messages about condoms and abstinence over safe needle use. Simply translating existing material will not work given that the emphasis is on condoms and safe needle use.

Eisenberg et al put the issue this way. `The challenge of HIV/AIDS in a multicultural society is to move beyond the translation model, so that each and all the NESB cultures in society can own the issue of HIV/AIDS equally. This means, at the very least, that the needs of individual NESB communities regarding HIV/AIDS education may not be identical, and may have to be ascertained. ….. each NESB community has to have sufficient education and prevention resources to be able to deal with HIV/AIDS on its own cultural terms and in its own way meet its own specific needs.’

Translation is an attractive model because it is relatively cheap compared with what is being proposed here.

Issues in care and support for people from ethnic communities with HIV-related illnesses

The cultural framework also presents as an issue in the provision of care and support for people from ethnic communities with an HIV-related illness.

Arnel Landicho, worker with the ethnic gay men’s project at ACON suggests a number of factors that should be taken into account when considering counselling or support programs for people from ethnic communities.

First, says Landicho, it is important that we understand and examine a cultural group’s experience of living in a foreign country especially if there is an history of oppression or discrimination in the country or culture of origin. A knowledge of this experience will help us understand an individual’s response to AIDS. How does the group respond to stigma and oppression? How has oppression or discrimination shaped the group’s response to outsiders and institutions? They may have a lot of difficulty trusting outsiders and institutions or perhaps even difficulty in seeking assistance and counselling.

Secondly, it is important for us to understand high risk behaviours and beliefs about homosexuality, the use of drugs and the issue of having multiple sex partners from their cultural point of view. These beliefs and how we deal with them in front of our clients’ or patients’ would influence our client’s self-perception and self-esteem, their willingness to disclose an AIDS diagnosis and involvement in high-risk behaviours and the degree to which they feel they deserve assistance from their family, friends or even service providers.

Thirdly, AIDS is a life-threatening disease and as such, it is essential that we are aware of different cultural beliefs about disease, death and dying and medical treatments. Some people might prefer traditional healing methods rather than the western hospitals and medical services. An understanding of these could tell us about the individual’s spiritual beliefs which may be vital to the individual’s perception of AIDS/HIV and the process of making decisions about issues like euthanasia, early death or artificial life-support.

Fourthly, social and emotional support is also a vital component to the well-being of people infected with HIV, but this support might be manifested differently from one culture to another. Examining social and familial roles and wether or not the needs of the individual comes before the needs of the family or group will indicate the kind of support that is available, how and when or where it will come from. For example should the family spend its resources on a member who has AIDS or should they keep their resources for their future use? Should they look after the sick person at home or would they leave the person to health institutions. Will a person confused with their sexuality seek counselling and advice? Some cultures accept counselling others do not.

Fifthly, we need to develop an understanding of how people from other cultures express themselves, verbally or non-verbally. The more direct approach of Western cultures may not be the way for other cultures. People from other culture may see this kind of approach as rude, intrusive, disrespectful and even hostile. They may prefer a more indirect approach, cautious with their words and may even employ the services of a go-between. Similarly, in non-verbal communication. People differ in their interpretations of body language and behaviour, such as eye contact, touching, crossing the legs or folding the arms or even a wink of the eye. For each culture these actions and/or reactions could manifest or imply a host of meanings.

Lastly, it is important that we evaluate the client or patient level of acculturation. How well is the client integrated into the mainstream society? There are two levels of looking at integration. First, on the objective level. This includes the client’s command of the English language and being able to function outside of the immediate cultural community. Secondly, on the subjective level and this includes the client’s comfort about being outside his/her cultural community, about being different and about identifying more with one particular culture.

How might this operate in service provision ? Trotter looked at the issues for a group of men from ethnic communities admitted to RPA with HIV-related illnesses. The group was typically middle-aged, married, often with children.

Among the common issues encountered by this group he identifies as:

. disbelief of diagnosis

. denial of risk behaviour and so seeking alternative explanations for HIV infection

. hiding the diagnosis from their family, friends and cultural community

. isolation from family and/or cultural community

. inward cultural conflict

. lack of culturally specific support in most areas

. at death, issues surrounding the death certificate and an open casket

This leads to the need, says Trotter, for nursing staff `to be aware of, and deal with, issues that are in many way different for these men form the many and well recognised issues for HIV positive gay men and injecting drug users.’

The issue of denial of risk behaviour presents a dilemma here. On the one hand, there is no reason to determine risk behaviour as far as nursing care is concerned, except perhaps in the case of intravenous drug users where issues of withdrawal, for example, may be important. On the other hand, if we are to ever get a good picture of the extent of infection in ethnic communities and the modes of infection, the questions have to be asked.

Getting the individual to accept their diagnosis and then share that diagnosis with their family, particular their wives, needs to be sensitively handled.

Trotter highlights the extra load that is placed on health staff when the person with HIV isolates themselves and/or their family from their cultural community or where they are isolated by that community. Isolation cuts them off from the community from whom they would usually get support. This can lead to health staff becoming the only source of emotional support that the patient and family can use.

This dependence on the health professional can increase as the person progresses in illness. The usual pattern of AIDS related illness means that the person is likely to become weaker and more physically unable to do the usual activities of daily living. Many people form ethnic communities, says Trotter, feel they cannot accept assistance for fear of their condition becoming known.

We need to also realise that the experience of being ill is also culturally mediated. What sickness means and the relationship between an individual and health professionals will be different for different ethnic communities. Arnel Landicho, Ethnic Project Officer with ACON says `Illness, disease, dying and death itself, fall under the category of taboo subjects, which, like sex and sexuality, are not talked about’[4].

There is an added complication where the main social supports for the individual are still overseas.

Trotter advocates that health staff make use of the co-worker model provided by the Multicultural HIV/AIDS Education and Support Project.

But one caveat that should be put on the use of bilingual/bicultural workers is the fear of some people from ethnic communities that their confidentiality will be broken.

Farquharson, looking particularly at the needs of Spanish-speaking people with HIV/AIDS, also draws attention to the isolation the individual feels or is subjected to[5]. Farquharson is an HIV/AIDS worker with the Sydney Spanish-speaking community. `Many times’, he says, ‘migrants must face, and face alone, not only the possibility of biological death but also of social death. They feel deeply that they might be rejected by their own communities as some kind of modern day leper.’

Culture and identity

Recognising the importance of the social/cultural group in maintaining identity is crucial to understanding denial and secrecy in relation to people with HIV/AIDS and people from ethnic communities.

Put yourself in the position of not having your familiar social supports and cultural reference points. What sense of yourself would you continue to have ? Is it surprising then, that you might not want to put those supports at risk by disclosing something about yourself that you believe will do just that ?

How much less likely are you to do that if you are doing it in a foreign country where those supports and cultural reference points are already fragile, challenged by the hegemony of the country you now find yourself in.

The potential for ostracism from family and community, says Landicho, `for someone who comes from a culture where the unity of the family is of the utmost value, this could lead to a loss of meaning to one’s existence’.

HIV/AIDS and Multicultural agencies

Landicho believes it is difficult for people from ethnic communities to approach mainstream agencies such as AIDS Councils or community health centres for information or support. The likelihood of someone finding out weighs too heavily.

If there are problems in providing HIV/AIDS services to ethnic communities through mainstream or generalist services, what delivery, or opportunity for delivery is there through services with a focus on ethnic communities ?

Eisenberg, in 1992, conducted a study of the needs, in respect of HIV/AIDS information and education, of multicultural agencies in the Central Sydney Health Area. This Area covers, among others, the local government areas of Leichhardt and Marrickville, and has a larger proportional number of people from ethnic communities than the whole of NSW, accounting for 60% of the population of the Area. Eighteen services were interviewed.

The agencies studied included both ethnic specific services and mainstream services with ethnic specific programs.

Few of the agencies’ activities were HIV/AIDS directed, except, says Eisenberg, in a peripheral sense – one-off public forums, a phone-in, a community newspaper item for World AIDS Day, and a condom demonstration in one women’s health group.

One agency had an HIV/AIDS Advisory Committee and was planning an HIV specific service. Another had some HIV/AIDS focus in its drug and alcohol service. Two agencies had a staff member who was a sessional worker with the Multicultural HIV/AIDS Education and Support Project. No agency had provided specific HIV/AIDS training to its staff.

When asked what they perceived as the needs of their communities, no agency suggested HIV/AIDS. Moreover, says Eisenberg `while the formal answer to the direct question regarding the importance of HIV/AIDS for their community was frequently “important or very important” (58%), the underlying ambiguity of HIV/AIDS for agency staff is quite apparent in their comments”.

`It’s not obvious….is it there ?’

`Homosexuality…it’s a shame among us, no one talks about sex….I don’t know anyone who has the disease.’

`It’s a taboo subject. They don’t admit it. It doesn’t exist. It’s not an issue for people in their own community, only when they mix.’

`There’s this feeling in the community that IT only happens to Caucasians….there’s a negative attitude to those who have it.’

`There are the connotations of AIDS: the stigma of drugs, the taboo about the modes of transmission, the family/community shame.’

None of the agencies had an HIV/AIDS poster displayed. The majority (61%) did not have HIV/AIDS pamphlets displayed.

Eisenberg puts this down to three things:

. their lack of information generally

. the relative paucity of appropriate multicultural HIV/AIDS resources. There are only two pamphlets available in NSW targeted at ethnic communities in general, and only one poster. There are specific pamphlets and posters targeted at men who have sex with men

. posters available in English were considered to confronting by the agencies. Some agencies had recently accepted a decorative, less explicit Aboriginal poster.

No agency had condoms displayed. When asked about displaying condoms in the future, half the agencies said no, one third said yes, and the rest could not give a definite answer.

Those who said no made comments such as:

`For us,it would be in bad taste.’

`It’s taboo. It’s against our culture.’

`It would be a problem for us because of our religion.’

`We have to appear respectful and conservative, religious and morally upright to the community.’

Almost all the positive answers came from the mainstream agencies.

When asked questions about their knowledge on a range of HIV issues, however, the staff from all agencies were well-informed on th major modes of transmission and prevention.

It’s very clear that the barrier against effective HIV/AIDS intervention in these agencies is not a lack of knowledge, and not entirely a lack of acceptance that HIV/AIDS is an issue for ethnic communities, but a cultural context which the agencies either accept, or feel they cannot go against.

Eisenberg suggests that there are other constraints operating. Multicultural agencies, she says `are often affiliated to church bodies, which if not prescriptive, are certainly normative in their philosophy.’

She also suggests that many agencies rely on one year government grants for funding. This may mean frequent staff turnover and so a less of expertise in HIV/AIDS. In the average small agency , she further suggests, where the focus is on largely on welfare and settlement issues, HIV/AIDS is structurally not likely to become a major agenda item. I don’t find these arguments as persuasive. They are conditions under which most non-ethnic agencies also operate. It seems to me from the comments she records that cultural barriers are paramount.

Homosexuality, HIV and AIDS: The NESB challenge

The title for this section of my paper is taken from Farquharson. I do so because I agree with Farquharson’s thesis that the key barrier to HIV/AIDS work in ethnic communities is the equation of AIDS with homosexuality.

Farquharson’s belief comes from work he has done with the Spanish-speaking community, where the link between homosexuality and HIV/AIDS is evident in comments made at workshops he has run.

`Look, I don’t have any problem with a person who has AIDS, I’m just afraid he might be queer.’

`If a person acts that way, what can one expect ?’

`I would kill myself if my son was like that.’

Trotter’s comments on the denial of their likely mode of transmission of the patients he sees seem to confirm this. It is the fear that disclosure of AIDS will lead to a disclosure of homosexuality that lies at the base of this denial and the refusal to tell others.

The comments from the multicultural agencies also imply this same dynamic. It is religious and cultural prescriptions against homosexuality that I believe primarily lies at the base of their fears about overtly raising the issue of HIV/AIDS.

Farquharson argues that much of the education directed at people form ethnic communities suppresses one side of this equation, the homosexuality side. As an example, he points to the NSW South West AIDS Education Unit’s HIV/AIDS Cross Cultural Training Program, which uses the word `gay’ once in its 40 pages, and the word `homosexual’ not at all.

The problem with this, he says, is that the largest proportion of those HIV infected in Australia (85% – 90%) are men who have sex with men. The heterosexualisation of AIDS, he argues, will not reduce it’s prevalence among men who have sex with men, but will instead push many individuals further into concealment. This will inevitable make it harder to reach these men with education programs or to encourage them to come forward for early testing in order to engage them in early illness prevention.

Farquharson argues that this approach to ethnic communities conceals the fact that male to male sexual behaviour is a reality in all cultures.

I have not seen a breakdown of the number of those known to be HIV infected coming from ethnic communities who are also known to be men who have had sex with men. Anecdotal evidence would say that the overwhelming number of them are.

Farquharson believes that to effectively address HIV/AIDS issues in ethnic communities we need to:

(a) analyse the interaction that exists between the AIDS = homosexuality equation and the cultural norms of individual cultural groups within multicultural Australia; and

(b) work towards modifying specific cultural attitudes about homosexuality, so that given the existence of the AIDS = homosexuality equation, not only HIV/AIDS but also homosexuality become social realities to be understood rather than evils to be feared and rejected.

ACON’s Ethnic Peer Education Project

I want to turn finally to an example of a successful project with ethnic communities, the peer education project of ACON for men who have sex with men and who are from ethnic backgrounds..

The need for this project was recognised in early 1989. No AIDS education program had at that time been targeted at this group. The programs targeted at the ethnic communities, such as the translations of the Australian AIDS tape, had not included gay specific messages. To that date, all the gay community targeted programs had been in English, using Anglo-Caucasian cultural expressions and images.

The exception of one poster form ACON which used an image of a clearly Asian man in bed with a man from a less explicitly non-European background. This poster had been produced in English.

A significant population of gay men of Asian origin had developed in Sydney. There were two reasons for this.

First, in large Asian migrant communities (Chinese, Vietnamese, Filipino) a significant component was gay.

Secondly, Australia in general and Sydney in particular have historically been seen as the Asian and Pacific regional gay capital. Many gay and bisexual men from countries in the region attempt to study and/or migrate here, or otherwise stay illegally here. This in particular is the case for Indonesian, Thai, Filipino, and Japanese men, as well as Hong Kong and Malay and Singapore Chinese.

Through close contact with the Gay and Lesbian Immigration Task Force, ACON was is in touch with a considerable number of these men.

Their experiences indicated that there were five factors suggestive of the need for a specific program HIV/AIDS education program targeted at these men:

(a) knowledge of HIV/AIDS among these men was extremely variable;

(b) English language skills were extremely variable, suggesting that English-language AIDS prevention materials would often not be understood (especially those using medical and/or vernacular phraseology and including only Anglo-Caucasian imagery)

(c) their involvement in the identified gay community is often erratic or marginal, making contact with existing AIDS prevention programs doubtful

(d) racism within the gay community was a barrier. Many felt excluded from the gay community and so were not receptive to messages conveyed through that community

(e) myths of Asian immunity to HIV, arising from low incidence of AIDS cases in Asia, provided convenient denial mechanisms for some Asian men.

In respect of contact of these men with the gay community, it must be kept in mind that, as with other groups of men who have sex with men, not all would identify themselves as gay or homosexual or bisexual. In Asian communities, as in many ethnic communities, homosexuality or bisexuality are taboo, not culturally acceptable. As with other ethnic communities, then, some Asian men who have sex with men were likely to be using public venues for sexual contact, such as parks, toilet blocks or saunas. Contact with them with a view to education had been difficult.

For some of these men, contact was also complicated by two other factors. Many were refugees from countries where oppression had been a traumatic experience for them, making them less likely to trust authorities such as doctors and medical personnel. And many of them were also illegal. Contact with a doctor carried the real fear their status being exposed through medical records.

A proposal for funding a worker with ACON to develop peer support among these men was successful, and the project began in November, 1989.

The overall aim of the project is to minimise the transmission of HIV/AIDS among South east Asian men who have sex with other men in the Sydney metropolitan area.

The project has the following specific objectives:

1. To assist in establishing safe sex as the community standard among South East Asian men who have sex with other men and who come to the support group in the next twelve months.

2. To expand services to people in the target group who reside in the Sydney West metropolitan area.

3. To assist those in the target group to come to terms with their sexual identity with support in adopting safe sex practices.

4. To promote skills of people in the target group in maintaining safe sex behaviour including assertiveness, negotiating skills and limit setting.

5. To change attitudes towards alcohol and its effects on safe sex and self-identity.

6. To increase facilitation skills amongst some members from different sub-groups and cultures.

7. To increase the sense of belonging to a supportive community of Asian men who have sex with other men.

8. To be able to provide support and make available appropriate referral services to those already infected and/or affected by HIV/AIDS.

9. To extend existing educational and support services to two other Asian cultural or community language groups.

10. To investigate the needs of non-Asian men of non-English speaking background in regards to HIV/AIDS information and safe sexual practices and the need for resources of people in this group.

The outcomes of the project from that time have been considerable.

A pamphlet targeted at men who have sex with men and are from an Asian background has been produced which is culturally sensitive in its approach to the framing of homosexuality in those cultures. The pamphlet is available in Chinese, Vietnamese, Thai, Tagalog and Indonesian.

The earlier ACON poster was reproduced for these cultural/language groups as well.

Negotiations over funding for printing the pamphlet are illustrative of the kinds of difficulties that can occur when an initiative in education comes from within the ethnic communities themselves. Clearly, an important part of the contents of the pamphlet had to be clear instructions on the use of condoms. Since many of the target group were likely to have language difficulties not only in English but also in their own, the use of photographs to illustrate the correct usage of condoms was seen as appropriate. A focus test was done on a support group established through the project and the response was in favour of using photographs. ACON had earlier produced a similar photographic pamphlet for an English-speaking audience. It remains one of the most successful pamphlets despite having had to classified as restricted material by the NSW censor.

When the funding proposal was put to the Commonwealth Department of Health , however, the Department saw the proposal as offensive and obscene and rejected it. AS a result of bureaucratic delays, the pamphlet eventually had to be produced using illustrations only, despite the expressed whish of the target group that the material be in photographic form.

The major success of the project, though was the establishment in May, 1990 of the group “Asians and Friends,” a social, educational, support group for Asian gay men and their friends. At the time there was a great need for a social support group for gay men from an Asian background. Although there are other social groups around, none of them were primarily concerned with issues relating to Asian gay men; their problems about sex and sexuality, cultural differences, cultural pressures, discrimination, social life, etc. Combining this function of social support with AIDS education has proved to be an extremely successful strategy. It has enabled the translation of some of the key components of the successful education and support programs developed for Anglo gay men into the setting of non-Anglo gay communities, particularly those principles of pride in gay identity and community, the incorporation of safe sexual practice as a part of that identity and community, and peer support for safe sex practice.

Men in the group come from Indonesia, Japan, Korea, Philippines, India, Laos, Vietnam, Singapore, Taiwan, Malaysia, Thailand, Hong Kong, Mainland China, American born Asians and those born in Australia and New Zealand.

The group is also in contact not only with locally based groups (Sydney, Melbourne and Canberra) but also with other groups from overseas that run HIV/AIDS education and support for Asian men who have sex with other men. These are groups based in Thailand, Malaysia, Singapore, Indonesia, Philippines, America (several), and England.

Following on the success of this program, ACON has recently received short term funding for piloting a similar support group for Asian men who have sex with men and who live in Western Sydney, and for a program of peer support for HIV positive Asian men who have sex with men.


This program works because it takes as its basic building blocks the kinds of approaches I, and the others whose work I have reviewed, have suggested are necessary for effective responses to the HIV/AIDS needs of ethnic communities.

[1] Eisenberg M, Painter L & Todaro P The challenge of HIV/AIDS in a multicultural society, National AIDS Bulletin, Volume 7, No 2 March 1993

[2] Trotter G No Identified Risk, National AIDS Bulletin, Volume 7, No 2, March 1993

[3] The Last Coming Out, Con

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