Joint Committee on Health and Children debate -
Thursday, 5 Dec 2013

HIV-AIDS Strategy: Discussion

Chairman

I remind members, witnesses and those in the Gallery to have their mobile telephones turned off or in flight mode because they interfere with the broadcasting of proceedings and it is unfair to members of staff who must endure the noise in their headsets.

The first of two sessions this morning deals with the issue of HIV and AIDS. Last Sunday was World AIDS Day and it is timely that we as a committee convene to discuss this issue and our strategy regarding HIV and AIDS. In this regard, I welcome all of the witnesses to the meeting. I will not go through all of their names individually now but I will welcome them all again later. It is important that we give this topic consideration and discussion. I would ask members making presentations to keep within the five-minute allocation because there is a large number of witnesses who want to give testimony and there will be questions as well.

Witnesses are protected by absolute privilege in respect of the evidence they give to the committee. However, if they are directed by it to cease giving evidence on a particular matter and they continue to do so, they are entitled thereafter only to qualified privilege in respect of their evidence. They are directed that only evidence connected to the matters under discussion should be given and are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against a person or an entity by name or in such a way as to make him, her or it identifiable. Members are reminded of the long-standing parliamentary practice and ruling of the Chair to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official by name or in such a way as to make him or her identifiable.

I welcome Dr. Tony Holohan, the Chief Medical Officer, and ask him to make his presentation.

Dr. Tony Holohan

I thank the Chairman and the committee for providing the time. I am joined by my colleague, Dr. Kate O'Flaherty, who is now heading up the health and well-being programme in the Department which, as the committee will be aware, is a new unit established to drive the implementation of Healthy Ireland which was approved by Government in the early part of this year. Kate comes to us from the Pharmaceutical Society of Ireland, PSI. She is both a pharmacist and a journalist and she has responsibility for sexual health.

On behalf of the Department, I welcome the opportunity to be here today, in particular, to brief the committee on the development of the national sexual health strategy, which is the context in policy terms for our consideration of the issues this morning and which is currently being finalised.

The implementation of that strategy will be undertaken by the health and well-being division of the HSE, and Dr. Stephanie O'Keeffe and her team from the HSE will speak to that. They will be supported by the key stakeholders in the area. The strategy and its implementation are underpinned by the goals and principles of the Healthy Ireland framework which I have mentioned already.

This new strategy is the first time that a nationally co-ordinated approach has been developed to address sexual health and well-being and to reduce negative health outcomes, including in the specific area of HIV. The strategy's vision is that everyone in Ireland experiences positive sexual health and well-being, and has access to high quality sexual health information, education and services throughout the life course. The strategy takes a life course approach, which is consistent with the underpinning concept in the Healthy Ireland framework, and acknowledges the importance of developing healthy sexuality throughout childhood and adolescence and builds on that foundation for positive sexual health and well-being into adulthood and older age.

Sexual health is an important part of overall health. It means in the first place the absence of disease and infection but also covers well-being, the ability to control fertility and to have children and the ability to enjoy fulfilling relationships free from discrimination.

Worldwide, sexually transmitted infections, STIs, are among the most common causes of disease and are an increasing cause of ill health. Apart from the initial symptoms and discomfort, they may result in long-term health problems such as infertility, ectopic pregnancies and genital cancers. In Ireland, rising STI rates have increased the level of concern in this area among health professionals, the Government and the public, and are something we are certainly concerned about.

Sexual health infections prevention and treatment services include a broad range of health care at different levels, both public and private, throughout the health care system. The main elements include: prevention of sexually transmitted infections and clinical care for those with STIs; contraception; screening for diseases such as genital chlamydia; psychosexual counselling and support; and specialised services for high-risk groups and diseases.

HSE public STI screening services are almost exclusively based in hospitals and special community clinic settings around Ireland and they are free at the point of access. In places, some GP practices and family planning services may provide STI services for a fee.

The national AIDS strategy committee, NASC, was established in 1992 by the Government as a response to the HIV crisis. It comprised a wide range of stakeholders, including academia, the health sector, the health boards, Dublin Aids Alliance, and other NGOs, and I would like to acknowledge the commitment and effort over the past 20 years by all the stakeholders in the implementation of that strategy.

Ireland has experienced many changes regarding sexual behaviour and sexuality in recent decades. This changing landscape is evident in legislation introduced in recent years and more openness generally in attitudes and culture around sexuality and sexual health issues.

In the area of treatment, and specifically in the area of HIV, the treatment of HIV has been revolutionised with the introduction of highly active antiretroviral therapy, HAART, which is a special drug therapy which is effective in managing HIV. However, it is equally recognised that the culture can be further improved and that consequences such as non-disclosure of HIV status or late diagnosis continue to be issues that require further efforts and that the fear of stigma or discrimination may prevent people accessing the medical assistance or counselling supports they need. It is also recognised that a broad range of non-health determinants all impact on sexual health and well-being, and sexual health inequalities - the extent to which they are unevenly distributed throughout society - and this is a key feature of the approach taken under the Healthy Ireland framework.

For many individuals, their sexual health service needs are not complex and they can and should be delivered, as with all other health services, at the lowest level of complexity appropriate within our health services, which is within primary care. Notwithstanding this, there are people at greater risk of and-or vulnerable to experiencing negative health outcomes and who, therefore, require specific interventions to achieve and maintain positive sexual health and well-being. The development and implementation of a national sexual health strategy emanates from recommendations of the 2009 review of NASC report. It is in the process of being finalised. A steering group to oversee the drafting of a strategy was established in May 2012. Its terms of reference set out that the strategy would provide a strategic direction for the delivery of sexual health services and a focus on improving sexual health and well-being in addition to addressing issues such as surveillance, testing, prevention and treatment of STIs and HIV, crisis pregnancy, and sexual health education and promotion. The strategy was intended to be in line with the Healthy Ireland framework, which was in development also at the time. The drafting of the strategy has been supported helpfully by our colleagues in the Institute of Public Health. More broadly, the steering group and working groups referred to a number of existing policy documents, including excellent work done by the college of physicians as well as the crisis pregnancy programme, during their deliberations.

The work of developing the strategy is in its final stages, with a final draft to be circulated to the steering group shortly, with a view to the document progressing for Government approval and publication early in 2014. The group was chaired by the Department of Health and comprised representatives of key agencies and stakeholders involved in delivering sexual health services, including a significant number of those who sat on the NASC. The steering group did its work through three working groups on education and prevention working group, services working group and health intelligence, which is surveillance and monitoring.

The health and well-being division of the health service directorate will take responsibility for leading the implementation of this strategy, operating with the overall parameters of the Healthy Ireland framework. The implementation will include the appointment of a national lead on sexual health and the establishment of a national advisory group, drawn from key stakeholders, to support and oversee the development and roll-out of the implementation plan. Among the key first steps for the implementation of the strategy will be exercises to map current services and assess needs, and develop an evidence informed approach to target those most at risk of negative sexual health outcomes. Ongoing monitoring and evaluation of the implementation plan and outcomes, including the use of specific indicators to monitor its progress will be facilitated by through an outcomes framework, which will include a research and data dimension as part of our overall work on Healthy Ireland. In addition, in line with the principles of Healthy Ireland, opportunities to improve co-ordination and communication and maximise synergies between other strategies and polices in health and education, as well as other sectors, will be identified and pursued.

Chairman

I also welcome Dr. Kate O'Flaherty. I call Dr. Stephanie O'Keeffe to make her presentation.

Dr. Stephanie O'Keeffe

I thank the Chairman for the invitation to attend the meeting to discuss this area.

Under the new governance arrangements of the health services there are five service divisions on the directorate, one of which is the new health and well-being division. The division provides people with knowledge, services and supports to help them live healthier and more fulfilled lives. The division includes public health departments, health protection services, child health, health promotion and improvement services, environmental health services, emergency management and health intelligence. National frameworks and strategies such as Future Health, and Healthy Ireland - A Framework for Improved Health and Wellbeing 2013-2025 underline the commitments at national level and service wide to increasing the proportion of people who are healthy at all stages of life, reducing health inequalities, protecting the public from threats to health and well-being, and creating an environment where individuals and all sectors of society can play their part in achieving a healthy Ireland.

Improved health and well-being, importantly, is one of four pillars of reform outlined in Future Health. This pillar of reform demarcates a shift in policy, service design and practice away from simply treating sick people to also keeping people healthy. The new division will work with the director general and other national directors to ensure health service reforms result in a greater focus on disease prevention, early detection and intervention and self-care.

One of a number of priorities in 2014 for the division is to review the co-ordination, effectiveness and impact of sexual health services and preventive work. We plan to build on the existing capacity and expertise that we have in the area of sexual health, in health promotion and improvement and public health within the division and with our colleagues in primary care, social inclusion and acute hospitals to improve co-ordination in this area. We also plan to identify a clinical lead to look at sexual health services and improve standardisation in this area. This work will be aligned, as appropriate, across the service divisions of the health service. We will continue to take a strong and strategic partnership approach to addressing sexual health issues involving key stakeholders ranging from other Departments, professional bodies, academia, NGOs, the media and all the groups represented at the meeting.

The work of the health service in this area in more recent times has been guided by the NASC and three national strategies dealing with the prevention of crisis pregnancy. As Dr. Holohan pointed out, the Department of Health established a steering committee and we worked closely with the Department and other stakeholders in developing the draft strategy. A significant volume of work is undertaken every day across the health service and by a range of partners across the statutory, non-statutory and community sectors in the area of sexual health. This work is focused on preventing negative sexual health outcomes from unplanned pregnancy to STIs and HIV-AIDS. This work is targeted towards at-risk and vulnerable groups and has been informed by a robust research and information agenda over the past ten years.

Surveillance is an essential part of any framework to support and inform the delivery of sexual health services and supports. Surveillance of STIs and HIV, in particular, has improved in recent years due to the work of clinicians, departments of public health and the Health Protection Surveillance Centre, HPSC. I refer to trends in HIV diagnoses. In 2012, 341 newly-diagnosed HIV cases were reported in Ireland, which equates to a rate of 7.4 per 100,000 population and represents a 7% increase on the 2011 figure of 319. This reversed a downward trend since 2008. A total of 6,629 cases of HIV have been reported in Ireland since the early 1980s. This figure does not represent the number of people living with HIV in Ireland, as it does not take into account factors such as migration or death. Among the reported new cases in 2012, the median age is 33, with the majority male. The probable route of HIV acquisition is men having sex with men, MSM, in 48.7% of cases. This is the largest group and this figure has been increasing since 2004. In addition, 38.1% of new cases were acquired heterosexually and 3.8% through intravenous drug use.

The health service has a strategic objective to improve knowledge and awareness of sexual health and relationships through the delivery of targeted communication campaigns, customised information and educational programmes and other initiatives across a range of settings. This is achieved through the ongoing management, funding and evaluation of communication campaigns and education and prevention programmes. It is also achieved through significant partnerships with, for example, the Department of Education and Skills and the out of school sector and service providers.

The health promotion and improvement service has more recently worked with the Gay Health Network , GHN, on a two-year campaign targeting MSM to destigmatise HIV, reduce homophobia, and encourage early testing and taking protective measures to reduce risks. Public health services, through the gonorrhoea control group, are engaged in information campaigns for MSM. A social media campaign for sexually active young heterosexual adults encouraging safer sex is planned to go live on 9 December. In addition, the HSE crisis pregnancy programme launched a new phase of its Think Contraception campaign last month to encourage consistent use of condoms and other forms of contraception among sexually active young adults. This phase of the campaign directly addresses both unplanned pregnancy and STIs.

The health service is involved in a number of education initiatives targeted at specific audiences from parents, teachers, youth workers and young people to improve knowledge and skills around relationships and sexuality as part of its approach to improve sexual health and well-being and to reduce stigma and negative sexual health outcomes. This has involved significant inputs in the area of relationships and sexuality education, RSE, and social personal health education, SPHE, in schools and working very much in partnership with the Department of Education and skills and in out of school settings through work with National Youth Council of Ireland, Foroige and Youthreach, among others.

Examples of this work also include the development of the B4uDecide.ie campaign and supporting resources for teenagers, parents, teachers and youth workers. The aim of the B4uDecide website, information materials, and teaching resources for schools and youth work settings is to give young people the information they need about sex and sexuality, and to promote healthy, informed and responsible decisions about relationships and sex.

A range of materials to support parents in talking to their children about relationships and sex are disseminated through healthpromotion.ie and other channels direct to parents.

Sexual health services in Ireland provide a wide range of services, including STI screening, diagnosis and treatment, contraception, crisis pregnancy services, counselling, advocacy and support, health promotion, outreach, data collection, information and support, and psychosexual services. Some services are exclusively information or education services, some are exclusively clinical or counselling services, and some are a mixture. Some services are particularly targeted at groups such as men who have sex with men, and young people. Services are currently provided in multiple community and hospital based clinical and non-clinical settings, by a mix of public, private and non-governmental organisations.

As well as providing services directly, the health service is also involved in funding programmes such as those delivered by the Dublin Aids Alliance, the Sexual Health Centre in Cork, and the Red Ribbon Project among others. It is also involved in the provision of free condoms in GUM and drug services for IV users.

An important initiative that has been developed through EU funding is training for people working in this field to improve the effectiveness of prevention work. The health promotion and improvement service has been involved since March 2013 on an EU-funded project on quality improvement in sexual health services preventing the spread of HIV in particular. The aim of this project is to develop a cross-country policy model, standards, tools and training which will be applied by all states and NGOs to work in an effective way across Europe and within individual countries. This dovetails with the approach of the new national sexual health strategy to work to standardise service delivery in the area of sexual health.

In the area of HIV-AIDS, as with all work in such fields, service user involvement is important to ensure that services are targeted and delivered in a manner that supports their use and effectiveness. Involving people living with HIV in the design, implementation and evaluation of prevention initiatives is an important component of the work undertaken by NASC and the Gay Health Network.

Health intelligence supports good decision-making for better health and health outcomes by using an evidence base to inform such decisions. This includes the work of the health protection surveillance centre, HPSC, and commissioned work and reports from various partners. Over the last ten years, a large amount of research work has been undertaken in this field.

The Gay Health Network has received funding to produce a number of reports and surveys such as the all-Ireland gay men's sex surveys, the European men who have sex with men Internet survey, and the EMIS Ireland reports.

The HSE's crisis pregnancy programme and the Department of Health have commissioned a number of nationally representative surveys and reports that have covered sexual health behaviours and attitudes, such as the 2006 Irish Study of Sexual Health and Relationships, ISSHR, and the two Irish contraception and crisis pregnancy surveys in 2003 and 2010. The findings from this research have been disseminated and used to inform strategy development, including the new national sexual health strategy and the content and targeting of national awareness campaigns and education supports and services. I have to say they have been hugely useful.

In conclusion, the new health and well-being division will move forward with its planned review of sexual health services and preventative work to ensure a more co-ordinated and integrated approach in this area. The division will co-ordinate the development of an implementation plan for the new national sexual health strategy as part of the broader Healthy Ireland framework. We have aligned our work plans with the Department of Health and look forward to continuing to deliver on this agenda in partnership with a broad range of partners and stakeholders, as I mentioned earlier.

That concludes my statement. Together with my colleagues, I will endeavour to answer any questions that members of the joint committee may have.

Chairman

I thank Dr. O'Keeffe for her presentation. Our next speaker is Mr. Tiernan Brady, policy director of Gay HIV Strategies, the Gay Men's Health Service, and the Gay Health Network.

Mr. Tiernan Brady

I wish to thank the Chairman and other members of the joint committee for deciding to discuss this issue about which awareness needs to be raised. I will examine the figures and talk about some of the trends that are emerging. The most recent full-year data is for 2012. As regard gay and bisexual men and MSM, in recent years we have seen a significant rise in the rates of diagnosis. In 2005 we had 60 cases, while last year we had 161 cases. That represents a 160% increase in diagnosis rates in that time period. It is not a random spike, but a clear trend if one examines the graphs I have included in the document.

In 2010, for the first time, MSM became the largest population group of new HIV diagnosis rates, with 48% of new cases last year. For the first six months of this year we are roughly at 50% again, so unfortunately the trend continues building on previous years.

Figures for the first six months of this year show that the trend is still continuing. We had 72 cases of HIV in MSM diagnosed in that period, which is up to 82 this year.

A key point is that the median age at which people are being diagnosed is getting lower. That trend has been happening consistently in recent years, to the point where for the first six months of this year the median age for young gay and bisexual men being diagnosed is 31. There is also a time lapse between when one gets a condition and when it is diagnosed. We can therefore take it that people are contracting the condition at a slightly lower age than 31.

The figures show that there is a significant issue for a specific group of people - gay and bisexual men. Within that group, that can be targeted down to younger gay and bisexual men. We know that from the statistics which are very good in Ireland. We have a good information gathering service with the HPSC.

Building on the figures, what do we do to address the situation? We can examine two key areas. First, we need to raise awareness about HIV for groups that are most at risk. Second, we need to get people to access sexual health services so that they can make the best possible decisions and get the best sexual health outcomes.

One of the key points about raising awareness is through the kind of campaigns the committee will hear about from other groups. Those must be targeted to groups most in need. We are no longer in the 1980s or 1990s where generations could remember blanket radio and television campaigns about HIV and AIDS. Those resources simply do not exist nowadays. It is now about taking what resources are there and focusing them on groups that are most at risk.

The other key part of raising awareness is through education. There is a good curriculum on sexual health, which is called the Trust curriculum that was developed in Ireland. One of the challenges, however, is that it is not being taught everywhere. The question, therefore, is how can we address the barriers that prevent it from being taught. Why do people feel uncomfortable teaching the course? Young people in secondary school are a captive audience who can be furnished with the information they need to make the best possible decisions for themselves. No more than in all parts of health, this is about giving people information and the capacity to deliver on their own health outcomes in so far as they can.

Engaging with health services is a critical element. We know that when people contract HIV, they are most contagious in the early stages. It can be passed on more easily in the early stages but, unfortunately, that is the time when one is least likely to know one's status. We need, therefore, to get people to know their status. People must be able to engage with sexual health services and get tested. The quicker people know their status the less likely it is that HIV will be passed on. Most HIV is passed on by people who simply do not know they have it. We must be able to address that problem which is about engaging with services.

Just as we talk about addressing barriers to teaching the curriculum, one of the key things about getting people to engage with sexual health services is by trying to address barriers that stop people from doing so. There are significant social barriers for all people to engage with their sexual health services, but most especially for gay and bisexual men. Many recommendations in previous reports have been developed through NASC and the education prevention committee, discussing how best to engage with those services. Some of them are contained in our document.

The key recommendations we suggest include continuing further campaigns on HIV prevention and raising awareness. These must be targeted to groups at risk. In addition, we need to develop and implement national campaigns to address the stigma and discrimination facing people living with HIV, and the knock-on effect that has in getting people to engage with services.

We also recommend the completion of the national sexual health strategy. I am glad to say that I am on the steering group of that strategy and it is wonderful to know it is coming close to completion. We also need a proper analysis of the barriers preventing teachers from feeling that they can roll out the Trust curriculum to raise awareness.

Ultimately, this is about people making the best decisions to protect their own sexual health.

Chairman

I ask Mr. Quinlan, manager, Gay Men's Health Services, Health Service Executive, to make his opening statement.

Mr. Michael Quinlan

Gay Men's Health Services, GMHS, HSE, is a community-based service and remains the only statutory body providing dedicated sexual health service for gay and bisexual men and men who have sex with men, MSM, in all of Ireland and one of the few in Europe or worldwide. The United Nations uses the term “men who have sex with men”, MSM, which covers gay and bisexual men, transgender people and sex workers.

On October 6 1992 the Gay Men’s Health Project, as it was then known, opened its first STI, sexually transmitted infection, clinic. It became so busy that it went to operating two evenings a week in January 1993. An important part of the service was an outreach service to the community and the provision of counselling services. The outreach workers maintained HIV prevention and sexual health awareness in the community, various groups and agencies during the years. The number of outreach workers has been reduced from four to one who is on a career incentive break. Counselling was provided by one full-time person but is now provided by two sessional counsellors in five client sessions per week. The GMHS STI clinical team of doctors, nurses, counsellors, health advisers and assistants are employed on a sessional basis for the two evenings per week. They are engaged from agencies or individually, which has proved ideal for this type of service and is cost effective. The medical team is trained in sexual health and many work in other STI services. GMHS works in partnership with the GUIDE Clinic and the microbiology laboratory at St. James’s Hospital, as well as a consultant in infectious diseases providing medical direction.

The GMHS STI checkpoint is based in Baggot Street Hospital, operates two evenings per week and is very busy. Over 9,800 MSM have registered since 1997. Up to 825 of these men were first-time attendees, with 39% aged 24 years and younger, a significant increase of 20% in this age group when compared to 2011. There was a 25% increase among men from counties Dublin, Fingal, Wicklow and Kildare. STI screens numbered 3,672, with over 4,500 nursing contacts. There were 261 cases of gonorrhoea, a 43% increase when compared to 2011; 156 cases of chlamydia; 52 cases of HIV, a 37% increase when compared to 2011; and 56 cases of syphilis, a 22% increase when compared to 2011.

The clients attending come from diverse cultural and ethnic backgrounds and travel from across all 32 counties. For instance, between 2009 and 2012, of the 2,949 new registrations, 37% were born in Dublin, 26% in the rest of Ireland, while 37% were born abroad, covering 95 countries. Since 2011 we have registered ethnic backgrounds. In 2012, of the 825 new registrations, 85% identified as white, with the remainder being black African, Asian or of mixed race. Both findings indicate much more diverse backgrounds among MSM than in the national census of 2011.

During the years GMHS has helped to establish such groups as Gay Health Network, Outhouse, the LGBT community centre, the BeLonGTo youth service and others. GMHS is part of the National AIDS Strategy Committee, NASC, and was represented on the service-working group for the national sexual health strategy. In 2009 GMHS was involved in producing the important document, LGBT Health: Towards meeting the Health Care Needs of Lesbian, Gay, Bisexual and Transgender People.

Gay Health Action, GHA, initiated the response to AIDS and HIV in Ireland among homosexual and bisexual men in 1985. It produced and disseminated information on transmission and also challenged the perception of AIDS as a gay disease. It helped found the Lesbian Health Action, Cairde and AIDS Action Alliance, later Dublin AIDS Alliance. GHA disbanded in 1989. It is worth noting that it could not receive funding from the Department of Health or hold meetings with the then Minister because of the legal position on homosexuality.

In 1989 the then Eastern Health Board established the AIDS Resource Centre at the Baggot Street Clinic providing a needle exchange programme and outreach services for intravenous drug users and free HIV testing for the general population. GMHS was established in 1992 and was also based at the Baggot Street Clinic. The AIDS Resource Centre had been renamed the AIDS-Drugs Service. GMHS was also involved in the Lesbian and Gay Health Caucus from 1990 to 1992 which was based at Dublin AIDS Alliance.

The establishment of the Government’s National AIDS Strategy Committee in 1992 was vital and recognised that the criminalisation of homosexuality inhibited promotional work in this field. It also called for legislation to be amended to allow for the sale of condoms from vending machines.

The Gay Health Network, GHN, was established in 1994 and is an all-Ireland network of agencies, organisations, individuals and MSM living with HIV. All have a shared ethos and commitment to achieving the purposes of the network, sharing ideas, work, resources and experiences. The main purpose of GHN is to promote HIV prevention and sexual health awareness among MSM, with a focus on men living with HIV, and to combat the stigma associated with HIV. GHN and its members provide a range of front-line services. The actions of the network are evidence based, strongly linked, developed and guided by accurate knowledge of the behaviour of MSM and are based on the findings and recommendations of research and relevant reports. The Gay Health Forum has been held since 2000 with the support of the Department of Health and HSE - social inclusion.

In Ireland HIV and other STI infections, particularly syphilis and gonorrhoea, are in high numbers among MSM. This trend, with the Government’s 2002 national AIDS strategy report and the education and prevention plan for the period 2008 to 2012, highlighted the need for actions with and for MSM. In the 1980s and 1990s communities, including the gay community, were greatly affected by AIDS-related sickness, death and emigration. Since the 2000s, with new treatments, various committees and the national AIDS strategy, efforts have been made to address the issue with some success. Nevertheless, the increase in the level of HIV infection seems relentless and proves the need for continued investment in prevention and support and partnerships with various communities and groups such as the Gay Health Network. Another issue is AIDS-related stigma and challenging this needs to be part of prevention awareness campaigns.

Research is the key to planning and strategy. In fact, GMHS was established as a result of a survey carried out in December 1991 of the Dublin gay scene. The report published by the then Eastern Health Board on the 470 gay and bisexual male respondents showed that, although nearly half had been tested for HIV, two thirds had never been screened for a STI and 84% had never had the hepatitis B vaccine. Since its establishment, GMHS has led on research among MSM in Ireland. With GHN members, it has produced many of the research reports on health needs and HIV prevention and support services.

The most recent report is on the European men who have sex with men Internet survey, published by the European Centre for Disease Prevention and Control, ECDC, last May. This was the largest survey of its kind in the world, with 180,000 respondents across 38 European countries, including 2,610 respondents from the island of Ireland, the largest number ever here.

The seven MSM research reports produced between 1992 and 2012 showed the rates of not ever having had a HIV test had increased from 47% to 62%, as had rates of HIV positive results from 5% to 9%. We were also able to indicate the non-testing rates for all counties in Ireland for planning purposes.

The Man2Man report two, Living with HIV, found that a significant number of the 143 respondents had experienced direct stigma and discrimination. Over nine in ten respondents indicated that they had personally heard others say unfavourable or offensive things about people with HIV and had seen or read things in the media about people with HIV that were hurtful or offensive. Three quarters of the men indicated that others had treated them less favourably when they learned that they were living with HIV. Importantly, a total of 44% of men have been advised to lower their expectations in life because they have HIV, while 11% indicated that they had been denied medical help because they were HIV positive. Encouragingly, a large number said their friends were supportive and understanding on learning that they were living with HIV.

The most recent Man2Man report three, Our Sex Lives, takes a look at sexual activities, happiness rates and substance use. It highlights how important it is for men in steady relationships to talk about their HIV status and to be tested together before they decide to stop using condoms. The main European men who have sex with men Internet survey, EMIS, report also shows the need for comprehensive STI screening services for MSM. They include throat, genital and ano-rectal examinations, with tests for HIV, syphilis and hepatitis. GMHS has shown that type of service and access are key and can be successful. We hope to lead the way for the next 21 years and look forward to participation in the implementation of the sexual health strategy.

I spoke about the lack of outreach workers owing to the effects of the recession and recruitment embargo, but we continue to provide a service, as do others. Recently GMHS has developed partnerships with other GHN members such as Outhouse, BeLonGTo and Gay Switchboard Dublin to continue the personal development and assertiveness courses, outreach services in the community and the availability of safe sex packs. Sustaining these efforts will be a cornerstone of funding requirements.

As mentioned, MSM are recognised as a key target group for HIV prevention. Knowing one's target audience is vital in planning services and health promotion strategies. EMIS devised a 3% guide figure in estimating the MSM population. According to the 2011 census, there were 2,272,699 males in the State. Using the figure of 3%, we estimate that we have a minimum target population of MSM aged 15 to 69 years of 54,000. We have also devised this figure by HSE region.

As a result of HIV and STI trends, research and other reports and the partnership approach adopted by the GHN and the HSE's health promotion and social inclusion office, the first national HIV and sexual health awareness programme for MSM was born. The Man2Man programme, a joint initiative taken by the HSE and the GHN, was launched in December 2011 with support from the then Minister of State, Deputy Róisín Shortall, and the Lord Mayor of Dublin. In December 2012 it ended with the support of the Minister of State, Deputy Alex White, for translating Man2Man, taking account of the ethnic mix of MSM.

I will now hand over to Ms Donlon who will make a presentation on the Man2Man programme and the GHN.

Chairman

I will be strict on time because Mr. Quinlan has eaten into the time available.

Ms Susan Donlon

As Mr. Quinlan mentioned, the Man2Man programme is a joint initiative taken by the GHN and the HSE that commenced in December 2011. It was the first programme of its type of in Ireland specifically targeted at MSM and one of the actions recommended in the Department of Health's National AIDS Strategy Committee's HIV and AIDS education and prevention plan for the period 2008 to 2012. The key messages of the programme were strongly linked with the findings of key research, particularly the EMIS study referred to. The programme messages were on promoting HIV prevention, including the promotion of testing and condom use, providing access to free condoms and promoting services such as LGBT telephone helplines. The programme was promoted primarily through social and online media. There was specific targeting of the HSE Dublin North East and Dublin Mid-Leinster regions. The results were quite promising following 12 months of promotion. They showed an 81% increase in the number of website visitors, a 65% increase in the number of calls to LGBT helplines in the ten counties specifically targeted in the Dublin north east and Dublin mid-Leinster regions, a 1,650% increase in the number of YouTube views on the Man2Man Ireland channel and a 9% increase in the number of attendees at the GMHS-HSE clinic for testing, which included a 25% increase among men living in rural Ireland.

Given these promising results, the HSE and the GHN agreed on the importance of building on these achievements and the investment to promote consistent and sustained HIV and STI prevention messages among MSM in Ireland. The recommendations include continuous development of Man2Man.ie, the only sexual health information and resource website specifically targeting MSM in Ireland; promoting social inclusion and increasing access to information for harder to reach groups living outside urban areas; establishing peer-led volunteer outreach services; and continuing to respond to emerging needs.

While we have worked to secure funding throughout 2013, we have also progressed some of these recommendations, including constantly updating the website. Our partners in Gay Switchboard have launched a new drop-in sexual health information service and a new e-mail support service. The new peer and volunteer outreach service has commenced in Dublin and Cork. The GHN has been actively participating in the gonorrhoea control group co-ordinated by the public health department of HSE East in responding to the increase in the number of gonorrhoea infections among MSM. In partnership with GMHS, we also published a new research report arising from the EMIS data.

Other programmes strongly associated with the Man2Man programme are under development. The BeLonGTo youth service is developing a personal development course for younger MSM aged 18 to 24 years, while Gay Switchboard Dublin will deliver a course for MSM aged 25 years and over. GHN is the only network of its kind in Ireland that has a specific focus on HIV prevention for MSM. It is a partnership of a range of organisations and individuals, including men living with HIV. Organisations involved in the GHN are primarily those involved in front-line services, including the Gay Switchboard Dublin, the BeLonGTo youth service, Dublin AIDS Alliance, GMHS, Rainbow Support Services at the Red Ribbon Project, Open Heart House, Outhouse LGBT Community Centre and Positive Now. These are just some of the partners involved. We all know partnership is a very cost-effective approach. This is very true for the GHN as there are no salary costs involved. Members give of their time on a voluntary basis or on behalf of the organisations with which they work, which reduces costs significantly and there are no overheads involved.

While funding resources are vital for the sustainability of programmes - there is a requirement to have a consistent HSE prevention message - partnerships must be sustained. It is important that the Government and other key stakeholders recognise and consider that reductions in funding and other resources for individual organisations involved in front-line services impact on their ability to engage actively in partnerships such as the GHN. These partnerships are vital to sustaining a consistent HIV prevention message targeted at MSM nationally, for the implementation of further programmes and activities and if we are to truly challenge and combat HIV-related stigma and discrimination.

Chairman

Our final speaker is Mr. Goulding who is involved with Positive Now and the GHN.

Mr. Jimmy Goulding

I thank the committee for giving me the opportunity to speak about HIV and AIDS issues. I have been living with HIV for the past 23 years and I am a founding member of Positive Now, a voluntary group of people living with HIV. We are representing the voices of people living with HIV at NGO and Government level. Ours is an all-island network and it is a unique and diverse group. We are also represented in the Gay Health Forum and the GHN and involved in the Man2Man campaign.

Positive Now began in June 2010 when there was no national group for people living with HIV in Ireland. The eight members of Positive Now have over 120 years of experience living with HIV. We have an office in the premises of Dublin AIDS Alliance on Parnell Square, with which we work on a voluntary basis.

We are also represented in the sexual health and HIV network. We believe the issue of HIV should be put back into the public arena in order that we can tackle the matter of HIV stigma head on. Positive Now frequently hears of incidents of HIV stigma and discrimination from people living with HIV. Many of these incidents involved health professionals and Government service providers who refused to treat or provide services for people living with HIV. These incidents can add to stigmatising people living with HIV and drive the issues arising further underground. Stigma also prevents people from being tested.

I am grateful for the opportunity to make a number of recommendations. Our first recommendation is that the Government put HIV back onto the agenda and work to highlight the issue of HIV stigma through a national campaign. The Government should also implement the Equality Tribunal's recommendation from 2009 on providing HIV training and education in order that misconceptions among front-line staff can be addressed effectively and immediately.

Our second recommendation is that the Government work in partnership with organisations promoting HIV testing in hospital and community settings. The World Health Organization estimates that in Europe one person in three is living with HIV without knowing it. Many people are not tested until they are sick and can no longer respond to treatment. The promotion of testing will also help to break down the stigma surrounding HIV.

Our third recommendation is that the Government demonstrate its commitment by highlighting HIV-AIDS Day on 15 June and World AIDS Day on 1 December. In many countries, including the United Kingdom, politicians and broadcasters wear a red ribbon to highlight HIV awareness. I am very passionate about raising awareness of HIV and thank the committee for allowing me to address the issue.

Chairman

I acknowledge that Dr. Lyons and Mr. Goulding are wearing ribbons. The rest of us should also be wearing ribbons, for which I apologise.

Deputy Billy Kelleher

This is an important discussion. As policy makers and citizens, we should all be concerned about the increase in the incidence of sexually transmitted diseases. As a teenager during the 1980s, I become concerned when people speak about advertising campaigns. While the advertising campaign of the 1980s was effective in terms of the shock and horror impact, it was not very informative and it stigmatised a large number of people in the gay community both in Ireland and internationally. It is my personal view that it set us back several years in the promotion of equality. By stigmatising people with HIV, it discouraged people from coming forward to seek assistance. As health awareness campaigns can work both ways, our ideas for an active campaign should be carefully thought out.

We all know that there are simple forms of prevention that can be effective, but, in terms of testing, how do we encourage people to be more proactive in being tested on a frequent basis? What methods can be used to encourage high risk groups to be tested more frequently and what barriers are in place to prevent them from doing so? There is still a stigma attached to sexually transmitted disease and for personal reasons, people may not want their local GP to know they are sexually active. Is this a stumbling block in the relationship between individuals and their GPs and can it be addressed by making testing services more readily available? Screening conjures up images of checking people against their will. It is critical that they are not discouraged from coming forward. The process should be user friendly and informative.

We never discuss the topic of cancer in the context of sexually transmitted diseases. Why are they not mentioned when we are, for example, discussing oral or cervical cancer? I presume we should be conscious of these issues when speaking about sexually transmitted diseases. We must be more proactive in education, but any education or advertising campaign should pay heed to the potential downside in stigmatising certain groups.

Deputy Caoimhghín Ó Caoláin

I welcome our guests and thank them for their contributions. I understand the national sexual health strategy is being prepared by the Institute of Public Health. Dr. Holohan has indicated that the strategy is being finalised. When does he expect it to be ready for publication and will it present an opportunity to address some of the deficits and areas of concern that he and other speakers have identified? Can it be launched and used as a means to highlight this area and draw public attention to the issues arising? Is there an island-wide dimension and is there North-South engagement in the strategy? That is important.

What supports are available from the HSE for those recently diagnosed with HIV-AIDS in terms of counselling and other support services? Are they being developed on an ongoing basis?

It is my perception that the HSE and the NGO sector, in terms of dealing with the gay and lesbian community, have developed a good partnership. Is that a false perception and is the partnership as good as it should be or are there deficits that need to be highlighted and addressed?

Mr. Brady has noted that the age group most at risk is decreasing. What does this indicate? Further to Deputy Billy Kelleher's comments, is it indicative of the fact that the generation highlighted, with an average age of 31 years, is not as exposed as people from our time of life would have been?

I concur with his view on how it was presented and the impact that had. Nevertheless, we must recognise that there is not quite the same address and focus on this by the services or in the media. What strategies is the Department developing for promoting testing, particularly within high-risk groups, and for minimising the number of HIV-positive people who are unaware of their HIV status? It is very important that we address the lack of awareness of infection. The earlier infection can be diagnosed the better for the individual and the population.

Is funding available for a national campaign to highlight the importance of regular testing that will facilitate the earliest detection possible and address HIV stigma? It may or may not be possible to deliver both messages. That can be done only with engagement between the NGO sector and the Department of Health. Mr. Quinn indicated in his address that there is a significantly smaller number of outreach workers. There were originally four and there is now only one, who is not in situ. What is the impact of that? Is it something that would give Mr. Quinn concern? Should those positions be restored?

Senator John Crown

I welcome our various speakers. Another consequence of being old is that I can remember the story of HIV as a disease right from the beginning. I recall reading the first reports that came out of New York and Los Angeles about unusual infections among gay men and the occurrence of a very rare cancer called Kaposi sarcoma. I am also old enough to have, I believe, seen and diagnosed the first two cases of HIV-related illness in Ireland when I was a young doctor working as a non-consultant hospital doctor, NCHD, in the 1980s. I subsequently went to New York at a time when the city and the medical community was deeply in the grip of the consequences of HIV infection. This awful tragedy being visited on people was an illness which was mysterious in its origins and universally fatal in its outcome, and the prospects seemed so incredibly awful.

People need to reflect for a second. This is the greatest triumph of modern scientific medicine. What happened with HIV was unprecedented. In 1985 or 1987, when we knew we were dealing with a virus, and realising how miserably difficult viruses were to deal with because we cannot treat them with antibiotics, no living person - no rational doctor - would have imagined that within five or six years the life expectancy for this illness would be so dramatically transformed. It is important that we record this, the greatest modern scientific achievement.

My questions are for Dr. Holohan. How many genitourinary medical consultants per head of population do we have in the Republic of Ireland? What are the figures for the UK? What is the average figure for most European countries? How do we compare with North America? What is the average waiting time to be seen electively in a genitourinary clinic for a non-urgent consultation?

Chairman

Those figures might not be readily available from the top of Dr. Holohan's head, but we will see if we can get them for the Senator.

Senator John Crown

They should be, because it is the core of the problem.

Chairman

I understand that, but-----

Senator John Crown

It is the core of the problem in every area of Irish medicine. Genitourinary medicine is no different.

Deputy Catherine Byrne

I thank all the speakers. It is a first for me to hear people with such great passion and expertise here. There was much information and many figures, and it takes a while for me to get them into my head. All the figures are disturbing. I still find it very difficult to hear that men and women, young and old, straight and gay, do not understand the huge health risk there is around their sexual life. My immediate worry is about young people in school and college. We live in a society in which drink has topped every other drug for young people. There are huge complications with people drinking at even younger ages.

When my children went to school they went through all the educational steps mentioned earlier about being safe and seen. The problem lies in school. I frequently speak to young people in transition year in local schools about their drinking activities. The proper solution is not to ask the teacher who teaches other subjects in a class to talk to young people about drink, drugs and sex. Young people do not want to talk to a teacher they might have in an hour's time for maths. It needs a separate approach, particularly regarding sexually transmitted diseases, of which there has been a major increase.

I live in an area with the highest population in Ireland of young lone parents and people having sex at a younger age. This is all scientifically measured. Unless we come to grips with this in the classroom, whatever chance we have of getting these people into their 30s without having one of these sexually transmitted diseases is diminishing. I would like to see something done in the classroom, not with the teacher but with somebody who comes in on a regular basis to deal with young people and allow them to ask the questions they might not want to ask Mrs. Brown who teaches them home economics in an hour's time.

Deputy Ó Caoláin asked why people have to wait so long to be diagnosed with infections. It is a crucial time for them and they should not be left waiting. Are there plans for a national screening programme in this country, as in England? Dr. Holohan said there were services including STI screening, diagnosing and treatment. Where are they? Can we have a list of where they are? I would like them to be more frequent, particularly for people in schools. Are there plans through the Department or the HSE for a national campaign, similar to the road traffic campaign, on television or radio to identify with young people? There are plenty of radio stations out there and young people listen to them every minute of the day. It is time we started spreading the word to them through those stations.

Deputy Sandra McLellan

I thank the witnesses for their very informative presentations. Like others, I was around in the 1980s and I remember the campaigns, which I found shocking and effective. There has been a 160% increase in HIV infection, which I find alarming. Why has there been such a spike? How widely is the Trust curriculum being taught and what are the obstacles to facilitating it? There seems to be a broad trend of increases in sexually-transmitted infections. Is this due to factors such as the economic crisis, or have cutbacks to some services and reductions in accessibility contributed to it?

A substantial increase in calls to helplines was mentioned, and this raises the challenge of capacity. How is the current level of calls being managed and is there a need to increase the helpline services? Mr. Goulding has faced some very severe challenges in his life. Is adequate HIV testing available, and if there are gaps, what are they?

Dr. Stephanie O'Keeffe

I will make a few general points touching on a number of the issues raised. With regard to campaigns, over the past ten years significant resources have been directed towards developing targeted, integrated campaigns directed towards at-risk groups. In response to Deputy Kelleher's comment that he hoped campaigns had changed, there is considerable science and literature behind how they are conducted nowadays, with resources put into evaluating them right across sexual health campaigns such as Think Contraception and the Man to Man campaign. We are going back to the target groups to make sure the message is being communicated, is effective and is not wearing down with people becoming tired of it. It is also to ensure that campaigns are linked with a broader integrated strategy in order that where a person is listening to the message, he or she is also hearing the same message at school, at home, in the workplace or wherever, and we are also looking at new means of communication. Some of the more recent campaigns, including the gonorrhoea campaign that will be launched next week, are based on social media initiatives. There has been huge improvement and experience within the country, in government, among health services and among partners in how to do this work. Sexual health is one of the areas in which one can say good work is happening. The literature is clear about what works and what does not in terms of using fear tactics. Sometimes they work - with road safety or smoking, for example - but not necessarily with sexual health. The messaging around those campaigns is about empowering and informing, destigmatising and normalising certain behaviours.

Our teenage birth rate has decreased from 20 per 1,000 to 12 per 1,000. We have seen significant successes in terms of consistent condom use among at-risk groups. My colleagues, who have more experience than I, will discuss testing behaviours, working with GPs and so on. Over that period, we have seen more campaigns, partnerships, research and services. When one thinks about where we have come from in this country in the area of sexual health, we would all acknowledge that we are in a different space now compared to ten years ago, not to mind 20 years ago.

The Deputy asked about partnerships. I have worked in the sexual health area for a number of years and partnership is the significant element of how we do this work. Partnerships can be difficult. They involve a level of trust. One must work hard at them but one can see that in the sexual health area, it is a critical piece of the broad integrated approach to addressing these issues and ensuring the messages are consistent. We are trying to bang the same drum with one message collectively. There has been much better practice in this area over the past ten years compared to the previous period.

Investment in research in sexual health has been impressive. We have much better data and information and we are able to answer the questions posed about, for example, sex education in schools. It is provided in 86% of schools, according to young people who report, and 90% of them say they have had it in schools. We have a much better environment to have robust and informative dialogue with the Department of Education and Skills and the out-of-school sector in ensuring the curricula we have developed are implemented in a more sustained way. I do not suggest that this is without challenges, because there always are challenges. There is always a new generation of young people coming through at different stages of their lives and it is important for us to have a sustained, strategic approach regarding how we address that.

Dr. Lyons will take the questions on testing and so on.

Chairman

I thank Dr. O'Keeffe for staying and for replying to those questions.

Dr. Tony Holohan

I will do my best to go back over the questions and if I inadvertently leave some out, members can let me know.

Deputy Kelleher's first question was about cancer prevention capacity in regard to STIs. That was a substantial part of the rationale for the introduction of the HPV campaign and the immunisation provided to girls in their young teenage years. The uptake in Ireland is at least at or ahead of the rate in most other countries and it will be an important part of the prevention of the cancers the Deputy mentioned. That will be acknowledged as part of the strategic importance of STIs in the context of the new strategy I referred to earlier.

The Deputy asked questions about prevention and testing, which Dr. Lyons will address. The questions of HIV testing and screening and targeting of high-risk groups are considered as part of the new strategy.

Local barriers to GPs and access to knowledge are a continuing issue in access to services, particularly for young people and particularly for sensitive areas around sexual and reproductive health, whether it is access to contraception, STI services or, particularly in rural areas, people's fear of or unwillingness to attend a local GP. This is a consistent barrier and services then have to try to provide alternatives for people to be able to get around that. We acknowledge that this is a problem in the delivery of services that can be accessible in local communities.

With regard to Deputy Ó Caoláin's question about the strategy, it is our intention that we will finalise and present it for the Minister to bring to Government for approval and to publish before the end of the first quarter of 2014. He asked about Northern Ireland. As he mentioned, the strategy is chaired by the Department and it involves all the major stakeholders. We heard from some individuals who are participating in that during statements earlier. For example, Tiernan Brady is a member of the steering group. It is supported by the Institute of Public Health, which provides the secretariat and the expertise behind much of it. It is a North-South body and it has through that mechanism provided a great deal of access for the group to expertise. When one gets into public awareness of a range of issues that are not confined to sexual health, there is probably significant cross-Border value in working together, if for no other reason than to recognise the fact that we share many media, and if we work collaboratively we can share the cost burden and the expertise available to both. We want to progress that as part of the implementation of the strategy.

Dr. O'Keeffe dealt with the funding of national campaigns and the science that underpins the provision of campaigns and that continues to apply to many of the national campaigns provided principally by the HSE.

Senator Crown asked how many genitourinary consultants we have per head of population. I do not have the precise figures but I can get them for him. I do not have figures with me about international standards, but if the Senator is seeking information I see no difficulty providing that.

Senator John Crown

How many GUM consultants do we have?

Dr. Tony Holohan

My understanding is that we have two, but we have a number of infectious disease consultants who are not specifically GUM consultants but who provide expertise and can be involved in the management of cases. Perhaps Dr. Lyons can add some colour to that. We are happy to research the question and provide the Senator with specific answers because he asked specific questions.

Senator John Crown

Please do not take this as a disrespectful comment, but it does not take that much research to tell me how many there are if the number is two.

Chairman

To be fair to the officials, the Senator's question was more substantive than how many GUM consultants there are.

Dr. Tony Holohan

I am not in a position to say the full and final answer to the question is two, but perhaps the others can answer that.

Chairman

We will follow up with the chief medical officer to get the information in reply to the Senator's elongated question.

Senator John Crown

I look forward to that.

Dr. Tony Holohan

The Senator described it as the core of the issue. We would have to relate those figures to international figures in regard to STIs to see where the country stands, because it needs to be seen in that context.

Deputy Catherine Byrne asked a number of questions on education and access to young people. About three or four years ago I was invited to address Dáil na nÓg on the issue of SDIs and access to sexual health education. That ultimately led to a very important contribution by Dáil na nÓg, representing young people, to the ongoing consideration of the HPV issue at the time, which was an important part of changing the mindsets at a political level in helping to get the necessary decisions to introduce that HPV programme. It would have raised considerable concern about the level of access that people had to education. I am pleased that the Department of Education and Skills is involved with us in the development of this strategy. Officials from the Departments of Education and Skills, and Children and Youth Affairs are also members of the national steering group. We have very good relations, particularly in the context of Healthy Ireland, with the people who are involved in providing services in that regard in the Department of Education and Skills. I might ask Ms O'Flaherty to speak to that in more detail because it is a very important point.

Deputy McLellan asked about the reason for the spike. We outlined some of the reasons. There has been a change in the epidemiology of not just HIV but of STIs in general. There has been a change in the profile of those in whom the incidence is greatest in this country. Some of the reasons obviously relate to changes in behaviour and so on, about which we are all concerned. If we consider chlamydia as a broader SDI issue, an emerging problem we will have, for example, will be in terms of infertility arising as a consequence. Ms O'Flaherty will deal with the trust programme as part of the answer on education. If I have not covered anything else that was not dealt with by Dr. O'Keeffe, I am happy to be pulled up on that.

Chairman

I call Ms O'Flaherty. As we must finish by 11.45 a.m., I ask her to keep her answers brief.

Ms Kate O'Flaherty

I will build on what Dr. Holohan and Dr. O'Keeffe have said about education. As part of the Healthy Ireland approach, it is about building on the interdepartmental and cross-sectoral relationships, seeking to improve those, better use our resources together and avoid duplication of effort where possible. As Dr. O'Keeffe has said the focus of campaigns for the general population is destigmatising the many issues around sexual health and empowering people. That would be the strategic approach in terms of educating young people.

Another important thing that has been referred to in terms of the barriers in the education sector of providing that kind of information to young people so that they feel empowered, and have the knowledge and information to look after their own health, is seeking better ways of standardising those messages, having a consistency of information and ensuring that all young people have access to that. I know the Trust and other resources are already provided by the HSE and other agencies.

One of the things for us to look at is providing more and easier access to specialists, support teachers and others in their work with young people. Curriculum reform represents an opportunity to have those discussions. The Department of Children and Youth Affairs is developing a new child and youth policy framework to which we are contributing. A key part of that in terms of the health of children is where we can work more closely together to achieve the outcomes that we would all like.

As Dr. Holohan mentioned, a key part of that policy framework development is listening to the voices of children and young people, and knowing that what we are delivering to them meets their particular needs and answers their needs for looking after their own health into the future.

Dr. Fiona Lyons

It has been a privilege to have been a health-care professional working in this very exciting area for the past 20 years. It is great that we are discussing this matter at this Oireachtas committee meeting. There were many questions on breaking down the barriers to promote testing. The past 20 years have taught us that from an individual perspective and a population perspective, the benefits of knowing one's HIV status are beyond all doubt. Improving availability of and access to testing will take several strands, but normalisation is key. It must become normal to have a HIV test. As I have learned in the past 20 years of medical practice, this virus does not discriminate. It does not care whom it infects. Unfortunately certain people in our community are more likely to be affected, but it does not care whom it infects.

We have demonstrated that we can do this. The antenatal screening programme introduced in 1999 has been a resounding success in reducing the number of vertically infected children. It has happened and the percentage uptake rates have been in the high 90s. It was introduced in 1999 following anonymous unlinked testing. We decided that if it went beyond a certain threshold, there was a benefit at a population level to introduce screening and that we would stop doing anonymous testing when the uptake exceeded 95%. In every year since its introduction the percentage uptake has been in the high 90s. We can do this in this country. So it is about normalisation, and the developing and fostering of partnerships.

With respect to why we need to do this, some very important data have been published in the press over the weekend about the number of people who were diagnosed having presented at the Mater Hospital emergency department. It is not just about targeting high-risk groups; given the prevalence in our population, certainly in the greater Dublin area, we may need to consider that everybody, regardless of whether they are in an at-risk group, is at a point where they would benefit from knowing their HIV status. Some 14 cases were picked up in the Mater where they did not come for a HIV test but had a HIV test, with 11 of them being brand new cases. That represents a very significant benefit for those individuals as well as at a population level.

I would like to speak about what the 2012 HIV figures show us. Everyone has acknowledged we have come a long way but we still have some problems. Based on the 2012 data, the proportion of people who are presenting late is still too high. Some 48% of people who presented with HIV at the time of their diagnosis had evidence of significant damage to their immune system at that time. There is a clear need to get people to access testing. That needs to be addressed from a service-user perspective and from a service-provider perspective. As a health-care professional, I work with my colleagues in trying to make it normal for people to have a HIV test.

Within the 48% of people who are presenting late, some 63% of the people who acquired infection through heterosexual sex were late, which is much higher than the proportion of men who have sex with men who were newly diagnosed in 2012 and were late. That demonstrates the successes in promoting testing.

Chairman

As there is a vote in the Dáil, I ask Dr. Lyons to conclude her remarks and we will suspend when she finishes. She has two minutes.

Dr. Fiona Lyons

I will not need two minutes. We have a problem with late presentation. Within the group of people who are presenting late there is a disproportionate representation of heterosexual males, some 63% of whom were presenting late. We need to ensure we know what we are doing and it is not just about targeting MSM. As I have said, this virus does not discriminate and HIV testing needs to become much more normal. There is a lot of work going on and we need to inform ourselves on how best to proceed with making HIV testing normal for all people to know their HIV status for their own good and for the public good.

Chairman

Does Mr. Goulding wish to make some comments before we go to the vote?

Mr. Jimmy Goulding

I wish to make a point about inaccurate testing. While there is rapid testing, it is very costly. Most consultants would give rapid testing, but it is very costly.

The other question was about the barriers. It is just stigma all the way that is preventing people.

Mr. Tiernan Brady

Deputy Kelleher asked about the barriers to accessing health care. We are aware of significant social barriers when it comes to sexual health in general. We want to try to mainstream sexual health, full stop, so that, as Dr. Lyons has said, it becomes normalised. There is another set of barriers lesbian, gay, bisexual and transgender people face, as they want to access services. The HSE commissioned research carried out by us in GLEN and BeLonG To, called Understanding LGBT Lives. From that document we have worked with the National Association of General Practitioners and the Psychiatric Nurses Association of Ireland to build those guidelines to try to build capacity at a health-care professional level to understand what those barriers are. They need to be aware that they have lesbian, gay and bisexual patients and that those patients face significant social barriers when it comes to engaging on their sexual health.

Like all guidelines it is all about what we do with them. They can either sit on the shelf and gather dust or we can work out how to roll them out. We have been working with St. James's Hospital, the Mater Hospital and the Irish College of General Practitioners to roll them out throughout the country. It is about building capacity for health care professionals to understand what blocks people from dealing with their sexual health on weekly basis at primary care level in the same way they deal with other health issues they have.

Mr. Michael Quinlan

Access is the key to challenging barriers. It can be on the basis of outreach clinics, the opening times of clinics and the cost. Rapid tests for HIV are being offered at present which cost €70 but they are not rapid because the test is not for HIV. If one has a reaction one must still go for a blood test. These techniques need to be streamlined.

I take the point made on STI screening, but it is important people have full STI checkups because we have seen an increase in gonorrhoea among young heterosexuals. STIs are a cofactor in acquiring HIV. It is important various populations are recognised because if we state something is particular to an MSM other people will not take on board the message.

With regard to outreach we have a good working relationship with the various groups and we have had long discussions on the sexual health strategy and the need for more services.

Sitting suspended at 11.12 a.m. and resumed at 11.27 a.m.

Chairman

I apologise to our witnesses and guests for the pause for the vote. Democracy does take place sometimes.

Mr. Michael Quinlan

The presentations we made and the documents we submitted mention research. This research covers the reasons men get tested or not and the areas in which they are getting tested. There is an urban and rural issue and an issue on access to services and where the services are based. Some of these matters have been addressed. Clinics in Letterkenny, Monaghan, Drogheda and Dundalk were established as part of a cross-Border EU funded project also involving Newry, Portadown and Omagh.

The EMIS surveys, the Man 2 Man report and previous reports provide much information on sexual behaviour. The most recent survey covered sexual happiness and what men want. Men want relationships and to be more confident, but there is also a fear of STIs and HIV. For men living with HIV or STIs the fear of passing them on was the highest barrier to-----

Chairman

Will Mr. Quinlan repeat that?

Mr. Michael Quinlan

With regard to sexual happiness, men want relationships, to be more confident and to address fears of HIV and STIs. However, for those living with HIV, the fear of passing it on is most important.

Any campaign dealing with people who may not know they have HIV must be peer involved and accessible, such as the Man 2 Man campaign. Dr. O'Keeffe mentioned good methods in this regard.

Ms Susan Donlon

Deputy Kelleher mentioned the fear-based programmes in the 1980s and 1990s. Much research has taken place since then to show such campaigns do not work.

It is important to point out that during the development of the Gay Health Network campaign the key messages were developed by a younger peer group of men who have sex with men and facilitated by BeLonGTo youth services. It is also important that people living with HIV be included in developmental programmes. We recommended that this be done in the national sexual health strategy.

Regarding access to tests, there are many free STI testing public clinics across Ireland, but it is necessary to provide access in isolated and rural areas. Information is key, as people may not know the risks. As Mr. Goulding mentioned, stigma is a major barrier, while people fear HIV test results. This needs to be combated.

It is correct to say the younger generation had not been exposed to information on HIV until we launched the Man2Man campaign in December 2011, the first national campaign in many years. A sustained HIV prevention message for younger men is required.

On funding for national campaigns, I can speak on behalf of the GHN which has received funding to run a consistent message and build on the successes of the Man2Man programme throughout 2014. That funding has come from the health promotion and social inclusion units of HSE North East.

Deputy Catherine Byrne referred to young people not wanting to speak to teachers about their sexual health. It can be difficult. From research, we know that sometimes teachers also find it embarrassing. There are many ways to break down these barriers, one of which is through training. It is important that people are trained to deal with lesbian, gay, bisexual and transgender, LGBT, issues. Mr. Brady raised this point in the context of training for general practitioners.

The issue of sustainability is important. BeLonGTo youth services have developed a national support network for young LGBT people across a range of counties. One can supply funding for one year, but if one does not know what is happening next year, it becomes an issue. As young people grow up and are replaced by others, long-term sustainability, as opposed to a year-to-year budget, becomes a requirement.

Deputy Caoimhghín Ó Caoláin asked about our partnership with the HSE. It is good. As Dr. O'Keeffe pointed out, partnerships require a great deal of work. It is definitely a work in progress. It is not new to the GHN to partner the HSE. Gay Men's Health Services of the HSE has been a successful partner for many years. We are learning from each other and hope our partnership can continue.

Deputy Sandra McLellan asked whether the economic crisis had contributed to HIV and STI transmission rates. From our work in Dublin AIDS Alliance, it is anecdotally a contributory factor. We have a programme through which we supply free condoms. More than 300 people attend every week looking for free condoms because they cannot afford to buy them. It is important to point out that migrant communities are an at-risk population group for HIV. Those seeking asylum only receive €19 per week. That is a major issue, as they have no money for condoms.

The Deputy also asked about the increase in the number of calls to the Gay Switchboard Dublin helpline. Gay Switchboard Dublin is a partner of the GHN. The switchboard is run voluntarily and the service will be 40 years old in 2014. It has 36 volunteers and receives no statutory funding. It would welcome such funding in order that it might increase its services to meet rising demands.

Chairman

I pay tribute to those volunteers for the considerable amount of work they do. It goes unnoticed by the general public, but it should be acknowledged at this meeting. Without giving a commitment this morning, perhaps we might consider where a source of funding might be found with the Department of Health and the HSE.

Mr. Tiernan Brady

I wish to address the question of having young people tested. As with trying to get people to engage with health services in general, in encouraging people to be tested we face significant barriers. The last 20 years have been phenomenal for lesbian and gay people in Ireland. There has been great change, given the fact that there was decriminalisation only 20 years ago. Despite the phenomenal change in legislation and society, however, for many people the individual experience is still not one of change. They face rejection and isolation which they fear. All of this creates pressure and prevents people from engaging with the services that we need to provide.

Another key barrier is that no one wants to have a sexual health test. No one skips to the doctor to have the test done. It is a question of how to use existing technologies, for example, rapid testing, to make the process convenient, swift, inclusive and non-judgmental. In London lunch-time clinics allow people to pop in during working hours in order that they do not need to tell anyone that they are taking the day or three hours off to be tested. In Copenhagen the testing centre is located inside a shop on the main shopping street and one need only pop in. We must move our testing centres to where people are in order that they can access them in a way that is convenient for them.

Dr. Nazih Eldin

The saying is "Prevention is better than cure". It is not a mantra but a way of working. I emphasise something Dr. O'Keeffe highlighted, namely, that Ireland is leading two prevention work plans with the European Union. One is about how to set standards for prevention with our partners in the voluntary sector and the health service. The other is on standards in policies. We are delighted to be present at this meeting to work with the members on improving this aspect.

Deputy Sandra McLellan

The sexual health strategy was due to be published last year. What has happened to it? Does the National AIDS Strategy Committee still meet? I heard that it had not met for 18 months.

Deputy Caoimhghín Ó Caoláin

In tandem with that-----

Chairman

There will be a vote in the Dáil soon.

Deputy Caoimhghín Ó Caoláin

To clarify, I asked Dr. Holohan whether he would commend the utilisation of the launch of the national sexual health strategy as a means of addressing some of the issues about which we were talking. I do not expect him to expose any of the detail of the HSE national service plan for 2014, but has it been agreed to set aside additional moneys to address the areas about which we have a shared concern in raising public awareness and encouraging people to come forward for testing early and regularly?

Chairman

I will leave the last word to Dr. Holohan.

Dr. Tony Holohan

I apologise, as I overlooked answering Deputy Caoimhghín Ó Caoláin's specific question. It should, of course, provide such an opportunity. It was something we committed to finishing last year, but we did not get it done. We are committed to having it done as soon as possible in early 2014 in line with the timeline I mentioned in response to the Deputy's question.

Regarding the specific question on the HSE service plan, it is still under consideration, but, generally speaking, it is challenging to prioritise everything, particularly prevention services, at a time when public resources are challenged. I am not saying anything specific, but the Deputy can be certain that the people before the committee fought hard behind the scenes to maintain the focus on issues of health and well being in general.

That is as much as I can say at this stage.

We were asked a number of specific questions by Senator John Crown which we have noted and will respond to in writing. We will also respond in writing to the Chairman's question on funding for Dublin Gay Switchboard.

Chairman

I acknowledge it is a challenging economic time.

Dr. Tony Holohan

It is an issue on which the HSE might reflect and give a specific reply in writing.

By way of a general response, I welcome the opportunity provided for us by way of engagement with the committee to hear about the issues of concern to members and some of the other guests which we will carefully consider in the finalisation of the sexual health policy. There was a time when we as a society could not even have contemplated developing a policy with that title. Part of the normalisation process is, perhaps, evident in the fact that we are able to do something like this and respond to the types of issue raised this morning.

Chairman

I thank Dr. Holohan. Mr. Quinlan might consider inviting members of the committee to the forum next year. It is a two-way process. While it is important that the committee engage with the delegates, it is also important that they engage with us. There is a committed group on this committee who transcend party lines.

Mr. Michael Quinlan

Thank you, Chairman. This may be the first time many people have heard about the existence of the Gay Health Network.

Chairman

My apologies to Ms Diane Nurse who did not have an opportunity to speak. However, I thank her and everybody else for attending and for their excellent presentations. I remind Dr. Holohan to forward a response to the committee secretariat on the issues raised by Senator John Crown and me.

The committee will now suspend proceedings until noon when we will discuss the heads of the plain packaging legislation with the Minister for Health, Deputy James Reilly. I understand Dr. Holohan will be staying with us for the next part of the meeting.

Sitting suspended at 11.45 a.m. and resumed at noon.