Joint Committee on Health and Children debate -
Tuesday, 1 Dec 2015

HIV Incidence in Ireland: Discussion

Chairman

Apologies have been received from Deputy Catherine Byrne and Senator Imelda Henry. I remind members and delegates to ensure their mobile phones are switched off or left in airplane mode as they cause interference with the broadcasting of proceedings.

In keeping with the joint committee's ongoing work on this issue and this being World AIDS Day, the purpose of the meeting is to have a discussion on the incidence of HIV in Ireland and emerging trends and key responses in that regard. I welcome Mr. Niall Mulligan, executive director, HIV Ireland; Ms Deirdre Seery, CEO, Cork Sexual Health Centre; and Mr. Tiernan Brady, director, gay HIV strategies, GLEN.

By virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of the evidence they are to give to the committee. However, if they are directed by it to cease giving evidence on a particular matter and continue to so do, they are entitled thereafter only to qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any 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 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 invite Mr. Mulligan to make his opening statement.

Mr. Niall Mulligan

I am the executive director of HIV Ireland. The organisation has been in existence since 1987 and was formerly known as Dublin AIDS Alliance. I thank the joint committee for giving me this opportunity to discuss with it the topics of HIV in Ireland and HIV related stigma. Over 7,000 people have been newly diagnosed with HIV in Ireland since the 1990s. We estimate that approximately 3,500 people are knowingly living with HIV in Ireland today. While there has been a significant and welcome improvement in treatment for HIV, concern remains about the rising numbers of those newly diagnosed in Ireland. In 2013 there were 344 people in Ireland newly diagnosed with HIV. This figure increased to 377 in 2014, an increase of 33 on the figure for 2013. The 2014 figures from the Health Protection Surveillance Centre show that HIV continues to disproportionately impact on men who have sex with men. However, there is also a sizeable number of heterosexuals contracting HIV. According to official figures from the Health Protection Surveillance Centre, in the first two quarters of 2015 there were 203 new HIV diagnoses in Ireland. A similar number of diagnoses were made in 2014. The statistics for routes of transmission were: men who have sex with men, 95; heterosexuals, 38; people who inject drugs, 26; mother to child transmission, one; and unknown, 44.

It should be noted that the 2015 figure for people who inject drugs for six months is only one behind the figure for the 12 months of 2014. We need to keep a close eye on why that is the case. Current thinking attributes it to more frequent use by intravenous drug users of a drug combination called snow blow. There is close monitoring of this issue across the country by us and the public health authorities.

Provisional data for the period January to November 2015 indicate that there have been 427 new HIV diagnoses to date, a worrying increase of 85 of the figure this time last year. While some of the new diagnoses can be put down to increased testing, it is likely that we are only now beginning to see the true picture of HIV levels in Ireland. We must continually remind ourselves that as HIV diagnoses continue to increase, the World Health Organization estimates that 30% of people who are living with HIV are not aware that they have it, such that the true HIV figures are likely to be higher. There can be many reasons for this, including lack of access to testing, lack of awareness of HIV and the ongoing stigma attached to living with HIV.

As I said, HIV Ireland has been in operation since the 1980s. With the onset of improved treatment in the late 1990s, there was much hope the stigma attached to HIV would begin to dissipate. People using our services and others across the country began negotiating on the possibility of new relationships and careers and further education and travel, while some began thinking of buying apartments and houses. Members will be aware that for a person diagnosed with HIV in the late 1980s and early 1990s, that was not on the cards because they would have been given only one or two years to live. On the surface, these are incredibly reasonable objectives for any person. Unfortunately, the change presented far more complex issues for them and us as an organisation. People began to experience the negative consequences of disclosure of their HIV status in these new situations and witnessed the chaos that disclosure could cause in their workplaces, colleges, community employment courses and, more worryingly, many health care settings. They were now fit enough to travel but were barred from entering many countries to see their families and friends. That remains the case today. There are now more than 50 countries to which people living with HIV cannot travel.

Sadly, the support and advocacy work we do today is not that different from what it was all those years ago. We still work to navigate people through their diagnoses, disclosure and its repercussions. Unlike in the early days, we now have the arm of the Human Rights and Equality Commission, the Ombudsman’s office and the Garda ombudsman’s office to investigate situations where someone living with HIV is treated differently from someone whose HIV status is negative or unknown.

The stigma attached to HIV is as insidious as the virus. Like many other stigmas, it is complex. Who stigmatises, how they stigmatise and why are research questions often asked of people living with HIV. They are seldom, if ever, asked of the classmates, employers, health professionals, police, media and faith communities our service users cite as having stigmatised or treated them differently because of their HIV positive status. The word "stigma" is thrown around a lot, but I will try to give it some practical context.

As part of our work last year, we provided support for a man who had found a job as a fitness instructor on a cruise ship but was fired two days later when he disclosed his positive status and for a woman who had been told by a leading national disability agency that she could not avail of its services. We spent some time trying to convince a crèche manager that she did not have to inform all parents of a child’s HIV status. There was no requirement for her to do this, but she thought she should do it. We also provided support for a woman who had been informed by an holistic therapy college that she could not practise reflexology and dealt with several dentists who had refused to treat our service users, referring them instead to the Dublin Dental Hospital, even for minor procedures, for which they were given the last appointments each day because of concerns about cross-infection, which concerns are not sustainable. The list goes on. Self-stigma also impacts, at times profoundly, on people’s lives. Feelings of self-shame and worthlessness require a level of personal support that is increasingly being left behind by our quantitative based, outcomes oriented, value for money approach to health.

Worryingly, HIV stigma is institutionalised in Ireland.

When a judge orders compensation of €100,000 to a garda who was spat on by a man whose HIV status was not even known or when a social protection worker has to take six months leave because she too was spat on, they held, to cite Ms Justice Mary Irvine, a significantly inflated view of potential risk. There was indeed no risk, even if the individuals were HIV positive.

Despite the advances in medication, our work is far from over as these examples testify. All of us working within the area of HIV and AIDS seek to challenge HIV-related stigma. We aim to make HIV a health issue rather than a question of morality, culture or lifestyle. There are many practical responses to challenging stigma and these are encapsulated within the current national World AIDS Day campaign of providing solidarity and support for people living with HIV, increasing our knowledge of HIV and the visibility of HIV within society and challenging HIV stigma and discrimination as and when we encounter it. Fundamental to this is accepting people living with HIV as equal human beings who are not simply defined by their illness. Like everyone else, the people with whom we work have a right to education, to make informed decisions about their own lives and to be respected. Stigma takes these rights away and can result in dehumanising people living with HIV. The responsibility lies with all of us to break it down.

Chairman

I thank Mr. Mulligan. I invite Ms Seery to make her opening remarks.

Ms Deirdre Seery

I thank the committee for the invitation to speak to it. I am the CEO of the Sexual Health Centre in Cork and have been there for 25 years, which some might say is a long time. I will discuss the changes that have taken place in terms of HIV in that time. It is nice to see some Deputies and Senators from Cork.

As Mr. Mulligan stated, there were 203 new cases of HIV diagnosed in the first half of 2015, which is more than one person per day. So far this year, there have been 427 new infections, an increase of 85 on 2014. HIV is preventable. We need to reflect on how we can improve our HIV prevention. Why is the incidence of HIV increasing and what can we do about it? We do not have concrete data on why it is increasing. It lacks visibility and we know about the context of stigma.

Regarding visibility, before the current treatments were available and when HIV led to AIDS and, ultimately, death, there was no escaping its reality. People were "outed" when they developed AIDS. They had no choice in the matter - the virus did it. Families and friends had to embrace the news of the diagnosis, often within a short timeframe between knowing the status of the person with HIV and his or her death. Frequently, this was accompanied by the realisation that people not only had a terminal illness, but they were gay and-or men having sex with men. Or maybe they were injecting drugs or it was down to heterosexual transmission. There was a lot with which to cope. People with HIV feared rejection and isolation at their time of greatest need. Families kept things secret, locking themselves away from their own support systems and often blaming themselves, for example, parents wondering whether it was their fault that a son was gay or whether they were good role models.

Today, there are effective treatments for HIV and those on treatment are unlikely to develop AIDS. People living with HIV are no longer "outed" by their condition. They have choices about who and when they tell and even whether they tell. This is a cause of celebration and a basic human right of anyone living with any illness. However, has the lack of visibility made us complacent? Is it a case of someone not knowing anyone with HIV and, therefore, it does not exist? I hear this all of the time. HIV is no longer a death sentence, no longer visible, so can we take risks?

Undeniably, an increase in risky sexual behaviours is increasing the risk of HIV and STIs. To combat complacency, we need to raise the visibility of HIV continually. This year, there is a national campaign around World AIDS Day. We need integrated, joined-up thinking and actions. Awareness raising needs to be sustained and of sufficient scale so that HIV remains visible.

Community-based Rapid HIV testing is also a welcome response. Gender, Orientation, Sexual Health, HIV, or GOSHH, in Limerick and the Sexual Health Centre in Cork undertook one-minute HIV testing at gay venues last week during European HIV testing week. The willingness of people to test shows that we can develop this approach further. Mr. Brady will discuss our joint new initiative further.

Mr. Mulligan has mentioned stigma, so I would like to discuss self-stigma. There is social stigma and self-stigma. With social stigma, people may be judged negatively by the people around them. Mr. Mulligan has given concrete examples of social stigma that our agencies around the country have experienced in our advocacy work. However, there is also self-stigma, where people fear the judgment of others and consequently close themselves off from the possibility of negative judgments. Self-stigma stops people from accessing services and supports. They may even be afraid to enter our buildings in case they are seen, discovered, exposed. This is the reality with which we are dealing.

People may internalise how they believe others perceive them. For one person who spoke about this, it felt like being a human time bomb waiting to go off. It made another feel worthless. Some newly diagnosed people can feel suicidal at first. We have seen people change completely when they receive counselling and support. Their lives can turn around and they can live healthy and fulfilling lives, where HIV is a diagnosis, not their total identities.

We can show solidarity to people living with HIV by challenging stigma and discrimination. This is within our control. We can provide support to individuals so that stigma is not just something that society does to people with HIV. Stigma loses its power over people who have self-confidence and positive self-esteem, people who know that a HIV diagnosis is just that. It is not their whole person. They can lead satisfying lives, including sex lives. Counselling and support helps this process. We provide these. Not only do we need to provide good support services, but we also have to reflect continually upon how to make these services safer and more accessible to people when they feel at their most vulnerable. That requires joined-up thinking and multisectoral partnership between policy makers, implementers and HIV services.

In addition to counselling support, there are effective treatments. These treatments have revolutionised the response to HIV. They not only protect the health of people with HIV, but they decrease the possibility of passing HIV to others because they reduce the amount of the virus - the viral load - in people's systems. Treatment is expensive to the State but, thankfully, extensive and free to individuals.

Before someone can access treatment, though, he or she needs to know his or her HIV status. The greatest challenge now is to increase the level of testing. We are promoting testing with such vigour because it is important that people know their HIV status. Testing has also been revolutionised. Some HIV tests require a wait of one or two weeks for results. However, outreach testing can offer a HIV test that gives the result in one minute. This is indeed Rapid. When the Minister for Health, Deputy Varadkar, launched the national sexual health strategy recently, he announced that funding was being made available for free testing in community settings using targeted outreach. Prior to this, GOSHH and we had to charge for that service. The UK is making free home tests available so that people can send their home tests to a lab and get their results in three days. Scaling up HIV testing is an important step in improving HIV prevention. As they say, we have the technology.

The trials for pre-exposure prophylaxis, PrEP, where drugs are provided that help prevent HIV transmission, were shown to be so successful that they were stopped early. We need to know more about how PrEP can be best applied in the Irish situation to maximum effect. We have a clinical lead for the national sexual health strategy in place to steer this process. We are getting there.

Condoms are old-fashioned, but they are still the most effective way of preventing STIs. They are cost effective. If condom use declines, STIs may increase. As such, we still need to promote condom use. However, we also need to make regular STI screening accessible in community outlets. Hospitals cannot cope with broadening out STI screening to a large extent, but there are increasingly new testing kits being produced that make testing in non-medical settings possible and cost effective. They just need to be more affordable. I have one such kit with me. It is small, easy to use and tests for 12 STIs.

At the moment it is expensive. We hope to be able to use these kits in our agencies to detect sexually transmitted infections, STIs, and therefore reduce onward transmission.

With regard to targeted HIV prevention, surely after the success of the Yes Equality campaign it is okay to be gay. For the majority of Irish people it is okay, especially for younger gay people. There are still many men who have sex with men who do not identify as gay, who may be married, living secret double lives. They are difficult to access. In our community outreach testing, we particularly target men who have sex with men and those hidden populations. I have not yet mentioned talking about sex. How can we negotiate safer sex without being able to talk about sex? Good quality sex education has been shown to be effective and it is imperative to our future HIV and STI prevention programmes. I mean sex education and not just information on reproduction. We are competing with pornography, which is the biggest educator of young people today. It has a major impact on misinformation to people and what is regarded as normal sexual behaviour. We need excellent and proactive sex education.

New and younger generations of people are becoming HIV positive who would not have been exposed to the old safer sex and safer drug use campaigns, so we need to keep those up. What can we do? We are increasing testing that is rapid, community-based and free. We need to continue to promote condom use and safer sex and we need to assess the use of pre-exposure prophylaxis, PrEP, for those most at risk. We have free counselling, support and advocacy, and we must continually challenge stigma in order that people can feel safe in accessing these services. We need targeted outreach to those most at risk of HIV. As service providers, we must continually reflect and improve. We need to work in partnership with all the key actors. We provide great services but it is not enough, however, to do the right things. We need to do the right things right. We have not won the HIV prevention battle yet and we need the committee's continued support to do it.

Chairman

I thank Ms Seery and her staff for the work they do in Cork. I am being parochial in that way.

Mr. Tiernan Brady

I thank the committee for having us. Before we say anything, it is always worth saying that one of the great things about the committee simply having these meetings is that it raises an issue that finds it very difficult to get airtime. The figures demonstrate that diagnosis rates are getting higher in younger people, especially with gay and bisexual men. These generations have grown up in the absence of the type of national awareness campaigns in the 1980s and 1990s that we would have seen right across the world. Having committee meetings like this, which are broadcast and get coverage, is incredibly important and beneficial. I thank the members and the Chair in particular for doing this.

There are two issues I wish to discuss. I want to try not to say anything that everybody else has already said. The two key areas are the trends emerging and continuing among gay and bisexual men for HIV in Ireland, which are worrying, and one of the key responses we hope to put together, starting in 2016, as part of tackling that. There are a couple of key recommendations about how we might move forward. Mr. Mulligan has highlighted the overall figures, but within those figures, unfortunately, the picture for gay and bisexual men is not good. If we take a ten-year view on this from 2005 to 2014, there has been a more than 200% increase in the gay and bisexual diagnosis rates. There were 60 cases in 2005 and 183 in 2014. That will increase this year as we are already well past last year's figures and, unfortunately, we still have another month to go this year. These are the highest diagnosis rates on record for gay and bisexual men and the highest percentage of the total diagnosis that gay and bisexual men have represented. Of the total diagnoses, 48.5% are gay and bisexual men this year, which is a record high.

Within this figure there is another incredibly worrying trend that is exacerbated especially among the gay and bisexual population. The median age of a diagnosed person in 2005, to take a ten-year span, was 37 but the median age last year was 31. Younger people are contracting HIV and this new generation of people are being exposed to risk. Cases of people under 35 now represent six from ten of the new cases. Between 2005 and 2014 - the ten-year span - there has been a 500% increase in new diagnoses in those aged between 25 and 34. There is a large key target group emerging from these figures. This is not just gay and bisexual men but within that are, very clearly, young gay and bisexual men.

One of the key parts of our response to this, as highlighted by both Mr. Mulligan and Ms Seery, is the importance of people knowing their status. There are two clear reasons for this. From the person's perspective, the sooner somebody knows his or her status, the better. If it is negative, it provides great peace of mind, and if it is positive, the earlier one is diagnosed, the better the long-term health outcomes. The second element flowing from this is that most HIV is passed on by people who do not know they have HIV. Getting people to know their status radically reduces onward transmission rates of HIV. The challenge around this is how to provide services and get people to engage with such services when we know it is a difficult area for engagement with people. Simply providing the service, opening the door and saying, "Here we are, this is HIV testing," is not an answer by itself because nobody looks forward to getting a HIV test. Nobody wakes up in the morning and asks, "Guess what I am doing today," before heading to the STI clinic or the general practitioner to talk about sexual history and get tested with a smile. We must accept and recognise that this a service that has significant barriers to people accessing it. Many of those barriers are socially constructed so how do we identify and dismantle them?

One of the pilots we are introducing in 2016 will address many of these barriers. We hear from those engaged in prevention research that many people do not like clinical settings or having to wait a long time to get a test result. Many people find cost a barrier. If one goes to the private sector, one can get a rapid test result but it will cost €150 or €200. We put together a proposal that I am thankful the Minister, Deputy Varadkar, has agreed to fund for 2016 to provide community-based, free and rapid HIV testing. The technology has moved on and our approach to how we get people to test needs to move on with that. We have technology that now means somebody may walk into a community setting, such as the Gay and Lesbian Equality Network office, a bar when it is not open or a community centre, for example, and get tested, with a result in 60 seconds, before going back out and getting on with life. It is about trying to make this service as accessible, convenient and non-judgmental as possible, because we understand this is not a service which most people ever look forward to.

The rapid pilot will start in 2016 and run for 12 months. We are making it clear that this is a pilot. It is a piece of research and we want to shape policy with it. We want to see how well this works and whether it increases testing rates. We want to see what places work more effectively in engaging people to test. Judging from research across Europe, I am pretty convinced it will be successful but we cannot prejudge such issues. We must be able to take in the data and see, at the end of the 12 months, if it can shape better policy and get more people to engage for the reasons we discussed. The more people who know their HIV status, the better it is for them and for cutting HIV rates in Ireland.

Ultimately, we have a couple of other key recommendations to look at. This has been a good year, to many degrees, with respect to sexual health. The first national sexual health strategy has been launched and the pilot programme was initiated for HIV testing as part of that.

That means that for the first time we are, I hope, going to have clear, strategic implementation of a unified approach to sexual health targeted at and tailored to meet the needs of those who need it most. That is something with which we are incredibly happy, especially from the perspective of gay and bisexual men. Of course, like all strategies, what matters is what will happen to implement it. There are plenty of lovely strategies that sit on shelves all over the world, but we must ensure this one becomes a reality in the next three years in order that it can have the impact everybody genuinely wants it to have.

Another recommendation is that testing be carried out in conjunction with the GOSHH in Limerick and the sexual health centre in Cork in order to gather data from outside Dublin because there are gay people and others who live outside the capital. We need to ensure we engage with people nationally, not just in the capital city.

Our final recommendation is that we remind ourselves all the time that the level of knowledge and awareness of HIV is not what it was. Those of us who are of an age that we have a conscious memory of the 1980s, even if we were only three years old at the time, will have embedded in that memory massive national public advertising campaigns about HIV and AIDS which carried the words, "Don't die of ignorance". They were campaigns based on fear and featured icebergs and tombstones which are etched in our memories. If we want to be effective about how we create the right level of awareness, we must realise we will not have that kind of national campaign anymore, but we do need to marshal our resources and target campaigns at those groups which are most at risk in order that we raise their level of awareness. Ultimately, HIV is preventable. If we can build people's capacity, they will be the instruments of creating their own best sexual health outcomes as they become aware of and confident in the decisions they make, thus reducing their exposure to harm. As we roll out the national sexual health strategy, that targeted approach will I hope be at its centre.

I thank committee members for their time and look forward to answering questions they may have.

Chairman

I thank Mr. Brady. As it is the first opportunity he has had to appear before the committee since the referendum, I thank him for the work he did in that regard. I know that it is separate from today's business, but I thank him nonetheless.

Deputy Billy Kelleher

I welcome the presentations made by Mr. Mulligan, Ms Seery and Mr. Brady. At the risk of being repetitive in talking about the national sexual health strategy, it is important to promote awareness among the general public, as well as the target groups. Mr. Brady said people who were born in the 1960s and 1970s would remember the 1980s quite well. Clearly, it was a difficult time to be gay in this country and many other parts of the world, given the stigma attached to the gay community in the context of HIV and AIDS.

Ms Seery pointed to the diminishing impact of public awareness. I suppose people lose sight of the risk factors. In promoting the sexual health strategy it is equally important that we do not reinvigorate attitudes in terms of the stigma that can be attached to people. The dilemma is that if one actively promotes awareness by advertising and one is not careful, one can also enhance the stigma and make life more difficult for individuals. I hope, therefore, that we will be conscious of this in implementing the national sexual health strategy.

Our obligation at this committee is to promote a healthy sexual lifestyle and healthy lifestyle in general. In doing so these figures are disturbing, to say the least, especially when one looks at the age profile published by the Health Protection Surveillance Centre. There was a time when a lot of people from sub-Saharan Africa would have featured in the increased HIV figures, but those figures have dropped off dramatically. We now have an issue with people born in this country contracting HIV. It is evident, therefore, that our message is not getting through as much as we would like it to.

Mr. Brady asks what we can do. I am concerned about this, as I said last night in the context of mental health services. We all have great confidence in the local family GP. However, I sometimes think the family doctor may be the last person a young person with a mental health issue or who may feel he or she is at risk of contracting HIV would want to go to. That is because the GP is also his or her mother's and father's doctor. In close knit communities this can be a barrier and some people will not cross that threshold. I have experience of dealing with people who believe they cannot go to their family doctor about such matters. In that context, clinics and outreach centres are critically important. Equally, most people are unaware that they can have these tests done quickly. Most still believe they are costly, that they have to go through a GP and wait an inordinate length of time. We need to promote the fact that this is not the case. I would encourage anybody to go to his or her GP, but it is a stumbling block, particularly for younger people who will not go to their family doctor for this purpose. If we could do anything to promote awareness of the fact that such tests can be done quickly, easily and efficiently, it would be welcome.

Mr. Brady has said the national sexual health strategy will be resourced and funded, but who will come up with the campaign? That is often the critical part. Will it be undertaken by a professional company that can assess what is the best way to get the message across, or will it be conducted through the Department of Health with its typical campaign which, while getting the message across, can sometimes have other implications, as I alluded to? Let us be honest and say there are certain barriers to sex education in the education system. We must, therefore, be conscious of how we try to get the message across to the peer groups most at risk. There is an obligation on everybody to provide resources for schools and third level colleges for that purpose. We should not always depend on NGOs and advocacy groups such as the ones represented to do it. We should be doing it in conjunction with them and supporting them, rather than expecting them to do it alone.

Deputy Caoimhghín Ó Caoláin

I join the Chairman in welcoming the delegates whom I thank for preparing and making their presentations to us on World Aids Day. I will have to leave the meeting and may not be able to await their responses. However, Deputy Sandra McLellan will brief me afterwards. I have another engagement, but I wanted to be here for the presentations especially.

Mr. Mulligan talked about the figures for people who injected drugs. He has said current thinking attributes it to the more frequent use of a drug combination. Is this evidence-based? Will he expand a little on what he means by "current thinking"? If that is the case, what efforts are being made to properly inform the potential cohort of users of the serious risks posed by injecting this drug combination?

The increase in the first two quarters of the year was mentioned. It becomes more shocking when we see the figures up to November. We are already exceeding the figures for 2014 for new diagnoses. This is a worrying development, yet Mr. Mulligan is absolutely on the button when he says we are perhaps only starting to see the full picture.

Considering the World Health Organization's suggestion that perhaps 30% of people living with HIV do not know they have it, there should be some way of encouraging those who may be HIV-positive to get tested. It is only through testing that one can definitively establish whether one is HIV-positive. That has to be matched by a societal effort to ensure the very recognisable consequences of disclosure, as referred to by the delegates, are addressed by each and every one of us. That the consequences of disclosure are as outlined in the workplace, colleges, CE courses and, as rightly stated by the delegates, "in a variety of health care settings" is absolutely unacceptable and most worrying. I do not believe the problem is confined to dental practices, as referred to. Quite clearly, it is much more widespread in the health services. Perhaps the delegates would like to expand on it.

As a shadow health spokesperson on a health committee, I want to make it absolutely clear to the Health Service Executive, if it is taking note of this engagement today, that it has a duty to confront this problem within the health system. It needs to be confronted. No amount of trite words will suffice; action needs to be taken. We need to be quite specific in pointing out exactly where the fault lines are. They should be addressed properly. The stigmatisation should be raised in practice and nobody should ever be subjected to it again.

The stigma surrounding HIV is as insidious as the virus itself. I absolutely agree on this. I see that same stigma in a number of other areas. The delegation will excuse me not for making an analogy but for stating that the reaction to the disclosure of a mental health problem almost mirrors the reaction to the disclosure of HIV. It is imperative that all these issues be addressed.

I give credit to the members of this committee of all political views for being absolutely correct in their strong, assertive position on the unacceptability of stigmatisation in any of these circumstances. The committee can be justly proud of that. It is likely that there are other voices who take a different view, but I am happy to say I am a member of a committee that is quite united in expressing its disgust for the stigmatisation of people who have the courage to indicate, rightly and openly, what they are coping with and dealing with. Irrespective of what challenge a person faces, the best way to deal with it is in the open.

Let me address the view that HIV is no longer visible. We have said this to Mr. Brady on a previous occasion. I have not had the opportunity today to peruse the national newspapers. Yesterday, as shadow spokesperson on health, I issued a statement to the national press saying that we must challenge the stigmatisation of HIV and AIDS. I warrant that it did not see the light of day in any print organ. We are looking for answers here. There is now a degree of invisibility, and people are almost taking the view that this is one of yesterday's challenges that no longer has currency. Let me outline what I am doing about this today. We are all representatives of local constituencies. If the national media no longer feel the challenge has currency, the local print and broadcast media will most certainly pick it up. As Oireachtas Members, we could reach a much greater audience through the local media collectively than through any of our national broadcasters or outlets. I encourage colleagues to do what I am doing. I rewrote my statement of yesterday as I was sitting here earlier and will issue it for publication in my local media this week. I really feel the only way to address the problem is by continuing to shine a light on it. It has gone off the boil in terms of attention from the bigger players.

I have a number of other points I would have liked to mention, but the Chairman is very forceful at this committee. Therefore, I must conclude by saying "Well done" to the delegates. We will continue with our work.

Deputy Seamus Healy

I welcome our visitors and thank them for their presentations, which were very informative. All three have referred to the worrying increase in numbers in 2015. First, there was an overall increase and, within that, an increase in the number of young people affected. Against that background, perhaps each organisation could let us know what resources and funding they have to deal with the issue. What work are they doing in this area? They might elaborate on the questions of awareness and education also.

All three delegates referred to stigmatisation and the consequences of disclosure. Perhaps one of them will expand on these consequences. This matter can be particularly difficult. How can we address it? What practical steps can we take in this regard?

Some 30% of people with HIV do not know they have it. Obviously, that is a considerable problem. A related point, on which I may be previous, concerns the pilot programme Mr. Brady spoke about. I take it he has not yet considered how and when it might be rolled out nationally. Is it a possibility, or will the programme operate in but a small number of areas? I believe it should be rolled out nationally and as soon as possible. Could Mr. Brady expand on that, please?

Deputy Joe Costello

I thank the delegates for their presentations. I missed a little bit of the earlier presentation, and I apologise for that.

It is very welcome that the delegates have appeared today to present the facts and figures on the increase in the incidence of HIV infection over recent years and the further increase this year, for which we do not have the final figures. This is mirrored by an increase generally in sexually transmitted diseases throughout the country. It seems this is as a result of a decrease in awareness of the problems associated with sexually transmitted disease, concomitant with an increase in the effectiveness of medication. The problem has gone off the radar to a degree.

It is very welcome that there have been improvements in medical expertise and the quality of the drugs available, but if the result is that people are less concerned with protection, that could be a major contributor to the situation.

It is certainly true that there is not the stigma there was in the past, but there is still a stigma. In the late 1980s HIV and AIDS were associated with homosexuals and prisoners because of intravenous drug use. In one terrible situation the prison authorities asked the prison population of Mountjoy to volunteer for testing and those who were found to be HIV-positive were very quickly told to pack their bags. Everything was put into black bin bags, the prison officers donned space suits and they were carted off in trucks to the Curragh prison. At that stage the stigma was such that being HIV-positive was seen as a death sentence and they had to be immediately separated from everybody else. That form of panic and stigma is gone but nevertheless there is still a serious community stigma. Perhaps, as one of the witnesses suggested, community-based testing could take place rapidly, with results given immediately, and it would not be specific to any group in society. That would lift the stigma, and with proper awareness and highlighting of the issue we could make progress, particularly, as the witnesses have pointed out, when so much sexual transmission is through people who are unaware of being HIV-positive. They may not belong to any of the categories we have talked about.

The Minister of State with responsibility for the national drugs strategy, Deputy Ó Ríordáin, has recently raised the question of providing medically supervised injecting centres. That would stop the covert street injecting in telephone kiosks and dark laneways and sharing of needles, which is very dangerous from every point of view and causes anti-social problems. There seems to be a lot of intravenous drug activity with amphetamines and snow blow, a party drug, without concern and care. This is extending to the vulnerable, such as the homeless population, and needs to be considered. It is a new dimension to the problem. It is fantastic that the witnesses are highlighting the issues. They are the people to do it. They have brought it to our attention and it is very important that we find forums to do that, because unless there are platforms for highlighting the issues too little attention will be paid to them.

I have always thought that we need a special task force to respond to the changing nature of drug abuse. We still have not come to terms with prescription drugs. There are constantly changing chemical compounds and we do not have the mechanism, means, supports or resources to deal with them. We need a special task force of experts in the medical scene and elsewhere that will be able to respond as they come on the scene, before they get a firm foothold, rather than a couple of years later trying to get to grips with a problem that could have been dealt with earlier.

Deputy Dan Neville

I welcome the presentations. One of the biggest challenges has been highlighting the stigma. That is the most difficult thing to change, as we have seen in the area of mental ill-health. It can even be subtle: where people know that someone is HIV-positive and say they do not have a problem with that, why would they have to say so if they really did not have a problem? It is ingrained once it is established because of the history.

Has any research been done on the level of stigma in society? St. Patrick’s Hospital did research in the past two years on mental illness, and the results were quite frightening. Stigma allows the political system to pay less attention to the area. Society does not demand that something be done about HIV because the people who are HIV-positive do not raise it with politicians because of the stigma. The whole area is extremely challenging. The press has an enormous role to play in this respect too. Does it recognise what the witnesses have presented today in respect of HIV? Is it informed or does it have any interest in being informed about the situation? In some sections of the press, sensationalism is more important than information. Over the decades, around the area of HIV and AIDS there was certainly sensationalism. There is an element of that present in the debate on HIV. The challenge is to inform the press. I am not painting all of the press in that light. Some have made fantastic positive contributions in this area, especially radio. The attitude is hopefully moving away from sensationalism, but we have a long way to go in society in terms of the way people discuss it or avoid discussion of the area, which is nearly more important.

Senator Colm Burke

I thank the witnesses for their presentations and the work they are doing in this area. Many welcome changes have occurred over the past 15 or 20 years. The average age of HIV diagnosis fell from 37 years in 2005 to 31 in 2014. Has a generation missed getting the information, or have the witnesses carried out any studies to identify why this has arisen? If the average age is 31, there must be some who are much younger.

Could the witnesses give us more information?

Are the schools' sexual health programmes falling down in some areas? In some cases, is insufficient background information available to the people at the coalface who are providing the information? What would the witnesses do in order to give more detailed information that would assist those who are dealing with young people? It is extremely important, given that the figures for 2015 seemed to indicate that we are missing a generation regarding education. While the witnesses explained that there is better availability of diagnoses, one would imagine HIV should be decreasing rather than increasing. Can the witnesses explain it?

Deputy Sandra McLellan

I welcome the witnesses and thank them for their presentations. When we first heard about HIV in the early 1980s, it was a death sentence and everybody was afraid of it. We have moved on a little. People realise that, with effective treatments, HIV does not become AIDS but can be treated effectively. On a lighter note, what do the witnesses think of the soap opera storylines that touch on HIV and AIDS? Over the summer I was following one on "Emmerdale". Do they help educate people, or are they way off the mark?

Mr. Tiernan Brady

Deputy Kelleher asked about access to services and GPs. He is exactly right; most people go to their GPs for all their health needs, by and large. Irish research shows very clearly that for LGBT people, the first port of call for almost everything is the GP, the same as everybody else, but not for their sexual health. More than 50% of LGBT people in Ireland are not out to their GPs. A person who is not out to his or her GP cannot engage with the GP regarding his or her sexual health.

Chairman

Is there a particular reason for it, or is it just pure culture?

Mr. Tiernan Brady

A couple of reasons feed into it. Strong Irish research was carried out, the second phase of which is to be published next year, which identified a collection of perceptions. People perceive that their local doctors will not be familiar with LGBT issues. People perceive that they have had negative reactions in the past when they have engaged with others regarding their sexual orientation. People fear a negative reaction and judgment. One of the great challenges for all health services, and services in general, is that LGBT people have grown up with the expectation that, more often than not, they will encounter a negative reaction. The way they access services is terribly damaged as a result of it, especially sexual health and other health services. Unfortunately, people presume that somewhere along the line they will be rejected or judged negatively by people. Rather than go through this experience, they decline to engage with services.

How do we address those barriers within primary care services? Most of it is by building the capacity and knowledge of health care providers. To get most people to test, we must provide a full range of services. No one service is right. Most people go to primary care services. There are STI clinics, NGO services and community settings. Rather than identifying one best model, we must understand that, due to the nature of sexual health and the fact that most people do not look forward to testing, we need to provide a full range of services. We must ensure there is a service that suits each person, no matter what their previous experiences have been. It will not always be primary care. GLEN does much training with primary care nurses and doctors about it. So much of it is just about awareness building. There are great courses, and the primary health care providers get a lot from them. We have created guidelines with the Irish College of General Practitioners about how to engage, but this will always be only one pathway.

Given that sexual health is so stigmatised and taboo in general, we must always be thinking about innovative, imaginative, new pathways in order to make it as easy as possible for people to do something they are not looking forward to doing. This lies at the heart of the challenge. Next year’s project will be an innovative part of it. We will be happy to keep the committee fully updated as the pilot rolls on. As Deputy Healy mentioned, I would love it to be a national project. I am convinced it will work, as evidenced by all the research from Europe, the European Centre for Disease Control guidelines and the number of countries that are already doing it. We are very late to the table. This is the first national rapid testing project. It has been happening in many countries for years.

A few years ago, Ms Seery and I visited Denmark, where they do these tests upstairs in a shop on their equivalent of Grafton Street. It is a lovely little place, where people can pop upstairs, have their test, and off they go. It is the entire test, and all the medical equipment needed is a chair. It is a nice comfortable place where people can do it. The more we keep up with the technology and the more accessible and convenient we can make the test, the more successful it will be. Nobody wants to wait seven days. When we design services, we should think about what we would like if we were attending the service rather than providing a service, opening the door and awaiting the customers. Sexual health services will never work this way. I hope the pilot will be a success and will shape national policy. There is no reason this cannot be provided in every corner of the country and every conceivable setting possible. The more it is, the more we combat the stigma around sexual health and HIV.

Deputy Costello was correct to highlight how interwoven sexuality and bisexuality was with AIDS at the beginning. When it was first noticed and named, it was called gay-related immune deficiency, GRID. While we have managed to move past the stigma for lesbian and gay people to become one of the best countries in the world, we have not done the same for HIV stigma. Given the journey of gay and lesbian people in Ireland, we know it is possible. It is about committing to building awareness and investing in the type of anti-stigma programmes that can deliver the change that has taken place in other areas of Irish society. It is not impossible.

Chairman

I will suspend the meeting until after the Dáil vote.

Sitting suspended at 5.20 p.m. and resumed at 5.35 p.m.

Mr. Tiernan Brady

Senator Colm Burke asked about the reduction in the average age of diagnosis. Unfortunately, there is no one simple answer, but there are several trends. There is a lack of knowledge compared to 20 years ago, when there were huge national public awareness campaigns. The words “AIDS” and “HIV” were pretty much unavoidable as they were very much in the public broadcast space or on billboards. That has gone, however. Within the challenge, there is the problem of our success with science. Science has moved HIV from being an incurable condition that will kill somebody acutely to still being an incurable condition but one that is chronic and can be treated. That makes messaging much more complicated because there is not that fear-based message of the 1980s and 1990s, which was so stark and pierced the consciousness so much. Coming back to Deputy Neville’s point, it is a fine line where the stigma kicks in then.

There are other issues which feed into this. There is the process called othering, which exposes people to great risk. People get the idea that HIV happens to somebody else; they "other" it away. They think it only happens to people from sub-Saharan Africa, heterosexuals or gay people; it does not happen to one's own group. As a result, people do not think there is a risk that is close to them and then they increase their exposure to risk.

Part of the challenge around HIV is that a person who has HIV but does not know he or she has it looks like everybody else. Do people understand that? What is people’s knowledge of what HIV is? People are sometimes exposed to greater risk due to a lack of knowledge and lack of awareness of the proximity to risk. One of the key areas around that is lack of education. Sexual health education is critical in changing people's attitudes and actions. As was said earlier, HIV is such an easily preventable condition. Building people's awareness and capacity is actually quite straightforward, but it involves education so that people can make decisions that will ensure they have really strong, positive sexual health lives and good health outcomes. This is phenomenally achievable, but it is about making sure we have an education system that provides sexual health education in a uniform and inclusive way, especially when we are talking about gay and bisexual people. It must be about involving everybody in the classroom, and they can see it is about everybody. In doing so, we will build the capacity of people to make the best decisions for themselves. Ultimately, how we radically change this is through group sexual health promotion - when people are able to take decisions into their own hands that will radically reduce their exposure to risk. Education lies utterly at the heart of that.

Chairman

Do the figures presented to us today show that we have all missed that bus on one level? I applaud everything GLEN is doing. I have a text from a guy who is getting tested and is critical of the availability of times in Dublin. How do we get to a point at which Mr. Brady does not have to come in here? I mean this with the best will in the world, and I know GLEN is doing phenomenal work. I like Mr. Brady's phrase about positive sexual health lives. There is a generation of young people who feel they are immune to HIV and that it is not the death sentence it was before. How do we ingrain a different attitude into people's minds?

Mr. Tiernan Brady

Education is always at the heart of it. We are building people's capacity to make the best decisions for themselves. Given the information, people have phenomenal capacity to make the right decisions on harm reduction and on the best possible health outcomes for themselves. They cannot do that in the absence of information and education. If they do not know the circumstances, they will be making those decisions anyway but without the facts and, as a result, will be putting themselves in a position of greater risk. Education could be targeted at adult populations who have missed the boat on this because it was not on the curriculum previously, or adopted at curriculum level so that we can provide inclusive sexual education, knowing the hugely positive impact it will have on people's capacity to make independent, good decisions for themselves.

Chairman

In saying that, Mr. Brady's opening statement and figures show a 210% increase. I taught religion for 16 years when the curriculum was totally ambiguous around homosexuality - or rather, it was totally clear about it. Sexual education was very black and white - they were not to do anything and that was it.

Deputy Dan Neville

That would have been the end of the human race.

Chairman

Exactly. They did not have sex until they got married and, God forbid, those who were gay did not have any sex at all because they were impure and whatever. Now, we have never had more exposure, with apps, information, rapid testing and the work all the witnesses do - I am not patronising them - and that has brought about a new era in terms of transparency in sexual health. What are we missing? A 210% increase in diagnoses is staggering.

Mr. Tiernan Brady

All three of us will have different answers because we are missing quite a few things. Education is something we are missing. We are not building people's capacity or giving them the equipment they need to make the right decisions. They are making the decisions anyway. As we found out over centuries, no one is going to decide not to have a sex life. People will have sex lives. The question is what information they have at their disposal to make the best decisions for themselves. When people have the right information, it creates the capacity to reduce risk and leads to better health outcomes and a happier life. It is better for the individual to have a healthy sex life as well. I am sure Ms Seery and Mr. Mulligan will have other bits to add to that, but I would say education is the point at which we allow people to take control of their own lives.

On one other point, I was not expecting a question on "Emmerdale" when I was preparing for this meeting.

Chairman

It is easy to know that Deputy McLellan is not going for re-election.

Deputy Sandra McLellan

That was during the summer break.

Mr. Tiernan Brady

Not having seen the specific storyline, I do not know. One of the great stories of the change in attitudes towards gay and bisexual people in Ireland was about visibility. People from all over the world are now coming to Ireland to talk to organisations such as GLEN about what happened. I could have been a criminal in 1993, while I was in college, and now I can be a full and equal citizen under the Constitution. That changed in 22 years, which, in terms of social progress, is radical. Lots of people come to ask us why, and I have always been convinced there is one answer, which is tied to HIV stigma. Visibility of people humanises the story, so that it is no longer about a thing but about people. It is not about "gay", as would have been the case in the 1980s. It is not about HIV but about a person living with HIV. The more visibility we can create through people who are brave enough to be out there in the public domain, those in the media who want to write stories about it or those who want to put it into "Emmerdale", the better. I would never underestimate the importance of putting the issue into a soap opera like "Emmerdale" to really get into the public consciousness. People can see the human face. The Irish story of the gay and lesbian experience can mirror the HIV stigma experience. As we create visibility, people see the person. That changes everything.

Ms Deirdre Seery

Sex education is one of my big topics. The Cork Sexual Health Centre has been doing sex education in partnership with teachers and schools since we changed from pure HIV education to sex education in 1997. We did that on foot of research which we carried out in Berlin and the Netherlands to see what they were doing there. To get evidence from our own schoolchildren in Cork, we also had a questionnaire for 800 young people. In the Netherlands at that time, they were planning to mainstream it so that teachers would be providing all the sex education. We thought that was fair enough. However, according to people in Germany and the Netherlands, they realised that a partnership approach to sex education is where it is at now. That is largely because young people in school are so influenced by what they see on the internet and in the porn industry via the internet. Sexual practice norms have been influenced by people accessing misinformation. I will not talk here about the kind of information that young people are getting from porn sites which they regard as normal, but it is scary. They need people like us - not me in particular, but those from our organisation - to be able to address these issues and free the teacher up to talk about the other core values around good sexual practices, such as respect, listening, talking - all of those kinds of things - without having to deal with the actual sexual practices that have become norms. We have to challenge those practices and say they are not norms.

Chairman

Last night RTE aired a "Prime Time Investigates" programme on the sex industry. Ms Seery commented in her presentation on the use of condoms and the unintended consequences. She is right in saying that young people access a variety of different sources for information. She said that young people get information from porn sites which she would not want to talk about here. Is it worthwhile for ILGA-Europe, the European Region of the International Lesbian, Gay, Bisexual, Trans and Intersex Association, or Ms Seery's umbrella organisation, to meet with those who are involved in the porn industry at a worldwide or European level? I am not sure whether we have an Irish industry.

Ms Deirdre Seery

The people in the porn industry are in it for commercial interest and will do what they do. I am interested in working with the schools and third level institutions.

Chairman

What concerns me is that, if young people are impressionable or are influenced by what they see, how do we go beyond the point at which Ms Seery is engaged to educate them at a different level as well?

Ms Deirdre Seery

Just by saying that it is not normal behaviour and bringing it right down. AIDS West in Galway has done a lot of research on the impact of sex education in schools as well, so we work hand in hand with them.

It is clear that when one gives young people good quality sex education it does hit the mark. We want to maintain that partnership, and not expect teachers to go beyond their boundaries, and have those conversations with young people.

Chairman

To be fair to Ms Seery and her organisation in Cork, the centre has a very good outreach partnership with schools.

Ms Deirdre Seery

Yes.

Chairman

I met the organisation in Ashton school recently, where there is a good awareness campaign.

Ms Deirdre Seery

That is right. Since 1997, and even before that, we have developed really good partnerships. We are not in all of the schools. We would like to be in more but we are getting there. In turn, young people come to us for further information. The programme is definitely a good partnership.

In terms of stigma, one of the things that we have not talked about is disclosure to partners with whom one might be having sex when one is not in a regular relationship. Such disclosure is one of the really hard things for people to do. When one starts a new relationship, it is difficult to know at what stage one should tell somebody that one has HIV. That is one of the issues that comes up for us. If one does not tell the person straight away then, at some stage, if a relationship develops, one has to say: "Well, actually, I didn't tell you this all along. You weren't at risk." The other person will respond by saying: "You kept a secret from me." Yet if one tells the other person too soon and the relationship does not develop then the information is public knowledge and of course the person is stigmatised. That is another element. That is why we have a campaign called Be Sexy Stay Healthy - to try to get to the forefront of everybody's mind that one can be sexy and protect one's self. It is important that we put pleasure at the forefront of our work. People have sex because it is pleasurable and we cannot deny that is pleasurable. Therefore, we must be able to say, "Yes, have fun, have sex but it is also fun to have healthy sex". That is part of our way of dealing with the stigma around disclosure.

In terms of visibility in the national press, I agree with the remarks made by Deputy Ó Caoláin. It is very hard for an organisation to get coverage when it is located outside Dublin, but we keep trying. We do get coverage in the local media. It would be nice if the national press was truly a national press.

Chairman

Is there a reason the national press does not cover the issue? Does it skirt around the issue? Does it draw attention to the subject by using dramatic headlines?

Ms Deirdre Seery

The national press cover things primarily in Dublin, even if we do something bigger in Cork. I am not griping, but such media coverage, in terms of social responsibility, gives the impression that these issues do not exist outside of Dublin, so it does not help the centre. The Evening Echo in Cork is fantastic, as it gives great coverage to our testing programmes. I agree with Deputy Ó Caoláin that local media have a role to play. When the Evening Echo covers our rapid testing services, people come to us, so media attention does work.

Chairman

Deputy Neville is from Limerick, so I want to know whether the pilot scheme in the region has been covered by the local radio and newspapers.

Ms Deirdre Seery

Yes. We have worked very closely with GOSHH in Limerick. My centre and GOSHH have taken out the same advertisements, which have been funded by the European HIV-Hepatitis Testing Week. The events have had local media coverage as well.

Chairman

What about local radio?

Ms Deirdre Seery

Local radio is fantastic because it is immediate and people listen to the campaign. Local works.

With regard to Deputy Neville's comments on mental health, we know that if young people are anxious about their sexual health it will have an impact on their mental health. Good sexual health has a knock-on effect on mental health. One of the services that my centre is involved in is the youth health service, which provides a counsellor half-time for a year who works on providing support to young people, not just on sexual health but also on mental health. We hope to continue with the programme. Having gay-friendly and youth-friendly services makes a difference to people's overall health and not just their sexual health.

With regard to testing and stigma, I have been in this business a long time, yet I am still surprised by how quickly things change. When we conducted tests in a gay bar the other night - and GOSHH has conducted tests in saunas - I thought to myself that people will not walk around wearing a little plaster on their finger, thus letting everybody know that they had taken a test, but they did. Outreach testing breaks down the stigma; it is working, and we are normalising testing. I look forward to carrying out a pilot programme with Dublin, because my centre conducted outreach testing in Limerick and Cork for three years.

A question was asked about how our tests are funded. We did not get funding so we charged people who could pay €50 for a test. Anyone who could not pay got the test for free and those who could pay a bit still got a test. That is almost the definition of a not-for-profit service. We work in the NGO sector so we must be innovative and learn from what happens in Europe. I am very involved in European initiatives. When I see that something works in Europe then we have to try it here and, invariably, it becomes mainstream. This pilot will become mainstream.

Chairman

Is it the case that what works in Europe works here?

Ms Deirdre Seery

No, not necessarily. It does not work in the same way or with the same groups. We must put our toe in the water and test the system. What works in Dublin does not necessarily work in Cork and vice versa. That is why we continuously reflect on practices, analyse models of work and learn whether they work. What worked yesterday does not necessarily work today. The environment is one of constant change and improvement. We are constantly aware of what works and what we must change. The national pilot scheme will give us a lot of opportunity to work together in different parts of the country and to reflect on what works. I hope that when we come back here next year we will have more information.

Chairman

I hope we will all be back here next year.

Ms Deirdre Seery

Our future life may depend on the Chairman's future, because we have been so lucky in having such a sympathetic Chairman.

Chairman

I thank Ms Seery.

Mr. Niall Mulligan

I am in the lucky position that Mr. Brady and Ms Seery have covered most of the questions.

Ms Deirdre Seery

We left Mr. Mulligan the question on snow blow.

Mr. Niall Mulligan

Yes.

Chairman

We must address that issue.

Mr. Niall Mulligan

Yes. Deputy Kelleher asked who would develop and run a campaign. All stakeholders involved in this area should develop and run a campaign, especially people living with HIV. No campaign should be developed without them.

Deputy Ó Caoláin asked about snow blow and what has been the response to drug users. The figure for drug users has been going down for a number of years, which can be related to a harm reduction response to drug use and the introduction of methadone and needle-exchange programmes. Hopefully, as Deputy Costello has pointed out, medically supervised injecting centres will be part of the landscape in the not too distant future.

In 2014, figures for drug use started to increase and we were not too sure whether it was a spike in numbers or a trend. Unfortunately, the trend has continued into 2015. The response was quick from a public health perspective. Therefore, public health organisations and many NGOs within the sector, particularly within the addiction sector, met earlier this year and developed a quick response. It was a targeted response to the issue, as there was no point in conducting a general campaign because it was a particular cohort of drug users - injecting drug users. In response we had the usual posters from community drug teams and community projects.

More specifically, they worked with the outreach workers who already had relationships with those drug users and tried to get two messages across, namely, the message that has always been there from a needle syringe programme about not sharing needles or paraphernalia and the message about safer sex. What we have been told by the various community drug teams around Dublin is that this is down to a mixture of sharing paraphernalia and more sexual activity rather than heroin use.

Ms Deirdre Seery

It is a stimulant.

Mr. Niall Mulligan

It has a different impact. The figures are still increasing. Another response was to make needle syringe programmes more available.

Deputy Ó Caoláin's second question was on health care settings and stigma. Mr. Brady answered it, so I do not need to, but I will reiterate his statement that this comes down to education, raising awareness and attitudes. This is a wider issue than just health care settings. There is an organisation called Positive Now.

Chairman

Yes.

Mr. Niall Mulligan

It is the all-Ireland network of people living with HIV. In a good document that it published approximately 18 months ago, it examined the question of rights and responsibilities, not just of the people living with HIV, but of general society. It outlined certain actions that could be taken within the health and education sectors. I would recommend that document as one for the committee to read.

Deputy Seamus Healy

What is it called?

Mr. Niall Mulligan

"HIV: Our Responsibilities".

Chairman

That group appeared before us last year. For some reason, we did not get them back this year.

I received a text today from someone in Dublin about the availability of free testing. Are there plans to make it more available? The person was attending Baggot Street hospital and made the point that testing was only available between 5.30 p.m. and 6 p.m. on Tuesdays and Wednesdays.

Mr. Niall Mulligan

My understanding is that the Rapid HIV test will become available in Dublin. There is free testing beyond the clinics. HIV Ireland offers free testing on the second and fourth Wednesday of every month. There is a free testing locator map on our website.

Ms Deirdre Seery

We are not on it. If one is looking in Cork, remember that we are here, too.

Mr. Niall Mulligan

The Sexual Health Clinic will soon be on it.

Chairman

I got the text from someone who was watching these proceedings.

Mr. Niall Mulligan

Like everything else, there is a need for more free testing within and beyond clinics. Thankfully, we were able to announce the development of our community testing in the north east as a pilot project next year. There are innovative ways of providing testing.

Mr. Tiernan Brady

When do people want to test? Will people tell their bosses that they need a half day off work to attend sexual health clinics? How inconvenient an experience is that for someone who is probably trying to find reasons not to attend the sexual health clinic anyway? We are trying to design services that better understand that we must be in the way of the person and convenient to him or her instead of telling him or her to come and get it. We were in London where there was Saturday and Sunday testing in the main gay and bisexual testing centres. The queues were out the door because that was when people were free.

People might go for tests when they are worried. They were out on Friday night and something happened, so they could go for tests on Saturday. This might not necessarily get them a result, but it will certainly get them into the system in some way because they will have engaged with it and whoever is providing the test will be able to tell them to return in a few weeks' time. They have taken that step, as opposed to someone who becomes worried on a Friday night or Saturday morning but has nowhere to go because the tests are not provided on Saturdays and Sundays, in the evenings when people are off or at lunch time.

Chairman

How did the chambers event at the weekend go? I am referring to the testing.

Ms Deirdre Seery

It was successful. We ran it with the Big Red Quiz, in which people were interested. Mr. Gay Cork became Mr. Gay Ireland. We had a lot of competition, but we found that people were open to being tested. Since then, many people have approached our organisation to be tested.

Chairman

A test was given last Friday or Saturday night and the result was given-----

Ms Deirdre Seery

Instantly. It is a one-minute test. If a test is reactive, that is, if there is a possibility that someone has HIV, we must deal with it sensitively. A part of normalising HIV testing is to have people involved who will not panic in the event of a reactive test. Supports and treatments exist. It is just a question of ensuring the people are supported if they receive reactive tests. In Cork, our testing is done on Monday to Friday, 9 a.m. to 5 p.m. On Tuesday evenings, we have walk-in and by-appointment testing. Next year, we will have more outreach clinics. Whenever there is an event like Valentine's day, we do more testing. We are making it possible for people to test at times that are convenient for them.

We do not have environments in our centres where people must queue and wait. They can come in, have coffee and take their tests. It is actually quite a pleasant experience. That is what people have told us in our evaluations. They come to us anxious and leave relieved, even if they get reactive tests.

Chairman

Did Senator Burke wish to ask a further question?

Senator Colm Burke

No.

Chairman

If members are happy with that, I will thank the witnesses most sincerely. It is important that we celebrate and commemorate world AIDS day today and that we raise awareness and educate people. Education is key. I hope that the people watching and listening to this meeting will read the in-depth papers provided by the witnesses. As Mr. Brady stated, early diagnosis can improve outcomes. It is important to get tested. Equally, it is important to note that one can have a positive sexual life.

If we return in this capacity next year, I hope to hold another meeting. As Deputy Ó Caoláin stated, that our committee has tackled and raised issues of social complexity and brought awareness of and visibility to them during the lifetime of this Oireachtas is important.

Deputy McLellan referred to "Emmerdale". One of the most vivid images that I have is of the film "Philadelphia". If people were to watch it, they would see the journey that we have taken. I thank the witnesses for attending and those in the public Gallery for their work.

Ms Deirdre Seery

We thank the committee for its invitation.

Chairman

The joint committee will adjourn until 11.15 a.m. on Thursday.

Deputy Billy Kelleher

The morning off.

Chairman

Yes. However, the Select Sub-Committee on Children and Youth Affairs will meet at 9.30 a.m.

The joint committee adjourned at 6.10 p.m. until 11.15 a.m. on Thursday, 3 December 2015.