We will discuss sexually transmitted diseases with Dr. Susan Clarke, consultant on infectious diseases at St. James's Hospital. I welcome Dr. Clarke. Before Dr. Clarke commences her presentation, I wish to draw her attention to the fact that members of the committee have absolute privilege but this privilege does not apply to witnesses appearing before the committee. Members are also reminded of the long-standing parliamentary practice to the effect that members should not comment on, criticise or make charges against a person outside the House or an official by name. I ask Dr. Clarke to begin her presentation following which members may ask questions.
Sexually Transmitted Diseases: Presentation.
Dr. Susan Clarke
Good morning. I thank the committee for inviting a representative from St. James's Hospital to address it. I am originally trained in genito-urinary medicine, which traditionally is the speciality which looks after sexually transmitted infections. The words "infections" and "disease" are interchangeable in this regard. It is a bad reflection that when I finished my training in that specialty no jobs were available, as Ireland had only one genito-urinary medicine consultant at the time, and that is still the case. I continued to study infectious diseases, which explains my current title. At present, consultants in infectious diseases take an interest in the treatment of STDs. The point that more consultants in genito-urinary medicine are necessary is a good one with which to start.
I assume what brought this meeting about was the release of new documentation showing a 12% increase in the instance of STDs during the past year. In reality, that is a significant underestimation of what is happening. Those figures come predominantly from STD clinics, including the largest one at St. James's Hospital where I work, and several other smaller STD units throughout the country. Many general practitioners perform STD screening and the notification system is not the best.
I appreciate that many committee members have no, or minimal, medical knowledge. The predominant sexually transmitted infections under discussion have big names. Women's magazines such as Cosmopolitan discuss chlamydia. Gonorrhoea, also known as “the clap”, warts, herpes are the types of STDs we see in a large number of cases.
How does an STD affect a person? Does it cause them to be admitted to hospital for six months? Do they come through casualty every night? Do they sit on a trolley or block casualty beds? None of that is the case. STDs are easy to treat and is a rewarding job to have because, by and large, one sees young patients coming to clinics with problems about which they are exquisitely worried. They can be treated fairly quickly and discharged.
However, STDs become a major economic burden if they are left undiagnosed and untreated. An untreated STD can lead to serious pelvic infections. One of the most difficult problems caused is infertility or ectopic pregnancy, where pregnancy occurs outside the womb. This creates a major economic burden.
From my point of view, providing services for STD clinics would not be expensive.
Currently, STD services are predominantly provided by a few public health doctors in smaller units. St. James's Hospital has the largest unit but, despite running six clinics per week, we are completely overrun. If someone has a sexually transmitted infection, he or she should be seen and assessed quickly. It is obviously a public health problem. If a person has an infection that is untreated, and is left out in the community, the chances are that by the time he or she is seen and assessed, on average, he or she will probably have passed that infection on to one, two, three or four other individuals, depending on how long they have to wait to be seen. It is essential that they are seen quickly. There is no point in giving a person with acute gonorrhoea an appointment for six weeks or six months time. That sort of practice cannot be defended from a public health point of view. The recognised minimum time is 48 hours, and St. James's can just about provide that service, but giving the patients a huge waiting time when they actually come to the clinic. Even at that level of service, we are swamped.
We should not compare ourselves to the UK all the time, but recently, the Department of Health in the UK set out five of its main objectives for the next year, one of which is to provide better sexual health services. A significant amount of funding has been allocated to centres to meet this objective.
An important factor when dealing with this issue is the wider provision of services within hospitals and, by virtue of these, the development of general practitioners' capabilities. A gastroenterologist, cardiologist or plastic surgeon in Tallaght Hospital would not necessarily be happy to share his or her funding so that another doctor can be employed to treat STDs in the community. If funding became available, the consultant's preference would be to hire a specialist colleague. The impetus to provide funding for additional consultant jobs and improved services has to come from the Government because it will never come from the hospitals. Positions have only become available in St. James's because Professor Fiona Mulcahy has built the impetus on the matter. Such is not the case in other hospitals and that is why there are only a few consultants. The development of STD services has nothing to do with the local plastic surgeon. It is up to the Members of these Houses and ourselves to provide central funding to hospitals and to demand that services be provided. The nature of the current structure means that hospitals will not take the initiative by themselves.
The increase in STD cases over the past ten years has been almost logarithmic. The approximately 25,000 patients seen in St. James's each year are reflected in the figures on STD infection I have put before members but these may be an under estimation. A number of small studies conducted in ante-natal clinics in which people were routinely tested for STDs revealed a shocking 10% to 15% positive rate for chlamydia and other STDs. Similarly, some GP practices which have conducted their own surveys have found high rates of chlamydia. These results are consistent with studies carried out in the UK, where chlamydia rates of 12% and higher are seen in asymptomatic women. We cannot continue to ignore this problem.
St. James's is supposed to supply a service to the southside of the city but, in reality, it provides services to the entire country. People travel from all over Ireland to avail of treatment there. The Mater Hospital runs one clinic per week but is extremely short-staffed and restricted in space. As such, the service is appallingly small and poorly funded, especially on the northside. In terms of my earlier comment on the necessity for prompt treatment, it is criminal from a public health point of view that a better service cannot be provided.
Last year, we established a young person's clinic to treat boys and girls under the age of 18, run by an advanced nurse practitioner. The clinic saw about 300 patients last year and found a 15% incidence of chlamydia. That is a significant figure among under 18 year-olds. Even with that small number of patients, the clinic is swamped but it would still be busy if it was open four times per week.
Good services are being delivered in Galway and there is a public health service led centre in Waterford. However, it is agreed among experts in Ireland and elsewhere that a partnership approach is needed between general practitioners and hospital based services. Patients should be able to choose whether they visit a general practitioner or a hospital based service for treatment because they may be unwilling to be screened for STDs by a doctor who also sees spouses and family members. However, they should not be forced to travel across the country for proper assessment.
Both services must be in place because GPs are busy people and we do not want to add this problem to their workload. Many GPs are willing to provide a service but they are under pressure in terms of seeing patients and meeting targets. The issue of funding will have to be addressed if a partnership system is to be successful. A central consultant led service is needed in all regions as the starting point. We can then train dedicated GPs in certain regions so that people will have local access to STD services. Resolving the problem is not simply a matter of treating patients but will also require rapid access to services, training, health advisers, contact tracing for partners of patients with STDs and sex education programmes in schools. In my vision for the future of STD treatment, most regional hospitals will have a consultant led service as a central hub, while GPs do additional routine work. An ability to rapidly refer people to hospitals will also be required.
I know Dr. Clarke did not intend to be dramatic but the numbers in themselves are dramatic, especially the 25,000 who present for treatment in St. James's Hospital. It is nonsense to suggest that there should be an information campaign, given that she made the point that a need exists for consultant staff rather than information. The figures prove we should act on that.
The joint committee is not totally bereft of medical knowledge. It comprises a number of doctors and several others who are experts on health issues.
I thank Dr. Clarke for her presentation. Chlamydia, gonorrhoea and syphilis are treatable with antibiotics but HPV and herpes are very difficult to cure. At the beginning of last week Ben Dunne said he had never seen a graph that continually goes upwards. He was talking about the economy but that is what seems to be happening in the case of chlamydia. Is this because chlamydia can be relatively symptom-free for many patients? Is chlamydia difficult to diagnose? I understand a regular swab is insufficient and a more detailed swab is needed to detect it. I have often recommended that a test for chlamydia be part of a routine cervical smear. Can Dr. Clarke promote that course of action?
I am surprised that 50% of patients between the ages of 15 and 24 had a sexually transmitted disease. A recent article in the Irish Medical Journal on the subject of emergency contraception stated that 80% of women surveyed between the ages of 14 and 51 said they had their first sexual experience before the age of 19. This corroborates Dr. Clarke’s point that sexually transmitted diseases affect a young section of the population, between the ages of 15 and 24. As Dr. Clarke said, this will lead to huge problems in fertility, especially as many women now postpone having a family.
Does Dr. Clarke find that alcohol plays a role? The Irish Medical Journal article on emergency contraception found that women who had drunk excessively were up to four times more likely to require emergency contraception. Has Dr. Clarke found evidence of the role of alcohol in her time working in STD clinics?
Dr. Clarke said there was a need for more consultants and clinics. Sex education is also necessary but in secondary schools it is piecemeal, haphazard and poorly taught. Many people aged between 15 and 18 do not understand much of the reproductive system, sexually transmitted diseases and the consequences of unprotected sexual intercourse. Does Dr. Clarke inquire as to a patient's level of knowledge when he or she presents at the clinic? A poor level of understanding may be a contributing factor, as with hepatitis B and HIV, which are as serious and difficult to cure as HPV and herpes.
I appreciate the doctor is busy and I thank her for attending today. What she has said is very disturbing and some of the figures are worth noting. Increases in cases of chlamydia of 2,000% in ten years, of herpes simplex of 426% in five years and a 45% increase in gonorrhea over two years would alarm anybody. They warrant a response in terms of policy and management.
It makes sense for general practitioners to play a bigger role in STD screening. I take it screening is not included in the GMS scheme at the moment. Would it help if it were?
I was not sure I understood the doctor's reference to a waiting time of 48 hours. Is that a target or a minimum? Could it be shorter?
I am concerned that many people who receive treatment do not necessarily receive advice, information or encouragement to practise safe sex and family planning, etc. Should there be more integration of the two aspects of treatment? Doctors seem only to be able to deal with the symptoms. Dr. Clarke raised an interesting point about who detemines resources. This requires a policy at Government level but I am not aware of a national sexual health policy or strategy. Dr. Clarke might tell me if one exists.
How many genito-urinary specialists do we need? Where should they be located and how should the service be run?
Dr. Clarke said there was a gross underestimation of the extent of STDs. Surely these can be reported to the HSE as infectious diseases. There is nothing more appropriate to the description "infectious diseases" than STDs. In doing so we would at least acquire data informing us of the extent of the problem. GPs should be central to the process as they are accustomed to dealing with notification of infectious diseases.
I thank Dr. Clarke for attending and giving a clear, if alarming, report on the progress of these diseases. The percentage increases in recent years, especially the suggestion that the increase of 12% in the past 12 months is an underestimation, show we do not have the problem under control. The fact that the diseases in question are easy to treat makes it a bigger tragedy because if people presented themselves for treatment we could alleviate the problem.
Deputy Twomey referred to alcohol and drugs. In recent years there has been a vast increase in the amount of alcohol consumed by young people. Is there a correlation between that increase and Dr. Clarke's figures? Is there evidence that sexually transmitted diseases increase with an increase in drinking?
What efforts are being made to target likely sufferers in the future? Have there been any attempts to introduce awareness classes in secondary schools as part of the school curriculum? We must educate young people, who are often not aware of the diseases they can contract.
There is a service in the city of Dublin and for people who are prepared to travel to Dublin but many in rural Ireland will suffer for a time before presenting, often due to the embarrassment of presenting themselves at a clinic. Is there much evidence that embarrassment prevents people presenting until they have no option? What suggestions would Dr. Clarke make to break the taboo surrounding sexual diseases?
Dr. Clarke
Dr. Twomey asked what we can do to diagnose diseases more successfully. He also suggested carrying out tests as part of cervical smears. Part of the reason for the increased diagnosis of chlamydia is the improvement to the tests.
When I began as a house officer almost ten years ago, the sensitivity rates in testing for chlamydia were approximately 50% or 60%. Many cases were being missed and many people were left undiagnosed. In the past two or three years, a special amplification test has been used, so if the tiniest trace of chlamydia is present, it will be found. It is an expensive but useful test, which is now freely available. This PCR test is excellent. Tests are good, freely available and used by GPs. With the costs to GPs, patients must be charged extra. If people go to a family planning clinic they will be offered chlamydia testing, but it is expensive and it must be paid for. It is certainly not free or on the GMS.
The concept of opportunistic testing of people for chlamydia when they visit a facility for another reason, such as having a cervical smear test or being at an ante or postnatal clinic, is being examined. That is where we are getting rates in asymptomatic people of perhaps 10% to 12%, which are scary figures. It is good to do this, but there must be a structure in place for the treating of the patient and the contact tracing of the partner.
Going back to Deputy McManus's point with regard to GPs being able to serve notification of these cases of chlamydia and other infectious diseases, one of issues is that GPs are so busy, although no more so than anybody else. The notification system for infectious diseases, including chlamydia, is a long and laborious process, although one might think it would not be. It can be redefined. Most GPs do not have time to go through the process as they are treating patients and doing as good a job as they possibly can, or better, given their resources. They do not have time to carry out contact tracing, finding out who a person's partner was, chasing him or her up and making sure he or she is tested also. We have the roots of a service to provide this, and we have health advisers who specifically contact and trace people's partners, ensuring these people get tested. That is as important as treating the index person, the initial patient.
With regard to the effects of alcohol, we have specifically examined the issue, particularly in our young patient clinic. There seems to be an association. We are carrying out a simple questionnaire study with the aim of seeing if there is a link between these diseases and alcohol. As people would expect, there is a link, and many people have more unprotected sex when there is more alcohol on board. There is no question mark over this. With regard to education, one of the best facets of our young persons' clinic is that specific social workers are assigned to it on a specific morning every week. This is a big issue for people under a certain age, and there are many medical legal issues with regard to seeing these patients. There is no real paediatric service available to look after 15 year olds or 16 year olds who have STDs, and we are generally taking the brunt of this.
Sex education is fundamental. Several years ago, before I went away to continue my training, we seemed to have an extra one or two health advisers. These would be specially trained nurses, and they used to visit schools to carry out sex education. That used to be a fair amount of their job. We are currently down one or two health advisers and we do not have enough funding to provide any more jobs for health advice. The advisers do not have the time to go out to educate as they are so busy within the unit itself. Anybody coming to our unit in St. James's Hospital can see a health adviser, and if a person has a specific STD we would advise that the person sees a health adviser to receive extra education on safe sexual practices in order to prevent the infection recurring. We are swamped, and it is very difficult to provide a good service with our current resources.
The 48-hour limit was a target brought about in the UK. The idea is that from the time a person develops symptoms of a sexually transmitted infection, he or she should ideally be seen, assessed and treated within 48 hours. This would prevent the spread to other people and minimise symptomatology. We were not able to meet such targets within our own unit using an appointment system, so it has been changed to a non-appointment system. We now provide a walk-in service, which makes it very busy. People will sometimes turn up at 7 a.m. to get a low ticket number to enable them to be seen in the morning clinic. They could be there from 7 a.m. until they leave, which could be 2 p.m. in the afternoon.
If people come to the clinic in the morning, they will have been seen, treated, assessed and discharged by that lunchtime. If these people sought a dermatology appointment, they could be waiting six months, a year or even 18 months. Having a walk-in service gets us away from the 48-hour rule because if people can get to us from their part of the country and are willing to give up most of their day, they will be seen and assessed. We are turning people away because we can only see so many people in a morning or afternoon. I am not sure we could carry out the process in less than 48 hours, except in an ideal world. It is not a bad target.
With regard to family planning and other issues for young people with sexually transmitted infections, we have just one advance nurse practitioner in St. James's Hospital, and she told me this morning before I left that pilot funding has been received to carry out a small programme linking our unit with one of the family planning units. Patients coming to us for an STD screening will receive a voucher to go to the local family planning clinic. We do not have a family planning clinic on site, but we would like to. We do not have the requisite space, time or people to offer this service. In the long term it would be ideal to have a one-stop shop where people could have all their sexual concerns addressed in one place.
There is a sexual health strategy, which is under way currently. One was published a few years ago. With regard to numbers and locations of physicians and consultants, I stated earlier that every hospital does not need a big STI unit. There is no point in looking for something I will definitely not receive. All major hospitals should have at least one consultant-led service, and that person could be the hub around which general practitioner services can run. We have previously considered figures of ten of these nationally, at least. This presentation is more about STDs rather than the prevention of HIV, although they are clearly linked. An overview of how many consultants are out there and the available services in all hospitals is well overdue.
I have answered the question of under-reporting in secondary schools. Confidentiality is a significant issue and a reason that I am not contending that GPs can be trained to do all the work, leaving me to deal with HIV. This cannot be done, as GPs are too busy and there are many complicated reasons that patients with STDs must be seen by a consultant. It is important that patients get the choice, as Deputy Connolly mentioned. There can be many reasons that people do not go to see their local GP, as the secretary could be their neighbour, for example.
It is a difficult area and there is a taboo. If we put on our collective public health hats and want to do the greater good for public health in the community, we must provide services for patients that will be used. I have seen patients who took an antibiotic which was lying around in preference to going to a GP. Occasionally that may work, but the partner may not get treated and infection can recur. We must provide services that patients want to use where they will not be intimidated or concerned about a breach of confidentiality. I am not sure if I missed any of the joint committee's points.
What is the cost of the PCP test for chlamydia?
Dr. Clarke
It is under €100, although I am not sure by how much. In places where there is a charge for the test, it is approximately €50 or €60. That is expensive.
The next round of questions will be taken in rotation from Deputy Devins, Senator Glynn and Deputy Fitzpatrick.
I welcome Dr. Clarke. I presume her clinics are self-referral open clinics. From the number of people presenting, can she estimate the prevalence of the disease overall? Obviously those attending the clinic have education to recognise that something is wrong and the motivation to go along. Are any statistics available on which we could reliably bank regarding the prevalence in the wider community?
Does Dr. Clarke come across many patients suffering from repeat disease? It may happen that a person contracts a disease, comes for treatment, and six months later returns in the knowledge that he or she will be diagnosed and treated. Is this a problem or are most patients presenting for the first time?
I am interested in Dr. Clarke's comments about the role of GPs. When I was in practice I had a particular interest in this field. One of my reasons for stopping was that I did not have the back-up facility from the laboratory. However, at the same time a clinic started operation in Sligo General Hospital, which is very good. GPs must have speedy access to a good laboratory and not need to wait for three or four days for results.
Dr. Clarke's title is consultant on infectious diseases. Does she mainly deal with STIs or does she deal with other infectious diseases? If so does she have a role to play in the dreaded avian flu in the event of it coming here?
I welcome Dr. Clarke. Every pleasure has its corresponding pain and given the graph presented today, it is clear the pain is on the increase. Is there an increase in the incidence of STIs or are the diagnostic procedures just better? Based on the graph, syphilis reached its peak with 300 cases in 2002, having been fewer than 10 cases in 1980. It then fell to just 150 in 2004. In Dr. Clarke's experience as a consultant has she come across many cases of syphilitic heart disease? What are the implications for the health service?
I welcome Dr. Clarke and thank her for attending. Dr. Mary Houlihan, who runs the sexual assault unit in the Rotunda, appeared before the committee some time ago. She provided a horrifying correlation between drink and assault, etc. Dr. Clarke touched on the matter without going into much detail. Is Dr. Clarke's work paid for from hospital funds or from general Government public health funds? How many sessions does she run each week in St. James's Hospital? I understand that Dr. Clarke only deals with the overt manifestation of STDs. Some incidences may only be picked up without any such manifestation at antenatal clinics, etc. Would those cases also be referred to Dr. Clarke in her hospital practice? Could the service be provided in satellite health centres? The centre in Ballymun opened recently and having a consultant treating people there would take a load off the hospital service.
Dr. Clarke
One of the questions was about the rates of chlamydia seen by us versus the rates in the community. Many patients we see at the moment at asymptomatic people who are aware of sexual health issues and aware of getting a screen for such transmitted infections. We see many, what we would call, worried well people who just want a check-up. They would account for quite a few of our numbers. They are a scary bunch of people because they are asymptomatic, they feel they are perfectly well and yet we are finding high rates of chlamydia in that group also. Some small studies have been carried out, including one by the public health specialists in Limerick. They looked at a group of 50 or 100 men attending a local gym to ascertain their rates of chlamydia, which I believe was found to be 11% or 12%. They were asymptomatic men with significant rates of underlying asymptomatic chlamydia.
In general, rates in GUM clinics are somewhat higher than would be expected to be found in the community for obvious reasons. Granted the tests for chlamydia are better than they used to be, but this does not take away from the high rates of 10%, 12% or 15% regardless of whether the rates were that high a few years ago when our tests were not good enough to pick it up. I am sure that was not the case. Either way those are the rates with which we must deal.
Does Dr. Clarke mean 10% to 15% of the general population or 10% to 15% of those screened for asymptomatic chlamydia?
Dr. Clarke
No large population study of the disease of any decent size has taken place in Ireland. Studies in the UK have found rates of asymptomatic chlamydia in the community of between 5% and 10%. Authorities in the UK are in the process of rolling out a big chlamydia-screening programme for the general population in the UK. I know that has been considered here also. In family planning clinics and GUM clinics the rates tend to be higher, at perhaps 10%, 12% and up to 15% in some clinics. In certain select populations a variation of figures can be found. However, at 5%, 10% or 15% the figures are huge.
While we see a certain amount of repeat disease, it is not a huge problem. In certain patient populations we see it somewhat more. Senator Glynn referred to the syphilis outbreak. Members may not be aware that the syphilis outbreak in Dublin is ongoing as is happening in major cities worldwide. While we have it under control to a certain extent, we are still seeing many cases of syphilis. The gay population is somewhat different and we would tend to see more repeat STDs in that population than would be the case in the heterosexual community. While we see some repeat patients, they do not account for our major population, which consists mainly of people being screened once and treated.
Syphilitic heart disease happens much later on if someone has untreated syphilis. Following the huge outbreak of syphilis recently we could see an issue in 15 years' time. For every patient seen, diagnosed and treated, God only knows how many others were never seen, tested or treated. As such they have untreated asymptomatic syphilis and in ten or 15 years time may well present with syphilitic heart disease or other problems associated with long-term untreated syphilis. A huge effort has been made over recent years to encourage people at risk to be tested for syphilis. I am sure we have seen only the tip of the iceberg and it could be an issue in the future. At the moment is it not an issue, but it could well be in ten or 15 years' time.
I agree with the comments of Deputy Devins about laboratory facilities. The test for chlamydia is excellent and fast test that is very sensitive. However, the sample must be in a fridge and brought to the laboratory within, I believe 12 hours, to be assessed quickly. A really good system of testing needs to be in place for a general practitioner to offer the service. As someone else mentioned, they are not just routine swabs. Specialised tests are taken. It is not a standard form of screening.
I was afraid that someone would ask me about avian flu because they heard about it on the radio this morning. I am a consultant on infectious diseases, but I have an interest in sexually transmitted diseases because that is what I started off doing. It was my first love in medicine. I look after people with all sorts of infections, such as meningitis, in St. James's Hospital. I am on the local committee that will be responsible for the control of avian flu if it comes to Ireland. I suppose the committee might want to contact me if that happens, but I do not intend to speak about it this morning.
Dr. Clarke's comment about syphilitic heart disease is worrying. It is somewhat comparable to undiagnosed type 2 diabetes, or when people discover they have heart conditions. The Department of Health and Children and everyone concerned have a responsibility to make available throughout the community the information that is available to them. If people have doubts about their personal health which relate to sexually transmitted infections, they should have the appropriate tests. I do not think people should wait in such circumstances. The information in question should be put in the public domain if it is not already there.
Members of the committee should understand that as syphilis moves through its various stages, it does not have any other symptoms or signs after the initial ulcer has healed. Patients will be aware that they have syphilis in the initial stage of the infection, but there are no signs thereafter.
Dr. Clarke
That is one of the major concerns. While it may be a good idea to initiate a public health education programme, it should be borne in mind that many people do not realise they are at risk of having a sexually transmitted disease. Half of the hospital's patients who have infections would not have perceived themselves as having had a high-risk contact. There is no point in putting an education programme in place and then telling people they have to travel to Dublin or Cork to get an assessment. We need to develop a system whereby people can be assessed locally if they so desire and treated appropriately by somebody who is trained in how to do it correctly.
Alcohol was a huge issue when I worked for a couple of years in a sexual assault unit with Dr. Mary Houlihan. Some of my most vivid memories are of not being able to assess people properly because they were so intoxicated and their memory of events was incomplete. It is something we are trying to look at in a much more methodical way in the infectious diseases unit. We are doing some research to try to focus on this matter. I completely agree with Deputy Fitzpatrick that this is a huge issue in any consideration of sexually transmitted diseases, pregnancies and sexual assaults.
The unit in which I work does not get any funding other than the funding it gets from the hospital. It has to fight for funds, which can be quite difficult. It is a public health issue, in essence.
The point I was making is that it is a public health issue. Every health issue is a public health issue. If the unit is looking for extra funding, I would have thought it would look outside the hospital.
Dr. Clarke
Absolutely.
It is something about which the committee could write to the Minister or the Department.
Dr. Clarke
The Deputy also asked about the unit's dealings with patients who come to us with symptoms. As I have said, we also see many people who have no symptoms at all, but are worried and want a check-up. Patients are constantly picked up in antenatal clinics and GP practices. Some GP practices routinely treat such patients before referring them to the clinic to get further assessment, to contact or trace their partners or to follow up their cases by ensuring they have been treated appropriately and their follow-up tests are negative. Other GP practices do some of that work within the confines of their capabilities. Similar work is done in antenatal clinics, most of which routinely refer patients to the unit if they are found to have an infection.
Deputy Fitzpatrick also asked about the number of sessions which are organised at St. James's Hospital. There are six sexually transmitted infections clinics each week, one each day between Monday and Friday with two on one of those days. All those clinics are full — it is standing room only.
Are the clinics in question walk-in clinics?
Dr. Clarke
Yes. We put time aside for some appointments, but the clinics are generally walk-in clinics.
We will move on to the next round of questions. I remind members that Dr. Clarke must leave at 12.30 p.m.
I welcome Dr. Clarke to the meeting. She mentioned the tracing of partners, which is an important issue in the treatment of sexually transmitted diseases. I wonder whether people are generally co-operative in this area. I suppose there is not much the unit can do about it if people are not co-operative. While it might be embarrassing to present at a clinic with a sexually transmitted disease, it might be much more embarrassing to have to give the names of partners. I wonder how the unit deals with that. How does it encourage people to be more co-operative in that area?
One of the unit's suggested solutions to the problems of confidentiality is the establishment of dedicated sexually transmitted infections clinics. If one is sitting in the waiting room of one's general practitioner, one could be there for any purpose — not necessarily to have a sexually transmitted disease treated. If one is in a sexually transmitted infections clinic, everyone will know why one is there. I would have thought it would offer much more confidentiality to provide such services through general practitioners. I would appreciate Dr. Clarke's comments on that.
I would like to ask about the level of confidentiality afforded to people under the age of 18 who report to the unit. I presume that no provision is made for compulsory parental involvement in such cases. What is the position in that regard?
Can Dr. Clarke give details of the gender breakdown of those reporting in the first instance, and those who actually have sexually transmitted diseases? Is the incidence of such diseases pretty equal between the sexes? Dr. Clarke mentioned that more than 50% of the unit's patients are between the ages of 15 and 24. I wonder how those figures break down as people get older. Does Dr. Clarke find there is not a huge incidence of such diseases among older age groups?
I apologise for not being here for Dr. Clarke's presentation. I was hoping that the meeting would not start on time, but it did.
We always begin on time.
The start of the meeting is sometimes delayed by arguing.
Yes.
I would like to ask about the status of the sexual health forum which was established to implement the recommendations of the eastern regional health strategy. Can Dr. Clarke give the committee details of the current status of the strategy? Has progress been made in that regard? I presume that was the strategy to which she was referring when she mentioned a sexual health strategy. Does Dr. Clarke think that strategy, which is quite localised, is sufficient or is it just a good starting point for a national strategy? I regret the fact that we do not have a national strategy. To what extent could the strategy form the basis of a national strategy? Does it constitute 80% of a national strategy? Is the Department of Health and Children in a position to turn it into a national strategy?
Having read Dr. Clarke's submission and listened to her responses to earlier questions, it appears that this country is badly served in terms of the optimum service to which she referred earlier. It is worrying that the service provided in a city like Limerick is quite small. I am familiar with Limerick, which is one of this country's major cities. It is worrying that a consultant-led service has not been made available there.
Would Dr. Clarke like to comment on the statement of the former Eastern Regional Health Authority that community-based services for sexually transmitted diseases are under-developed in the eastern region? Is it better for people to operate from hospitals, general practitioner clinics or family planning clinics?
Deputy Cooper-Flynn referred to the moral dilemmas in dealing with under-age patients. We need to be realistic if we are to solve this problem. Children under the age of 18 who are engaging in sexual activity have an equal entitlement to privacy as patients. Can the Deputy discuss the concerns she might have about the moral or legal problems in this regard? It is something that we need to tackle. We will not solve this problem if we do not implement hard-hitting programmes of education which are aimed at developing in young people a commitment to a lifetime of good sexual health and activity. It is slightly unfortunate that Dr. Clarke and Deputy Connolly used the term "taboo" because if we continue to use that term when speaking about matters if this nature, we will build a taboo. We should not use such terms. As Dr. Fitzpatrick indicated, it is a public health issue. Does Dr. Clarke believe that explicit advertising similar to that currently shown to prevent further road carnage is required for sexual health? Given that the Crisis Pregnancy Agency has spent considerable sums trying to persuade people to use contraception and engage in safe sex, perhaps it is time to be more explicit.
We hear about the horror of what can happen if sexually transmitted infections are not treated. Would people not think twice or, for example, use condoms if they knew the truth about sexually transmitted diseases? Would it constitute good use of public money if the Health Service Executive launched an education campaign?
Does Dr. Clarke find the cost of condoms prohibitive, particularly for young people? Last week, I was prompted to raise on the Adjournment the need for the Minister for Finance to zero rate condoms in the forthcoming budget. The Crisis Pregnancy Agency carried out research which found that cost is a major factor in preventing people from using condoms. Removing VAT from the sale of condoms would make a major contribution to combating sexually transmitted diseases.
Dr. Clarke noted that while the notification process for chlamydia is lengthy and cumbersome, it could be refined. Why has it not been refined? If there is a better way to proceed, surely it should be applied.
I apologise for missing the presentation which was due to my attendance at another meeting. I compliment Deputy Fiona O'Malley for pursuing this issue in recent years. Access to information is key in the area of health, particularly the issue of sexually transmitted diseases which is characterised by a lack of information. I was not aware, for example, that sexually transmitted disease clinics were located in Kilkenny, in my constituency, and the nearby city of Waterford, or that these diseases are linked to heart disease. This is news to me and many others. A vigorous campaign is necessary to inform people of the location of STD clinics and the side-effects of sexually transmitted diseases.
Attending a talk on diabetes in Trinity College Dublin some time ago, I noted a large number of posters highlighting the risk of having unprotected sex. I was amazed to learn that, in addition to condoms, vibrators are for sale in the toilets of UCD. Young people are being bombarded with images of sex from the ages of four, five or six years. Images of the singer Britney Spears are an example of this. The danger is that they are not exposed to the downside and risks of sex. There is an onus to publicly highlight the health risks and side-effects of STDs, including the risk of heart disease. Balance is, therefore, needed.
One hears astonishing stories about teenage discos. I could not believe that stories in my local newspaper, the Carlow Nationalist, were true but, having checked them out, it transpired that they were. My old office used to be beside the premises in which the discos are held. On returning from Dublin one night I entered my office and saw teenagers passing by who were wearing incredibly few clothes. The antics that take place in these discos — I will not repeat on record the types of behaviour about which I have heard — are very worrying. I am not being a prude in saying this because I am still relatively young. It is essential that members of the public be informed of the risks involved in engaging in sexual activity. We need to balance and counteract the glamorisation of sex with which children are bombarded from an early age.
It is bad enough to break up with someone and have a cooling off period during which there is a lack of communication but to be obliged to tell one's former partner that one has tested positive for an STD would not be the best way to get back on terms. This presents an awkward dilemma. Are people obliged to inform their partners that they have tested positive for an STD? If not, should such an obligation be introduced?
Dr. Clarke touched on the issue of avian influenza, a matter I have highlighted. Does her clinic also deal with MRSA? If so, perhaps the joint committee will invite her back to speak on that issue.
Dr. Clarke
One of the reasons it is difficult for a GP practice to take on the function we perform is the fact that contact tracing — following up patients' partners — is a job in itself. For example, during the peak of the syphilis outbreak some 18 months ago, our unit acquired funding for extra health advisers — I am not sure from where — because the contact tracing side was so busy. This is a major task which general practitioners by and large do not have time to do unless additional funding is provided.
How do we approach this issue? We tell the person who tests positive for a sexually transmitted disease that he or she needs to inform his or her partner. For those who are currently in a relationship, this does not by and large present a problem. They will usually bring their partner with them at the next clinic visit or the partner will come along in person the following day. If the person who tests positive for an STD does not want to inform his or her partner in person, we offer them anonymous partner notification. Essentially, this involves sending the partner an anonymous letter stating that he or she has been in contact with an infectious disease and needs to attend the clinic. He or she will then attend our clinic. If he or she sees me and I have seen his or partner previously, there will be complete confidentiality.
How far back does the clinic trace?
Dr. Clarke
It depends on the person's history but usually no further than his or her current partner. If we believed that he or she contracted the infection from the one partner or a previous partner, we may be obliged to go back several partners.
Does the clinic trace back several months or years?
Dr. Clarke
That varies and depends on a person's level of activity.
Is the reason for sending an anonymous letter that it does not indicate who was the contact?
Dr. Clarke
Precisely. We do not indicate who was the contact but obviously the person will come to the clinic and ask who told us about the sexual contact and who gave them the disease. We do not tell such persons anything.
What if they have only had one partner?
Dr. Clarke
We leave it to them to draw their own conclusions. Many people would prefer us to contact the person anonymously, especially if they have broken up. This approach works reasonably well. It is essential that we are very thorough when the disease in question is HIV. We contact previous partners when HIV is detected because it is a long-term, chronic illness. We actively encourage contact and if someone is reluctant or refuses outright to give us partner details, a certain amount can be achieved by talking to him or her, counselling and explaining the reason it is important to contact previous partners. We have excellent medical social workers who will become involved in this process. If the person refuses to give us the name or address of a sexual partner, there is little we can do short of following the person home in his or her car.
As a matter of interest, is the letter sent by registered post?
Dr. Clarke
No, it is sent by routine post.
It would be preferable if a person could personally sign for a letter. One only needs to imagine a letter arriving in a shared flat, a wife accidentally opening it and so forth.
Dr. Clarke
Yes, it can be difficult.
What approach is taken when the person tested has had extramarital relationships in light of the fact that, in theory, people in marriages should not contract STDs? If a wife or husband is contacted, it reveals that his or her partner is having an affair.
Dr. Clarke
If someone comes to us seeking treatment for an STD and does not want his or her spouse to be informed or treated for the STD, he or she will be reinfected if the spouse does not receive treatment. As such, he or she will return to the clinic with a recurring problem. People in that position do not have a real choice about informing their partners. This is difficult and it takes some time to go through the issues. It is very stressful for everybody concerned but usually people do not have many choices.
The contact tracing aspect of the issue takes up considerable time in our clinic. I agree with Deputy Cooper-Flynn on GP confidentiality. By and large, people sitting in our clinic could be attending to have any infectious disease treated. Potentially, they could be attending to have tuberculosis, MRSA, avian influenza or some other disease treated, although I hope in the latter case the person would not be sitting in a clinic with 50 people around them. Nevertheless, this is an issue and also applies to many of our patients who have HIV and do not want their GPs to know about their infection or to receive ongoing communication from our clinic about it. People's primary concern relates to those who work in GP practices in, for example, small communities, because they would be afraid that someone will pass on the information. Obviously, everyone concerned should abide by confidentiality obligations but it is sometimes difficult to convince patients of this and, therefore, they lack trust. I agree, however, that a person could be sitting in a GP's surgery to have any condition treated.
By and large, women are more likely to be asymptomatic — to have no symptoms whatsoever. So if one looks at symptomatic people coming to a clinic, the ones with most symptoms are male. Most people coming for a routine screening just to have themselves checked out are female. There is a kind of split. We see 50:50 males and females, but most of those who are symptomatic are men. As people get older the numbers diminish. Once one goes over the age of 40 the incidence of STDs is much lower. It predominantly affects the younger age group which, as has been said, is the group that is being targeted, especially those who are in college. If one is not going to college or university and frequenting the student union building, one is not getting blasted with all of this information.
Going back to the point about education, a short, sharp, shocking programme is useful in the short term but it is essential to set up better long-term education programmes within schools rather than just talking about pregnancy issues. I used to give talks in one or two schools in a former job in the UK. The school authorities always wanted to go through the slides beforehand to ensure nothing too shocking was shown or done. That takes away from the process to some extent. One almost wants to show some gory photographs to illustrate what can happen, to show what warts look like, for example.
The issue around the age of the patients we see is a difficult one. We spend a great deal of time talking about the preferred age of our patients. If we see a 16-year old in our clinic who we know has been having sex, we must decide what to do about it, such as whether we report to the Garda that he or she has been having underage sex. We must decide if it is consensual and if so, whether we should report it anyway. This is a difficult issue and there are many legal issues to be considered. Currently, there is not a service for STDs and young people.
Does Dr. Clarke mean people aged under 18?
Dr. Clarke
Under 16, which is the legal age of consent. There are various ages of consent for different kinds of sexual activity.
Does that mean if a 14-year old presented——
Dr. Clarke
If a 14-year old were to come to our clinic with an STD with his or her partner it would indicate he or she had underage sex, which is illegal. As such, he or she should be reported to the Garda. The partner should also be reported to the Garda.
I do not know if it is fair to ask if Dr. Clarke does report people. I presume she does not, if she is treating a patient, for reasons of confidentiality.
Dr. Clarke
Legally, all those patients should be reported to the Garda. We are trying to encourage people to come to our clinic so they can be seen by us. It is pretty much done on a case by case basis. Anyone who is underage is thoroughly assessed and evaluated. We try to encourage people coming to our young persons' clinic to come with a parent or guardian and their partner as well so we can treat both at the one time. We allocate extra time for that clinic to go through all these issues. Obviously, if we are remotely concerned we would report any kind of sexual activity we felt was not consensual. It is a legal nightmare. It is very difficult.
In cases where a decision was taken not to report an individual to the Garda, would parents be advised?
Dr. Clarke
We would have a long conversation with the individual concerned and his or her partner about what should or should not be done.
A lack of control is evident for young people in such situations. If I was 14 and I had an STD I would not be volunteering to come to the clinic because of the number of rubrics involved. If the first objective is to deal with the disease——
Dr. Clarke
We are trying to encourage people to come to us so that we can educate them about safe sex and family planning issues. We assess them for STDs and treat them if necessary. We do not want to have it hanging over patients that we might report them to the Garda.
If Dr. Clarke is running a school programme and answers questions in the way she just has it will be a washout.
Let us say a 16-year old came to the clinic with a parent, and the parent insisted on staying although the patient was obviously uncomfortable with the parent being there, would Dr. Clarke request the parent to leave?
Dr. Clarke
Yes but to be honest, that does not happen.
We are going to wrap up this session. To be fair to Dr. Clarke, she has business to attend to in the afternoon. I thank her for attending the committee. The last few hours have been most informative. I wish we had more time.
Do circumcised males have a better rate of not contracting STDs?
Dr. Clarke
I am not sure. I wonder why the Senator asked that question. Some recent data presented at an international HIV conference suggested that circumcised males were less likely to acquire HIV than non-circumcised males. As regards general STDs, there is not a very good association there at all. There only appears to be a lower risk for circumcised males in contracting HIV. The data referred to select populations in parts of the world where there are very high rates of HIV in any case. It is an interesting topic.
What is the status of the sexual health forum?
Dr. Clarke
One has been in place and various recommendations have been made. I would enter a caveat as I have only been in this position since October last year so I have not been privy to many of the other committees and forums that have been taking place. One of the main reports from the surveillance centre which was published at the end of the last month made many recommendations as to what should happen in terms of GP practice and what is needed but it does not have a great deal of power to make sure that happens. Along with Dr. Fiona Mulcahy and some of the other consultants involved in this, I would be delighted to participate in a more nationwide programme to try to develop all these services.
On that note, I thank Dr. Clarke.
The joint committee went into private session at 12.37 p.m. and adjourned at 1.05 p.m. until 10.30 a.m. on Thursday, 13 April 2006.