Hardly a day passed in the early 1990s without AIDS making the headlines. Whether it was grim projections of death tolls, news of drug research or advice on prevention, the issue was constantly in the spotlight.
Some 332 people have died of AIDS-related illnesses in the Republic since 1985, according to the Department of Health's most recent statistics. A further 650 AIDS diagnoses are recorded and 1,986 people are reported to have HIV infection.
These figures are at least somewhat more detailed than those available several years ago. Breakdown by age, for example, is now given for newly reported infections, although a regional breakdown for infections is still incomplete. Figures for the Eastern Health Board (EHB) area are recorded separately but all other health board areas are combined into one - a method is far from adequate for targeted HIV prevention strategies.
The general emphasis of the way in which the information is presented focuses on AIDS diagnoses and related deaths, effectively playing down HIV prevention. In fact, the spending on HIV prevention by the Department's Health Promotion Unit has been a paltry £160,000 for each of the past two years.
Given that AIDS has largely disappeared from headlines recently and that the money spent on HIV prevention wouldn't buy you a second-rate TV commercial for a detergent, it is all the more alarming to see that newly reported HIV infections for the years 1985 to 1998 continue to rise steeply (see graph). HIV and AIDS may have disappeared from the news, but the problem has certainly not gone away.
The Government's figures on HIV and AIDS among intravenous drug users, on whom most of the Eastern Health Board's resources and energy and focused, shows targeted HIV prevention strategies do work. The figures for reported new infections among HIV drug users (see graph) indicate a levelling-off of infections in this target group. The Government is to be commended for this sustained and necessary action. But what about other groups susceptible to HIV infection?
With such concentration of resources on drug users, a glaring need exists for similar effort to be put into HIV-prevention work with gay men - while the numbers of HIV cases fall among drug-users, figures for newly reported HIV infections among gay men show sharp increases. Clearly, there is a direct correlation between not spending money in a strategic and comprehensive way and not making an impact on the spread of HIV infection.
"Sometimes you must go back a stage or two to deliver effective HIV-prevention messages," says the director of the Government-funded Gay HIV Strategies, Kieran Rose. The situation is particularly acute in places such as Waterford where, with no gay bars and no gay clubs, the only places gay people can meet are in the town's cruising grounds.
"This makes this group difficult to reach because of its social exclusion," explains Rose. The way to get effective messages to these men is by socially including them.
He praises the Waterford Area Partnership's moves to bring gay men in from the cold by making sure their interests are represented in development plans. Chris Flood, Minister of State at the Department of Tourism, Sport and Recreation has endorsed the partnership's work. But Rose is critical of the national Area Development Management who, he argues, "have done nothing to facilitate the Waterford initiative".
"For local or regional action to be effective there needs to be a major improvement in the support and leadership provided by agencies such as (ADM)." Ed Johnson of ADM, who is responsible for the Waterford area, explains: "We've no problem including groups such as gays in our work on social exclusion but we have a limited budget."
"There's no way they'd say we're not dealing with this group till we get funding if it wasn't AIDS," one local source claimed.
Anger and frustration characterise the feelings of those who have been pushing for hospice-care provision in Cork for people with AIDS. It defies logic that one of the major centres outside Dublin - Marymount Hospice in Cork - has received funding only in the past few weeks for bed-provision for people dying with an AIDS-related illness, and training for staff to deal with them.
"We would wish to extend services to all categories of patients including those with HIV/AIDS," says Dr Cyril O'Brien, medical director at the hospice, "but we operate under a legal requirement not to spend more than our funding allocation allows."
The long-standing problem began in the early 1990s. A Southern Health Board spokeswoman says: "The SHB received additional money in our 1999 letter of allocation from the Department of Health to be used for developments at St Patrick's Hospital (Marymount Hospice), Cork." The spokeswoman also confirms: "An AIDS strategy for the SHB region is being developed and will be presented to the board later this year." But why the delay?
All is not well within the EHB either. Internally, services are trying to sort themselves out with salaries, promotion, grades and the like. Despite strike action several years ago, the issues are still not resolved.
One health board source speaks of a "worrying trend in the UK, where money is taken from the psycho-social realm and pumped into the medical". The fear is that the same will happen here.
The psycho-social and medical are the opposite sides of the same coin when dealing with AIDS. An article in last month's issue of Gay Community News illustrates what can happen when the medical predominates to the detriment of the psycho-social. In it, a man diagnosed with AIDS who had been on the new triple-combination therapy (a cocktail of three different drugs), tells how his doctor wrote to him informing him he had failed the therapy. There's surely a better way than by letter of informing a patient that what seems to be a life-saving treatment isn't working for him.
Another concern for people living with AIDS is the reduction of specialist HIV counsellors. This is directly related to the overriding emphasis on the treatment of drug users at EHB level. With a shortage of accredited addiction counsellors, and as part of the solution to the ongoing EHB industrial relations dispute and wage agreements, HIV counsellors were asked to sign an agreement to take on a generic counselling role. At present, there are technically no HIV counsellors working within the EHB.
Any diminution in this function could not only interfere with the Government's collation of statistical information on HIV infection and hamper clearer understanding of the epidemiology of the infection, but could also prove disastrous for people considering taking an HIV test and, worse still, receiving a positive test result.
The combination therapy has proved remarkably effective in the treatment of large numbers of people living with AIDS. While the long-term prognosis is unclear, many now live virus-free and appear to have a future - something unthought of not so long ago. This, however, brings its own problems.
People who did not foresee living beyond their late 30s and early 40s now face the prospect of old age. For some this means life without their already deceased friends; for others it can mean life without jobs and homes. Some people had sold their homes, fearing they could not afford mortgages. Others had given up their jobs because of debilitating illnesses before the discovery of combination therapy. In other words, they live in a time when the need for psycho-social counselling was never greater, yet the services aren't there.
Ger Philpott is a former AIDS activist and now a film-maker.