NEWS FOCUS:THE RECESSION may cause a drop in the number of HIV infections reported each year in Ireland because people have less money to spend on drinking and travelling, two of the biggest driving factors in the prevalence of HIV, according to a leading specialist in the field, writes COURTNEY BROOKS
“These infections often parallel economic activity,” says Dr Derek Freedman who specialises in sexually transmitted infections (STIs).
“After the Wall Street crash in 1929 there was a huge drop in infections. In the 1980s there was also a drop.”
He has noted a decrease this year in the number of people coming into the free Department of Genitourinary Medicine and Infectious Diseases (GUIDE) clinic at St James’s Hospital in Dublin, although he says it is too early to finalise statistics on it.
However, a recent report on HIV and Aids shows a 3.6 per cent increase in the number of people newly infected with HIV in 2008 over 2007 and an overall decrease in the number of people who have progressed to Aids.
The number of people diagnosed with HIV has been increasing since 1990. This took place during the years of the Celtic Tiger, but as Ireland is now in a period of recession, the pattern may be changing, Freedman says.
The report, from the Health Protection Surveillance Centre (HPSC), shows that the increase is mostly concentrated in “risk groups”, particularly men who have sex with men (MSM) and people coming from areas with relatively high infection rates, such as sub-Saharan Africa and Eastern Europe. There has been a drop in infection as a result of intravenous drug use (IDU).
“The easiest trend to see is if you look at where we were back in 1990-2008: you can see a very dramatic rise there. It is what you would expect to see where the global epidemic is going,” says Aidan O’Hora, one of three people who prepared the report.
Alison Begas, chief executive of the Dublin Well Woman Centre, says there is also a chance tighter budgets could prevent people from getting tested. At the centre, a full STI screen costs €160, and she says there can be lengthy waiting times at free clinics. At the GUIDE clinic, the first 30 people who show up during walk-in hours are treated.
“People who are economically, socially and educationally deprived are more vulnerable,” says Freedman.
“[STIs] are all concentrated in people in areas of deprivation – knowledge deprivation as well as economic.”
There were 405 new cases of HIV reported to the HPSC in 2008, compared with 391 in 2007, raising the cumulative number of infections to 5,243. Of these infections the probable rate of transmission was 56 per cent heterosexually (a 3 per cent increase from 2007), 31 per cent MSM (a 4 per cent increase), and 11 per cent IDU (a 6 per cent decrease).
There was only information for probable transmission for 318 cases out of the total 405. The report also suggested that 20-30 per cent of infected people may not be aware that they have the disease.
O’Hora says that immigrants coming to Ireland from countries with relatively high rates of infection play a large part in contributing to the rise.
Of the people diagnosed with HIV in 2008, 123 were of Irish origin, 121 were from sub-Saharan Africa, 28 were from western Europe, 24 were from central and eastern Europe, eight were from Latin America and the Caribbean, five were from south and southeast Asia, one was from North America, two were foreign-born and the origins of 93 were unknown.
Freedman says that Irish men and women travelling to countries in Africa and Asia, where both sex trafficking and HIV infection rates are high, also played a part in the increase.
Of the 97 people who contracted HIV through MSM, 55 were born in Ireland, as were 37 of the 178 cases transmitted in heterosexual relationships and 25 of the 36 transmitted through IDU.
“The positive impact of care and management on HIV-related illness is evident,” the report says.
“However, with an average of 320 new diagnoses each year, the demands and need for healthcare services, both clinical and diagnostic, grows.
“It is important to ensure that services are accessible to all and that the increasing demands do not compromise capacity to manage the increasing burden of illness safely and effectively,” it says.
It also makes several suggestions for supporting and planning the delivery of services, such as reviewing the governance and reporting arrangements of the HIV case based reporting system in order to improve case reports.
Also, assuring access to early diagnosis, care and management by providing culturally and gender appropriate services, which in turn requires a coherent framework for action at regional, national and international levels.
Begas says Ireland needs a better approach towards sexual health in general, and that outside of Dublin the provision of STI testing is patchy.
“The advice for preventing infection is very simple. Abstinence is efficient and effective but it doesn’t work,” Freedman says.
“Sticking to one partner, knowing your partner, is highly effective, but again, not everybody can do it.
“Using a condom and following safe sex practices is highly efficient. Also sex, like any athletic sport, is best performed soberly,” he says.
He adds that education in schools is important to promoting safe-sex practices.
“STIs are lightly touched upon in a religious health education curriculum: a very light touch.
“Pre-adolescent kids are very bright, educated, and like to get the facts. They are certainly not fooled by fairy tales,” he says.
In recent years there has been a resurgence of the STIs syphilis and gonorrhoea in Ireland.
“One of the cornerstones of both HIV and STI prevention is that people should be fully screened if they feel that they have taken a risk or been put at risk.
“One thing is that you cannot rely on symptoms, because these infections are all silent.”
The Centre for Disease Control generally recommends STI testing every year for adolescents and those in risk groups, he says.
Ireland does not have guidelines for STI testing, but after changing sexual partners or if someone feels they are at risk, they should go for a test, he says.
The HIV virus is the most active, and so the most contagious, for the first six months after the initial infection.
In the United States more than 50 per cent of new HIV cases are reported to have been contracted from people who were in the initial stages of the infection, Freedman adds.
This makes early diagnosis key to preventing the spread because once people know they are infected they change their behaviour, he says.
“People who know they are HIV positive are much more conscious.”
In 2006 the Centre for Disease Control also recommended universal testing for HIV which, Freeman says, is one of the most effective ways of controlling the spread of the virus.
This change is represented in a move from an opt-in policy, where patients have to ask for the test, to an opt-out policy, where testing is part of normal procedure and patients would have to ask not to have the test done, something the GUIDE clinic has been practising for about 20 years.
Freedman says that people in risk groups should also be screened at regular intervals.
The recent resurgence of STIs in Ireland indicates that people are taking greater risks, particularly in the younger generation.
“What we surmise to some extent is that they have grown up in this era of HIV/Aids and either they believe that they are invincible or that it is worth the risk,” he says.
Begas describes a certain “blind denial” among both young people in Ireland and, interestingly, older people coming out of long-term relationships who aren’t aware of the high prevalence of STIs.
Freedman doubts that the price of condoms, or the VAT on condoms, is contributing much to this phenomenon. “They certainly cost less than the price of a pint or Viagra,” he says.