Increasing HIV infections and the lack of sex education

Whereas infection rates of HIV are decreasing in most European countries nowadays, they are still on the rise in Ireland. Reasons for that are diverse but one in particular is outstanding: Ireland’s inability to talk about sex.

Conor O’Brien* always knew he could get HIV. He knew how the virus is transmitted; and that as a homosexual man he was at even higher risk of catching the disease. Nevertheless, the Irishman slept with strangers – without using a condom:

“I was depressed and found a quick and easy way to feel better in sleeping with pretty random guys and didn’t care whether they use protection or not because it got a buzz. That is principally how I ended up positive.”

Therefore, the 43-year-old is one of the 9,344 people who have been diagnosed with HIV in Ireland since the early 1980s. 523 new diagnoses were made in 2018, which is an increase of 7% to the year prior. According to the European Centre for Disease Prevention and Control, Ireland is among the seven European countries with a substantial increase in HIV infections in recent years. Whereas the number of new infections is decreasing in most European countries, they are on the rise in Ireland.

At the moment, statistics about Sexually Transmitted Infections (STIs) have been “thrown up in the air“ because of Coronavirus, says Adam Shanley from the non-profit organization HIV Ireland. Because services have been reduced dramatically or even shut down there have only been a small number of infections recorded, which is therefore not truly reflective. “But if we look back to the most recently completed data set last year, that showed HIV for the third or fourth year running having peaked over 500 new notifications in that year,” Shanley confirms.

However, when examining these figures one has to differentiate. “That doesn’t mean all of them received the diagnosis for the first time but it was the first time they registered in Ireland,” says Shanely. According to him a lot of gay and bisexual men arrive in Ireland from Latin-America, “where HIV might be more endemic.“ The latest data from the Central Statistics Office show that almost 90,000 people have immigrated to Ireland in the year up to April 2019. Only 26,900 of them were estimated to be Irish nationals. Of the new HIV diagnoses in 2018, 21% were born in Ireland, 71% abroad, and 8% didn’t provide information on country of birth.

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Erin Nugent is the community support and testing services manager at HIV Ireland. She has noticed that her clients have changed and a lot more migrants are seeking help at her organization in recent years. “Now the majority of people we deal with are probably migrants, but only a slight majority,” she says. However, migrants aren’t the reason for rising infections, at least, not according to Nugent, who has 27 years of experience under her belt. Shanley agrees. He says that there is still a considerable number of new diagnoses, “even if you take away those who transferred their care to Ireland.“

What the experts know is that even if everyone can get infected with the virus, there are certain groups that are more at risk than others. The latest report on HIV in Ireland showed that 56% of infections in 2018 were among men who have sex with men, heterosexual transmission accounted for 31%, and 3% of new diagnoses were among people who inject drugs. “The group of infected drug users dropped dramatically“, says Shanley. The reason for that is the opportunity to access needle exchanges. Moreover, Merchants Quay Dublin is now planning the first center in the country where drug users can go to inject drugs under the supervision of a medical professional. Moreover, testing has improved over the past few years. “Nowadays, there are more services, more ways of accessing and interacting with them and quicker turn-around time,” says Shanley.

The bigger problem is that even though the number of people being tested increased, it is still not enough. O’Brien only went to the hospital because an old friend told him about his HIV infection. After two tests, the doctors confirmed in March 2009 that the then-31-year-old man was HIV positive. “I was kind of numb,” he says, recalling the moment he got the diagnosis. But at the same time, it wasn’t a big shock for him: “I wasn’t that surprised.“ Nevertheless, the first few months were tough. After his diagnosis, a friend took O’Brien to a support center in Belfast. “Meeting other people was great, it really helped because suddenly you weren’t alone,” says O’Brien. That was the moment he realized: “This is not a death sentence, this is something else, it’s a life sentence.“

At the time of his diagnosis, he was self-employed, but doing a lot of work for one particular employer. After O’Brien told him about his disease, he still paid him even though he was not able to work. In the beginning, he had to take five pills a day. Soon, side effects like general fatigue, diarrhea, and illness set in. At one point, O’Brien even gave up on medication. “I just couldn’t take it with all the side-effects,” he says. But the hardest thing for him was to quit his job as a scout leader. As HIV attacks and weakens the immune system, the risk of being exposed to a lot of kids who could transmit other diseases was too high. “But that was the only thing that got stopped because of the diagnosis.“

Now, the 42-year-old is a scout leader again, living in county Laois with his husband. “Back on diagnosis, I thought no-one would ever want to go out with me again.” His smile reveals that he knows better now. He started to date his current partner in 2010 and things were going well. After they got to know each other a bit, he nervously told him about his HIV status. That was a big step for O’Brien. “You’re always worried you might be rejected.“ But his now-husband surprised him with his reaction: “He just put his arms around me, gave me a big hug and said: What’s the problem?“ O’Brien’s partner knew about HIV and possible ways of transmission. He was also aware that when taking medication properly, the virus can be suppressed and the diseased person is not infectious anymore. However, Erin Nugent and her organization observed that while most people seem to understand that HIV is only transmitted via blood and other body fluids like semen and vaginal fluids, “they don’t really know how they can not get it.“ One question she still gets regularly is about whether someone can get infected when a diseased person spits at them or uses the same toilet. “There is probably a little bit of that missing in terms of HIV education within the schools,” Nugent says. She notices that a lot of young people are unsure about how HIV is transmitted. “If the schools were really up and at-em about overall HIV education that was probably something we wouldn’t see.”

O’Brien remembers his own sex-education in Northern-Ireland: ”It was dreadful.“ Even though they were told about the existence of HIV there was “no real talk about that or any of the other STIs.“ For him, a boy who knew that he was not interested in girls by the age of nine, sex education didn’t help at all. His teacher said she couldn’t talk about gay sex because of Section 28 in the Northern Ireland Act from 1988. This part of the legislation said that local authorities “shall not intentionally promote homosexuality or publish material with the intention of promoting homosexuality” or “promote the teaching in any maintained school of the acceptability of homosexuality as a pretended family relationship.” But for O’Brien the cause lies elsewhere: “I think the predominance of one particular church and its influence in education is really what’s at the root of this problem.“ He knows that the country is getting better. In the last ten years, Ireland has legalized both gay marriage and abortion. But, in his opinion, regarding sex education “it got a bit lost.“

Nugent knows that talking about that topic is very important. Whereas in the past a lot of discrimination happened in goods and services, for example, not being served in a pub, HIV positive people don’t look sick nowadays and experience less discrimination as a result. That’s why stigmatization now mostly happens within the healthcare sector: “for example, healthcare professionals who are unsure of really what to do with somebody living with HIV.” With HIV Ireland, she went to schools, talking about sex education. Originally, she was obliged to teach the whole topic in only 40 minutes, but they’ve changed that since. Now, Nugent is focusing on training people who work with young people. “It’s really something we’d really like to see more standardized“, she says. “Where everyone gets the same information and not only in 40 minutes so the teacher can tick it off at the end of the year and say I’ve done that.“

That sex education is something that “is done quickly just to get it done“ is also the impression of students that were questioned for a review of Relationship and Sexuality Education (RSE) in April 2018. However, since then nothing has changed. There is still a Relationship and Sexuality Education Policy Guidelines provided by the same department, whose purpose is to assist schools with the process of developing their policy for RSE. Moreover, these guidelines are from 1997 and therefore completely outdated. Present topics like LGBTQ (an acronym for lesbian, gay, bisexual, transgender, queer) are not included.

Attempts to change the conduct of sex education have a long history. According to an article in the Irish Times, the then-Minister for Education, Gemma Hussey, already said in 1985 that there was a need for sex education. However, religious groups always opposed that idea. Aoife Boyle* says the way sex education is taught depends very much on the teacher: “There is a huge diversity and that is a problem.” In her South Dublin school, sex education is done differently by individual teachers.

Shanley says that leads to many young people hearing about STIs for the first time only when they get their diagnosis for Gonorrhea. HIV aside, the infection is a prominent disease that is also on the rise in Ireland. According to a report from the Health Protection Surveillance Center (HPCS), chlamydia and gonorrhea infections increased by 7% between 2017 to 2018. “The lack of inclusive and comprehensive sex education in Irish schools is undoubtedly a driver of HIV and STIs,” says Shanely. Furthermore, he mentions that sexual health is not only about diseases but about sexual well-being, the realization that sex can be enjoyable. “If there is a lack of self-work or understanding it is not a surprise that young people start their sexual careers not knowing that they’re possibly doing harm to themselves or others unwittingly,” says the expert. That is why the organization joins the queue of people trying to change sex education in Ireland. “We have advocated the government around inclusive sex education and they have made some steps but unfortunately religion still plays a huge part in our education system,” Stanley says.

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O’Brien doesn’t think that better sex education would have helped him to avoid getting HIV. However, the two Irishmen, as well as Shanley and Nugent from HIV Ireland, think that not talking about sexuality and STIs is a driver for rising infection rates in Ireland. As such, the root of the problem appears to run much deeper, namely in the predominance of the Catholic Church and its influence in education – that is what talking to HIV-positive people, experts from HIV Ireland, teachers, and students revealed. “A church that basically tells you that using a condom is a sin makes it difficult to teach about safer sex in general,” O’Brien summarizes. In his opinion, a general campaign about the disease is what the country needs. As a HIV positive person, he notices that there is a huge lack of awareness. Sometimes people who find out that he has the virus contact him, ask him to stop taking his medication and give it to them. “I don’t know why but that happened to me many times“, the Irishman says, shrugging his shoulders in bafflement.

What incredible incidents like these show is that it is important to breach the gap between HIV negative and positive people, says Shanley. “We all have a responsibility in stopping the transmission.“ The biggest part of that is getting tested. It gives the negative the choice to stay negative and the positive the chance to get to know treatments, stay healthy, and protect others. If everyone knows their status, “everyone who is positive can take medication and after all of us die, there is no HIV“, says O’Brien. “It sounds simple, but it is. We just have to do it.“

*names changed