Examination of Witnesses (Questions 640-659)
THURSDAY 12 DECEMBER 2002
DR SIMON
BARTON, MR
SIMON COLLINS,
MS RUTH
LOWBURY, DR
ADE FAKOYA,
MS CHRISSIE
GREEN AND
MS HEATHER
WILSON
640. Another issue I wanted to pick up was about
teachers being unable to deliver a sex education programme. Is
that because of legal constraints or because teachers feel there
are legal constraints or because the teachers are ill-equipped
to provide that education?
(Mr Collins) I would say a combination of all three,
but certainly the political climate is not to encourage open discussion
of sexuality and sexual health.
Chairman
641. In relation to the points which have been
made about sex education, and some of us are very receptive to
this so it would be a message we are receiving, Ms Green talked
about education on various issues from quite a young age, but
what about the sensitivity to orientation? At what stage does
that come in or become appropriate in your view?
(Ms Green) That can be quite young as well.
642. What age are you talking about?
(Ms Green) That is very difficult.
643. I know it is a very difficult area but
we shall be asked to be specific on some of these things and it
is important we are aware of what the witnesses feel.
(Ms Green) Primary school I would say.
(Mr Collins) Children are pretty smart pretty young.
You certainly live in a society where multiple sexualities are
now generally accepted. Anything other than recognising that would
make issues more difficult in later life. I guess on that level,
as it becomes appropriate and as individual children become inquisitive
or ask questions or develop their own sexuality, then it is obviously
appropriate. Many of the gay men I know are convinced that they
knew their sexuality at primary school, that sort of age, very
early on.
644. Your message would be strongly that primary
school would be appropriate.
(Mr Collins) Yes, within the whole context of education
on sexual health. It should be recognised as an equal choice.
(Ms Green) Children are far more aware than adults
give them credit for at quite a young age.
Mr Amess
645. I am not going to give a view, but I find
it absolutely fascinating listening to all of you with your views
on how you deal with children. At the same time as you are giving
this very early sexual education to children, what is your suggestion
for how you deal with the media and all of that? Unless you can
watch children morning noon and night they have access to the
media which is a very, very powerful influence and it may not
be singing the same song as each and every one of you appears
to be singing. Do you have any suggestions as to how the Committee
deals with that?
(Dr Barton) Are there not lessons from some of the
work on smoking in terms of counteracting the effects of powerful
advertising, linking it to messages which do make it very clear
that there are dangers to health, there are adverse outcomes of
something which can be very pleasurable and that is the message?
You have to use sophisticated and quite clever techniques to insert
the message you have in the way the media might be promoting sex
as being something for all at any age. What we do not want as
professionals is to be looked on as killjoys, but looked on as
something which is giving people a measure of responsibility for
the longer term to avoid problems which may affect the rest of
their lives.
646. How do you control the content which is
put out on the TV? This is not a trivial matter. This is absolutely
core. The media is all-powerful, as we are experiencing at the
moment. This is all wonderful, but what is your suggestion of
how you control what the media puts out and when it puts it out?
(Ms Wilson) You can educate young people in thinking
in a critical way about the media as well. The Healthy Schools
scheme, which is a big WHO initiative, is run all across the
country and has a programme which is usually euphemistically called
Relationships and Family Life. It starts at primary school
level and it encourages the children to think for themselves and
to look at that stuff in a certain way. Schools often have problems
with adopting that particular module of the scheme, which is interesting,
because it exists and addresses a lot of these issues. Often the
parents say they want the accident prevention module adopted or
the drugs module and it is difficult for them to sell the sexual
health module. You may not be able to control the media, but you
can help young people think about the messages they are receiving.
647. I have five children and this module which
is being rolled out across the country is news to me. Perhaps
the Committee can receive a little detail. You say this is all
across the country in all our schools.
(Ms Wilson) It is a school scheme.
648. Is this being taught in all our schools?
(Ms Wilson) No; it depends on whether schools take
it up. It is on offer.
649. What is the take-up?
(Ms Wilson) I do not know what it is. I do not work
in education. I just know it exists because I have been involved
in the implementation in our local schools.
650. Where is this?
(Ms Wilson) In Barnet. I would not be able to tell
you what percentage of schools in the country have taken it up.
It is across Europe. It is a WHO initiative.
Chairman
651. We can pursue this with the appropriate
Minister who will be coming to the Committee.
(Ms Wilson) Yes, it is an education initiative.
(Mr Collins) The importance of the media just highlights
why it has to be something which can be addressed within schools.
If you suddenly have a subject which you cannot talk about but
which is so prevalent it is in every newspaper, is an integral
part of drama and TV and you can watch gay episodes of The Simpsons
but you cannot talk about it in schools, that is just an amazing
situation. You need to resolve that.
Mr Amess: Perhaps we shall leave that to the
next round on education.
Dr Naysmith
652. One of the things which has become clear
in this investigation is that there seems to be quite a marked
increase in co-infections between HIV and other sexually transmitted
infections. It is even suggested that picking up some other infections
like chlamydia is an indication that safe sex is not being practised.
However, I do not want to talk about that for the moment. Does
co-infection have any particular effect on treating HIV infection?
What difference does it make that other sexually transmitted infections
are present?
(Dr Fakoya) There are certainly co-infections with
a number of different agents. We can talk about co-infections
with hepatitis B and hepatitis C which are increasing, particularly
as people with HIV live longer and those infections are being
identified. There is also an issue about sexually transmitted
infections increasing the infectivity of HIV as well. Those are
the two issues.
653. Is there a suggestion that it increases
the infectivity?
(Dr Fakoya) Yes; certainly genital infections increase.
In fact the majority of sexually transmitted infections will increase
the risk of transmitting HIV to another individual.
(Dr Barton) Any ulcerative condition which breaks
the skin or mucosa will increase the likelihood both of transmitting,
because the viral presence, the viral quantity in those sores
will be greater, or of acquiring it from a person with it. Hepatitis
increases the problem enormously because of the effects on the
liver affecting drug metabolism and affecting the other treatment
needs of the individual. On the sexual health issue, including
syphilis and gonorrhea, many of the new cases in London are in
HIV positive people and that does raise a lot of questions about
how we link together the sexual health and HIV care of individuals.
Many of us feel that people with HIV are a target group for better
sexual health management and prevention. They are a target group
for preventing future infections. One thing is certain, the longer
people live and the healthier they feel, the more opportunity
there is for taking riskier activities. People will behave as
human instinct dictates and that is something we must address
and that is why people were so glad that the sexual health and
HIV strategy were put together.
654. For a long time there has been differential
treatment of people infected with HIV and other sexually transmitted
infections. You are suggesting it might in a way be a good thing
that that barrier is breaking down.
(Dr Barton) Absolutely. In our own unit and many units,
people are working to provide regular sexual health screening
of people attending for their HIV treatment follow-up. So they
do not have to go to queue separately and make an appointment
a week hence at their local sexual health clinic. We can offer
the one-stop approach. The other point is that it can be difficult
when you have known people for a long time to raise the whole
issue of sex and potentially having unsafe sex in a consultation
where you have been talking about HIV treatments etc. This is
the reason for the multi-disciplinary team, having health advisers,
counsellors, nurses, all working together. It should not always
be the doctor who brings that issue up and may not be the most
appropriate person to deal with it. Having a nurse for sexual
health screening as part of HIV clinics is good practice.
John Austin
655. I am not denying that there may be an increase
in risky sexual behaviour or that the better prognosis may be
leading to more risky behaviour, but because people are not dying
as a result of HIV infection, they are living. Inevitably there
are more people who are HIV carriers, who potentially may have
other STIs, who are sexually active. So even if there were no
increase in risky behaviour there would be an increase, would
there not?
(Dr Barton) Yes. Equally there is also the issue of
potential transmission of a resistant virus. People who are doing
well on treatment could potentially acquire another HIV which
mutated so that is resistant to the drugs they are on. That is
something which is being looked for carefully in many parts of
the world.
Dr Naysmith
656. I want to turn to another aspect, which
relates to something Dr Barton said earlier. I want to quote what
one of the witnesses to the Committee has said to us already,
Dr Evans of the Communicable Diseases Surveillance Centre (CDSC).
He told us that the main heterosexual component in the HIV/AIDS
reported cases is now comprised of "people who have acquired
their infection within an African context and have migrated to
the UK". That was very similar to what you said. You obviously
accept that it pinpoints more the African context than general
immigration. Do you think that is true?
(Dr Barton) Yes. It is one of Ade's specialist interests.
(Dr Fakoya) Yes, on the whole that is true.
657.
Some people are arguing for mandatory testing
of asylum seekers. I just wondered what your views were on such
a policy being instituted. It is obviously very controversial.
(Dr Fakoya) It is a very controversial issue. From
the point of view of somebody in health, if you are going to perform
a mandatory test on an asylum seeker you have to decide what you
are going to do with the results. You either test people and then
offer them treatment or you test them and bar them from entering
the country. Presumably if they are asylum seekers that will not
go down well with a number of different people, including myself.
If you are saying you are performing a mandatory test in order
to offer them treatment, then that will set off another debate.
658. Do you think that would be a good thing?
(Dr Fakoya) No, I do not because I do not believe
in a mandatory test. I believe there are other health problems
among people who are asylum seekers which may be more easily addressed
which are not being addressed at the moment such as tuberculosis.
History has shown us that any of the countries which have looked
at implementing mandatory testing for HIV have failed. It has
just driven an epidemic underground and caused a lot of problems.
I do not think mandatory testing is the way to go forward.
659. I am interested in what you said. Is there
any relationship between the increase in tuberculosis and the
immuno-deficiency which is caused by HIV?
(Dr Fakoya) Yes; clearly there are links between HIV
and tuberculosis on a number of different levels both on the biological
level with HIV making you more at risk of developing tuberculosis
and also tuberculosis making your HIV accelerate faster.
(Dr Barton) I would agree with everything Ade said.
Mandatory testing can mean a lot of different things; a lot is
going to happen before you can make a judgement from a medical
point of view. Many of the people, African, have acquired HIV,
they have come here seeking asylum, they then present late. They
come into our units very sick with very advanced HIV disease previously
undiagnosed. Any discussion about how to diagnose them earlier,
sooner rather than waiting for them to become very ill and very
consuming of resources in patient care, would be desirable. You
could do that by offering them voluntary testing in better settings
as a targeted group. Mandatory testing, if there were a positive
health outcome which could be really demonstrated as part of the
asylum process and if that were something which in terms of civil
liberties and human rights was acceptable, if that would achieve
the medical end, which is what we want to do, to diagnose people
but diagnose people who have been prepared for the diagnosis,
we would feel that those individuals needed to give informed consent
both to the test and as part of the process. That is the case
for some countries and I believe when people apply for immigration
to Australia they need to have a test. There are the practicalities
of that in that if they test negative you then keep them in quarantine
for three months and do viral load tests. Equally, how effective
has that been at screening out TB which is a notifiable disease
and which is already screened for as people come through the ports
of entry. There are many other ways of achieving the health goal
end, one of which is diagnosing people earlier and keeping them
healthier at a more cost-effective rate.
(Ms Green) Maybe you have to look at the incidence
of stigma as well if we do mandatory testing when we are trying
to reduce the stigma which is attached to HIV. Asylum seekers
often have double stigma coming into the country and that may
be increased by mandatory testing.
(Dr Fakoya) The view that people have of asylum seekers
in the media and in the community is very different from the view
of asylum seekers whom we see within the clinic. The majority
are women; we have a number of women who have presented in the
last year who have either been raped overseas or have been raped
as asylum seekers in this country. The youngest person I deal
with is 14 and she is pregnant at the moment. We have had ten
in the last year under 20. It is quite important that when people
think about asylum seekers, they should think about the types
of individuals we see on a day-to-day basis.
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