AMR is declared to be one of the top 10 global public health threats facing humanity. The WAAW 2022 campaign materials state that in 2019, nearly 5 million human deaths worldwide were associated with bacterial AMR — of which 1.3 million human deaths were directly attributable.¹

World Antimicrobial Awareness Week (WAAW), a global campaign founded by the World Health Organisation (WHO) to improve awareness and understanding of antimicrobial resistance (AMR) through effective communication, education and training has just come to a close. This year’s theme was ‘Preventing Antimicrobial Resistance Together’ with all sectors called on to encourage the prudent use of antimicrobials and increase the prevention of AMR through a collaborative approach.

Rising antibiotic resistance

There is a paucity of innovative antimicrobials in development, but high rates of resistance against antibiotics used to treat common infections — including urinary tract infections, sepsis, sexually transmitted infections and some forms of diarrhoea — are being seen globally. Antiviral and antifungal resistance are also growing concerns, particularly in immunocompromised patients.

When faced with a dispensary bench replete with prescriptions waiting to be filled, it can be difficult to recognise how community pharmacists can play their part. AMR is driven by the overuse and misuse of antibiotics, and preventing infection is key to breaking the cycle of infection transmission. We are already working in a pressurised environment, and tackling these huge, potentially existential issues can sometimes be too overwhelming to contemplate.

Pharmacy staff who are usually the first point of contact for the public can also help.

How pharmacists can help

Community pharmacists have more contact with the general public than any other healthcare professional, so they can educate the public and foster good antimicrobial practices. Supporting patient self-care and reducing expectations and demand for antibiotics are two areas where pharmacists have a significant role to play.

Pharmacists are best placed to advise on the OTC remedies available for symptom control for coughs and colds and to remind the public that antibiotics are not effective against the viruses that often cause these ailments.

Pharmacy staff who are usually the first point of contact for the public can also help. Being aware that coughs can, for example, last more than a week, they can discuss the self-limiting nature of conditions with patients. Not referring patients prematurely to the GP can reduce unnecessary consultations and inappropriate antibiotic prescribing. Such advice can be delivered swiftly during the routine course of an OTC discussion. Promoting vaccinations, such as the seasonal flu jab, can similarly be carried out by pharmacy staff and will support infection prevention.

Taking antibiotics correctly

Being alert to local prescribing policies and routinely counselling patients on antibiotic use behaviour at the point of dispensing contribute to the WHO’s notion of collaboration. Pharmacists or appropriately trained pharmacy staff should counsel patients to take their antibiotics exactly as prescribed and that doing so means bacteria are less likely to become resistant.

Common side effects can be warned about. Advising which antibiotics can or cannot be consumed with alcohol is worthy of consideration as stopping antibiotics due to a social occasion (especially with the impending festive season) is certainly not unheard of. Leftover antibiotics should be returned to the pharmacy, and a gentle reminder that sharing or saving antibiotics is an absolute ‘no-no’ will not go amiss.

Community collaboration

In summary, despite the colossal and seemingly unassailable challenge posed by AMR, everyone has a role. While not being anchored to R&D laboratories or driving policy decisions, community pharmacists and their colleagues can still play their part. By working with other local HCPs and continuing to educate and advise the public and patients, pharmacists can contribute to the WHO’s collaborative approach.

[1] Antimicrobial Resistance Collaborators. (2022). Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. The Lancet; 399(10325):P629-655. DOI: https://doi.org/10.1016/S0140-6736(21)02724-0

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The stigma associated with HIV is very real and can have a lasting impact.

When I think about stigma, I think of it as a weapon used against people living with HIV. Being stigmatised and treated differently because of my diagnosis is something I will never completely get over. I recall when I have been abused, how I have been alienated and how being someone identified as living with HIV has felt like modern-day leprosy.

Double the stigma

As a trans woman, I have experienced a double stigma. Being trans and living with HIV is something society finds hard to accept. There is a view that, perhaps, by being who I am, I am responsible for what happened to me. There is a real lack of understanding of HIV, and there is little awareness of how things have changed.

People wrongly believed they could get HIV
by simply drinking from the same cup.

Ignorance and fear

I remember the fear surrounding HIV and AIDS in the 80s and 90s. People wrongly believed they could get HIV by simply drinking from the same cup. I feel that today, thanks to advances in treatment, people are a bit more blasé about it. Unfortunately, parts of society have forgotten about HIV. There is ignorance about it. That ignorance leads to fear, exclusion, marginalisation and discrimination against people living with HIV.

Tackling stigma

I believe we will never be truly rid of stigma until people really understand HIV, what it means to live with it and what it means to be on treatment. My medication keeps my HIV suppressed so that it doesn’t affect my health. I eat well, I exercise, I get tested regularly, and I take my medication. I know that because of the treatment I am on, I cannot pass on HIV to my sexual partner. My HIV is undetectable and, as a result, it is untransmittable. In other words, I know that U=U. When I’m asked, I always say that HIV doesn’t discriminate. HIV can affect anyone, and it’s nothing to be ashamed of. My wish for World AIDS Day is for everyone to wear red, get tested and own their body.

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New HIV prevention methods could save people, but high prices are keeping them out of reach to those who need them most. 

This year has been a breakthrough year for HIV science: a new, long-acting medicine has been proven effective in preventing HIV. It is approved for use in the US and Zimbabwe with other regulatory agencies across the world expected to follow suit. 

HIV injectables

The medicine can be taken as an injection once every two months rather than taking a pill a day. This kind of injectable medicine is likely to become more widely available for HIV treatment in the future.

It could have the potential to save thousands at most risk of HIV. But there are huge obstacles in getting these medicines into the hands of people who need them — namely monopolies, high prices and regulatory bottlenecks.

Between 1997 and 2005, around 12 million people
in African countries died of AIDS because
the medicines were too expensive.

Another awakening

It is a stark reminder of when the first HIV treatments became available. Between 1997 and 2005, around 12 million people in African countries died of AIDS because the medicines were too expensive. At USD 15,000 per person annually, only rich countries could afford them, leaving people in the countries most affected to die.

It wasn’t until activists and governments from developing countries raised their voices that global mindsets shifted, and generic producers were able to supply the market with more affordable and quality-assured antiretroviral medicines. This movement saved millions of lives and continues to do so for the 28.7 million people with HIV who are alive and well today because of access to these medicines. However, almost 10 million people are still waiting for treatment.

The price of treatment and daily pills have decreased, but this is not yet the case for the HIV prevention injectables which — at USD 22,000 per person annually — are out of reach for people in need, even in high-income countries.

Maximising tools

In 2022, we are facing the same obstacles. UNAIDS’ latest report ‘In Danger’ showed that the world is drastically off-track in stopping new HIV infections with 1.5 million new infections in 2021 alone. The target is to reduce new HIV infections to under 370,000 by 2025. 

We should make full use of the biomedical tools that are becoming available. They must be 1) lower in price, 2) generically produced, 3) quality assured and 4) financed by funders, and 5) governments and communities must quickly implement policies with equitable and efficient delivery systems that will enable widespread access.

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In Ireland, contraception has transformed from being illegal to being made available for free by the Government and included in sex education — but there’s more to do.

Growing up, many didn’t get the best sex and sexual health education, so if you feel like there are questions you still don’t know the answer to — you’re not alone.

Research carried out by morning-after-pill brand ellaOne last year found that 72% of Irish 18 to 34-year-old women are not clear how the morning-after pill works, while 21% said there were more occasions they could’ve taken it — but didn’t. When asked why, 32% said they decided to risk it and hope it didn’t result in an unplanned pregnancy.

Attitudes on sex and contraception

There has been an enormous positive shift in how we view sex and sexuality in recent years. We have a better understanding of different sexualities, genders, sexual pleasure, consent and sexual violence. This means people are more empowered in their relationships and identities and can find support when needed. Moreover, people are more aware of different contraception options, so they can explore what works best for them.

Sex, contraception and abortion were difficult topics in Irish society. People had to find their own education, sometimes from friends or websites that may have provided misinformation. They may only learn about the morning-after pill in a time of panic and crisis, which is not the best time to calmly learn new information.

Positive sexual rights

Sexual wellness is as important as mental or physical wellness. While we are dismantling the stigma around mental wellness, there is still work to be done on dismantling sexual stigma. With holistic and inclusive sex education to be introduced into Irish schools from 2023 onward — and the widespread availability of consent classes — this stigma will, hopefully, become a thing of the past.

While we are dismantling the stigma around mental
wellness, there is still work to be done
on dismantling sexual stigma.

Being free to make informed choices about sex and emergency, short-acting, long-acting and permanent methods of contraception allows people agency over their present and future. This aspect of positive sexual rights holds the power to truly transform society and the lives of individuals.

Free access

This year, huge strides were made in improving contraception access for Irish women — as the Government launched a free contraception scheme for those aged 17–25 which will be expanded to 16 to 30-year-olds next year. The next step is modern and inclusive sex education that includes contraception and increased access for all, so people can be empowered to control their sexual health and choices.

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The 2020s have heralded a new age in the fight against HIV. Underpinning the future of sexual health in Ireland is the commitment to having no new HIV diagnoses by 2030.

The Gay Health Network (GHN) and our partners are committed to achieving no new HIV diagnoses in Ireland by 2030 through a coordinated three-pronged approach: treat, test and educate.

Treatment as prevention

In 2019, free pre-exposure prophylaxis (PrEP) was introduced as a game-changer in the fight against HIV in Ireland. PrEP is a medication given to prevent someone from becoming HIV-positive.

In other jurisdictions, this has led to dramatic reductions in new HIV cases. Covid-19 and the Health Service Executive (HSE) cyber attack mean that we don’t yet have good statistics. Preliminary results indicate some reduction in HIV rates. However, limitations on the availability of PrEP for those needing it will hamper progress. We need the Irish Government to release more resources to achieve the 2030 target.

Treatment as prevention is also available through post-exposure prophylaxis (PEP). PEP is a course of tablets you take following possible exposure to HIV. It is available at sexual health clinics and emergency departments and must be taken within 72 hours of possible exposure. Treatment as prevention is the gold standard in reducing new HIV rates. Ireland must ensure its programmes are meeting that standard.

Treatment as prevention is the gold standard
in reducing new HIV rates.

Know your status

If you are HIV-positive, seek treatment to protect yourself and others. One pill a day will allow you to lead a healthy life with a viral load low enough that HIV is undetectable in the body. Not knowing your HIV status puts people at risk. HIV is now a manageable disease, and we need to break down any stigma surrounding it.

Get tested

HIV and STI testing services remain too under-resourced to meet demand. Home STI test kits are available from the HSE at sexualwellbeing.ie and are helping to reduce waiting lists. Testing services need to be ramped up to ensure that more than 90% of people with HIV are aware and treated.

Education

It is clear that sexual health education as part of overall education is needed. Equipping the next generation with the skills and knowledge to value and look after their sexual health as part of their overall physical and mental health and wellbeing is vital.

With this multipronged approach to HIV and sexual health, the goal of no new HIV cases by 2030 can be reached.

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HPV, which can cause cervical cancer, is highly contagious — but we know how to stop it.

Human papillomavirus (HPV) is so common that over 80% of people will be infected at some point in their lives. There are over 100 types, with about 13 ‘high-risk’ types that can cause cancer.

Bernie Carter, the Assistant Director of Nursing Services at the Marie Keating Foundation, explains: “HPV is extremely contagious. It can be transferred through any type of sexual contact — even just skin-to-skin in the genital area. Most people are infected with HPV shortly after the onset of sexual activity. Almost all cervical cancer is caused by HPV.”

Don’t blame your partner

Carter says: “You could test negative for HPV then positive a few years later even if you have not been sexually active in between. Your results cannot tell how long HPV has been there, and having a positive HPV result does not mean your partner has had sex with someone else.”

High-risk HPV usually causes no symptoms, but it can cause cancer of the cervix, vulva, vagina, anus, penis and oropharyngeal (throat).

HPV can cause cancer in both men and women.

How to protect yourself

HPV can cause cancer in both men and women. Fortunately, we can all protect ourselves against cancers caused by high-risk HPV.

Protective measures include HPV cervical screening, limiting sexual partners, using condoms (though there can be skin-to-skin contact outside of the condom), quitting smoking and avoiding sexual activity. Vaccination is the most effective method, and the current vaccine used in Ireland is 90% effective against cervical cancer with protection against other HPV-caused cancers in both men and women.

Until 2019, the vaccine was free until the final year of secondary school. From 2019, anyone not in the first year of secondary school (or equivalent) must go to their GP or sexual health clinic and pay EUR 180–240 per injection. This is one of the reasons why the uptake of HPV vaccination in Ireland — previously around 80% — dropped to 50–55%. Thankfully, it is now up to roughly 70%.

Ireland catching up

Carter says: “Ireland had no catch-up programme offering free HPV vaccinations for children who missed them. Now, we are delighted to hear about the announcement of the Laura Brennan HPV Vaccine Catch-Up Programme.”

The programme, which is expected to launch in mid-November 2022, will offer free HPV vaccines to all in second-level education who have not yet received it. Young women up to the age of 25 will also be eligible to receive the vaccine.

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In recent months, the number of newly notified cases of HIV in Ireland has risen sharply. The Health Protection Surveillance Centre has been notified of approximately 700 cases — double the number in 2021. 

Every person living with HIV in Ireland, regardless of means, can access free, effective treatment through the public health system. Antiretroviral treatment reduces the amount of HIV in the body. Moreover, people on effective treatment who attain an undetectable viral load are also unable to pass on HIV through sex — a medical fact, known globally as ‘U=U’ or Undetectable = Untransmittable.  

Daily discrimination 

Unfortunately, a great deal of work remains if we are to realise the global ambition of ending new HIV transmissions by 2030. One very significant reason for this is the pervasive levels of stigma that continues to surround HIV and AIDS. 

Recently published preliminary results from a study on HIV-related stigma by the European Centre for Disease Control (ECDC), which included data from Ireland, found that “people living with HIV in Europe are as likely to have experienced stigma in recent years as a decade ago,” particularly in healthcare settings where both the fear and reality of stigma remain pronounced.  

Similar research conducted this year by Dr Elena Vaughan of NUI Galway, supported by HIV Ireland, found that among healthcare workers who were not HIV specialists, 83% claimed knowledge of ‘Undetectable = Untransmittable’ (U=U) and treatment as prevention. However, 40% said they would still be nervous about drawing blood from a person living with HIV, leading to unnecessary ‘extra’ precautions (eg. excessive use of PPE).  

When we end stigma, the numbers will fall, and we will be on our way to ending new HIV transmissions.

Uniting with science 

Upsetting instances of stigma and discrimination can be avoided with adequate training and education for health and social care professionals. Several community organisations, including HIV Ireland, provide such training. Changing negative attitudes in wider society is, unfortunately, a more difficult endeavour. 

For years, HIV Ireland has promoted a campaign to end HIV-related stigma coinciding with World AIDS Day (1^st December). The campaign is not just about solidarity but also equality, to echo the theme of World AIDS Day this year. It is about accepting the science that underpins treatment as prevention.  

It is about ensuring that people living with HIV enjoy the same barrier-free and stigma-free access to goods and services. When we end stigma, the numbers will fall, and we will be on our way to ending new HIV transmissions.   

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Sexual pleasure can be good for you both physically and mentally. Everyone deserves to have it in their lives if they want it.

The sexual pleasure topic has often been accompanied by discomfort or a lack of understanding. Understanding from a young age that all sexual experiences should be pleasurable and consensual, empowers young people to foster better sexual attitudes and self-esteem.

Education in schools

Gender, sexuality and relationships content editor for spunout, Rebekah Connolly, believes sexual pleasure needs to be part of relationship and sexual health education in schools. “The draft of the new curriculum for Junior Cert Relationships and Sexuality Education (RSE) and Social, Personal and Health Education (SPHE) was recently published and covers many topics such as consent, contraception and pornography.”

“However, the importance of sexual pleasure is not included. We miss an opportunity to teach young people to recognise sexual pleasure as a valuable tool to support their mental and physical wellbeing, both by themselves and with consenting partners.”

We want sexual pleasure to be central to young people’s understanding of sexual wellbeing.

The pleasure picture

Director of spunout, Kiki Martire, adds: “For a long time, our conversations and information about sexual wellbeing have been centred around prevention: STI prevention, unwanted pregnancy prevention or prevention of sexual violence. Those are all extremely important. But for young people, it can lead to a fear-first sexual education that leaves pleasure completely out of the picture.”

“We want sexual pleasure to be central to young people’s understanding of sexual wellbeing. It all comes back to what pleasure looks like for you, and how can you explore and embrace that safely from an appropriate age, without shame or fear?”

Bodily integrity

Ollie, a contributor, believes embracing sexual pleasure can help with accepting one’s body.“Sexual pleasure can come from sex with people, but it can also come from ourselves.”

“We’re taught from a young age that masturbation is dirty and shameful, but I used it as a way to discover what I like sexually. It helped me reconnect to my body as both a survivor of sexual assault and a non-binary person. There’s nothing dirty about getting to know your own body.”  Understanding that sexual pleasure begins with oneself, can be enjoyed alone and is a core function of bodily autonomy can be empowering. Feeling good is the foundation of consensual sexual experiences, and helping young people understand this can allow them to become attuned to their feelings, desires and bodies.

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