 Dwi'n gweithio ar gyfer y 8 ym 2024, ar sefyllfa y 6, ar gyfer y cyflau, y Cyflauedd Cyflau Gwneud a Ymwyllgor Gwaith, mae gennym ni'n cyffredig ym mhwng. Yn ymddych chi'n gweithio'r ysgolol, Yn ymddych chi'n gweithio'r ysgolol, Maria McNeir a Evelyn Tweed a'u gweithio'r muniwch chi'n bwysig. Os ond, gwnaeth Allah Parwfa sut i mall savell? Felly mae'n cwm UponLyn. I'm sorry, Evelyn. Can you repeat that? I think we cut off the first part of your answer. Thanks, convener. Just similarly to declare that I was also a councillor at Stirling Council in the same period. That's great. Thank you, Evelyn, and good morning to both of yous and welcome to the committee. Our second agenda item is consideration of the following negative Scottish statutory instrument, SSI 2024-41, act of cedrant, fees of messengers at arms and sheriff officers, amendment 2024. I refer members to paper 1. Do any members have any comments to make on the instrument? The letter from Alan McIntosh contains quite interesting suggestions and obviously the reductions in sheriff officers sounds quite attractive to me. Obviously it's not feasible to do end just now. Can we at least pass the letter on to the appropriate ministers so that at least it's not lost? Cheers. Thank you for that, Marie. I think that that is a reasonable request. Are members agreed? Does anyone have any other comments to make? No, we don't. Okay, we can have that. Thank you so much. That concludes the consideration of the SSI. Our third agenda item is to take evidence on the HIV anti-stigma campaign and achieving zero new transmissions of HIV in Scotland by 2030. We take evidence from two panels this morning, and I welcome our first panel. We have Alan Eggelson, head of services at the Terence Higgins Trust Scotland, Professor Claudia Estcourt, Professor of Sexual Health and HIV Glasgow Caledonian University and Gabrielle King, Policy and Research Manager, Waverly Care. Joining us remotely this morning, we have Dr Brydie Howe, British Association for Sexual Health and HIV Scotland Chair and HIV Lead at NHS Highland. You are all very welcome to join us this morning. I refer members to papers 2 and 3, and I will invite each of our witnesses to make some brief opening remarks, should they wish to do so. I will start with Alan. On behalf of Terence Higgins Trust Scotland, I thank the committee for inviting us to give evidence today and for the focus on ending new cases of HIV in Scotland and ensuring that every person living with HIV has equitable and comprehensive access to care, treatment and support. I would also like to congratulate the convener on her recent appointment to convenership of this important committee and thank the clerks and the previous convener, Cockabsture, for their time and interest in this topic. Terence Higgins Trust is a leading UK HIV and sexual health charity. In Scotland, we support people living with HIV and amplify their voices and help the people using our services to achieve good sexual health. Our work includes peer support services, testing services, health promotion, counselling, advocacy and working with our partners to combat stigma and achieve positive change for people living with HIV. We have a national ambition to end new cases of HIV in Scotland by 2030 and we have all the tools we need to achieve this. We can do it without a cure and we can potentially become the first country in the world to do so, but that will not happen by accident. We need bold action and focused investment to test more people for HIV, widen access to PrEP, retain people in HIV care and combat the stigma that still surrounds an HIV diagnosis. Importantly, if we are to achieve ending new cases of HIV by 2030, we need to tackle the inequalities that still persist and ensure that progress is felt equally amongst all communities. We have the opportunity to lead the way not only in the UK but across the world, but we are letting this moment pass us at rapid pace. The reality is that in Scotland we have fallen behind other UK nations in our HIV response. We all know what the end goal is to eliminate new transmission by 2030, but we don't yet have a published plan on how to achieve this or the funding resource to make this ambition a reality. If we are to be successful in reaching our 2030 goal, we need equitable progress among all communities impacted by HIV and sustainable investment to match this. We need bold words to be met with bold action and resource. Without substantial refocusing of our approach and a funded framework on achieving our common goals, we are at risk of failing the very communities that we seek to support. The Scottish Government must refocus and match the words with action and investment. The publication of a funded action plan has been long promised and is long overdue. This needs to be delivered as a matter of urgency. We need to see the normalisation of HIV testing through a national HIV testing week for Scotland and substantial emergency department opt-out testing pilots of at least 12 months with a bidding process that is fit for purpose. We need to increase awareness of PrEP and make it easier for people to access this game-changing drug. We need to invest in our third sector and in our sexual health services so that people living with HIV in Scotland have equitable access to support, care and treatment, and we need to continue our work to combat HIV stigma wherever it presents itself. Scotland's HIV epidemic is one of inequality driven by stigma and harmful yet common misconceptions about the virus, but we can choose to meet this head-on unwavering in our determination to leave no one behind as we seek to end new transmission of HIV in Scotland by 2030. We're therefore pleased that the committee has taken timely interest in that area and look forward to discussing the matter in more detail. I am the lead for the Scottish Government-funded ePREP research project. I'm co-author of the HIV transmission elimination strategy and I'm co-leading PREP implementation as part of the roll-out of the transmission elimination strategy. My main research focus is on prevention of transmission of STIs and HIV predominantly through eHealth and public health interventions, and I'm also a consultant physician, so I see people who could benefit from PREP when I work in the Sandyford sexual health clinic in Glasgow. Thank you so much. We move to Gabrielle King, please. Thank you convener, committee and clerks, for the time on this topic. So Waverly Cares, Scotland's HIV and Hepatitis C charity. Over the last 40 years, we've seen the transformation of HIV care to a point where someone today can live with an undetectable viral load. On more days of 2020, we heard commitment from the Scottish Government to reduce new transmission of HIV to zero by 2030. Today we're almost halfway to 2030, but our concern is that action isn't happening fast enough and that it risks being insufficiently resourced, and this means that we don't live in a Scotland where people have equitable access to testing treatment and to support of HIV. And I want to outline some of these challenges which inhibit reaching zero new transmission and reduced quality of life. The first is access to services and particularly for rural communities, this is patchy across the country. In some regions that aren't sexual health services and people are required to travel for hours to access treatment, sometimes out with their own health board, and so way you live determines the care and support that you can get. The second is testing. Many people across the country won't know their status when it comes to bloodborne viruses, and this is particularly challenging in the context of getting to zero new transmissions and identifying those living with undiagnosed HIV and also those who are lost to care. And it also means later diagnosis, which is detrimental to quality of life. Without a substantive nationwide testing provision, we simply can't support people and reach targets, and this goes hand in hand with the need for up-to-date data. Third, certain groups continue to be underserved in testing and support, as well as in accessing preventative treatments like PEP. PEP is a game changer for some people in terms of stopping transmission, but it's not a game changer of equality. Since PEP was made available in Scotland, 92% of people accessing it have been white. 2020 data shows that fewer than 10 heterosexual men and fewer than five women were prescribed PEP. Women, minority ethnic communities, trans folk, those in refugee and asylum systems, those facing a range of intersecting inequalities, and those in rural areas aren't having their need met through the existing provision, and there needs to be ongoing, tailored and community focused approaches. And fourth and finally, stigma misconceptions around HIV remain pervasive. The impact of stigma can't be understated. It affects quality of life and mental health, as well as the public health population. My levels of testing and education, and we know that people across the country feel unsafe to share their status, and so I wanted to finish with a few quotes from people living with HIV. I left Scotland in a recently returned because I felt unsafe. I've not told anyone apart from my doctor because I'm scared of how they will react. And so we need a society where people feel safe, cared for, supported. We want properly resourced and funded commitments, reliable data, tailored and person-centered approaches, and this need will only increase as we, if we, get closer towards the re-transmission by 2030. Thank you. Thank you so much. And we'll move on to Dr Hope, please. Hi, thank you for inviting me today. I am representing the British Association for Sexual Health and HIV, which promotes excellence in STI and HIV care across the UK and delivers and supports education, training and innovation in sexual health and HIV. I'm also part of the Scottish League clinicians group and the HIV lead for NHS Highland, so I come from a remote rural perspective and echo some of the concerns that Gabrielle has raised about patchy access to sexual health and HIV care in Scotland. Thank you very much. Thank you so much. We're now going to move on to questions from members, and I'd like to kick us off, if I may. We've heard about stigma already in your opening statements, and evidence suggests that there's still quite a lot of outdated views in regards to how people view HIV. I note that the Scottish Government funded a short film that was produced by the Terence Higgins Trust to try and help tackle the stigma. Why is it important to address stigma associated with HIV? It's important that, on many levels, stigma still acts as a barrier to people testing for HIV. It acts as a barrier to people accessing and then staying in HIV, dreaming and care. Before the recent stigma campaign, which was very much welcomed by the Terence Higgins Trust, I was delighted to work with colleagues across the sector to deliver that. We undertook some public attitudes surveying through a YouGov poll, and we also undertook focus groups with people living with HIV. It was clear that public attitudes are still very much in the 1980s, which was the last time that we had a national televised campaign about HIV in Scotland. We're currently working on evaluation of the anti-stigma campaign, and we can certainly forward on the results when those are available. What I would also say, though, is that we would be keen that that's just the start of a conversation. There are opportunities to follow on the stigma campaign with, for example, an ask to the wider public in Scotland within HIV testing week. Scotland is behind England and Wales, and both of those countries have a funded HIV testing week, and we in Scotland don't. That would be an opportunity to normalise testing amongst the general population, and it would be possible through existing testing provision, for example, the online postal self-testing service for HIV that the Scottish Government currently funds, turns against trust to deliver. Thank you. Would anybody else like to come in on that question? In addition to Alan's excellent points, we must be very clear that stigma relates to people's mental health. As soon as somebody feels stigmatised, they are unable to talk about their diagnosis or their potential for acquiring HIV. This also means that they cannot negotiate, say, for sex potentially with sex partners. They may not feel comfortable in talking to healthcare professionals. They may not even feel comfortable about looking for prevention information online for fear of privacy breaches in the home environment and what might happen as a result of them being found out. So if people are unable because they feel so stigmatised to find out about health conditions, they cannot protect themselves, they won't come to sexual health services, and we get a vicious cycle, which has to be broken absolutely. I'm not sure I agree that a national testing week is necessarily good value for money, but it is certainly one factor that we might want to consider in terms of raising the awareness of HIV in a very positive light to the population. Thank you. It's really interesting, so it's absolutely a barrier to additional support. Thank you. Just from that, to add on to what Claudia and Alan have already said, I think we know that stigma is so pervasive across Scotland. I think it can be really important to note the places that stigma can happen for people and that people can encounter it, so we know that stigma across health and social care is a real challenge. A survey done by Positive Voices in 2022 found that one in 13 people have been put off accessing healthcare support because of that stigma. We also know that it takes place in kind of allied health professions, so dentistry, and that can take the form of kind of indirect stigma as well, so people double-gloving, people being given appointments at the end of the day rather than slotted into a normal appointment schedule. But actually, as we see a population who are now aging with HIV, we also see stigma taking place in additional spaces, so that's in parallel and intersecting statutory services like housing and social security. It's also in care homes which just faces up before we haven't really encountered that level of stigma. And similar to what Claudia said, I think the impact of stigma on mental health just cannot be understated, so that same Positive Voices survey found that only one in eight people live with HIV have told most people in their life about their status and about their diagnosis, and that we know that people who live with HIV have a higher rate of depression, anxiety, post-traumatic stress disorder, and also, unfortunately, physical and sexual violence is experienced as well. And that then has a knock-on impact on the public level of testing and how empowered and supported people feel to get that, to know what their status is, and to get a HIV test. That then means that it's incredibly difficult to reach the goals of their new transmission by 2032. Thank you so much. I note that Dr Howe would like to come in on this. Thank you. Thank you. In addition to agreeing with all of the other speakers, I'd just like to add that in low prevalence areas such as the remote and rural parts of Scotland, where there is a lot less awareness of HIV and, therefore, stigma is often higher in those areas, so people affected by HIV and at risk of HIV have an additional barrier. Thank you. Thank you. That's really interesting adding in the geographical point on this. I'm grateful for your answers. I'm going to pass now on to Maggie Chapman who has some questions for you. Thank you very much, Karen. And good morning to the panel. Thank you for joining us this morning and for your opening remarks. I want to explore some of the issues around stigma in a little bit more detail. I suppose there are two areas. There's something around how we tackle it, and there's something about actually understanding some of the complexities around it. And, Brydie, you've both spoken about the rural inequalities and other inequalities. I suppose, firstly, what data do we have on the inequalities relating to stigma specifically, because that might indicate that we need different approaches to tackle stigma in different communities? Gabrielle, do you want to start off on that? Yeah, absolutely. So, there's been quite extensive research that's done usually on a UK or an international level about what stigma looks like and how pervasive it is in particular settings. But I think my perspective is that Scotland is typically quite underrepresented in a lot of that data collection. So, for example, the positive voices survey that I have referenced already. Only one clinic in Scotland was able to respond to that survey. And so, I think there's a real gap in terms of what we anecdotally know, all of these examples of stigma, and we have some local level data as well. But I think there's a real gap in Scotland-specific data across health and social care, across statutory services, although obviously Alan has already touched upon the Ugov survey that was done about public opinions. And it can be quite difficult to disaggregate that data also on the local level, touching what Brydie's already said, to understand how that stigma can be different across Scotland as well. So, in your work, do you have anecdotal information that you can use to target different types of anti-stigma messages? What are the kinds of things that we need that would help us understand exactly what needs to be targeted where and by whom? So, we have a range of outdated evidence from people who provide support services, as well as people who've done smaller-scale research, that's with trans communities, that's with minority ethnic communities, with people who are living in rural and remote areas. And from those conversations, we know some of the issues are culturally specific around the knowledge and understanding of HIV, around how that plays out. We know that there are significant structural barriers that can inhibit from people from accessing services. So, for example, refugee and asylum communities, if you're getting £48.18 a week or £8, I can't remember what the figure is, if you're getting accommodation with food, that doesn't enable you to have any resource to travel to a sexual health clinic or to increase that education as well. So, I think it's about tailoring the resource to the needs of those communities and asking what they need and what they would like. Claudia may have comments of an academic perspective to add to that. And then Brydie. Yeah, thank you. Yeah, we have research evidence. So, Scotland, as many people will know, was the first country in the Union to roll out a national programme of PrEP in 2017. And at this point, I do want to concur with Alan. We were game changers at that point and we have slid back since then. However, in those heady days of pre-COVID times, we were doing a lot in terms of leading the UK and leading the world. And associated with the rollout, we did some small research studies which had been really informative and one that speaks directly to your question was done in women of colour in both Glasgow and in London. And this was a qualitative study which we led from Glasgow Caledonian University in UCL, where we asked women of colour about their views and perceptions of HIV and reproductive health and also the services in which they might feel comfortable to discuss HIV prevention. And that study was incredibly helpful for us because it showed that women of colour at that particular time did not find sexual health services particularly amenable places because they felt that they were for people who'd already got STIs and that that wasn't an environment in which they felt comfortable, but also as an environment in which because of historical problems with health service access and racism, they felt that they might experience stigma. So then it became very difficult to consider how we might increase the proportion of women from those groups on PrEP if PrEP was only offered in those services. However, the challenges which I suspect will come on to as to how to deliver PrEP in community settings that would provide value for money and that would also be acceptable becomes quite difficult and so we get a little bit stuck here that we know that sexual health services do a fantastic job for certain groups in terms of delivering high quality HIV prevention and PrEP, but there are certain groups who do not feel that they're acceptable places and one of the key findings of this study was that for women of colour, we needed to wrap PrEP in with holistic reproductive care. So particularly in terms of reproduction, in terms of contraception and that PrEP had to be just one part of this and not singled out as some great intervention that was focused on this group for fear of the adverse implications of targeting that group. Thank you very much, Claudia. Brydie, if I could bring you in on this as well, and I suppose some of the rural inequalities that you've highlighted, how does stigma play out in those geographical inequalities? Yeah, thank you. I suppose I don't have data as such, just anecdotal stories and situations where in the sort of remote and rural communities people don't have secrets. Everybody knows everybody else's business and so it's a big deal kind of going to your GP practice or your pharmacy to ask for PrEP or ask for an HIV test or pick up your medication because it outs you, maybe your sexuality or your lifestyle and behaviors. So that is a big barrier to people to access care and in some places such as the Western Isles for example there isn't access to special sexual health services. So it is their GP that is the kind of first port of call for sexual health and it can leave people feeling really exposed because whilst we all know that health professionals are bound by confidentiality, I have also heard countless stories of receptionists or talking to neighbours and the receptionist might be your auntie or your next door neighbour and all of these kind of things are particularly common in the kind of small remote and rural settings and I don't know if there's data out there, I suppose the remote and rural aspect is underrepresented in these kind of research. I know that the University of the Highlands and Islands has done some remote and rural studies into sexual health but I don't know that there's been any particular stigma. Okay, thank you. Thanks very much. I think what you've all said so far is there's that challenge of data and I know some of my colleagues will come on to talk about some of the mechanisms that just maybe normalise testing, normalise all of that kind of thing but Alan, last but not least, if I can come to you, the film that Terence Higgins Trust produced which we saw in Parliament last year, how effective do you think that has been at challenging, tackling, combating stigma and do you see that kind of intervention as having an impact across the different communities that maybe have different cultural sensitivities, different access issues, all of the things that we've already heard around the inequalities and impact of stigma on them? I think that we would hope that it would help but it's not an answer on its own. I think that as I said previously we would hope that it's the beginning of a conversation, the beginning of work to update public knowledge on HIV now in the 2020s. I mean we know that the campaign was viewed by over 10 million people either through marketing activity or press coverage. It also had 4 million impressions on social media and 1.7 million viewers on STVs. We know that reach was good. We know anecdotally that conversations that were happening at the time for all of us as people who work in the sector, for our service users and so on, was a positive sign that people were having conversations but I mean I can give you some of the headline figures from the public attitudes survey that we conducted prior to launching the advert which found that 36% of people in Scotland still believe that people living with HIV will have a shorter life expectancy than others. 30% of people disagreed when asked if they believed that people living with HIV and on effective treatment can't pass the virus on to others. Only 35% of people said they would be happy to kiss someone with HIV. 25% would feel worried about receiving medical treatment from a doctor or a nurse who has HIV. 55% of people would not feel comfortable having sex with someone living with HIV who was on effective treatment and nearly half 46% of people in Scotland would feel ashamed to tell other people if they were diagnosed with HIV. Just on stigma in the health and care sector as well and this is something we hear about from our service users all the time, it's actually something I can share personal experience of as well as someone who's living with HIV so during Covid and the first rounds of Covid vaccination when I attended from my first Covid vaccination appointment as soon as I disclosed my HIV status the person doing the vaccination went off to the other end of the centre in search of a pair of gloves before undertaking vaccination so and that's now isolated we've heard very similar stories from others and it's not intentional I don't think there was any any malice but it points to the the kind of lack of education lack of updated knowledge and that's within our health and care system never mind the wider population. Okay thank you I could go on but I'll come back if there's anything else later on. Thank you Maggie thank you we're now move on to questions from Evelyn Tweet please who's joining us remotely. Thanks convener and good morning panel. I'd like to ask my first question to Alan to kick off. Alan you said that Scotland's falling behind and you mentioned the delivery plan. Alan can you give us your views on what do you actually want to see in the delivery plan and have we got any idea of what's taking time? Why is it taking so long? I imagine there are there are lots of reasons why it's taking so long but it is frustrating and obviously we are in the situation now where we are behind England published their funded plan in 2021 I believe and Wales published theirs in 2023. The timeline in Scotland was that we were I think the Scottish Government commitment to ending your HIV transmission by 2030 was made on World AIDS Day 2020. By World AIDS Day 2021 the HIV transmission elimination oversight group was being formed and by World AIDS Day 2022 that group presented its recommended as 22 recommendations to the Scottish Government. Since then another group the HIV transmission elimination delivery group was formed and the draft plans have been pulled together but I think there are various reasons of process that those have not yet been published. I mean what we want to see are funded commitments to expand testing on a number of levels so I'm expanding access to testing through specialist sexual health services, expanding access to testing through delivering on the commitment to a national STI and bloodborne virus self sampling service for Scotland, expanding testing through meaningful pilots of opt-out testing in emergency departments so we welcomed that the Scottish Government has funded three short pilots of opt-out testing in emergency departments but we would like to see this go further and was a minimum for 12 months opt-out pilot and an open bidding process that's fit for all boards who would like to implement that to apply for. We would also like to see investment in our third sector services to ensure wraparound support for people living with HIV, a recognition that as we get closer to zero new cases and we're identifying people who are currently undiagnosed for HIV there's a likelihood that amongst those people there will be greater support requirements and greater investment needed and we would like to see investment in education both within our health and care workforce and building on the anti stigma campaign with further targeted education work with the wider public in Scotland. Thanks Helen, does anyone else want to come in? Thanks if I can just come in here. I think a lot of work has been done to try and work out what the optimal interventions are that will achieve HIV transmission elimination by 2030 and they have to be very country and also regional specific. Scotland is not England light and it's not England light because we're different as a country, we have different numbers of people probably at risk of HIV and the distribution of the population is very different and we're also very different because England received 20 million pounds to support their transmission elimination strategy whereas to my knowledge there has been no sum of money anywhere near that degree of magnitude for Scotland and actually achieving transmission elimination requires people to do more work and to do more work differently. A lot of the provision of prayer pick fact almost exclusively is through sexual health services and I'm sure people in this room are very well aware that we are seeing unprecedented rises in STIs such as syphilis and gonorrhea such that have not been seen for decades. What this also does is adds additional pressure to services so that their prevention functions have to take second space to treating people with infectious diseases at their STIs. So without additional funding it's just simply not possible to meet the demands of the population who quite rightly need access to timely care for their acute STIs, need timely access to their reproductive health needs and because of that very little change can happen. This was markedly different from when PREP was introduced in 2017 and introducing PREP through sexual health clinics seemed a massive deal at the time but actually it's quite simple compared to what we need to do today that doesn't just involve sexual health clinics it involves many different parts of the health system all of which are under strain so even though to my mind the ideas and the interventions put forward in the plan of the right ones with the correct weighting it's almost impossible to achieve traction other than what very hardworking people across our disciplines third sector health services and others are doing already within a very very small budget. No one else wants to come along go on to my next question. Gabrielle King has requested to come in. Thanks Gabrielle. And it's very, I'll keep it very short because it very much aligns with what Claudia and Allen have already touched upon but I think for us our concern is this lack of funding and a funding delivered plan and that brings real questions to mind about how we can work to ensure that nobody's left behind in reaching the 2030 target. We know actually much as Claudia's already said that as we get closer to 2030 the people who we need to be supporting will require potentially more labour intensive resources and kind of really tailored person-centred approaches and we see that already through some work that Waverly Care does in Glasgow and Clyde around lost to follow-up which is very very intensive work supporting people who are struggling to engage in care or who've fallen out of the care system to re-engage with treatment and with services and we see real market successes of this. So between April and September 2023 through that process 63% of people, it's HIV and hepatitis, had been able to complete treatment bloods but the challenges of that work is that it's a massive resource for time for costs and for the third sector and there's concerns that the expectation will be that this work will potentially increase without a matched funding as well. Thank you. Evelyn, Dr Howe would like to come in as in this as well please. Sorry, I think there was issues with the underneath button there. Thank you. So in addition to what the others have said as to why we're falling behind in terms of addressing the stigma and elimination I just again I'm going to kind of add in the kind of remote and rural aspect in many of the health boards and the kind of smaller health boards there might be you know if if we're lucky one sexual health and HIV specialist who's you know often working part-time and in some parts of the country there's just there's just nobody so you know so that in those you know parts of the country you know how can we move things forward when there isn't the expertise there. Thank you. Thank you. Evelyn, would you like to come in with your next question? Yes, thanks convener. I was concerned to read that 31% of Scots think that they aren't the type of person who could contract HIV and obviously this is an issue when you look at the number of heterosexuals that are testing positive. What work is being done to tackle this misconception event? Would anyone like to come in? Have any indications? Does that mean no works being done? No, I don't think I have anybody coming in on that question, Evelyn. That's a challenge. It might be sitting that ourselves and Terence Against Stress can come back to it in terms of evidence as well because there will be work going on but none of it that's been denied. We can submit that after the session. Thank you. Are you content, Evelyn, with that? Thank you. I will now move on to questions from Marie McNair, please. Thank you, convener, and good morning panel. It's great to see you this morning. Thanks for your time. I certainly welcome the commitment to the pilot op-out bloodborne virus testing in Scotland and, as mentioned by the Terence Against Stress in the commented on its positive impact on increased diagnosis and reducing the length of hospital stays for newly diagnosed. Can you tell us what involves the patient and what overall benefits it brings? Is it a way to reach those groups who are more at risk of late diagnosis? I will pop it out to who would like to answer first. I think that it's really important to look at evidence wherever evidence is possible here because this, to my mind, is a place where a lot of money and resource could be spent with very little gain. We are really looking at approximately 100 people newly diagnosed with HIV per year in Scotland, and that doesn't count the people who have been earlier diagnosed elsewhere and moved into Scotland. That's a very small number of people, so we will have to do an awful lot of testing or we will have to be very clever in the places and the people to whom we offer testing. It's absolutely critical that we need to be quite precise and use evidence wherever that's possible. As part of a project funded by the sexual health and bloodborne viruses strategy, a group within my team are looking at possibilities for interactions with the healthcare system of people newly diagnosed with HIV. Basically, are there opportunities in the healthcare usage of people before they are known to be HIV where HIV could have been diagnosed earlier if somebody had suggested an HIV test? I think that's really important because it's very easy for us anecdotally to get completely the wrong idea. I know that from when I'm in clinic. I have an impression of what the clinic population is like and their infections based on who I see, which is not an accurate picture. I think that information will really help us because we could do a huge amount of testing in absolutely the wrong place at cost with very little gain. I think we need to be clever and we need to look at the prevalence of HIV and very much how England has done, which is stratify into high prevalence and low prevalence areas. Even the highest prevalence areas in Scotland, which would be the major urban areas, are nowhere near the high prevalence areas in England. We've just got to be careful about the resource that we're committing in areas where we think we will have very few diagnoses. In those places, there may be an argument for testing, but that's actually to reassure us that we're not finding new diagnoses. I think this is actually really important that we get this right and it is important where we test and to whom or where the opt-out is introduced. The other thing is what happens to the healthcare professionals. If I'm in a busy accident and emergency department, organising these additional tests, even though most of it is done at the laboratory level, adds to my workload, if we never find a new HIV diagnosis, it's very easy for the tick on the computer screen not to get filled in because I've got too many other priorities on my time. These are not without cost and they're not without cost to the health service and to the individuals responsible. I just think we have to be very careful. Evidence will be coming. It will be coming in about six months time because we're analysing the data at the moment. I would urge a bit of caution and just to proceed where we know there are high prevalence areas rather than absolutely blanket coverage of opt-out testing everywhere. Do you think there's any other potential negatives we should be aware of? I'm sorry, I didn't quite catch the question. Do you think there's any other potential negatives we should be aware of? Negatives. It's largely resource-based, I would imagine. Anyone else wants to come in? Thanks, Ellen. I would just say that we know from opt-out testing in England that I appreciate absolutely what Clodio says. We're not England, but looking for example at higher prevalence areas in Scotland such as Greater Glasgow and Clyde, where the biggest percentage of people living with HIV in Scotland are, and also where we'd expect to see the largest number of new diagnoses as well. We would say that opt-out testing meets people where they are, so it's likely to see people who may not have any other touch point with the healthcare system. I would say this potentially particularly relevant in Glasgow given the history of the outbreak of HIV amongst people who inject drugs particularly in the street homeless population. We can say in England in the first opt-out testing pilots that 45 per cent of people diagnosed with HIV were a black African, black Caribbean or black other ethnicity, which is more than twice as many as the nationwide average of 22 per cent. That's just an example. Thank you. Gabrielle. Really just to echo what Alan's already covered now, around opt-out testing is absolutely not something that we're necessarily asking for across Scotland for some of the reasons that Claudia has already outlined, but it is one of a plethora of ways of finding people who are living with undiagnosed HIV and particularly finding people who for a range of intersectional inequalities might engage with A&E as their primary care or who might be frequent attenders and we know that there's a correlation between people who are frequent attenders at A&E and those who might be lost to care through HIV as well. In terms of the negatives, I'm not sure if you want us to speak to the challenges yet or if you want us to hold that for a later question. Will you feel free to come in just now? Absolutely. I think some of the challenges and concerns are from our perspective also around how the process of opt-out testing has taken place in Scotland, so it's been a very, very rapid. We absolutely welcome the announcement of opt-out testing amongst those three areas, but I think the process of the excessive interest was incredibly fast and the amount of money offered was unsubstantial to really enable all health boards who wanted to take part and to play a part. For example, great guys going Clyde didn't put in the bid as partly as what I'm sure Nicky will speak to later of that very, very short excessive interest and the short length of the pilot of only three months as well as the funding that's available and associated with it and I think just on that funding as well, the funding goes to lab costs, but as Clyde has touched upon as well, that introduces some real challenges that there's no additional resourcing to support A&E staff who might be doing these tests and whilst opt-out should be as easy as possible, as we've already heard about, there's a massive amount of stigma amongst health and social care professionals and misconceptions which need to be addressed and so that requires additional training and actually the importance of that can't be under-sated because we know that in places like the prison service and the criminal justice system opt-out testing for blood-borne viruses should take place, but actually because there is for a number of reasons your training resource, it doesn't happen and so there's a risk that unless there's investment in training alongside and then my final point on that is as well as the investment in training that also needs to be investment in the additional support that people might need when they receive, if they receive a reactive result, either for HOV or for hepatitis which is also screened through opt-out testing and from people that we've spoken to and who we've sort of get involved in the some of the loathe and what are going on around opt-out, we know that receiving a diagnosis in any setting will quite often sweep people off their feet and it's not something that's necessarily even entered their mind and so there's an importance there to think about additional peer support and what additional resources those people might need and ensuring that that doesn't just fall onto already stretched services and for the third sector to address that need to. Thanks for that. Anyone online, Doctor Howe? Just thinking about the kind of positive aspects of opt-out testing the one thing is that it normalises testing for HIV particularly in settings that might not be used to testing for HIV such as the ED departments. However, I'm not sure that that's the most efficient way to kind of raise awareness and normalise particularly in the kind of really low prevalence areas such as Highland where we are doing one of the pilots that will be interesting to see what comes out of that. Thank you. The Sin was released by Russell T Davies. There was an uptake in HIV testing. Do you think that there's a place for our culture community and industry to play a part in this and help support the health sector? I'm certainly happy to speak a bit on that. Yeah, absolutely. I mean, we see a, you know, in the testing services that we offer it turns against trust across the UK, you know, any kind of major storyline, you know, and for example, it's a sin or more recently in EastEnders. You see a direct correlation and an uptick in HIV testing through postal services, through community services. So, yeah, absolutely a role to play for culture and helping to normalise HIV, I believe. That's great. Thank you. Thank you, everyone. We're now moving on to questions from Paul O'Kane, please. Thank you very much, convener, and good morning to the panel. In the opening contributions and through the conversation, we've spoken about PrEP, obviously, and I think it's an important area for us to consider further. The Scottish Government has been developing an online PrEP clinic, which obviously would allow people to order without having to go through specialists, as we've heard. Would you like to say anything in terms of an update on the progress of that? I don't know if we'll come to Professor Iskoor first. I think just going back to basics, I'm not sure if everyone is aware that, generally speaking, when people start on PrEP, PrEP is a medication that's extremely safe, but there are some people for whom it may have adverse consequences. Particularly in the west of Scotland, where we have quite a high proportion of middle-aged men who have pretty grotty kidneys that they may not know about, 40 per cent of the people on PrEP in the Greater Glasgow and Clyde service require more than the annual blood test for kidney function. What this means is that, generally speaking, somebody will start on PrEP in a face-to-face visit when all of their other sexual health needs can be met. They'll have a check-up for other STIs. They will be offered vaccinations to protect them against other infections. Then, quarterly, they will have their blood tests repeated. That will be for HIV and for also other STIs, because we know that there's often a group of people on PrEP who have a higher rates of STIs than others in the community. Then, once a year, everybody gets their blood tested to check that their kidneys are doing okay. This is quite a labour-intensive process. Certainly within the Greater Glasgow and Clyde area, approximately 60 per cent of people have very straightforward needs, so they would just need to be seen face-to-face once a year. Then, for the in-between times, they could, if they were sufficiently amenable and would like to, take their own samples, self-sample for HIV and for other STIs at home, have them tested in the laboratory. What we proposed was that they could do an online questionnaire-based medical consultation to check that it was still safe to continue with their PrEP prescription and to pick up whether they'd started any new medication. It's important to know that within a sexual health clinic, we have a completely different electronic medical record system. We're not like a GP. We don't know all of the medication that somebody is on. We just know what they report to us. So, my team proposed to the Scottish Government that this would be a really good development because, if all went swimmingly well, somebody, if I needed PrEP, I would have a text from my clinic saying, Claudia, your PrEP follow-up is due. You're going to get a postal self-sampling kit for HIV and other STIs. Log on here. You can answer these health questions online. If your test is negative, your HIV test is negative and there's nothing untoward, we'll send you your PrEP in the post. The idea initially with that was that it would allow a subsection of people who were quite digitally literate and were also quite good at self-managing, a way that PrEP just became part of their normal life. Doctoral work by Ross Kincaid on my team showed that the acceptability amongst people using PrEP, people thinking about PrEP, and third sector organisations was really high for this. So, the idea was that that might create capacity in the clinic context for people with more complex PrEP needs. But very excitingly, again working with my colleagues around the table and sitting behind, we're taking that also further to see whether this mechanism could work for people who have particular barriers to attending sexual health clinics. So, to increase access for those people we've already talked about, people who might be geographically remote, people who might have stigma about attending services or people who aren't particularly digitally or health literate. So, we actually had a great meeting last week with my colleagues around the table talking about how we could work together using that prescribing mechanism but supported by third sector organisations so that if I wasn't very good at doing my post or self-sampling I could take it to THT and they could help me do it or if I wasn't very good at understanding the healthcare questions I might go to a Waverly Care Peer Support Worker. So, trying to take it into the community. That works going really well. So, we've almost completed the first phase of work which is testing out how the health questions we will ask online compare with the face-to-face consultation and we are just starting work on the feasibility study which we'll start later on in the summer where we will offer something akin to this process to around 200 people using PREP and then do an evaluation which will include some early health economics evaluation too. Okay. Thank you. That was a very comprehensive overview I think for committee who perhaps weren't always fully aware of those sorts of issues. I don't know if anyone else wants to add anything. I just wondered if Dr Howe had a view on rurality just in terms of in Highland and how this might impact in terms of getting the service out more widely in a geographically challenging area. Yeah, thank you. I'm excited to see the developments with the ePREP and I think it will make accessibility better for a lot of the remote and rural health, literate population and it may well reach some of the people that typically don't access traditional sexual health services that there's a kind of particular subset of heterosexual identifying men who have sex with men that typically stay away from all health and sexual health services that may feel because it's online and quite sort of depersonalised that they have control over it. It might open it up for those and probably others that I'm less aware of. I suppose my only main concern is that there are kind of swathes of the country that don't have the kind of expertise within the health board area to kind of back that up and kind of have the clinical governance oversight and the kind of expertise to manage complex issues that occur. For example, our Garland Butte doesn't have any special sexual health service I've already mentioned, the Western Isles, and then there are other parts of the country where there might be part-time expertise, maybe one day a week from one consultant that then if they take leave or whatever there's kind of sort of part-time patchy cover. So that's my main, I suppose in summary, I think it's going to be great for some populations but there's also concern over kind of yeah the sort of expertise and kind of sexual health provision within certain kind of rural areas of the country. Thanks, that's really helpful and I think an important point about capacity more broadly and building capacity in order to underpin I suppose these services. I wonder if I can convener just come on to that point that was made about harder to reach groups I suppose in terms of access. You know I think Dr Howe outlined there people who who may be feel inhibited about accessing PrEP in many ways and I know Terence Higgins trust has looked at this in some detail around particularly transgender community, intravenous drug users, heterosexual men and sex with men, black and minority ethnic populations. So I don't know Alan if you maybe want to comment on how do we encourage greater access more widely for those groups. I think there are a few things we can do. We recognise that statutory sexual health services are not as easy for everyone to access. We're very much welcome the work being undertaken by Claudia and her team and look forward to continuing the conversation about how we support that in the third sector but we think that goes hand in hand with now exploring how you expand access to PrEP through for example community pharmacy, through primary care improving levels of PrEP awareness in communities that could benefit. We welcome initial commitments for example to a pilot of PrEP and primary care in Grampian and look forward to seeing how that develops. Also it's vital that alongside the E-PREP work that any capacity and potentially budget that is freed up within specialist sexual health services is redirected into assisting those who are currently underrepresented in PrEP uptake to be able to access PrEP. Thank you. Does anyone else? I think Gabrielle King wants to come in. Thank you. It's really very much in line with what Biden and Alan have already said but I think there's also a really important piece of information there in terms of reaching those communities around making sure that there is a culturally appropriate or suitable education around what PrEP is and the potential benefits and the use of it as well and that also includes some of the parallel statutory services that for example some work was done with people in drug and Glasgow and that work found that actually there was not a huge amount of awareness of PrEP and its benefits amongst health and social care professionals and so there were missed opportunities to to align people who might benefit from PrEP with some of that work as well and the importance really of also just investing in members of the community who understand how that community works and the best way to talk about PrEP and access to PrEP and really ensuring that they're they're used and valued and and compensated for that work that they can do most of PrEP champions going out to these communities too. Thank you. Thank you. Would you like to come in? Oh, Professor. Just thinking about other places where PrEP could be delivered, I just think we've got to be really careful here because the groups that you've mentioned are all really legitimate but they may have very different needs and I think we have to be explicit when we're considering the needs of somebody person who inject drugs which may be the same or may not be very different from a woman of black African origin and so the services and the way that we deliver them will need to be really tailored and the costs per capita of keeping somebody free of HIV from those groups may well really differ and that's absolutely fine but we've got to make sure that the people for whom delivering PrEP and keeping them free of HIV for a year is relatively cheap use the cheaper services and that we are looking at the more costly services tailored to the groups who are not accessing PrEP currently and I think that raises massive challenges and the devil is in the detail but you don't need to dig very far so for example delivering PrEP and community pharmacy there are structural barriers about drug costs which are massive and need changing and need changing by government before that even gets a look in and also the costs of a pharmacist conducting PrEP care are probably exceed the costs of a lower-bounded nurse doing it in a sexual health clinic that will be very legitimate if the pharmacy is reaching people who don't come to the sexual health clinic but if the pharmacy is just providing a more convenient option for people who would go to the sexual health clinic we are not running an efficient system so this is actually really quite complex and we need to think very carefully across the whole economy how we provide services to the right people in the right places while maintaining choice thank you a really interesting point thanks for that we have a supplementary on this from Megan Gallagher thank you very much convener and good morning panel it's been a really interesting and informative session so far so thank you very much for all the contributions thus far and I do you want to pick up on rural communities because this is something that's been running throughout the course of the discussion this morning and I'm really interested about the parity between health boards because it seems as though that those out with the central belt seem to be struggling in terms of how to tackle stigma surrounding HIV but also the education part as well so I'm just wondering if I can throw this out to Dr Howe firstly and how do we how do we effectively tackle and target particularly if there's issues relating to depopulation and recruitment how could we go about that with your expertise yeah it's a difficult question and I think yeah there is a lot of a lot to do with kind of workforce in there you know if you're a single consultant for example in your health board you know there's the clinical stuff but there's also the the governance and and planning and protocol that is just upon you you know so so kind of making developments and and kind of sharing education with your colleagues in different areas you know often goes way down the list of of your to-dos you know and and in the last five years you know there's been a lot of additional things with you know the pandemic and and then m parks and you know and all of these you know whilst whilst we may not have so many numbers in a in a kind of smaller in terms of numbers population health board there's still all of the planning and protocol that has to be done by that lone consultant um you know so so um whilst we are all very enthusiastic there's just a mountain of of things to be done and and education isn't is in there for sure um but yeah it's it comes down to to workforce I think and the recruitment issue um uh yeah is um is a problem throughout the the specialty um we're a small specialty the training posts have been underfilled um but in the kind of remote um and you know smaller health boards um we don't even have any training posts so recruit that kind of um causes problems with recruitment if you're if you have trained in a health board you're much more likely to take up a job there um if there are no training posts and no one coming through that health board you're you're less likely to to recruit um yeah so I don't have any um big solutions um but yeah um recruitment um and uh yeah workforce I think are um part of a bigger solution well thank you very much for that Dr Howe because when it comes to training as you say that's a step into the profession so that I think that needs to be addressed and that's really something you know that that can be raised directly with the Scottish Government in terms of how how are they going to tackle that so thank you very much and just finally um on the education element um how do we close that generational gap um you know in terms of parity in schools even to make sure that um younger people especially younger generations have a greater understanding of HIV and AIDS therefore that should help eliminate the stigma um you know moving forward through generations is that something again is being looked at um and how do we make sure that we're targeting those rural schools as well so we have full parity right across Scotland yeah I mean I don't know if it's been looked at um but yeah absolutely a systematic approach to kind of including um uh you know um up-to-date information about HIV and addressing stigma um you know systematically in the education systems whether that's the kind of you know school education or whether that's you know secondary and higher education um systems you know health and social care um absolutely it needs education is um is the key to addressing stigma um but yeah it needs to be done on a kind of um systematically rather than relying upon individuals um kind of taking it forward thank you very much thank you computer I'm not sure if anyone else is looking to come in but I'm certainly done with my questions thank you thank you Megan Gabrielle would like to come in thank you and and yeah just very much I can what um Byggy's already said I think we really welcome the RSHB consultation that took place in I wouldn't say November but it was before Christmas um and really look forward to seeing the results that and obviously part of that consultation it was around um the importance of ensuring that there is consistency in approach that um knowledge and information about HIV but also around sexual health more generally is up to date and challenges misconceptions from that early age and also ensuring that teachers have adequate support in place to enable them to deliver that recognising that quite often RSHB might be done on the side of another job and ensuring that that is consistent across all subjects that they're not students aren't going to an RSHB lesson and then going to a biology lesson and having a very very different message about sexual health and sexual wellbeing too thank you thank you it was really helpful um Alan you'd like to come in yeah just very quickly I would agree with all of that just on the the resources um for teachers as well um consistent support across areas might be helpful you know for example where we're commissioned to deliver health improvement services looking at blood bone viruses and HIV in particular um in those health board areas we've got specialist workers that support teachers to um develop education materials to have the confidence in the language to um speak to to young people um but I don't believe that's a consistent picture across Scotland thank you we will now move on to questions from Annie Wells please good morning computer thank you very much good morning um I've listened by interest for this whole what is it an hour almost 45 minutes um and the word stigma gets used a lot and this how do we reach zero transmissions so 10 seconds Alan I think you said in the start that you would support a national HIV testing week and the publication of um some regular data as well can you give us a bit of a background on that as to why these two things are important for the elimination of stigma um and I'll ask the other panellists if they agree with the need for a national week national testing week two things thank you um well I mean first and foremost I think we've said already Scotland is an outlier in the UK and not having a national HIV testing week um I think on its own it's not an answer but it certainly helps us focus wider public attitudes um normalised testing um increased awareness of of HIV um we also you know for example each year in England HIV testing makes these around 22 000 HIV tests ordered online um helping normalise HIV testing raise public awareness of HIV and find new cases of the virus um in terms of data um yes I mean it's without without um consistent um comprehensive data it's difficult to tell where stigma sits I think we've already heard that we don't have robust data on you know stigma within rural areas versus urban areas for example thanks very much for that oh I don't know if anyone else has got an opinion on this as to whether we should have an HIV testing week or not I'll come to professor escort first thank you they're great fun I've been involved in one in London and it was great fun it was a huge amount of work and I think what it was helpful to do was within healthcare professionals get the message across them we've talked a lot about structural stigma and institutional stigma so I think that's very helpful I think realistically in Scotland we're likely to diagnose a number of people with hepatitis b and hepatitis c who may well not know that they have that infection we will find some people who have HIV positive tests who already know their HIV positive there'll be some a small number who know their HIV positive but have fallen out of care and that provides a really good opportunity to re-engage them with care because if they've fallen out of care they're likely to have detectable virus so they may be at risk of passing that virus on in terms of really finding the people who've not yet tested for HIV and have HIV without knowing their diagnosis we will pick up a very small number of cases so I think if this is a route that the government chooses to take we should be very clear that we're not going to detect an awful lot of people newly and newly diagnosed them with HIV so we need to be clear about what the aims are and there's an exercise to reduce stigma we also need to know how much this is going to cost and who is going to do it because people in the health services cannot do this as well as the day job and it will detrack from other elements of their service and other elements of their work so we just need to be really clear about what the aims are how those how any impact will be evaluated and really where this sits within the bigger picture because really we're talking about destigmatising HIV but we're really talking about destigmatising sex and sex has been stigmatised but in in human culture since you know Adam and Eve for those who believe in Adam and Eve so I think this really fits within a much wider agenda which speaks to some of the previous comments about school education about sexual health and well-being about good reproductive health and it's all part of a bigger picture we tend to be very focused on our pet bloodborne virus or viruses and we've got to think about people and it's all about people so we don't sit in isolation we sit within that much bigger picture so we can't crack HIV stigma in isolation we have to be thinking at societal level about healthy sex and relationships and what that means for individuals thank you for that Gabrielle thank you and I think from our perspective the national testing week absolutely agree that it's not necessarily about identifying X number of new cases but it's really about normalising and tackling that stigma that exists on HIV and that's one of many different mechanisms that we need to be put in place I think there's models that can be looked at in terms of delivery from Wales from England so Wales I believe is is public health in conjunction with the charity and it's taken stress to really involved in the national testing week in England and so it's about normalising that aspect of testing and also empowering people to be aware of what their status is around sexual health as well as it's lesser about finding those diagnoses and more about normalising and and being one of a plethora of ways of tackling stigma perfect and I don't know if Doctor House got anything to to add to that um yeah I can come in um yeah just to to say I suppose um you know that testing aside I agree with um Claudia that you know um we're not going to pick up numbers and and in a way that shouldn't be the focus of of a testing week and it and it would be more about awareness raising so so the the kind of focus um would have to be on the the kind of public health messaging and and getting um the the publicity um right um and yeah and that that would be a focus of um the testing week rather than trying to pick up um numbers because there's going to be very few and probably none on my patch for example um yeah but yeah just echoing everybody else thank you thanks very much for that I've got one small question and I think you've probably answered this in in the last while um but is there any other suggestions that you have that would help address stigma and meet the target for net zero that we haven't spoken about already but just as there's anything else that we haven't touched on at all yeah um I suppose from from my perspective it's about you know a national testimony can all of that stuff it's also about having equitable provision and access to testing whether that's through a national online portal um whether that's through um easily accessible online testing that people can access regardless of their geography and I know that works going on at the moment with public health Scotland that I'm sure that Kirsty will speak to um in the following session as well um and I think kind of related to those points is ensuring that we have comprehensive data on in Scotland about what stigma looks like across all the statutory services that we've already spoken to and those that we know anecdotally are challenging about the rural issue that um I think Heidi's spoken to a lot as well um and also really invest in that education piece for staff who are working in those sectors and there's examples of work going on for example National Lades Trust have produced a HIV confident charter which is about supporting organisations to have an accreditation um to show that they are working they have um absolute understanding about HIV and and can work and to support people to do that as well and so I think there's lots of mechanisms to consider but what's really important is that those are properly resourced and properly funded too. Perfect thank you. I'm finished computer thank you very much thank you panel thank you thank you everyone that concludes our questions for our panel one this morning and I want to thank our witnesses for their evidence and we will now take a brief pause while we change over witnesses. Welcome back to our meeting this morning this is the second panel in our in our witness session and I'd like to welcome Dr Dan Clutterbuck, consultant in GU and HIV medicine at NHS Lothian, Nikki Coyah, health improvement manager, sexual health from NHS Greater Glasgow and Clyde, Dr Kirsty Roy, consultant in health protection from Public Health Scotland and joining us remotely this morning we have Dr Daniela Prawley, consultant in sexual health and HIV from NHS Grampian. So welcome you all to the meeting this morning and I will invite each of you to begin with an opening statement and I'll begin with Dr Clutterbuck please. Thank you thanks convener and thanks to the committee for the chance to speak so just briefly I'm a HIV clinician and that's my primary role the other hats and involvements I've had with this is I was involved in the HIV transmission elimination proposal that was published as has been mentioned in 22 I co-chair with Professor Nicola Steedman deputy CMO scoping group that sat a couple of times last year to propose a way forward and in Nicola's absence I've chaired the HIV transmission elimination delivery plan short life working group my there's a mouthful over the last six months developing ways forward and I work closely with the Scottish Government SHBBV team and also on on the strategic work I am going to just pick up briefly and try not to repeat some of the comments made in the first session just just to expand on them a little bit so the first thing I'm going to say is it is possible I think we need to hang on to that I think it is possible we are talking about low numbers 77 newly diagnosed infections in 21 108 in 22 but let's not make any mistakes that is given for reasons that we might want to expand on it is equally likely that we're in a at an inflection point and we will see an increase in infections the like that the relative likelihood of that I couldn't comment on and others may want to speak to that we're falling behind you other UK nations that's not just a way of getting leverage that is a fact prep was world leading it's really hard to overestimate what to overstate what an achievement that was and the credit to everybody involved and particularly for example claudia led the publication in a in a world standard journal we were one of the first places to show population reduction population level reduction in HIV incidence that was entirely driven within and by the sector there was no resource the third thing we've touched really well on stigma health inequalities and rurality and those are all things very dear to my heart and across the sector things are changing we have got a little bit into broader issues which of course is a great temptation I think we can say the population is changing there are all sorts of aspects of social aspects of immigration aspects of population aspects that are changing that make it I think equally likely that we're an inflection point rather than a continuing decline the fourth is for those as long into tooth as may have been in this sector for a long time it's even easier for us to forget that HIV was the sector it was HIV in the 80s and 90s that drove the co-working between patients communities advocacy third sector and professionals that we now take for granted across health it wasn't taken for granted and HIV was the sector that drove that it's an incredibly tight and small sector and we did it again with prep we did it again that prep was driven by the community admittedly largely one particular community and we've got some work to do in breading it out but prep drove that and we did it again we cannot do it this time it's too complex and Professor Escort has touched on that we can't do it within the sector without sport we should be under no illusions this isn't going to be like prep and the fifth is just to say the ambitions that we've stated and the words really need to be met by action that we can't do within the sector it may be that we can't do it within governance or even within parliament it may be require a broader commitment but we need to make a commitment thank you thank you thank you for the invitation to participate today i'm niki coya i'm a health improvement manager for sexual health and NHS greater Glasgow and Clyde i co chair the sexual health promotion specialist group which brings together my colleagues in the other territorial board to jointly plan and deliver some national level interventions around sexual health improvement and like dan i was on several of the iterations of the development of the hiv transmission elimination proposal which dan has largely led over the last year and i was also the co chair of the partnership group that developed the hiv stigma campaign last year and into early this year and i think just i think the only thing i would want to add at this stage is we have absolutely as dan said we have absolutely all the tools we can make this happen but addressing stigma we can have the best tools in the world in terms of eliminating new transmissions of hiv we can have the best prep services the best sexual health services but if we don't do the work around stigma certain communities and certain populations will not access them and so that has to be part of what we do in terms of eliminating new transmissions of hiv in Scotland thank you then we want to dr rhoi please thank you ladies and gentlemen good morning my name is dr kirstie rhoi i'm the consultant lead for stis which includes hiv in the clinical and protecting health division of public health scotland in that post i am responsible for the on-going monitoring and surveillance of the hiv epidemic in scotland and one of my key roles is to ensure that the data and the intelligence from that monitoring and surveillance influences strategies and actions to address the burden of hiv in my capacity i will be supporting colleagues across the board partners stakeholders in implementing recommendations and the actions of the proposed hiv transmission elimination strategy um i um sorry what else would i want to say probably just to say thank you very much for inviting me to give evidence to the considerations of the committee today um if there are any follow-up questions or queries that relate to my role in health protection or that go into um further public health responsibilities of public health scotland then um please don't have us hesitate to come and ask for a follow-up information thank you thank you so much we'll now move on to dr brawley please hi there thank you for inviting me to speak today and apologies that i can't be there in person um as i said before my name is dr daniela brawley i'm a consultant in sexual health and hiv in nhs grampion i'm also the local hiv lead and as part of that role i'm a member of the scotish health protection network hiv clinical leads group which i've co-chaired since 2023 and as part of that role i'm also a member of the hiv transmission elimination um iteration groups that have been in place since 2022 um and also the most recent implementation group which is chaired by dr clutter buck um my role is is mostly a clinical role and a condui between clinicians who are um providing care for people living with each hiv but also a strategic role locally and also nationally and i think to to add to my um description of my role it's just to reiterate some of the comments that have already been made by the panel that are sitting today so firstly to say that transmission elimination is 100 percent possible it's been seen in different parts of the world sydney have already said that they're almost approaching that in 2023 so it is 100 percent possible but as has been said before we do need commitment and most importantly resource not just within sexual health services and within our sector but also across the system because the only way that we can tackle this is to look at cross system working and i think secondly to say that all lower numbers have been reducing um i don't think we can be complacent with that post-covid the landscape has changed dramatically and we really don't know how things are going to pan out in the next few years and that's where the data is really important and i think finally the the last thing to say is that although do we have low numbers we still have quite a significant proportion of late diagnoses which have a massive individual impact to that individual but also have a costly health impact if someone is diagnosed late who is in an ITU bed for several weeks or months that is a lot more for us to deal with for it as a health system than if someone is diagnosed early or indeed if we prevent that infection with the preventative measures that we have at our disposable and last but not least just to reiterate the comments that have been made by Nicky Coyer that we can't do any of this unless we we really do properly tackle the stigma which unfortunately still exists around not just HIV but as professor escort said around sex itself thank you thank you so much we're now going to move on to questioning and i'd like to open that question session we spoke quite a bit um you know as you've just said there dr rolly about stigma and tackling stigma and um i would really like to get your personal viewpoints you know on why that is so important that we tackle stigma so if i come to um dr clutter book first please and i'll be way around thank you well i think we heard um we heard an enormous amount of helpful information from colleagues around stigma and alan eagleson gave some quotes um i would just reiterate that it's uh uh it remains a barrier to testing to um uptake and particularly retention in care we do have national and international data there's a really helpful stigma survey published annually and i was looking at 22 figures for another reason this week um so it still remains only about 50 percent of people living with hiv in 2022 who've disclosed to friends and family or to workers and certainly what chimes with my experiences there's still the figures are still around 10 percent who've disclosed to no one so that's there there um that's no one apart from the person who provides hiv care so that in many cases includes friends family partner gp or anybody else so they only see their hiv clinician or clinicians um so it would be yeah it's if i could have looked back from when i first started in this i wouldn't have anticipated the fantastic biomedical changes and the changes in prognosis they've been much better than expected no way would have a expected stigma to have made so little progress i find it astonishing that we've made so little progress in that regard thanks thank you niki coya please um so sorry can you repeat that to a question um just your your your views on why it is so important that we tackle stigma okay so i think just because i think for all the reasons that others have really eloquently described stigma affects every aspect of someone's life when they're diagnosed with hiv impacts on their mental health and wellbeing it affects their abilities to enter the workplace or retain employment but i think so in terms of like for the individual for that person it's important that we living with hiv it's important that we address stigma but i think i alluded to just at the opening if we if we want people to be well educated on in terms of safer sex if we want people to use and be able to negotiate safer sex if we want people to access prep and feel able to access testing at an appropriate level then we will need to address stigma because they very much act as psychosocial barriers to to those interventions so i think that's that's really why we need to do this thank you dr rhoi so from i mean it's very difficult to add any more to what you've heard already today um and to what dan and niki have just said there but i think from a a public health perspective reducing stigma has an impact on our efforts to reduce transmission because people feel more comfortable to come forward for testing and because they're more comfortable with having those conversations around risk reduction behaviors so it's really really key that we have that compassionate that well informed population in scotland thank you and dr brawley please yeah i think i'm just again reiterating the the messages that have been said today but it affects every aspect of the transmission elimination plan so it affects people's engagement with prevention if they think hiv is something that doesn't affect them because they feel it's a stigmatising condition they won't engage with prevention measures they won't think prep is for them if somebody you know is stigmatising against hiv they won't go for a test they won't accept a test and often that again will cause um challenges around treatment and care so for example we often as dan has said we often have people living with hiv who don't disclose to their gp and that is that creates challenges for clinicians in terms of managing that person's care safely if they have other comorbidities and other other issues and other health conditions that we need to to deal with and it's just really you know from our point of view really a sad that this hasn't moved forward as much as the other areas of the the sector have again as dan's alluded to so it's from an individual point of view it's from a service point of view it's from a clinician management point of view but ultimately and why we're discussing it today it's from achieving transmission elimination perspective unless we tackle that we won't be able to achieve that goal thank you so much we're going to move on to questions now and we'll move to Maggie Chapman please thanks very much Karen and good morning to the panel thank you for for joining us and for what you've said so far and i want to delve a little bit deeper into stigma and and how we tackle it and as with all of you work within within healthcare and either directly directly with colleagues in the nhs or or associated professionals what are the challenges what are the barriers what are the issues around stigma in health and social care that you see in in your daily work and how can we how can we start to unpick some of that because as dan and others have said you know there's this hasn't changed in 20 30 years in the way that we might have wished it so there's something cultural here um and there's obviously something structural within in the profession too how how would we how would you how would you see that changing what are the things we need to be looking at to change that in the health and social care profession dan i'll start with you for me so i think i'll leave why it's important and just just to mention um what we aspire to do as part of the delivery plan um so as as allen mentioned in the previous evidence session the stigma campaign the stigma campaign for the wider population i think was a real win and and it's wonderful to have some wins to report um what we would aspire to do is build on that with a tiered approach to education um that isn't currently signed off or funded but it's a well-developed idea that we've many of the people who've given evidence have been involved in so what we would hope is to for the entire health and social care sector to have a basic net level of knowledge and it might even be possible to go beyond that for example um to other potentially key influencers you might imagine for example nail bars or or tattooists or others with with a with a um a social care background um and that would be the real basics around you equals you that i hope everyone here is familiar with i won't go into but um the availability of prep and testing and then we'd build on that with a bit more detailed information now for some of the health and social care um workforce we do have some really good materials in fact daniella and colleagues and grampian have produced a superb piece of work and we have further work that nes are developing one thing that we haven't got that might make a difference is to um frankly to mandate that training and and my understanding is wales are actually um looking at doing that and i think are on the brink of actually doing it so um we mandate for example transfusion training for clinicians across the nhs and it wouldn't be out of the question uh to take that further thanks then daniella if i can come to you next and i mean dan mentioned that the training materials and resources that nhs grampians developed can you just say a little bit about how how those are used and how they are if if you've got if you've got the evaluation you know how they are being being successful in tackling stigma within the within the profession yeah so we've put together a resource that's a new learning resource which basically tries to address education around each IV so trying to dispel myths myths that people may have and it's very much aimed at health and also social care staff it's it's currently just been used within health care staff we're trying to to sort of reach out more to social care staff so that is in our plan um i don't have the figures for the the evaluation to hand but i'm happy to share that with the committee at a later stage but informal feedback is that it's been very well received um and often people will say i really didn't know that i wasn't aware that things had changed so much so i think just to lead on from that certainly my perspective is that if an individual has experienced stigma within a health or social care setting or someone is not offered a test because people feel that's not indicated for that individual it all comes down to the lack of education and the lack of training and that's really where we need to tackle our resource from my perspective and as dan has said whether we do that in a in a mandated way so that actually your coverage is much better um is probably up for discussion but i think that's certainly one of the ways that we could we could look at that and there are other initiatives that have been done in other areas such as HIV confident which is a an initiative that might have been discussed earlier today where organizations can be signed off as HIV confident and as um you know an organization that has that awareness and and that um that that understanding around the stigma and the initiatives that have progressed with HIV thanks thanks very much for that daniel like kirstie if i can come to you in your public health role that that that sort of connection into communities and professionals that that that work in in communities how is it that stigma is is best tackled in in those in those contexts okay so um i think one of the challenges of trying to address stigma is that it is is complex it's multifaceted you need to try and address attitudes beliefs and importantly behavior so you can have the knowledge but if you use that knowledge to change your behavior these are sometimes quite different things um bans already mentioned uh there is expectation of work to address improve awareness knowledge um and i think it's it's important to realise that it has to be on-going it's not just one-off effort this has to be an on-going piece of work and it will take time because you're trying to change behaviors um but we also need to try and ensure that we're continuing continuously monitoring stigma because that's the only way that we will be able to see that change and indeed if we're not seeing that change be able to identify perhaps um activities that we need to do to to address where we're seeing residual pockets of stigma okay thanks very much for that and niki if i can come to you in your experience and the work in the contact you've had with so many different groups of medical and healthcare professionals around the country what are the what are the things that you think actually do would work that we aren't doing or we haven't thought about we don't have a well-worked plan you know if we now we just need the resources as as dan has outlined what what are the things that we're missing in tackling stigma so in terms of what's missing i would say i said go by to what dan was saying that we need to have we need to have uh shall i take a step back if you think about what alan was sharing with us earlier about that population level you gov survey where half of people were saying that they would be they would be concerned to tell someone else that they were living with hiv so our health service is that's reflective of who works in our health service those population general population ideas is largely reflective of who works in the current health and care system so it's fair to say that if you don't work in the field of hiv your knowledge and education around hiv is probably not where it needs to be just now so one of the challenges that we have is it's really difficult to get staff released to attend any form of face-to-face training so things like the e-module that daniella referred to they will be really helpful i'm really reminded that i'm reminded that about 10 years ago in greater Glasgow and Clyde we actually worked with our hiv patients to develop a stigma campaign at that time a very local one focused on our acute services because and this is still the case today the health service is the place where people living with hiv most experience stigma it is the place where they most experience stigma and when we did that campaign 10 10 years ago you're absolutely right dan nothing has changed in terms of it just hasn't shifted the dial but at that time we worked with patients to kind of capture their experiences and it was done in very distanced ways because of the very nature of stigma but patients wanted to share their experiences with healthcare providers about this is this is what i'm experiencing this is what's wrong i think where we now need to get to is what does good look like how what is good's interaction and it's just basically good patient care what is good patient care for people living with hiv look like we were able to shift the dial a little bit in a very short period of time with a little bit of campaigning work that we did at that point we did put on training we did create resources we did use our internal communication newsletters and channels that we had our electronic ones and that shifted the dial a little bit but if it's not consistent it and there's nothing that follows on from it it needs to be it needs to be continuous and it needs to have a depth and a a reach i think training is is part of it but i think as others have said the the general population campaign is a baseline i think there's a campaigning approach that's needed within the health and care system as well it's not just about training it's about the testimonies the testimonies of people about this is not how i want to be treated this is how i want this is how i would like to be treated this is what good patient care would look like for me i think when we in the partnership developed the campaign people living with hiv took part in a number of groups and i think there's just one quote that's come from one of the groups that i would like to share from from you and it's actually from a nurse who works in the health care system living with hiv and she says i'm a nurse and another another another nurse whispered to me about a patient be careful with her she has hiv i didn't have the strength to tell her i do to and none of these nurses wanted to look after that patient so there's quite deep rooted stigmatised ideas that affect patient care and i don't believe that most people choose to come to work to be unkind to our patients i think in the health service we are very focused on doing the best that we can but i do think that our for most of our staff we absolutely need to kind of increase that level of knowledge and that level of what good patient care looks like for people living with hiv you okay thank you you've given i think a really clear outline of why we need targeted action in within the profession but but as you say it's that baseline it's society that produces our health care professionals isn't it so so there's that need too so i'll i'll leave it there for now thanks thank you thank you muggy well now move on to questions from evlyn tweed please thanks convener just took me a second to unmute there um lovely to see you panel thank you so much for your answers so far um i've been very interested this morning dr clutterbuck and others have said that we're starting to fall out sort of behind the rest of the uk and i'm interested to know from the panel what are you looking for from the sort of long-awaited delivery plan and do you have any concerns just now that you can share with us but really i want to get to what do you want to see in it and maybe to dr clutterbuck first well i suppose that's an interesting question for me what do i want to see in it because i've lived and breathed it for two years so one would hope that what i want to see it in it is in it um i i think that it sets out a realistic prioritisation of primary secondary and tertiary interventions to use the public health spiel it is it is by necessity extremely utilitarian it's the bare bones of a plan and that's because it's been done within the context of appreciating a very very constrained sector and significant financial constraints so there's a lot of cutting the cloth to be to be frank i'm very happy to expand on what's in it because i'm very familiar with it in terms of my concerns well i'd have to say one concern is that it remains unpublished and obviously i've got some insights into why that why that is but in short it's probably because the constraints that we refer to and i hate to go on about constraints all the time it's nice to talk about some of the wins but the constraints exist at every level including within the Scottish Government team and and other priorities and pressures and the capacity in the sector is very small. My other concern is as has been alluded to that our ambitions collectively are way beyond what we are realistically as it stands in a position to deliver so claudia mentioned some numbers in terms of other home nations it's a clearly it's a dangerous place to go i have to say claudias figures were extremely low even if we talk about what numbers we are available to us but you know in the in publicity are publicly stated the the gap is enormous it's probably near a hundred fold than 10 fold so that's the gap between scotland and and england so the the financial commitment it would be difficult to overstate the gap so we're working my concern is we are working and we've worked absolutely positively within that constraint but a lot of the discussions that including the discussions that have come up now for example around hiv testing week it's not that there's anything wrong with an hiv testing week it's not that you know it's not that it's a bad idea it's just that even at an incredibly modest cost and we could throw out a figure but it's it's not an expensive intervention by you know by national standards it's not an expensive intervention but given the funding constraints it simply doesn't hit our very very high bar in terms of the very difficult choices that we've made within the existing constraints and so my concern is that or one of my concerns is that our ambition so far outreach our abilities that we don't make any significant progress or as daniel has mentioned and I think I mentioned previously the possibility that actually we see a a rise in new diagnoses or we see a further we've had the outbreak we've had the significant enormous very very significant outbreak in a subpopulation in central Glasgow in only within the last 10 years that was the significant outbreak in people who inject drugs so that we see a we see a significant outbreak in a in a particular vulnerable population I'll leave it there thank you are you content everyone with your questions yes that's me thank you convener thank you we'll now move on to questions from Mary McNair please thank you convener and good morning panel yeah I think they're still in the morning great to see you here this morning I'm back to the questions about the kind of pilot opt-out bloodborne virus testing obviously in Scotland and I mentioned earlier the terms Higgins trusted made comment about the positive impact it's having on creased diagnosis and reducing the length of hospital stays for you know those newly diagnosed and I've got to say I was heartened to read about the positive data from Croydon University which found that when they first started the opt-out testing average hospital stay was 35 days and it's now 2.4 so back to Scotland again and to help us to learn a bit and more can you talk talk us through what involves in terms of for the patient and what the overall benefits are and I'll pop it to yourself Dr Clutter Buchs I really like your name thanks I'm pretty universally known as Dr Dan and I'm very happy for anybody to use that well universe not my mum but pretty much everybody else um so in terms of uh in terms of the benefits I think some have already been covered I think there is an enormous benefit for benefit to normalising um I think there is a discussion to be had and we've had that discussion and it's a really fruitful and interesting discussion and you've heard that that Claudia takes a brilliant a brilliant overview public health academic perspective on on what the interventions which should be and of course Kirsty's got great expertise and and so there's been we have some really healthy discussions what what I think I would say is the the baseline is we don't know we simply don't know whether opt out testing is the way forward or a seroprevalence study so just so that the essential difference is if we do opt out testing those people we find who have infections we know who they are and we can treat them whereas a seroprevalence is not linked to individual patients so we understand the rate of infection we understand the prevalence but we're not actually intervening I think the other thing that's not come up that I would just want to mention that in terms of opt out testing if we take the English example um actually the in terms of number of infections the biggest number of infections is hepatitis c and hepatitis b now very very significant over 100 even in the sentinel sites and we don't have a figure for the overall number several possibly into the several hundreds of HIV infections but very large numbers of hepatitis c and hepatitis b so just to mention from a scottish perspective of course there's an even greater urgency for hepatitis c elimination and similar challenges and you'll be aware that they actually their target is 2025 so very very imminent so opt out testing will very very likely to diagnose very significant numbers of undiagnosed hepatitis c infections so thinking about it from an HIV perspective is slightly a slightly false distinction because in terms of the processes they're all there with the benefits of diagnosing hepatitis c and adding in an HIV test again you could argue about the laboratory cost but it really isn't a massive deal so I think just to broaden it out is worth thinking in those in that sense many of the issues particularly for example around stigma are applied to hepatitis c although actually the awareness is probably even lower and in terms of benefits for any of these things if we make things routine and systematic they tend to work better another option that we're exploring and I'm very it's part of a great interest of mine is around indicator condition testing so that's improving the offer of tests when people have a condition that might be associated with HIV frankly we've been trying to do that for 30 years I think we do want to be able to do it better but any time we're depending on clinicians adding a test is difficult and anytime we don't is easy but I think as Claudia mentioned very described very eloquently we do have to consider if we are doing a very large number of tests for a small number of diagnosis clearly we have to we have to consider the financial implications so exactly what exactly what the right route between opt-out testing us or serial prevalence testing for sential monitoring is in Scotland we're not quite clear but actually that's not become an issue because again as Alan said we what all we have commissioned is these tiny pilots and that's not to diminish the effort and the work that's gone into them they're fantastic thing to do but they aren't actually going to they aren't going to answer the question for us. Thanks for that that was really helpful anyone else want to come in Dr Roy? So I think I'd just like to say that yes opt-out testing can be a proactive approach to diagnosing infected individuals it is however as you've heard affected by prevalence and with Scotland being a very low prevalence country we are unlikely to diagnose individuals with the opt-out pilots they are likely too small however what they will show us is that the approach can work the principles of the approach can work so it is helpful in in proving that you can implement and run it will also highlight if there are any barriers for example as you've heard you know when you're in those busy environments it might be challenging to actually roll out the opt-out testing it will have other benefits as you've heard hepatitis B hepatitis C diagnosis will be more likely in the pilots and it does have it will go some way to addressing some of the stigma both within the healthcare professionals in that environment and also with the the patients also coming into that setting they are costly undoubtedly these are costly endeavors to run I think when we are dealing with resource restrictions and we are having to prioritise normalising HIV testing making it routine throughout the healthcare setting I think has many benefits in that you are addressing stigma across the wider healthcare setting and indeed the wider population you need to be able to address stigma educate and thereby improve the offer of testing and also improve that acceptance of the offer of testing by the wider population that has contact with the service. Thanks your comments are really helpful I've no one else wants in I'll just hand it over to Dr Rolly online. Hi. No that's okay just to add in so we're in campaigner leading on one of the the pilots currently we don't obviously have data because we're still in the middle of the pilot but happy to share that obviously with the committee and the the wider sector once we do you have it. I think as Dan has said we still don't know whether this is the right road to go down although we have seen the success of opt-out testing for example in maternity services and such health services so there are there is some background data around that I think again just to sort of go back to what we see not just locally within my area but also across Scotland is still a quite a significant number of late diagnoses and actually if we can diagnose people earlier that there is a cost saving aspect to that so that has to also be balanced and taken into consideration when we're looking at the cost benefit of the opt-out testing and I think the last thing to see is that there will be you know the opt-out testing project that that is currently being run in a couple of board areas and in Grampian is is part of the emergency medicine department and often that is where different populations will present if they don't have good access to other parts of the healthcare system so we will be focusing on people who are priority groups who are most at need as well so that these other parts as well as obviously stigma and education for the clinicians who are part of the pilot which are positive outcomes as well as obviously the infections that that will be picked up throughout the pilots. Thank you. We'll now move on to questions from Paul O'Cain please. Thank you, convener and good morning to the panel. In the first session I was particularly interested in PrEP and the online clinic and the proposals for that so particularly interested to hear people's views on the progress of that and I suppose their wider views about how that online service could enhance the reach of PrEP and then we'll go on to talk a bit about I think those who feel excluded still from PrEP or who are facing stigma so I'm not sure who wants to come in with a kind of overview point first. Thank you. Maybe on the second point which is about some of the populations who are who we struggle to get PrEP to and I guess what I would say about that is there is I think Claudia can describe this really well in the earlier session about sexual health services being really appropriate for some parts of the population but we know that for some other parts of the population where the prevalence of HIV is likely to be higher that is not an optimal location so I think the ePREP work but also I think some other work that's coming alongside the implementation plan around changes to the prescribing guidance and exploring other service delivery locations I think will be really helpful for some parts of those populations. I think one point I would want to make though is that PrEP will be a great PrEP has been as others have said it's been an absolute game changer it has it's reduced our overall HIV numbers every year since it was implemented in 2017 but it's not necessarily going to be the solution for everybody in terms of HIV prevention so I think what I wanted to flag was just a note that PrEP is I think it's at the centre of our prevention our primary prevention strategies but we have other tools that absolutely need to be in that box as well that box of tools so we for other population groups it's about the education piece it's about making sure that anyone that wants to use condoms can access them it's about making sure I'm from Glasgow where we have the the outbreak among people who inject drugs it's about making sure that we still have some of those more traditional methods like cleaning safe and injecting equipment and the injecting safe and injecting facility I think will be a really helpful element of that so I would say I think we need to we need to make sure that we need to work in co-production with the population groups that can most benefit from an expanded provision of PrEP but we also need to be mindful that primary prevention is not just PrEP there's a range of other primary prevention approaches that we need to make sure they're still in the mix okay thank you and someone else want to comment on either of those issues thanks can't help it I think as you know professor escort I think very eloquently described the the PrEP pilot I'm really optimistic that it will offer us benefits primarily in terms of efficiency and releasing capacity which is very welcome and I think as as has already been said it's the idea that it might offer access to those who are affected by stigma and wanton anonymity is is really exciting I think in reality much of the population benefit in terms of HIV reduction from PrEP has already been achieved that's not to say there's nothing more to be done but in terms of the very highest risk of individuals I think some of that benefit has been achieved so I think it's the things that go alongside let's hope that the PrEP feasibility study is a success I think there's every reason to expect it will be it seems seems to be progressing really well let's hope we can move to implementation and there's going to be a whole question about resource there but within existing services and then I think isn't as Nikki's already said some of the things that go on in parallel to that around different ways of looking at PrEP for different populations simplifications of the dosing is probably where we as well we've got more to gain but also as I think Claudia described quite eloquently some of those interventions and quite often the ones that where it involves those groups with the greatest disadvantage most intersectionality whatever phraseology you want you want to use are often the most resource intensive and just as a note of caution I seem to come up with with the caveats every time we cannot in the current environment make any assumption that resource release from the PrEP pilot will go into other PrEP delivery because we're all in sexual health services in a very very constrained environment where we're looking at cutting services so trying to make a case however compelling it is within this room for redirecting resource savings generated by PrEP into for example PrEP outreach is not going to is not going to have a sympathetic hearing within boards. I think that that is useful I think for us to hear as a follow-on from the earlier conversation probably for us to consider so I think that's helpful convenient. Dr Brawley would like to come in on this point Paul. Hi there sorry I think Dr Clutterbuck's probably mentioned some of the comments already it didn't get fast enough on the keyboard but yeah just to reiterate that the PrEP pilot is extremely welcome I think it will help those who struggle with acceptability of services and also may help with some capacity although with the caveats that have been mentioned but you need to be aware of PrEP before you actually can use the E-PRIP so actually there's a bit around again education and awareness and I think that's where some of the work that's currently being done around some very very early exploratory work around pharmacy and primary care and where that might sit around PrEP delivery because there are large groups of individuals who will benefit from PrEP but don't access sexual health services and don't know about PrEP and the only way that we're going to get those messages out there is to widen that access to like we did for some different types of contraception back years ago that were only accessible in sexual health services and now are accessible in pharmacies and in primary care services but that will need resource and especially in those areas as well as sexual health but you know we won't be able to expand PrEP access and and offer out with specialist services unless we have resource behind it so again that's that's something I think that we need to bear in mind if we're looking at widening the access to other populations thank you we now move on to questions from Annie Wells please thanks convener hi good good afternoon it is now it's even here that long it's after noon time I know you were here when I asked my question to the previous panel about a national hiv testing week for Scotland and publication of data from from what I heard from earlier I think the general consensus is it would be a highlight to highlight the need for people to go and test but wouldn't necessarily give us enough results to make it to make it I don't mean worthwhile but resource intensive it would be resource intensive to get that and the publication of data I think we all kind of agree that we need to make sure that we're collecting data there but I think that the last part of my question would be that what else can we do I mean we've talked about education we've talked about working with the health health professionals as well as to how do we create a stigma and having been around myself in the 1980s and 1990s we did I thought at that point that was a very clear message that this is where this is what it is and this is and it's not gonna it's not gonna affect you it's not gonna hurt you it's but we got to that stage and I just think like I'm in my 50s now and I know people my age who are HIV positive and they still suffer that stigma they still don't want people to know and it's still a case they feel themselves that that they're the problem and it's not them so I think my last question is how do we really challenge that stigma and is there anything new that we can bring to the table around the stigma side of things? Nicky yeah so I think you've touched on something I think it's about the kind of multifaceted aspect of HIV stigma so we've talked about it in quite general terms today but the way that stigma works and I don't have an easy answer for this by the way but I think it's probably helpful to think about stigma in a few ways for people living with HIV there's a self stigma that happens and I think that's kind of maybe where you are alluding to the people that you know so people who are living with HIV often self you know often expect that adverse reaction and withhold information I think it's it's really interesting I think probably everybody in this room will have will know somebody or have a family member or a friend who have adjusted to some kind of change in their health a long-term condition of some sort and when you have that kind of like long-term condition you obviously you look to your loved ones for support and say this is this has happened to me this is and you look for that but for people living with HIV that's kind of not available or because of the kind of self stigma that plays out and then there's a layer which is I think particularly tricky and again I don't have easy answers but it's somewhere that we do need to focus and it sits between that population level and it sits between that self stigma and it's within the communities that most experience or that most acquire HIV so are gained by sexual men and other men who have sex with men population are people who have arrived in Scotland from high prevalence countries especially in the southern African continent and for people who inject drugs a lot of stigma that they experience comes from within their own communities so the examples of and we kind of the the examples that we included in the campaign and in the film that's part of the campaign were very much drawn from those kind of like genuine lived experience stories that came from people who contributed so it's within those kind of like sub populations if I can call it that and so there's something about how we do much more targeted work within those within those communities as well as that piece around the the broader population I think we need to build on the first year of the campaign I'd like to see in the the so I'd like to see that more focused work we did deliver the campaign to those particular population groups in a in a very focused way in the social media aspect of it but we need to kind of build on that build on that message we absolutely need to expand our anti-stigma work into the health and care system I think it's the one place that when we ask people where do you where do you want this to change most it's in the health system so I think a greater focus on the health system and that more targeted work within within communities from a from a public health scotland perspective excuse me from my role we see our data as being really important in guiding perhaps where some interventions could be targeted historically the hiv data that is published on an annual basis is broken down perhaps at an age an agenda a gender level breaking data down further would give insight into for example if there are certain marginalized populations subgroups of the population who are not accessing testing but there's a risk there you've got to balance you've got to balance that because you do not want to inadvertently cause more stigma by identifying subpopulations and certainly we recognize within phs that there are data gaps and we are working towards strengthening the surveillance systems that we have in place and expanding the indicators that we can share with our partners and stakeholders so that it can help inform the planning locally um we do have an annual publication but we're also looking at developing an interactive dashboard that will allow our primarily initially it will just be management information for our local health board colleagues to support the planning but over time what we'd like to have is a public dashboard that will allow we'll give that transparency with regards to reporting our data and show but hopefully over time that progress towards reaching hiv transmission elimination in scotland we can't promise all of that overnight like elsewhere in the health service we are we have limited capacity we are slightly on the back foot i would say within public health scotland in relation to reporting data my team was pivoted in its entirety to support the Covid response and we have not yet reached our full we haven't filled all our posts at this point going forward so we're in that very challenging stage of having to prioritise where we focus our surveillance activities and unfortunately timelines take longer than planned thank you very much for that i look forward to seeing how this all works out with interactive dashboard on that so thank you very much all that's great thank you again um are all members content they've asked all their questions i think that concludes our business in public this morning and i want to thank the witnesses for their attendance today and we will now move into private session