Testing Times: Interview with Registered Nurse and Counsellor Hilary Gerrard
Hilary Gerrard “just fell into” working in HIV after qualifying as a nurse in Edinburgh, Scotland, in 1985 – the year of the city’s first positive diagnoses.
She came to New Zealand in 1998 and, having discovered her passion was sexual health and HIV, became one of the HIV clinical nurse specialists at Auckland City Hospital from 2004-2011, during which time she also trained and qualified in counselling and sex therapy. She describes working with the New Zealand AIDS Foundation and being able to utilise all her training and experience in HIV, sexual health and counselling as her “dream job”. As well as general education, Hilary’s role is to provide a non-judgmental environment to work with people at risk of HIV, and those who are newly diagnosed. She works with clients, their partners, family and whanau to help them accept the impact that living with HIV will have on their lives.
2016 had the highest number of newly diagnosed HIV infections among gay and bisexual men ever recorded in New Zealand. With your perspective of having worked in the sector for more than 30 years, why do you think the testing strategy is so important in terms of Ending HIV in New Zealand?
Hilary Gerrard: For me, the role of testing is so that people know they’re positive and about getting them on treatment as soon as possible. The good thing is that now the CD4 threshold of 500 has been taken away as of July 1, that means that they can go on medication straight away and that protects their health and it also protects the community, and to me that’s maybe the most important part of Ending HIV.
So why do you think we’ve seen this rise in new cases of HIV?
HG: It’s very complex, we’re obviously testing more people more often, which is great - so we are likely to pick up more cases. But I wonder whether we are reaching the people we really want to reach – because although it’s always good to hear that you’re negative, what we’re looking for is the positives. The big issue here, for me, is that men who have sex with men can cover a broad spectrum of different sexualities. I think a large number of those men feel isolated in their sexual practices and keep that part of their lives secret. There’s also a lot of denial that goes on around sexuality. And, I think these men are the ones we’re looking for – the ones who haven’t tested. I feel that they’re the 1 in 5 that don’t know they’ve got HIV. We are doing a lot better by having peer testers going into the sex-on-site venues because we think there are a lot of high-risk men who have sex with men who go there.
Condoms are available in these places, but it’s up to an individual to make their own choices. Certainly, when I’m counselling someone who’s high-risk, it’s about working with that individual around what it means to them and their sexual identity.
Do you see the message of using condoms getting through to these high-risk groups or is it a hard sell?
HG: I think some people are very good at getting the condom message across, although it’s a hard sell sometimes. There’s a lot of research saying that if you use a condom your first time being sexually active, then you are a lot more likely to use condoms all the time. But there are also studies which consistently say we have 80% condom use in this country and I don’t know if it’s as high as that. From what I see and the more I talk to people, the more I hear stories such as “Ah, yes there was this time I didn’t use a condom’ or “I use it more now than I used to”. The term “condom fatigue” has been used for a long time in and I think people might be fed up of hearing that message. I look at it like a pyramid in terms of what’s available and I’ll always say that condoms are the top of that pyramid because they’re the cheapest and most widely-available tool we’ve got against HIV.
Is risk-taking increasing?
HG: Hard to say, but overall I’d think yes. But there’s no single answer as to why that is. There are lots of sides to risk. The sex-and-drug scene is not at the same level here as it overseas. We don’t understand exactly what is going on here in terms of Chemsex, but people I’ve worked with here who are into it are from quite a varied age group. Risk taking is across the board - it’s not just a thing for those in their 20s and 30s. Some have been in their 60s as well.
Have you seen higher rates of testing?
HG: Testing levels have gone up and that’s the goal of the NZAF. We’re aiming for 6,000 tests a year. When I meet someone who’s testing for the first time, I say “welcome to testing” so they get the message that they are able to come back and do this whenever they want: we’re always available. I’ve had people testing for the first time in their 60s and people who haven’t tested for quite some time in that age range but, on average, it’s younger men I see. And there’s certainly been an increase in Asian young men. I think it’s possibly hard for them because many don’t have family support here in New Zealand and that can be a problem because, if they tested positive – who’s going to be there to support them?
When you first started working with people living with HIV, a positive diagnosis was very much seen as a death sentence. How has that changed?
HG: I think generally now most people want to know their HIV status, although there is still that small pocket of people in denial about their behaviour who are not testing. It certainly isn’t the death sentence it was but there are people who still talk about it in those terms depending on their background and culture. It is still not unheard for people to be really worried about dying after receiving a positive diagnosis - often the first thing they’ll think of is that they are going to die. That’s why we link new diagnoses to immediate medical care and support.
And how has counselling changed as the treatment has improved?
HG: I’ve been working in that area since 2009, we’re certainly moving to a point where the counselling is not so long-term. If you were diagnosed pre-1996, when combination therapy came out, you were given a completely different and negative message about living with HIV. Back then, people needed longer-term therapy because there was a lot of guilt about surviving, when a lot of their peers had died. For those who have been diagnosed in the past five years, there’s a different mindset. A lot of the counselling is about holding them and through cognitive behavioural therapy, getting them to think about the diagnosis in a different way and rephrasing it around what it means to them. A lot of it is about self-stigmatisation and not what other people think about HIV – it’s about how they feel themselves and exploring that with them. For example, in terms of having a sex life, the message I always say is that those with HIV are entitled to a long and loving sex life just the same as anybody … and that’s achievable. That’s a long way from what it was like in the late 80s. Hope was the message back then, hope that you’d still be alive.
What are your feelings about the impact of PrEP?
HG: At a recent NZAF staff hui we had an exercise in which we had to stand on a line about where you feel about PrEP as a prevention strategy. I suppose I feel very much in the middle because of being a nurse as well as being a counsellor, I think that you can see results already in Australia where it’s readily available and the transmission rates have gone down by a large amount. Studies show that PrEP, when taken every day, can reduce HIV transmission by up to 99%.
But my concern is that we might look back in 10 years and think it wasn’t such a great idea because of other STIs dramatically increasing. Nobody was prepared for when HIV started to explode and my fear is, what if there’s another STI around the corner as equally devastating as HIV was in the early years. I’d want to prepare for that. I find the question about PrEP a hard one and it’s very much an individual thing – I’m just very cautious because I saw what it was like in the 80s. It’s not that I think it’s a bad idea – I can see reasons behind it and for a lot of people I see in my office I’ll know that it’s the only option for them. I suppose I’m a bit hesitant because no one knows what the future looks like.
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