Hadley Stewart talks HIV, PrEP and COVID-19 with the NHS England National LGBT Advisor.

Dr Michael Brady is a busy man. The doctor divides his working week across his three roles: HIV Consultant, Medical Director at the Terrence Higgins Trust, and National LGBT Advisor at NHS England. It’s a way of working that requires “careful diary management” he tells me as we speak over the phone. Our interview happens to fall on the morning after the announcement that PrEP will be funded by the government in England, allowing local authorities to supply the HIV-prevention drug to those who need it most. Michael’s washing machine has also broken down, so while we discuss the coronavirus pandemic, an engineer is busy trying to fix it in the background.

“Yesterday’s announcement is one that is welcomed,” says Michael. “There are a lot of people who have been involved in the fight for PrEP from the outset and they should be very proud.” He does acknowledge that there is still work to be done. “I think that the IMPACT trial has been a really good bridging opportunity for people who wanted to take PrEP, but were waiting for it to be rolled out on the NHS. This latest announcement will mean that nobody will miss out on the drug. There are of course groups that might not know a lot about PrEP or don’t have access to it, and I think the funding of it through the NHS will now provide us with the opportunity to really engage with these groups.”

For years, activists have been campaigning for the roll out of PrEP on the NHS, as a means of giving people additional choice when it comes to having safer sex. Now, as well as HIV, gay and bisexual men are being confronted with a novel virus when hooking up. Not only has the coronavirus pandemic delayed the funding announcement of PrEP, government social distancing rules meant that sex with someone outside of your household was also off the cards. “When we first put out some guidance at the start of the pandemic, it was much stronger,” says Michael of the Terrence Higgins Trust’s initial #NoHookups campaign, which was met with criticism from some gay and bisexual men. Michael argues that at the time of the initial campaign, cases of the coronavirus were rising dramatically, and the guidance was put out in an attempt to reduce the onward transmission of COVID-19 between households. “I think the messaging at the time was the right one.”

Fast-forward a couple of months, and THT published a second version of guidelines about having sex during the pandemic. “As a sex positive organisation, and one that has never advised abstinence, it was important to then shift that message and language to guidance that was more based on risk assessment, and to advice that was more pragmatic,” explains Michael. He says that the updated guidance reflects an awareness that a minority of gay and bisexual men are having sex with partners outside of their household. “I think we all have a responsibility to prevent the onwards transmission of COVID-19,” he reasons. “However, if you’re someone who is having sex with someone from outside of your household, we do have some pragmatic advice that we can give to try to make that as safe as possible.”

The current THT guidance states that your best sexual partner is yourself, something which Michael tells me he continues to advocate. What’s more, for people wishing to have sex with a partner, other recommendations include the wearing of face masks when having sex, avoiding kissing, favouring sex positions to not face your partner, and no kissing. Are these realistic, I ask. “It’s guidance, it’s advice,” replies Michael. “We’re not policing it and we’re certainly not telling people what to do. We are putting out information to allow people to make informed decisions for themselves.” I put to him that there were comments on social media, following the publication of the most recent guidance, that ridiculed the idea of wearing a face mask during sex. Michael says he saw these comments too. “Realistic or not, this is about responsibility. Whatever you think about the guidance and information, the absence of information altogether is far worse.”

Many gay and bisexual men were already finding negotiating safer sex challenging prior to the pandemic. Now they are being advised to wear condoms during oral sex and avoid kissing. Does Michael, I wonder, have any advice about negotiating this new advice? “I would always encourage people to have discussions about making a sexual encounter as safe as possible before having sex with someone,” he says. “I think things like PrEP and U=U has really opened up discussions between partners, where people are starting to feel more confident about having discussions around HIV status or STIs. Now, we could add in a conversation about coronavirus symptoms, risk and how to mitigate that risk.”

As the National Advisor for LGBT Health at NHS England, Michael is also responsible for improving the care received by LGBTQ+ people in the NHS, be that in hospitals or in primary care settings. “It’s clear from all of the data that we have, that LGBTQ+ people do experience quite significant health inequalities, do have poorer experiences when they access health services, do have poorer clinical outcomes in some areas,” explains Michael. “It’s an NHS-wide problem.” According to the 2017 National LGBT Survey, 16% of people who have access health services had a negative experience due to their sexual orientation, increasing to 38% when it came to gender identity. What’s more, 80% of trans respondents said they found it difficult to access gender identity services.

In response to this survey, former Prime Minister Theresa May pledged an LGBT Action Plan, which included the creation of the National Advisor for LGBT Health role. “The focus is very much on three different areas: data collection and monitoring; education and training; and delivering inclusive services,” Michael says of his responsibilities. He wants LGBTQ+ people to feel comfortable talking about their sexuality and gender identity when accessing NHS services, with frontline staff getting additional training in order to have these conversations. It’s a concept that mirrors that of the Rainbow NHS Badge, an idea that was created by paediatrician, Dr Michael Farquhar. The badges were initially posted out individually to his LGBTQ+ colleagues at other NHS hospitals. Now the badges are being worn by staff at over 150 NHS Trusts in England.

Dr Michael Brady is one of a slowly growing number of NHS clinicians who are opting for a career path that sees them using their skills away from clinical medicine. How does he manage this multi-hyphenated way of working? “Sometimes not very well, some of my colleagues might say,” he laughs. “I start off with trying to divide the week: one day at THT, two days at NHS England, and two days in clinic. Most of the time that works.” He says that there is a degree of flexibility across his three jobs, meaning that he can steel time from one job, if another is demanding more from him that week. “It starts to get quite tricky when more than one or all three are busy at the same time, but generally it works.” He also credits the teams he works with for his ability to spin so many plates.

Given that burnout is such a huge problem for NHS frontline staff, even before the coronavirus pandemic, I wonder what Michael thinks of the idea of more part-time clinical roles being a solution to staff retention. “Personally, I would recommend it,” he replies. “I think it’s a way to keep yourself interested and energised.” Michael also advocates for fellow healthcare professionals to apply their knowledge to work outside of medicine. “There are many clinicians that have skills that go beyond their clinical practice, and that could be used elsewhere. Burnout it a huge problem and I think one of the most important things is to protect your downtime and to protect your mental health and wellbeing. For me, having more than one job keeps the week interesting and keeps my brain stimulated.”

As we draw our interview to a close, against the backdrop of a looming second wave of coronavirus cases, Michael is keen to reinforce to people that HIV and sexual health services will always be open for them. “It’s important to remind people that services never completely closed, there was always a skeleton staff across HIV and sexual health. Patients should always know that services are here for them.”