Baroness Northover
My Lords, I congratulate my noble friend Lord Fowler on securing this important debate today, World AIDS Day. He has an outstanding record as the person who very much shocked us into an awareness of AIDS. He also deserves plaudits for his continuing interest in HIV and AIDS nationally and internationally, an interest that has done much to raise awareness inside and outside Parliament. As we know all too well, in issues such as this awareness is a significant part of the battle.
The report by the House of Lords Select Committee on HIV and AIDS in the United Kingdom, No vaccine, No Cure: HIV and AIDS in the United Kingdom, was most timely, given that it was 25 years ago when my noble friend led the Government’s response to HIV and AIDS. I commend the outstanding membership of this Select Committee, many of whom have a long record of work in this area, as I know from when I was an officer of the All-Party Parliamentary Group on HIV and AIDS. This report will help to inform the Department of Health’s new sexual health policy framework planned for next year.
In October, we published the Government’s response to the report and made clear that we agreed with many of the Committee’s recommendations on combating HIV and AIDS. World AIDS Day provides an excellent opportunity to reflect on the progress that we have made. Globally, there has been progress. The epidemic has stabilised in many regions. New infections have fallen by 21 per cent since 1997. Nearly 7 million people are on antiretroviral treatment—a more than tenfold increase over five years.
Today is also an opportunity to recognise the continuing challenges presented by HIV, both globally and at home. More than 34 million people are living with HIV and, as noble Lords have noted, there is no cure or vaccine in sight. Around 10 million people in need of treatment are not getting it. There are more than 7,400 new HIV infections every day, which is two for every person who begins receiving treatment. To compound the problem, HIV funding is flatlining, about which we can read more in today’s papers.
While the scale of the epidemic is very different in countries such as the UK, as my noble friend Lord Fowler pointed out, we are not unaffected by the global picture. Effective treatment from the NHS can transform the lives of those living with HIV or AIDS, but there is no cure or sign of a vaccine and HIV still attracts considerable stigma, which is a huge challenge.
The Government’s early response all those years back, led by my noble friend Lord Fowler, has helped to make sure that the UK has remained a relatively low prevalence country for HIV, particularly compared with some of our European neighbours. The early introduction of needle exchange and harm minimisation programmes, for example, has meant that we have very low rates of HIV in drug users who inject, unlike in other countries, as my noble friend pointed out.
Earlier this week, the Health Protection Agency published its annual HIV report for 2010. There are now around 91,500 people living with HIV, of whom around a quarter are unaware of their infection. This means that they are unable to benefit from highly effective treatment and risk unwittingly transmitting HIV infection to others. The HPA also reported that in 2010, new diagnoses in men who have sex with men—MSM—reached a peak of 3,000, and MSM remain the group most at risk of HIV transmission in the UK.
That is why I very much welcome the report’s focus on the importance of HIV prevention. The Government agree that we need to be more effective in supporting responsible sexual behaviour. HIV prevention makes good economic sense too, as noble Lords have pointed out. The HPA estimated that preventing the estimated 3,800 HIV infections acquired in the UK in 2010 would have saved over £32 million annually, or £1.2 billion over a lifetime, in costs.
This year, the department has invested £2.9 million in a national programme of HIV prevention for men who have sex with men and for African communities, delivered by the Terrence Higgins Trust and African Health Policy Network. On top of that, the NHS provides many HIV prevention services, some funded separately and some funded as part of mainstream services such as testing and distributing information and condoms. The Department of Health is currently considering how national HIV prevention programmes might be taken forward when the current programmes end. The Committee’s comments will help to inform what happens.
Of course, effective prevention requires effective testing. Late diagnosis is the most important factor associated with HIV-related morbidity and mortality in the UK. We agree with the Committee that HIV testing should be offered more widely and in various healthcare settings, particularly in areas of high prevalence. In September 2011, the HPA published its final report on pilots which the department funded in 2009-10 to help to reduce late diagnoses of HIV. The findings were encouraging and patients responded to being offered HIV tests. We are also funding the Medical Foundation for AIDS and Sexual Health to develop ways of helping GPs and primary care staff to offer HIV tests more routinely.
It is vital that the public health system is versatile and proactive enough to deal with HIV and AIDS. Reference has been made to how this is going to be structured in the future. Ring-fenced public health funding is central to our NHS and public health plans. This will allow us to plan spending on prevention without the money being raided for other projects. In today’s restrictive financial climate, this is a very noteworthy commitment in this area.
Finally, I turn to the concerns raised by noble Lords about the current policy to charge some people for HIV treatment. As we made clear in our formal response to the Committee, we are concluding an internal review of our current policy—I know that review does not please the noble Lord, Lord May, but I hope he will be encouraged in the end—and expect this review to be completed by the new year, including any discussions with the other government departments that have an interest. The review is considering many of the issues raised today. These include the increasing evidence on the public health benefits of early diagnosis and the significant role of HIV treatment in reducing the onward transmission of HIV.
Promoting HIV testing to reduce undiagnosed HIV and late diagnosis remain important priorities for HIV prevention. We would be very concerned if our current policy was to deter people from being tested for HIV, even though testing has always remained free of charge to all. I acknowledge that a small number of vulnerable people will not be covered by the current exemptions and that they may be deterred from accessing HIV testing services because they cannot afford treatment or are confused about the entitlement to free NHS treatment. In considering any changes to our current policy we must avoid creating an incentive for people to come to the UK for the purpose of free HIV treatment, without compromising our overriding responsibility for public health. I hear the powerful case made by the right reverend Prelate the Bishop of Wakefield in this regard. The department’s review has considered many of the issues raised today and we will conclude it by the new year.
I turn to some of the questions that noble Lords have put to me. The noble Lord, Lord Fowler, asked about supporting more HIV testing in general practice. I have made reference to the funding that we have provided to the Medical Foundation for AIDS and Sexual Health, which is working on a three-year project to try to support GPs and primary care staff in offering HIV testing. The noble Baroness, Lady Gould, also referred to that.
The noble Lord, Lord Fowler, and the noble Baroness, Lady Masham, asked about prisoner health. As they know, we do not routinely screen people in prison for HIV just because they are prisoners—rather, we have an active case-finding programme which encourages both prisoners and staff to consider whether their behaviour, current or previous, may have put them at risk of infection with HIV and provides them with an opportunity for testing. We respect the rights of prisoners to accept or refuse testing if they so choose, which reflects normal practice in the wider community.
The Department of Health offender health team has worked with the HPA to improve disease surveillance in prisons. We aim in the new year to disaggregate data on diagnosis made on people in prison. Condoms are routinely provided in prisons to prevent the transmission of STIs. NICE evaluated the evidence of effectiveness of needle-exchange programmes in prisons and stated that there was a need for more research on the added value. It felt that the condom programme was useful.
The noble Lord, Lord Fowler, and other noble Lords, including the noble Baroness, Lady Healy, spoke of the need for a new prevention campaign. The awareness campaigns of the 1980s, which targeted the whole population, were effective in raising the public’s awareness of a serious public health threat at a time when we did not know how HIV would develop or the main routes of transmission. By the mid-1990s, it was clear that men who have sex with men and people from sub-Saharan African countries were disproportionately affected by HIV. That is why, since 1996-97, the Department of Health funded programmes that focused on those communities. This approach is supported by community organisations and others including the HPA. The previous Government also subscribed to this. I hear what noble Lords have said and this will no doubt continue to be assessed on an evidence-based approach.
The noble Lord, Lord Fowler, asked about home-testing kits, to which I think I made reference in my speech. We are reviewing our policy on banning the sale of home HIV tests. We recognise anyway that the current ban is probably not sustainable given that home-testing kits are already available from overseas on the internet. It is essential if there is any change that home-testing kits are quality-assured, including the provision of clear patient information on following up positive or unclear results. It is extremely important that those kits are reliable if they are going to be used at home.
The noble Lord, Lord Fowler, asked about national procurement of ARV drugs, as did others. The Department of Health is keeping this under wider review. We are very keen to ensure that we have clinical collaboration in ensuring there is leverage on price and that experience from procurements on a local and regional basis will be used in evaluating the ability to take this forward on a multi-regional or national basis. It will be under review.
Various noble Lords, including the noble Lords, Lord Lexden and Lord Black, and the noble Baroness, Lady Gould, spoke about stigma. It is of course very much the case still that stigma is an enemy to progress. TB was a stigma in the 19th century and cancer in the 20th century and we have a problem here also when people are unwilling to come forward because HIV has the power to define a person in a way that an illness simply should not. Too many people with HIV still experience shame and isolation because of their diagnosis and that can manifest itself, as we have heard, in discrimination in all sorts of places.
The Department of Health’s new sexual health policy framework planned for next year will consider how key partners involved in HIV care work and others can work together to reduce and challenge HIV stigma. The national HIV prevention programme for African communities, funded by the Department of Health, has contributed to toolkits for faith leaders and communities in this area and we want to develop this further; that is a very important message that comes out of this report.
The noble Baroness, Lady Gould, asked whether the Department of Health would consider the HPA’s Time to Test for HIV report. The answer is yes and this will help to inform our forthcoming sexual health policy framework. She also asked about the public outcomes framework; we are considering responses to this, including a proposal on an indicator on late HIV diagnoses and we will publish that framework very soon. The noble Baroness also asked about tariffs on sexual health; as she probably knows there is ongoing work on tariffs and I will write to her in more detail about this.
My noble friend Lady Tonge expressed her reservations about our plans in general and this issue in particular. I can reassure her, at least in one or two areas. The £2.9 million on prevention that was flagged up as being inadequate excludes work done on prevention by the NHS, for example testing, condom distribution and local health promotion. There is more there than she might have felt. I will no doubt address many of her concerns on the health Bill more widely outside this Chamber, otherwise I am sure we will be here again until at least midnight.
My noble friend Lady Tonge, and the noble Baronesses, Lady Healy and Lady Massey, spoke about PSHE in school; I assure noble Lords that we recognise that children benefit enormously from high-quality PSHE which helps them make safe and informed choices. There is a slimming down of the statutory curriculum to give schools more freedom and space to teach a curriculum which engages pupils; however, we have launched a review of PSHE to identify the core body of knowledge pupils need and ways of improving the quality of teaching. I emphasise that we welcome representations, including evidence and examples of good practice, and I strongly urge noble Lords to feed into that process. As a result of the review we will be drawing up proposals, based on the evidence, and consulting on them.
The noble Baroness, Lady Masham, asked about the future of the HPA; we will be having further discussions about this in the health Bill. In fact, we almost came to it last night but I think it will now be discussed on Monday. As she knows, the HPA, along with a number of other organisations, will be brought together into Public Health England, which will be free to carry out research; it is an executive agency of the Department of Health that will be established in April 2013—always assuming your Lordships pass the health Bill. It can carry out research, it must give advice to the Government—it has that independence; those working will be able to apply for grants and so on. We will work to maintain the excellent quality of the HPA’s current HIV surveillance programme when it transfers to Public Health England.
The noble Lord, Lord Lexden, referred to Northern Ireland, and it was extraordinary to hear of the difficulties that he perceived there. It shows how in many areas, not only geographically but by community, some communities can be particularly difficult and harder to reach than others. Nevertheless, I assure him that the Department of Health works with the devolved Administrations to discuss issues that are common across the UK, such as increased testing, and to share good practice on prevention and care.
There was some concern about possible fragmentation because of local authorities being much more involved now in public health and also the NHS Commissioning Board. Again, we will no doubt return to these issues in the Bill, but the Department of Health is already working, and will be working over the coming year, with key stakeholders to map out the integrated sexual health pathway that will address the concerns raised today. This debate will no doubt feed into those concerns to ensure that work on the issue is joined up.
I have referred to the HIV home testing kits, which the noble Lord, Lord May, flagged up. The noble Lord, Lord Black, and other noble Lords spoke about HIV awareness in the general population being very low. Although we wish to seek improvement in all kinds of areas, it is quite interesting to note that, according to NAT’s Ipsos MORI poll, four out of five adults in the communities that are most at risk were aware that HIV can be passed on by having sex without a condom. In other words, the targeting of information, at least to those groups, is having an effect. I am pleased that that is the case.
The noble Baroness, Lady Massey, the noble Lord, Lord Gardiner, and others asked about the sexual health policy framework. We are seeking to take a life course approach—that sounds like a course that we are offering through PSHE—to sexual health needs, for young people through to old people, including people aging with HIV, and we are working with the Sexual Health Forum to agree this framework. That work is being undertaken at the moment.
The noble Lord, Lord Gardiner, asked about introducing HIV testing and learning from antenatal HIV testing. We have asked the UK National Screening Committee to consider the evidence on making HIV testing more routine. We await its response.
I hope that I have covered most of the points raised. If there are points that I have not answered, I will write to noble Lords. Clearly we have a tremendous amount to think about as a result of this report and there is still more to do. We all have a part to play in keeping HIV high on the agenda, and debates such as this and the coverage today in the media all help to raise the profile of the disease. I welcome the report and the extremely important cajoling from noble Lords today. I am aware that we shall return to some of these areas in the discussions on the health Bill. I look forward to being further cajoled and I hope that we can make progress in at least some of the areas that have been flagged up in this important debate.