The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I am most grateful to my noble friend for today’s debate on this important issue. All of us know how much he personally has done to ensure that HIV and AIDS remain firmly on agendas, both at home and abroad. I may not be able to give him a medal, but I congratulate him on his book AIDS: Don’t Die of Prejudice, which is very timely and draws on his great experience. It is most welcome given that there is still, as we have heard today, much to do around the world to reduce the stigma and prejudice associated with HIV. I welcome, too, his appointment as a member of the International AIDS Vaccine Initiative.
Compared with many other countries, HIV prevalence in the UK remains relatively low: just under three per 1,000 of the adult population were living with HIV in 2013. Thanks to the Government’s early efforts and the leadership of my noble friend back in the 1980s, we have been spared the higher prevalence rates seen by other European countries and countries in other continents. Our confidential sexual health clinics are doing more and more HIV tests—more than a million in 2013, up 5% from 2012. The NHS continues to provide excellent, high-quality HIV treatment and care for everyone, with 90% having an undetectable viral load. Diagnosed early, the outlook for people with HIV in the UK is very good and most people can expect a near normal life expectancy. We also benefit from government’s sustained investment in Public Health England’s comprehensive HIV surveillance systems.
A 2014 report for the National AIDS Trust by Ipsos MORI reported that overall public support for people with HIV is higher than ever, with 79% of adults agreeing that people with HIV deserve the same level of support as people with cancer. Today, it is much easier to get an HIV test, with virtually all NHS sexual health clinics providing the option of same-day testing results. Like many other countries, we have virtually eliminated mother-to-child transmission of HIV.
However, we are acutely aware that challenges remain in how we tackle HIV. Although overall HIV prevalence in the UK is very low, there are marked variations. In London, HIV prevalence in men who have sex with men—MSM—is much higher, and in 2013 one in eight men were living with HIV, compared to one in 26 outside London. In 2013, the prevalence rate of HIV was approximately 30 times higher for MSM and black African men and women compared to the general population in England. New diagnoses in MSM continue to increase, with 3,250 MSM diagnosed in 2013. Some of this increase will be due to increased testing but there is evidence of increasing risk-taking behaviours, which prevention services and community groups must address, taking into account the latest research and evidence. Achieving sustained changes in risk-taking is challenging for all.
Today, HIV prevention is just as important as it was in the 1980s. Investment in prevention also makes good economic sense, as noble Lords have argued, given that each new HIV infection represents between £280,000 and £360,000 in lifetime treatment costs alone. I will pick up a point made by the noble Lord, Lord Cashman. Although we have excellent NHS HIV treatment and care services, and antiretroviral treatment is highly effective, we are still seeing too many people diagnosed late, after treatment is recommended. This means they are unable to benefit from that treatment and risk transmitting HIV to their partners. Although we have seen improvements, HIV still attracts stigma, which is unacceptable and can deter people from getting tested and, if positive, taking their medication. I listened with care to my noble friend Lord Black on that theme.
In 2013, the department published A Framework for Sexual Health Improvement in England, setting out our ambitions to improve sexual health and well-being for all. These include reducing the rate of sexually transmitted infections, including HIV, using evidence-based prevention and treatment initiatives; tackling HIV through prevention, including increasing access to testing to enable earlier diagnosis and treatment; and tackling the stigma, discrimination and prejudice often associated with sexual health and HIV.
Late diagnosis is included as an indicator in the public health outcomes framework and progress is being monitored. Since we published the framework, we know that HIV testing services are changing and becoming more innovative and focused around the needs of people. A good example of that is self-sampling HIV tests to reduce undiagnosed and late diagnosis of HIV.
Self-sampling HIV test schemes, such as those provided through the HIV Prevention England programme and the 56 Dean Street clinic in Soho, show that new types of tests are acceptable. Importantly, they appeal to people who choose not to use traditional services, and they are picking up undiagnosed HIV. An assessment of more than 4,000 people using self-sampling HIV testing services in November 2013 indicated that the majority had never had an HIV test, yet were reporting high-risk behaviour. It is encouraging that the rates of late diagnosis are improving, albeit slowly—down from 57% in 2004 to 42% in 2013. However, I agree that we need to do more to reduce this. Last year, we removed the ban on the sale of self-testing kits, which will eventually provide further options for testing.
Healthcare services, including general practice, especially in high-prevalence areas, have a key role in offering HIV testing. We were pleased to fund the Medical Foundation for HIV & Sexual Health to produce a web-based interactive tool to make testing easier in primary care. That was launched by MEDFASH last November.
Finally, my noble friend Lord Fowler referred to the prevention budget. We are committed to protecting the national HIV prevention budget for next year. I agree with him that we will need to be more ambitious and innovative in our plans to prevent the spread of HIV. We will be announcing our plans very shortly and these are likely to include a contract with the Terrence Higgins Trust for the HIV Prevention England programme, but we are also keen to be more innovative and ambitious in our response. At that time, the answer to one of the questions posed by the noble Lord, Lord Collins, will become clearer.
I will endeavour to answer as many questions as I can in the time available but I will of course write to noble Lords whose questions I cannot answer today. The noble Lord, Lord Collins, referred to a lack of clarity, as he perceives it, in the overall responsibility for commissioning these services. We recognise that the public health and NHS reforms have presented some challenges for sexual health services, and a number of actions have been taken or are planned. Public Health England has worked with partners, including the Local Government Association, and last summer published Making it Work: A Guide to Whole System Commissioning for Sexual Health, Reproductive Health and HIV. It is planning to undertake a review of commissioning arrangements for sexual health and HIV, similar to the one just published for drugs and alcohol.
My noble friend Lord Fowler called for a new campaign to promote testing. As I mentioned, the level of testing in sexual health clinics is increasing, which is encouraging. More than 1 million tests were carried out in 2013, which was an increase on the previous year. I agree that that level needs to increase, with action by local authorities, especially in high-prevalence areas. We need to offer new ways of testing, as I mentioned—for example, home sampling.
The noble Lord, Lord Cashman, rightly said that engagement with HIV charities was vital in determining the way forward. We see 2015-16 as a transition year towards a longer-term plan for sexual health promotion and HIV prevention. Public Health England will engage with key stakeholders on their new strategy, and my department has been discussing 2015-16 contracts since last November.
My noble friend Lord Black mentioned stigma. I remind us all that it is not just the NHS or the Government who have a role to play here, it is everybody. Community and faith groups, the media and individuals all have a part to play in eliminating HIV-related stigma. We should not forget some of the good news, part of which is that people with HIV are now protected by UK equalities legislation. The department’s framework for sexual health improvement is clear that there is a need to build an honest and open culture, where everyone can make informed decisions and responsible choices about relationships and sex.
The noble Lord, Lord Cashman, referred to the role of local authorities. We believe that local authorities are best placed to make decisions on investment in HIV health promotion services and primary prevention services. Reducing the late diagnosis of HIV is included in the public health outcomes framework, as I mentioned. We have provided local authorities with £8.2 billion of ring-fenced funding for public health, including HIV prevention. I completely understand the arguments in favour of the ring-fence; it has played an important part in ensuring a smooth transition of services and will continue to apply through the next financial year. We have always intended to review the need for it after that. We will do that during discussion on the next spending round, but of course it is for the next Government under the ensuing comprehensive spending review to decide on the continuation of the ring-fence.
In primary care, there is evidence that HIV testing is acceptable to patients and healthcare professionals. My department was pleased to fund the Medical Foundation for HIV & Sexual Health for its HIV testing in primary care project, launched last November.
I just mention the issue of PrEP and Truvada, referred to by my noble friends Lord Fowler and Lord Black and the noble Lord, Lord Collins. The recent results from the trial are encouraging. Further work is needed, and NHS England has set up an expert committee to consider the results of the PROUD study and whether PrEP should be provided by the NHS. Some outstanding issues are being considered in that process which prevent us forging ahead immediately with any action. For example, there is the evidence supporting use in other higher-risk groups, such as black African groups, and whether the recommendation should be for daily treatment, as in the study, or only to protect individuals for a certain high-risk event. The service model is also important here. I can write further on that to noble Lords.
I hope that I can reassure my noble friend Lord Fowler on the continuation of methadone and reducing the harm that drug-taking can cause. Again, I shall write to him on that subject, as I shall to the noble Lord, Lord Crisp, and all those who have spoken about global issues. For now, my time is up. I thank all contributors for their expert speeches, to which I shall respond.