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Mike Freer (Finchley and Golders Green) (Con)
I beg to move,
That this House has considered HPV vaccinations for men who have sex with men.
Thank you for chairing this debate, Mr Hollobone; it is always a pleasure to serve under your chairmanship. This debate is a continuation of those that we have had over the past few years. The extension of the human papilloma virus vaccination programme to men who have sex with men—MSM—has been three years to the day in the making.
I first raised this issue in an Adjournment debate on 2 July 2013. I thank the then Minister for Public Health, my right hon. Friend the Member for Broxtowe (Anna Soubry), who, in responding to that debate, said that the issue could no longer be ignored. However, I reserve my heartiest thanks for the Under-Secretary of State for Health, my hon. Friend for Battersea (Jane Ellison), who is in her place today, for her unswerving support to ensure that HPV vaccinations are finally available for MSM. I have no doubt that without her personal support and her forbearance of my cajoling on a regular basis the new programme may not have happened.
Before turning to issues relating to the pilot of the new vaccination programme, it is worth reminding ourselves why such a programme is needed. I make no apology for raising yet again what some might regard as unsavoury issues—sometimes we do not like to talk about sexual health. HPV is responsible for nine out of 10 cases of genital warts, and men are six times more likely than women to have an oral HPV-related infection, which increases the risk of cancers of the mouth, throat, neck and head. Then there is HPV-related penile and anal cancer. HPV is associated with 80% to 85% of all anal cancer in men. In 2009, just after the general HPV vaccination programme started, there were more than 6,500 cases of these cancers. Some 47% of penile cancers and 16% of head and neck cancers are thought to be HPV related. The latest incidence data show that in 2010 there were 437 incidences of anal cancer, 5,637 incidences of oropharyngeal cancer, 515 incidences of penile cancer and 90,000 incidences of genital warts. Rates of some HPV-related cancers are on the increase in the UK and throat cancer has overtaken cervical cancer as the leading HPV-related cancer.
It is worth looking at the costs incurred in treating these cancers, which could now be avoided. Each HPV vaccination for the three-dose programme costs an estimated £260 on the open market—I appreciate that the NHS will, I hope, have negotiated a lower price. That compares with the £13,000 cost of treating anal cancer, the £11,500 cost of treating penile cancer, the £15,000 cost of treating oropharyngeal cancer or the £13,600 cost of treating vulva and vaginal cancer transmitted by an infected male. In 2010, the cost of treating genital warts was £52.4 million. The clinical and financial reasons are self-evident. That is why we started this debate three years ago, and today we have a pilot for making vaccinations available for MSM through sexual health clinics.
I will not detain hon. Members for long; this is really an update request. I have several questions for the Minister. How long will the pilot be for? Who exactly will the pilot vaccination programme be available to? Is it to men identifying as MSM or men identifying as MSM who request the vaccine? What if a man who does not identify as MSM asks for the vaccine? Will it be available to heterosexual males?
How will the pilot be evaluated? For example, will it simply be from the take-up of MSM patients registered, or will it measure the adherence rate, because the programme requires three doses, and for all three to be taken, to be effective? So will the evaluation include adherence to the dosage requirements? Is there a timescale to measure the impact on HPV-related cancers and genital warts? Will the results and any mid-pilot indicators be reported to the Minister and, eventually, made public?
I must also ask whether the vaccination programme will include adolescent boys if they turn up at a sexual health clinic. They might not technically or legally be men, but if they are at risk and go to a sexual health clinic, will the HPV vaccination be available to them because they are at risk, and if a clinician deems it necessary? Finally, I cannot miss the opportunity to nudge the Minister on whether we may have an update on when HPV vaccinations will be widely available to all boys in the UK.
Several hon. Members rose—
Mr Philip Hollobone (in the Chair)
The debate is due to finish no later than 5.45 pm. The recommended time limits for the Front Benchers are five minutes for the Scottish National party, five minutes for Her Majesty’s Opposition and 10 minutes for the Minister. The time between now and the first of the Front Benchers being called is open to Back Benchers, and the first person on my list is Jim Shannon.
Jim Shannon (Strangford) (DUP)
Thank you, Mr Hollobone, and it is a pleasure to be able to speak in the debate.
I congratulate the hon. Member for Finchley and Golders Green (Mike Freer) on securing a debate on such an important issue. He has been a stalwart speaker on the issue in this Parliament and the previous one. He never lets his subject matter fall, and I thank him for his commitment and his energy.
It is good to see the shadow Minister, the hon. Member for Denton and Reddish (Andrew Gwynne), in his place again. It is also especially nice to see the Minister in her place again—she is spending a great deal of her afternoon in Westminster Hall, but it is always a pleasure to have her here. I look forward to her response to this debate.
For years, often due to stigma and attitudes, the issue was ignored, so it is welcome that we can now give it the attention that it deserves, not only in Parliament, as today and in the past, but in all walks of life, because it is now part of national conversations on advancing healthcare. As the Democratic Unionist party health spokesperson at Westminster, I am pleased to participate in the debate, to encourage and support the hon. Member for Finchley and Golders Green in what he is talking about today, and to comment on what we have done in Northern Ireland, as I always do in such debates, hopefully adding to our general knowledge of the subject.
Genital warts are the most common viral sexually transmitted infection and are caused by the human papilloma virus. In September 2008, Northern Ireland introduced an HPV vaccination programme targeting 12 and 13-year-old girls in schools. It primarily vaccinated against HPV 16 and 18, which are associated with more than 70% of cervical cancers. From September 2012, 12 and 13-year-old girls were offered the quadrivalent vaccine, which protects against not only types 16 and 18, but types 6 and 11, which are mainly associated with the majority of genital wart viruses. It is expected that rates of first episodes of genital warts will be positively impacted by the introduction of the HPV vaccination programme.
In men, there is no reliable test for HPV infection. As the hon. Gentleman said, it is often difficult to diagnose, and there are no symptoms for high-risk HPV. People who are known to be at a high risk of having anal HPV and of developing anal cancer may be offered an anal smear, but nothing goes beyond that. It is frustrating to have some steps in the health process, but no steps to take things to the next stage and to do what the hon. Gentleman said. That is why we are having the debate today and why it is critical for men to start receiving equality with women in terms of the protection offered against HPV by the health service. Given the higher risk of HPV infection associated with men who have sex with men, surely the provision of a vaccine is a no-brainer.
In November 2015, following a review of the evidence, the Joint Committee on Vaccination and Immunisation published a position statement recommending the introduction of a vaccination programme for men who have sex with men, are aged up to 45, and attend genitourinary and HIV clinics. Some steps forward have been taken, but larger steps are needed, with more ground being covered.
Since the JCVI recommendations, and in line with them, the Welsh and Scottish Governments have announced that they will roll out vaccination programmes. I hope that the Department of Health in Northern Ireland will follow suit—the matter is devolved, as the Minister knows—and that men throughout the United Kingdom will get the long-overdue support that they deserve. It is about fairness, and when there is clear evidence that a section of the population might be at particular risk of something, appropriate action should and must be taken.
Continued monitoring of results is also necessary to ensure that the recommendations, when implemented, have the desired results, and that any changes or extensions to the plans can be made to ensure the most full and proper protection available is afforded to all those affected. To conclude, developments are long overdue. The debate has been welcome and an opportunity to highlight the issue—I congratulate the hon. Gentleman again. The fact that a goodly number of Members are participating is an indication that we, too, want to see change. It is about seeing the plans implemented and ensuring that the proposals work well in practice.
Sir Paul Beresford (Mole Valley) (Con)
I am delighted to see you in the Chair, Mr Hollobone.
I congratulate my hon. Friend the Member for Finchley and Golders Green (Mike Freer) on securing the debate and on leaving enough time for a few of us to add a few words in a few minutes.
I need to declare a short list of potential interests. I am a small—by which I mean I have a small practice, not that I am small in stature, because I am afraid my overweight problem makes that rather redundant—and very part-time dentist. I am also chair of the all-party parliamentary groups for dentistry and oral health, and on skin, both of which have a link to and provide an interest in the debate.
My hon. Friend has explained all the disasters related to this ghastly virus, and what it does. I am more interested in head and neck cancers, for obvious reasons, which he touched on. The statistics on head and neck cancer related to HPV make for hideous reading. Up to 70% of oropharyngeal cancers are caused by HPV. In addition, recent research has found HPV in nearly 20% of large periapical dental abscesses—not as the cause, but probably as a co-contributor to the infection.
Treatment of head and neck cancers are often debilitating, disfiguring and destructive of the patients and their self-esteem. Unless the cancer is caught very early, most frequently radiology and/or surgery is required, involving the face, the jaw and teeth, the neck, the tongue, the pharynx, the larynx, the oesophagus, or combinations of them. Only think of that and we can think how debilitating it is for the patient. Physical disfigurement is common, and speech and eating can be significantly impaired. In the global ranking of cancer deaths, head and neck cancers rank fifth. Furthermore, the prevalence of head and neck cancer is higher in males than in females—a ratio of approximately 2:1.
The cost to the NHS of treatment is astronomical. The latest figure I am aware of is from 2011, when it was costing us £310 million. Since the growth in the frequency of head and neck cancer is one of the fastest of all cancers in the UK, the cost must be considerably higher now—I am sure the Minister will correct me and give the ghastly figure, if the opportunity arises.
Vaccination programmes can eliminate, or virtually eliminate, certain diseases. The anti-polio campaign is such an example. The aim in such programmes is to produce what is called herd immunity. The success of the HPV vaccination programme for adolescent girls in the United Kingdom is progressing and becoming evident, but it is not producing herd immunity. Not every teenage girl participates in the programme, let alone completes the programme. Furthermore, given that today’s debate features men who have sex with men, they are obviously outside any herd immunity that might arise from the inoculations.
I also contend that heterosexual men—quite a proportion of us are left in the community—[Hon. Members: “Hear, hear!”]. I thank hon. Members for the support. We are also vulnerable. Not every girl has the inoculation, as I said, and not every girl completes the programme—I believe the estimate is that 10% of girls do not get full vaccination cover. So if, as some research has suggested—I am not sure whose research this was—an estimated 20% of 16 to 24-year-old men have had 10 or more partners, that means, statistically, one of those partners has not been vaccinated, although it could be more or less.
I fully support vaccination for men who have sex with men. However, vaccination programmes for boys and girls would lead to herd immunity and in time pick up that group as well. I understand that that would cost about another £22 million per year more than the cost now for girls. That is small beer when set against the £58 million spent on treating genital warts and is well below the £300 million spent on head and neck cancer treatment—and we must add in the pain and suffering of cancer victims. As I said to the Minister in July 2014,
“it is not fair, ethical or socially responsible to have a public health policy that leaves 50% of the population vulnerable”—[Official Report, 1 July 2014; Vol. 583, c. 866.]
to HPV and the dreadful diseases that so often relate to it.
What is important is not who is having sex with whom but the fact that we need herd immunity for the whole population. If Australia, Austria, Canada, Israel, Switzerland and the USA—and I suspect also New Zealand, but I have not asked—can achieve herd immunity across the board with excellent results, so can we.
John Nicolson (East Dunbartonshire) (SNP)
I congratulate the hon. Member for Finchley and Golders Green (Mike Freer) on securing the debate. Vaccinations against HPV were introduced in the UK primarily to target cervical cancer. The HPV vaccination programme for girls aged between 11 and 13 has been in place since 2008, and last year the uptake of the vaccination was 89.5% across the UK. It has therefore been a huge success.
However, there are more than 100 types of HPV and it is one of the most common sexually transmitted infections in the UK. HPV infections are highly contagious, as they are spread mainly by skin-to-skin contact, and nearly all sexually active people get infected at some point in their lives. Some HPV infections clear up with no treatment necessary; others will develop into treatable conditions, such as genital warts; and some will go on to cause cancer. Despite the fact that HPV vaccinations in schools are available only to girls, to target cervical cancer, not only women can be infected. As we have heard, among men, 80% to 85% of anal cancers and almost 50% of penile cancers are associated with the infection. Evidence that has emerged since the original HPV vaccination programme was introduced has shown that immunisation is likely to provide protection against a wide range of HPV-related diseases, including those cancers.
The widespread vaccination of girls was intended to create wholescale community immunity and prevent the spread of HPV to unvaccinated male sexual partners. In Australia, research has shown that to have been a success, with a 90% reduction in genital warts in heterosexual men and women under 21 years of age. However, the vaccination programme ignored a significant section of society, which is left defenceless against the dangers of HPV: men who have sex with men, for whom the burden of HPV-related diseases is significantly increased compared with heterosexual men. In particular, they experience a higher risk of suffering from HPV 16-associated anal cancers, with rates 15 times higher in men who have sex with men.
The Joint Committee on Vaccination and Immunisation’s recommendation that a vaccination programme should be introduced for men up to 45 years of age who have sex with men is therefore welcome. In March, the Scottish Government announced their intention to introduce a targeted vaccination programme as soon as possible, and this month NHS England will begin a pilot vaccination programme at selected sexual health clinics to test delivery in those settings. However, the decision to implement a pilot has been described as “unnecessary” and “a cynical stalling tactic” by the Terrence Higgins Trust, which has pointed out that the London North West Healthcare NHS Trust already provides vaccinations to men who have sex with men, with impressive take-up and results. The Terrence Higgins Trust rightly does not want to see delayed a full national programme that could prevent serious illnesses and save lives. Its fears can possibly be traced back to NHS England’s decision not to commission PrEP, a preventive medication for those at risk of HIV, after an 18-month investigation. Instead, NHS England opted to run a number of test sites over two years to research how that treatment could be introduced in the most clinical and cost-effective way. That decision was described as “shameful” by the Terrence Higgins Trust and “astonishing” by the National AIDS Trust.
The pilot HPV vaccination programme is intended to immunise 40,000 people and be followed by a review of its impact. That is a welcome first step, but it is clear that immunisation will need to go beyond sexual health clinics. Those who do not attend such clinics will not be immunised and many may mistakenly believe that they do not need to be vaccinated if they use condoms. Significantly, the optimum age for men to receive the vaccine is as 12 to 13-year-old boys—in other words, at school, at the same time as their female classmates. That is the logical next step.
The Joint Committee on Vaccination and Immunisation is currently considering this issue along with Public Health England and the University of Warwick, although it will not be in a position to provide its final advice until 2017. The Terrence Higgins Trust, HPV Action, the British Association for Sexual Health and HIV, and the British Medical Association all support expanding vaccination to boys through the existing school-based programme. That would mirror the position in Australia, Canada and the United States, ensure that high vaccine coverage rates are achieved and protect all males and females, whatever their sexual orientation, from such serious diseases.
In public health debates, there will always be competing claims about money, priorities and whether proposed action has more positives than negatives, but in this debate the jury has delivered a clear verdict. The vaccine has saved the lives of countless girls and women. Is it not time that we showed some gumption and delivered the same benefits for young men?
Danny Kinahan (South Antrim) (UUP)
I am glad to be speaking today, and particularly glad that the hon. Member for Finchley and Golders Green (Mike Freer) has secured the debate. I started as a new boy in Parliament last year and this issue came across my desk in September. The one simple thing that really shocked me was that we were only immunising girls. I could not believe that we had chosen to go for just one side. The debate is therefore necessary.
I knew nothing about the subject, so we put forward an early-day motion, but I was shocked to find that a whole mass of people here do not sign such motions. We should all support that motion, so I send a message to people to please look through and sign early-day motions, not just ignore them as a policy. The more I looked into HPV, the more I was appalled by how horrific the diseases were. I went to the pop-up drop-in meeting and was shown photographs of genital warts and other unpleasant diseases. They are quite horrific. We should be helping everyone with such diseases, whatever the cost, and we must find the most important and economic way of doing so.
I was glad to see that my colleagues in Northern Ireland from every party had signed the early-day motion. That shows that although we are a part of the world that is sometimes known for avoiding this sort of subject or avoiding difficult things, we can lead. I was glad to hear the update from the hon. Member for Strangford (Jim Shannon) on where we have got to, and I too will ensure that we push for everyone in Northern Ireland to be looked after and vaccinated. I ask the Minister to look at how we can get a vaccination programme in place as quickly and economically as possible, so that 400,000 boys a year can be vaccinated, the disease does not build up and get worse, and the vaccination is there for all people of every type. That is the message that I want to get across.
Martin Docherty-Hughes (West Dunbartonshire) (SNP)
It is always a pleasure to see you in the Chair, Mr Hollobone. I congratulate the hon. Member for Finchley and Golders Green (Mike Freer) on securing this important debate. I will concentrate on four points that I believe are fundamental: stigma, the recommendations of the Joint Committee on Vaccination and Immunisation, implementation and lessons to be learned. I have no doubt that living with HPV can be similar to living with HIV/AIDS. Nobody wants to talk about it, even today, and that cultural silence embeds the stigmatisation of those living with HPV, while limiting our ability to improve access to services and to reduce the indices of, in this case, men who have sex with men who are infected with HPV.
As my hon. Friend the Member for East Dunbartonshire (John Nicolson) said, HPV is one of the most prevalent infections. Statistically, most of us in this room will have been infected by at least one of the differing strains at some point in our lives. Although the majority of us deal with that infection naturally, which has already been mentioned, challenges in removing the infection remain for those, critically, who smoke, and those with compromised immune systems—for example, people living with HIV/AIDS.
As for stigma, let us be frank. Discussing anal warts can be a conversation stopper. For men, in particular, addressing and discussing health-related issues is problematic in general. With that in mind, I encourage Members to reflect on research undertaken several years ago in Scotland on male cancers for Cahonas Scotland by John Docherty-Hughes of Queen Margaret University, Edinburgh. I must declare an interest: he happens to be my husband. Entitled, “Men, Masculinities and Male Cancer Awareness: a preliminary study”, it found that men felt uneasy when being open about their fears in relation to their own health, specifically in relation to cancer for that research, but also health in general. I recommend Members avail themselves of that research as it challenges those who seek to improve services for men, whether cancer or HPV specifically. It is critical that we reduce stigma in relation to male health and wellbeing.
Let us return to the recommendations of the JCVI. As a Scottish constituency MP, I am delighted that the Scottish Government earlier this year announced that they will make men who have sex with men eligible to receive the HPV vaccine without recourse to a pilot. They are working to ensure that the vaccine can be introduced for men who have sex with men as soon as possible, in contrast to the pilot programme being proposed by the UK Government in England. On implementation, the roll-out of the HPV vaccine has so far been a resounding success, with HPV immunisation uptake exceeding 80% in Scotland.
As to lessons learned—I do not want to detain the House for long—the hon. Member for Finchley and Golders Green has, by securing this debate, given us the opportunity to inform and educate not only the policy makers sitting behind the Minister, but colleagues and those watching the debate in the Public Gallery and on television. The key to improving the health and wellbeing of men, from my perspective and in much of the research I have read, is education based on their lived experience culturally, socially and economically. That is whether they have sex with other men—frankly, one can identify as being heterosexual and have sex with other men—are homeless, are black or from a minority ethnic community, identify as heterosexual, homosexual or bisexual, or are transgender, because even men in transition must deal with the consequences of male health.
The key question is this: are the UK Government and healthcare practitioners in the NHS and the charitable sector able to meet the challenge and listen to the lived experience of men who have sex with men living with HPV and those who support them? Will they begin the full implementation of the recommendations of the JCVI and start the full roll-out of that vaccination across England?
Stewart Malcolm McDonald (Glasgow South) (SNP)
It is good to see you in the Chair for the second sexual health debate of the day, Mr Hollobone, at which you have been present along with myself and other hon. Members. I congratulate the hon. Member for Finchley and Golders Green (Mike Freer) on securing this debate. He started by saying that it is perhaps not always nice to discuss unsavoury issues. Just imagine the lives we could have saved if we had discussed unsavoury issues a lot more a long time ago. I genuinely welcome this debate, and indeed the other work he has done on matters related to gay and bisexual men’s sexual health, particularly PrEP, which we discussed in the House earlier today. He described this debate as an update request. I am afraid to tell the Minister I am going to go one further. I think we sometimes get too many updates and not enough action; it is action that we need to see.
We have had some incredibly thoughtful and well-researched contributions, including from, as usual, the hon. Member for Strangford (Jim Shannon). We have heard some excellent experience from the medical profession, and my hon. Friend the Member for East Dunbartonshire (John Nicolson) quoted the Terrence Higgins Trust, which has called the pilot scheme a “stalling tactic”.
I notice a pattern when it comes to these matters. There seems to be an attitude among the public that the Government—I do not doubt the Minister’s sincerity on these issues; I genuinely mean that—do not appear to be taking LGBT sexual health as seriously as they should be. We have a situation, as my hon. Friend the Member for West Dunbartonshire (Martin Docherty-Hughes) outlined, in which the Scottish Government have moved forward on this, the Welsh Government have moved forward on this, international partners have moved forward on this, but the largest constituent nation of the United Kingdom has decided to sit on its hands and go for an unnecessary pilot scheme. The message from sexual health charities and from the public is that that is just not good enough. I cannot understand, given the position we find ourselves in with this issue and with the PrEP issue, why we have not seen further progress.
My hon. Friend the Member for West Dunbartonshire mentioned the important issue of stigma. We cannot go back to the days when stigma caused people not to have conversations, seek treatment or seek to have a healthier lifestyle. That would be disastrous for public health and for the public purse. There is an appetite across Europe and across the United Kingdom to move forward on this issue, which does not stop at any border. It is something that we all have to work together on. We want to see the UK Government get a bit of “gumption”, as my hon. Friend the Member for East Dunbartonshire said, get off the fence, and start with some positive action on this issue and on the PrEP issue as well.
Andrew Gwynne (Denton and Reddish) (Lab)
It is a pleasure to serve under your chairmanship, Mr Hollobone. I add my congratulations to the hon. Member for Finchley and Golders Green (Mike Freer) on securing this debate, and on the important cross-party work he does in the House on championing the cause of men’s sexual health. I also thank other hon. Members for their contributions.
I understand the importance of the quasi-independent nature of the JCVI, and I do not want to change that, but I believe the Minister has an important duty to the country to ensure that the JCVI operates efficiently and with the right priorities in mind. In that spirit, I have a series of questions to ask her on this important matter, some of which have been covered in the debate. First, I will raise the long delay in the decision on whether all boys should be vaccinated. The JCVI began its assessment on whether boys should be included in the national vaccination programme in 2013. A decision was originally expected last year, but was subsequently rescheduled for 2017. Experts in the field are already convinced that boys should be vaccinated, and I urge the Minister to ask the JCVI to make its recommendation this year, so that implementation can begin as soon as possible.
Secondly, I want briefly to discuss the JCVI’s approach to making the decision. As we have said in other debates in this Chamber, the JCVI is far too constrained in its approach. Its analysis of cost-effectiveness focuses solely on the cost to the NHS and takes no account of social costs, the costs of care or welfare benefits, or the costs to employers and to individuals and families affected, in this case, by HPV-related diseases. For example, 50% of people with mouth cancer never return to work, so there really needs to be a wider assessment.
Thirdly, I would like to raise the issue of the implementation of the vaccination programme for men who have sex with men. The JCVI was right to recommend that men who have sex with men should be offered the vaccine via sexual health clinics, but since the recommendation was made in November last year, no announcement has been made about the implementation.
I asked the Public Health Minister about this matter in a written question last month. She replied that a pilot project was beginning this month, which I was pleased to hear. I would be grateful if she could explain what is being planned and the timetable to which that will happen. We already know that the vaccine works, and I have some fears that this could be an attempt to kick it into the long grass. I hope not and that she can offer some reassurances to Members today. Given the level of risk currently being faced by men who have sex with men because of HPV infection, including not least the very high rate of anal cancer in that group, there is surely a strong case for a national roll-out now so that as many men as possible can be vaccinated without delay.
Fourthly, I am concerned that the UK is in danger of being left behind other countries in its approach to HPV vaccination. As we have heard, Australia, Austria, Canada, Israel, Switzerland and the United States are among those now recommending gender-neutral vaccination. That is now under active consideration in the Republic of Ireland and Norway as well.
If I may, I will make a slightly tangential point. Is the Minister aware of the complaint made to the European Medicines Agency by the Nordic Cochrane Centre about the alleged maladministration of the safety review of the HPV vaccination? If side effects have been ignored or people more susceptible to side effects have been given the vaccine unnecessarily, that is a breach of trust and I expect that she will want to look into the matter.
Finally, I have been asked by HPV Action to announce that a letter from 13 eminent scientists and clinicians in the field of public health has been sent to the Secretary of State for Health, calling on him to ask the JCVI to accelerate its assessment of the vaccination of boys. The signatories include the director of the World Health Organisation collaborating centre for oral cancer, the president of the British Association for Sexual Health and HIV and the vice-president of the Royal College of Surgeons. Their views should carry weight in the corridors of Richmond House and I trust that the Secretary of State will listen very carefully to their points.
I also hope that the Minister has listened to the very valid points that hon. Members have made this afternoon. It has been a short but well informed debate, and I am pleased that we have had the chance, thanks to the application made by the hon. Member for Finchley and Golders Green, to be able to debate this issue in such a timely manner.
The Parliamentary Under-Secretary of State for Health (Jane Ellison)
Thank you, Mr Hollobone, for giving me the opportunity to respond to the debate. I have to say at the outset that we are actually announcing good news in this debate. I accept that Members of this House wish to challenge me on a whole range of areas in which we might go further, but this is the announcement of a major pilot, and I will go on to talk about what we are actually doing. I really think that we should see this as an important step forward and an important part of delivering on LGBT health. I just wanted to say that at the outset, because it was a bit hard to get that from some of the contributions. I will talk a bit about the issue of action, which I have been challenged on.
Let me start, as I should, by congratulating my hon. Friend the Member for Finchley and Golders Green (Mike Freer) not only on securing the debate, but on championing the issue so consistently and passionately. The point has been made that we should be talking about these issues more often—well, he has been talking about them consistently over many years and the persistence of parliamentary prioritisation is showing results. It is really good to see him in his place and I congratulate him on what he has done.
As hon. Members know, and as many people have mentioned, we are advised on all immunisation matters by the Joint Committee on Vaccination and Immunisation. Back in 2008, on the advice of the JCVI, an HPV vaccination programme for girls was introduced across the UK. It is worth reminding the House that the primary objective of that programme was to protect against cervical cancer. The latest data—just to remind people—shows that there are about 2,500 cervical cancer cases a year and up to 900 deaths from that terrible disease. To give some sense of comparison, there are around 300 anal cancer cases among all men in a year. Those are the origins of this programme.
The HPV vaccine has been given to more than 3 million teenage girls across the UK since the programme started, and coverage is actually among the highest in the world. Hon. Members have, again, made reference to international comparisons. I was recently in Geneva for the World Health Assembly, discussing HPV vaccination with a small group of other Health Ministers; our rates are the envy of much of the world, so we must accept that this is an important and world-leading programme. The number of young women with pre-cancerous lesions is falling, here and around the world, and we expect protection against cervical cancer to be long term, eventually saving hundreds of lives each year.
The vaccine has been subject to numerous safety reviews and I have gone over that in some detail in other debates. I will write to the shadow Minister, the hon. Member for Denton and Reddish (Andrew Gwynne), about the specific issues that he raised today, but I want to assure him about the EMA reviews and the WHO reviews, which are all publicly available.
Protecting girls against HPV has wider benefits and will result in fewer HPV infections and less disease in heterosexual males. However, I recognise, as the House has today, that men who have sex with men—MSM—receive little or no benefit from the programme for girls. It was the increasing evidence of the link between HPV and oral, throat, anal and penile cancers, alongside the incidence of genital warts, that led the JCVI to decide to consider the possibility of HPV vaccination for MSM, and to reconsider the case for HPV vaccination of boys. I will come to the issue of boys, which has been raised by several hon. Members, if there is time—I think and hope there will be. However, I want to focus most of my time on MSM, which is the subject of the debate.
I do not intend to include a lot of statistics in my speech, as my hon. Friend the Member for Finchley and Golders Green has set them out and described the context well. However, I want to point out, with regard to the detail behind the figures he quotes, that some of it is not directly relevant to an HPV/MSM programme, as the figures include both male and female cases and cases of cancer unrelated to HPV.
MSM are one of the groups at highest risk of sexually transmitted infections in the UK and the Government are already taking a number of steps to improve their health and wellbeing. Again, I reject any suggestion that this issue is not a priority. It is quite the opposite: there has been a focus in the last year or so on MSM health and on LGBT health—that is something that we had previously not even begun to do. That includes, for example, the first LGBT health conference run by Public Health England and a number of other things that we have done. I am happy to speak to the hon. Member for Glasgow South (Stewart Malcolm McDonald) about that separately on another occasion.
The JCVI’s advice was that a targeted HPV vaccination should be introduced for MSM aged up to 45 who attend genito-urinary medicine and HIV clinics, if procurement of the vaccine and delivery of the programme is possible at a cost-effective price. Everything in that sentence is the JCVI’s advice. It is not just about the vaccine but about the delivery of the programme and the interrelationship between vaccination and attendance at GUM and HIV clinics, which is germane to the way that we are introducing this pilot.
In the JCVI’s formal advice to us, it acknowledged that commissioning and delivering such a programme would be complex and challenging. It made it clear that the Department of Health and Public Health England would need to work together, and with others, to consider the commissioning and delivery routes for the programme. Over the last few months that is exactly what we have been considering with stakeholders, and on several issues. Demand is one such issue, and we have had to consider whether the programme will result in a greater than expected increase in attendance by MSM at GUM clinics, and the impact of that on broader sexual health services.
We have also had to consider administration costs and what is a reasonable and realistic price to pay for administration of this vaccine in GUM and HIV clinics. Stakeholders raised that during the consultation on the original JCVI advice. How do we monitor the success of a three-dose programme when data collected in GUM clinics are anonymised and MSM could go to different GUM clinics for each dose? There are complexities in this programme that are not present in, for example, the school-based HPV programme for girls.
Stewart Malcolm McDonald
Briefly, can the Minister tell me why those complexities exist here in England but not, presumably, in Scotland and Wales?
Jane Ellison
They do exist in other nations. I am making a statement of fact of how the system operates and how people access sexual health clinics. I will come to the devolved Administrations.
We have decided that the best way to resolve these and other issues is to pilot the programme. My hon. Friend the Member for Finchley and Golders Green asked who the vaccine will be available to under the pilot. The JCVI recommended a targeted programme aimed at MSM already attending GUM and HIV clinics, so under the pilot, MSM will be offered the vaccine during their existing appointment if they are at a participating clinic. Public Health England is running the pilot, which should confirm whether such a programme can be delivered at a cost-effective price.
In terms of evaluation, which my hon. Friend also referred to, data collected by clinics will be used to monitor coverage of the HPV vaccine and the proportion of MSM completing the course of vaccine. The impact of the vaccine on HPV-related cancers will obviously take many years to emerge, but the impact on the diagnosis of genital warts will be a useful proxy for that and will be seen much sooner. I expect to be updated regularly on the pilot’s progress. My hon. Friend knows that I have taken a strong personal interest in this programme, and I will of course consider how best to share the information.
I understand that some stakeholders are disappointed that we are not rolling out the programme nationally immediately and some hon. Members here today have noted that Scotland and Wales have committed to implementing the JCVI’s advice in full. However, they have yet to confirm how or when they will start. Scotland has not started yet, and we are happy to share lessons from the pilot as it is no doubt considering how to move forward. Officials from the Department, Public Health England and the devolved Administrations meet regularly on this issue and will continue to do so to share experience and learning. Health is a devolved matter.
I confirm that Northern Ireland officials are on our project board, but they do not yet have a ministerial decision on how they will respond to the JCVI advice on MSM. Obviously there are issues to be raised with that devolved Administration.
The key thing to stress is that this is a large-scale pilot and I was somewhat disappointed by some of the stakeholders’ comments, particularly talk of stalling or of small pilots. This is a large-scale pilot that should eventually reach up to 40,000 MSM— more than 35% of those who attend GUM and HIV clinics annually. It will have a good geographical spread, including areas with the highest MSM populations, as well as rural areas with smaller MSM populations. That is relevant because, although there has been some piloting of vaccination in some clinics, it has been in a very limited geographical area and would not tell us enough about how this would work in practice in a national roll-out. The pilots will have a much broader spread. I can also confirm that the pilot will use the vaccine Gardasil-4 which was successful in the recent HPV procurement exercise.
I am pleased to announce that the pilot in England has already started. Two clinics went live in the pilot yesterday and others will come on board as soon as they are ready, hopefully over the next few months. There has been a positive and enthusiastic response from clinics invited to participate, and I am grateful to all those working on the ground to make this happen.
My hon. Friend asked how long the pilot will run. It will run during 2016-17 and decisions on next steps will be dependent on the progress and outcome of the pilot.
Jonathan Lord (Woking) (Con)
Like other Members, I pay tribute to the leadership on this issue of my hon. Friend the Member for Finchley and Golders Green (Mike Freer) whose work is appreciated across the House.
I have been following the debate very carefully, but it is not clear in my mind how a pilot of MSM will act as some sort of proxy or in any way affect the decision on immunising schoolboys. I do not see how one will inform the other.
Jane Ellison
I have not claimed that one is dependent on the other. They are two separate recommendations from the JCVI, and I will explain what is happening with boys. There are many questions about extending the HPV vaccine to boys and I understand the wish for it to be available to all adolescents regardless of gender. The JCVI is reconsidering its initial advice on this and modelling is under way to inform its consideration. Public Health England expects to complete the modelling by early 2017 and the JCVI’s advice is expected to follow soon after that, after which we can respond. We will look at that as a priority when we get it.
We have discussed in this Chamber whether we can speed that up. I recognise the frustration that people have expressed and I have talked personally to Public Health England officials who are involved in the modelling work. It would be a huge programme to roll out to adolescent boys and JCVI needs to base its advice on very robust analysis of cost-effectiveness. To do that, a complex model is being built. I have been assured that this is not about additional resource. I have asked whether it is a case of needing additional resource to speed the work up, but I am assured that it is not. It is because of the complexity of the model development and the fact that some of the models are time-consuming to run. Essentially, they are modelling behaviour over time, and to do that, one needs time in order to be able to understand how different aspects of the model interact with one another. I have been told—I have no reason to doubt this, because I have asked experts involved in it—that shortcuts could undermine the validity of the results and could not be supported by the JCVI. The model is building on the cervical screening model to create an integrated model of both HPV screening and vaccination, so that we get an understanding of what the interplay is between vaccination and screening programmes in the prevention, diagnosis and treatment of HPV.
I am happy to write with more detail to hon. Members, but I hope that I have given them a sense of the fact that this is complex work: it is under way and we will look to respond to it as soon as we can. However, these are important decisions that the JCVI will take and, because the Government have always acted on its recommendations, it is important that it gets them right and they are based on the right data. This is a significant programme, but the work is well under way and I will look to report back to the House at every opportunity I can.
The HPV vaccination programme for girls is going very well, and there is now scope for an additional programme to make a difference to the lives of MSM, which this will. The pilot will provide answers to the questions that we still have and the answers that we need for a programme of this nature—I have hinted at some of the delivery complexities. We expect to see benefits from the pilot emerge relatively soon through the reduction in genital warts cases and through treatment in MSM, particularly by targeting higher risk MSM.
I hope that that updates the House as fully as possible at this stage. As I said, I will be happy to update it in the future on how the pilots are going. I want to end by again congratulating my hon. Friend the Member for Finchley and Golders Green on initiating the debate and on his persistent campaigning, and to reassure and commit to the House my determination to improve the health and wellbeing of MSM and to see this pilot as a significant step forward in that task.
Mike Freer
First, I would like to put it on the record that this pilot is a success. Hon. Members need only go back and read the previous debates to see how the JCVI had simply set its face against extending HPV vaccinations to boys and MSM. It was implacably opposed, and it took a lot of badgering from Members of this House and from Ministers to get the JCVI to change its terms of reference. It has taken us three years to get to this point, but I welcome the pilot and I welcome the Minister’s explanation of the complexities and why we have to ensure that the pilot is robustly monitored before we can take the extension of the vaccinations any further.
I finish by thanking colleagues for joining the debate today and for the broad cross-party support. We covered all perspectives, including MSM, boys, the minority known as heterosexual men and dental health practitioners—have I missed anyone out? Men are notoriously bad at seeking help with their health, especially sexual health. Vaccination is the way forward. I welcome this positive step forward and thank colleagues for their attendance today.
Question put and agreed to.
Resolved,
That this House has considered HPV vaccinations for men who have sex with men.