HIV and AIDS

Baroness Gould of Potternewton Excerpts

Monday 18th January 2016 Lords Chamber

[Baroness Gould of Potternewton (Lab)]

My Lords, I also thank the noble Baroness, Lady Barker, for initiating this debate as it gives me the opportunity to raise the plight of women with HIV and the particular barriers that they face.

Since the start of the global HIV epidemic, women have remained at a much higher risk of HIV infection than men, with young women and adolescent girls accounting for a disproportionate number of new HIV infections. As the noble Baroness, Lady Barker, said, a consequence is that HIV remains the leading cause of death among women of reproductive age, yet access to HIV treatment remains low. This lack of comprehensive HIV and SRH services means that women are less able to look after their sexual health and are more at risk of HIV infection—a problem that is often made worse for young women as such services are available only for married women with children.

In Kenya, Rwanda and Senegal more than 70% of unmarried sexually active girls cannot receive contraception due to age restrictions. That is not helped by healthcare providers often lacking the necessary training and skills to inform women on how to protect themselves, and on how to use anti-retroviral drugs. While overall access to HIV testing and counselling is improving it is still far too low. Discriminatory social and cultural norms are translated into laws which stop women and girls accessing HIV prevention treatment, care and support services. Women often face stigma and judgmental attitudes to drug use, sex work and homosexuality, resulting in the denial of healthcare.

The situation is that women are being left behind in terms of access to HIV treatment, exacerbated by the high cost of treatment, which creates weak and insufficient health systems and supply chains. This situation could be improved by community and home-based testing as an effective way of reducing costs. There is a correlation between HIV and poverty. Addressing poverty has shown to reduce sexual risk behaviour. A study in Malawi showed how cash transfers that were conditional on keeping girls in schools reduced HIV and STI prevalence, as well as high-risk behaviour. The World Health Organization states that 30% of women worldwide have experienced intimate partner violence or have been physically assaulted. These women are more likely to acquire HIV. Women experiencing abuse are coerced into sex and unable to negotiate practices such as condom use. Very often it seems that the men who are committing the abuse are more likely to engage in risky behaviour. A woman who depends on her partner economically cannot afford to jeopardise the relationship, even when she suspects that he may be HIV positive.

One hundred and twenty five countries have legislation criminalising domestic partner violence, sexual violence, child sex abuse and sexual harassment, but despite this progress the evidence for establishing the crimes is very weak. For instance, only 52 countries recognise rape within marriage as a crime, again making it difficult for women to protect themselves from such sexual violence or negotiate safe sex.

DfID has identified the needs of women and girls as a clear priority for the UK Government, but to date has not explicitly made the connection between the women and girls agenda and the HIV response. I ask the Minister to clarify the position, for addressing HIV and AIDS is not an additional burden or add-on to DfID’s core priorities—rather, it supports them. Will the Minister confirm that HIV is not being deprioritised and absorbed into other conditions? Surely our target has to be to end the epidemic and to increase focus on protection of women with HIV and AIDS, not the reverse. Additionally, the UK aid strategy makes no reference to HIV and AIDS and gives no indication of how the UK intends to contribute to meeting the SDG target.

In conclusion, it is widely recognised that gender equality is vital to an effective HIV response. There needs to be renewed political and financial commitment to eliminate gender inequalities and gender-based violence, and to increase the capacity of women and girls to protect themselves from HIV. We cannot forget, as so often seems to happen, that, in the words of the executive director of UNAIDS:

“This epidemic unfortunately remains an epidemic of women”.

Millennium Development Goals: Women and Girls

Baroness Gould of Potternewton Excerpts

Monday 9th March 2015 Lords Chamber

[Baroness Northover]

We are acutely aware of the position of women in Afghanistan and the progress that has been achieved, and we are determined, along with them, to ensure that it is secured. We are in dialogue with the Government of Afghanistan about the position of women.

[Baroness Gould of Potternewton (Lab)]

My Lords, I have a question for the Minister about another country, regarding the effect of Ebola in Sierra Leone and the fact that girls are no longer able to go to school and schools are actually closing down. Can she give some indication as to what support we might be giving to help to get the schools reopened so that girls can start their education again?

[Baroness Northover]

The Government’s priory is to eliminate the Ebola epidemic in Sierra Leone. We are making extremely good progress, as the noble Baroness will know. We are not there yet, but one of our aims is to reopen the schools. In the mean time, we are seeking to support children who are out of school by distance learning.

Tuberculosis

Baroness Gould of Potternewton Excerpts

Monday 8th December 2014 Grand Committee

[Baroness Gould of Potternewton (Lab)]

My Lords, I, too, wish to congratulate my noble friend on securing this important debate, in particular for his persistence, and for it happening so close to World Aids Day. I wish to concentrate my remarks on the need for better tools, research and development for HIV/AIDS, and why it is so necessary. Unfortunately, listening to the three previous speakers, the story is the same, which is a real tragedy.

HIV/AIDS has placed a huge burden on developing countries, where the majority of the 35 million people with HIV now live. The disease kills 1.5 million people each year. Two-thirds of those living with HIV are in sub-Saharan Africa, where families can ill afford to bear extra healthcare costs or care for orphan children. Initially seen as a male disease, HIV/AIDS is rapidly becoming a female epidemic, with further impacts on families, given the greater share of responsibilities of women within households. HIV/AIDS is the leading cause of death among young women of reproductive age in Africa. The region’s young women are twice as likely to contract HIV as their male counterparts. This is in part due to a greater biological risk, and in part due to the unequal status of women, the effect of which constrains women’s ability to negotiate condom use, which is a major problem for those women, particularly those who are sex workers. Risk to sex workers stems from an increased number of sexual partners, greater exposure to sexual violence, being forced to have unprotected sex, or accepting more money to have sex without a condom. Sex workers can also face harassment from the police, who in many countries have been known to use the possession of condoms, or attendance at HIV clinics as a reason for arrest, or as a basis from which to extort further money or commit incidents of sexual violence. I found it strange, but I was told by a cousin who for many years was a sexual health worker in Africa, that in the 1960s and 1970s they wrapped condoms in coloured paper to make them look like sweets for exactly the same reasons. Is it not an indictment that all these years later we are still having exactly the same debates?

There are other identified groups who are particularly at risk of HIV. For example, the estimated 75 million male clients who visit the 10 million sex workers globally, and are a key transmission group to other women and men in the community. Men who have sex with men are 13 times more likely to be living with HIV than the general population due to the biological risk of transmission and having higher numbers of partners, yet they are stigmatised if they attempt to attend an HIV clinic. It is truly frightening to witness the current slide to criminalisation of homosexuality, for this impacts on the wider population, given that men who have sex with men will often have wives or other female partners. Ban Ki-moon, the UN Secretary-General, recently remarked:

“Not only is it unethical not to protect these groups; it makes no sense from a health perspective. It hurts all of us”.

Therefore, it is crucial that tools are designed to provide diverse groups with innovative and long-term ways of protecting themselves from HIV/AIDS.

The International AIDS Vaccine Initiative, which I was fortunate to visit earlier this year with my noble friend, is undertaking trials on several innovative approaches, from broadly neutralising antibodies to cell responses, and including replicating vectors for vaccine delivery. It is also carrying out follow-up trials to studies in Thailand that pointed to the efficacy of two vaccine candidate compounds when used together. We hope that those will be able to be developed. Such a vaccine would protect women, particularly those most at risk such as the female sex workers whom I mentioned earlier. Not only is it essential in helping to save those women’s lives but, from the decrease in the need for treatment alone, the savings are estimated to be $95 billion over the first 10 years.

Another study by the International Partnership for Microbicides is undertaking clinical trials of its new ring. It is a simple and affordable product. It is worn internally and works by releasing an antiretroviral drug that has been found to prevent HIV infection. Other studies are looking into gels and films that work in similar ways. If there is ever going to be a reduction in, or the elimination of, the 2.3 million new cases each year, prevention is key. It is absolutely essential, and the funding and the resources have to be found to make that possible. There are four new cases for every three people who are started on treatment. Detailed modelling has estimated that, even after significant scaling up of treatment efforts, there will still be 1.4 million new cases each year. Add a vaccine to that, however, and the number drops to 400,000, and very likely, with herd immunity, it will be brought down still further year by year.

Moreover, we must look at what can be done to change a situation where diseases affecting richer countries are prioritised for research and development above diseases that affect those less able to pay. I found it absolutely shocking to discover that 15 FDA-approved drugs were initiated to treat hay fever in the last 50 years compared with the one drug for TB mentioned by the noble Lord, Lord Lexden. Health programmes must be targeted at the poorest and most marginalised groups, not at those where the pharma companies are going to make the most profit.

The millions of women I mentioned earlier who cannot protect themselves from HIV/AIDS desperately need leadership from people such as us. However, there is another side to this debate. I have talked about availability—the need for drugs to be developed—but there is also a need for the drugs to be affordable. The excellent report of the HIV/AIDS all-party group, Access Denied, records how the generic medicine industry has been pivotal in bringing down the price of antiretroviral drugs from more than $10,000 per patient to less than $100. This has allowed nearly 10 million people to access HIV treatment, with 1.6 million of these beginning their treatment in 2012. To put this in context, 28.6 million people are estimated to be eligible for treatment under new World Health Organization guidelines, and that figure is expected to be 55 million by 2030. However, only 34% of the millions in need can access treatment in low and middle-income countries. That is just for adults. Access to treatment for the 3.3 million children living with HIV in developing countries is only 18%—how disgraceful; that is half the adult rate.

Surely the partnerships that have been talked about should also agree that the price of essential drugs and vaccines should not be out of reach of those who need them—perhaps through voluntary or compulsory licensing of patented products. My noble friend rightly referred to this as market failure. De-linking the final cost of a drug from research and development incentives could not only spur investment in work on diseases of poverty but also ensure that those drugs can be marketed at a price affordable to the greatest number of people, and so save many millions of lives. After all, if we think about it, manufacturing a drug is a remarkably low-cost exercise. We should be looking to pharmaceutical companies to ensure that there is more transparency in their research costs, to make it possible better to access the level of finance needed.

The UK, as a global leader, can ensure that the partnerships can continue their work, but only if they get adequate funding to do so—funding that allows long-term planning to progress potential candidates through the many stages their work requires—and take steps to explore how a reformed system might work that pushes companies to do the right thing, which will allow us, one day, to cross World AIDS Day off our agenda.

Health: HIV

Baroness Gould of Potternewton Excerpts

Monday 17th November 2014 Lords Chamber

[Baroness Northover]

Indeed, we are acutely aware of that. The information that I have is that we are very effective in dealing with that.

[Baroness Gould of Potternewton (Lab)]

My Lords, I was pleased to hear the Minister talk about the importance of research for a vaccine. How much is the British Government’s contribution towards that research? Do they intend to maintain that level or increase it?

[Baroness Northover]

I will write to the noble Baroness with the figures on that.

Women: Board Membership

Baroness Gould of Potternewton Excerpts

Monday 17th June 2013 Lords Chamber

[Lord Pearson of Rannoch]

My Lords—

[Baroness Gould of Potternewton]

My Lords—

[The Chancellor of the Duchy of Lancaster (Lord Hill of Oareford)]

My Lords, I think there is time for both if we have the noble Lord, Lord Pearson, very quickly and then Labour.

--- Later in debate ---

[Baroness Northover]

The directive that is potentially coming from the EU is a useful discipline. We need British business to demonstrate that it does not need to be applied in the United Kingdom because we have already made sufficient progress.

[Baroness Gould of Potternewton]

My Lords, I appreciate that the Government are very keen to get as many women as they can on to company boards but does exactly the same position apply to the appointment to public boards for which the Government are responsible? Perhaps she could tell us what is the Government’s strategy to get more women on to public boards?

[Baroness Northover]

The noble Baroness is quite right. We have an aspiration, as she probably knows, that 50% of appointments to public boards should be women by 2015. I have seen the figures that are just being finalised for the current state of affairs, and it is looking encouraging that we are moving in the right direction, but we are not complacent.

HIV/AIDS: Commonwealth Countries

Baroness Gould of Potternewton Excerpts

Wednesday 13th March 2013 Lords Chamber

[Baroness Gould of Potternewton]

My Lords, I thank the noble Lord, Lord Black, for introducing such an important debate. As he says, it is the sort of issue that we do not discuss very often. I should declare an interest as co-chair of the Sexual Health Forum and a patron of the parliamentary group on transgender issues.

Part of the British Empire legacy to Commonwealth states 150 years ago was our then legal system, which we passed on and which regrettably included the old colonial draconian laws on homosexuality. These laws were not repealed when the former colonies won their independence, and they continued to ban gay sex between consenting adults. A consequence has been that the Commonwealth countries make up 30% of the world’s population but 60% of the level of HIV. It is interesting that the countries that were colonised by France under the Napoleonic code, which does not concern itself with homosexuality, do not have anti-gay laws or high levels of HIV. In the Commonwealth countries, however, laws are myriad, and with them come violence, murder, fear, stigma, rejection, impunity, the criminalisation of identity and persecutions. As the noble Lord, Lord Black, says, of the Commonwealth countries, 42 still criminalise same-sex relationships for men, women or both, with dire penalties. I find it unbelievable that the situation is getting no better. In fact, in some countries, it is getting worse.

If I may, I shall repeat some of the horror stories because the more often they are told the more people might listen. In Uganda, the anti-homosexuality Bill is repeatedly brought forward to impose the death penalty for men living with HIV. In Zambia, the maximum penalty has been increased from 10 years to 15 years in prison. Penalties in Trinidad and Tobago include 25 years in jail, and there is legislation to ban the entry into the country of known homosexuals. In Malaysia, the penalty is 20 years and flogging. In Malawi, there are prison terms of up to 14 years’ hard labour. And there is life imprisonment in Sierra Leone, Tanzania, Bangladesh, and Pakistan, which also imposes imprisonment for private same-sex intimacy.

These so-called civilised countries defend these criminal sanctions as an authentic expression of indigenous national culture and tradition: that they are breaches of public morality, public health issues and sexual normality. But those conditions do not apply to the 12 Commonwealth countries that currently do not criminalise same-sex acts. It is encouraging that some of those countries also have laws that protect LGBT people from hate crimes and prohibit discrimination against them. Botswana, for instance, amended its Employment Act in 2010 to prohibit discrimination on the grounds of sexual orientation. There is no question that legal penalties for homosexuality encourage public persecution. In Jamaica, gay men are so hideously and violently socially persecuted that many countries now accept gay asylum seekers from Jamaica into their own countries.

Again, in Uganda, tabloid newspapers have conducted witch hunts naming gay men and encouraging violence against them. In both those countries, the result was gay men being killed. All this shows that obstructive legislation contributes to the inability of HIV sufferers to claim their rights and increases the level of HIV stigma and discrimination. HIV sufferers face persecution and violence from employers, hospitals and community organisations. These draconian laws drive gay people underground, away from effective HIV prevention, treatment, care and support. As the noble Lord, Lord Black, said, it must follow that if you have to hide being gay, HIV-prevention agencies cannot give appropriate advice and may find it hard to reach you at all.

Additionally, where men or women have acquired HIV through gay sex, they are less willing to go for testing, so they pass the virus on. This situation is not helped by the continual harassment of HIV outreach workers by police who prohibit HIV-prevention activities on the grounds that they aid and abet criminal activities. Government agencies may be forbidden from working with illegal minorities. The situation, therefore, is that gay people face a double whammy: first, the risk of acquiring HIV, but at the same time being unable to ask for advice or support because they would have to admit to committing an illegal act.

Last year, the Ugandan authorities shut down a workshop bringing together advocates for the rights of LGBT people and providing information on how to avoid HIV transmission. In Cameroon, armed police broke up a planned three-day meeting on HIV/Aids and sexual minorities, organised by the Association for Adolescents Health against HIV/Aids. All that support and help therefore is not going to the people who need it.

Tackling homophobia can encourage gay men to be tested for HIV and other sexually transmitted diseases. There is no question that homophobia continues to be a major barrier to ending the global HIV and AIDS epidemic. The Commonwealth Heads of Government say that the fight against HIV is a high priority, adding:

“we are committed to accelerating action to implement the objectives outlined in the 2011 UN Political Declaration on HIV/AIDS“.

Nevertheless, only this week, when discussing the future Commonwealth Heads meeting, there was talk about the theme being democracy and human rights. If their goals on HIV/AIDS are really genuine, they have to tackle this situation. At the same time, the Commonwealth Secretariat—again, as the noble Lord, Lord Black, said—has not included LGBT rights, legal reform or HIV in its new strategy. The Commonwealth Foundation’s new strategy does not include any plans to support LGBT organisations or others working towards law reform.

Gay men and women are not the only people who suffer because of their sexuality. Illegality is also likely to be extended to transgender people and sex workers, who are similarly marginalised, hard to reach and often subject to legal sanctions. For instance, the high prevalence of HIV in Africa is driven by cultural, religious and political unwillingness to accept LGBT people, so the prejudice, harassment and isolation means lack of access to HIV prevention, including the availability of condoms.

This is a particular problem for transgender women because their identity as women is not recognised in many Commonwealth countries. Denial of their gender identity in law exacerbates the discrimination and marginalisation that transgender people experience. They often are the targets of violent hate crimes, are denied healthcare and education and struggle to find employment, so they are forced into sex work, all of which increases their HIV risk.

Finally, I follow the same theme as the noble Lord, Lord Black. How should the UK exert its influence? What should we be doing? The UK should actively support legal reform that decriminalised consensual sex between adults of the same sex and prohibited discrimination on the basis of sexual orientation and gender identity. We should be calling for targets on law reform and equality in the post-2015 development framework as a means to ensuring access to health and other services for LGBT people and other excluded groups. The Government can play a vital role by providing a more critical oversight of the Commonwealth institutions and by scrutinising progress made in delivering on their LGBT rights strategy, thereby reducing the level and the spread of HIV and AIDS.

Assumptions that criminalising sexual minorities will prevent the spread of HIV and AIDS are ill-founded, based purely on ignorance and long-standing prejudice. The global evidence is clear that public health is best served by removing discrimination and prejudice against all LGBT persons, giving them—the people who need it most—access to HIV prevention and treatment. Removing stigma through the decriminalisation of private, adult, consensual, same-sex sexual relations is the first step in promoting health and tolerant societies.

HIV and AIDS in the UK

Baroness Gould of Potternewton Excerpts

Thursday 1st December 2011 Lords Chamber

[Baroness Gould of Potternewton]

My Lords, I start by thanking the noble Lord, Lord Fowler, for making the meetings enjoyable, friendly and determined. We were absolutely sure that we were going to come to the right conclusions. The people out there who work in the field have welcomed the report. I have not heard one negative remark about the report and that says an awful lot, in many ways, about how the noble Lord, Lord Fowler, guided us through those many days. I support the noble Lord in his thanks for the staff. Sometimes we overburdened them but nevertheless they were absolutely wonderful with us. It was certainly a very concerted effort—every Tuesday morning for eight months. As one noble Lord said to me when it was over, he was suffering from Tuesday morning withdrawal symptoms—I am looking straight at him. I think that that applied to many others. If I raise any criticism of the response, this is in no way a criticism of the officials in the Department of Health, with whom I have worked for many years, and all of whom are fully committed to building the sexual health services, including for HIV, from the Cinderella service that it was to the improved service that we have today. Even the response goes in the right direction of travel. At this point, I declare an interest, among many, as chair of the Sexual Health Forum and as chair of the All-Party Parliamentary Group on Sexual and Reproductive Health.

I reiterate what the noble Lord, Lord Fowler, said—that the Select Committee was right to focus on prevention as a theme of the report, whether relating it to raising awareness, education, testing or treatment. It cannot be said too often that HIV remains the most serious infectious disease affecting the UK and prevention is the only way we will make that change. We had an interesting short debate during the passage of the Health and Social Care Bill on the need for national sponsored awareness-raising campaigns. But as with the response to the Select Committee report, I did not get any real assurance that national campaigns were on the agenda. While accepting the need in some instances for targeted campaigns—£2.9 million has been spent on those campaigns—there appeared to be a complete rejection of the idea of campaigns directed at the general public. That is a serious mistake as it does not take into account the rising number of UK-acquired infections among people not in the high-risk groups, who now account for more than 25 per cent of newly diagnosed infections each year. However, I was pleased to see the welcome given to the National Aids Trust website, HIV Aware, which directs its messages of prevention and awareness specifically to the general public. This is a classic example of the important role that the third sector plays in the alleviation of HIV and support for those affected. Has thought been given by the department or the Government as to how we could nationally disseminate the themes of the HIV Aware campaign more locally so that there is uniformity of message throughout the country? It would cover high prevalence groups as well as the wider audience. It would raise awareness and provide information and advice at very little cost. I do not think the argument against that can relate to cost.

Also in terms of awareness-raising, I was pleased to note the work taking place among faith leaders. As our visit to Leeds highlighted, it was possible to have dialogue with some faiths, but in other instances it proved to be very difficult. It is terribly important that this work is expanded for us to influence what is happening among some of the groups who find it difficult to accept HIV.

Overall, the public have become less aware of HIV and that has created widespread public ignorance. As the noble Lord, Lord Fowler, said, the lack of awareness by the public is one of the reasons why stigma persists and why there are so many mistaken beliefs on the supposed dangers of HIV. This creates a negative and judgmental attitude towards people with HIV. Stigma is still a daily reality for many people living with HIV. As in the instance given by the noble Lord, Lord Fowler, it can have a devastating effect on the life of someone with HIV and can often be compounded by profound health inequalities—for HIV is also about health inequalities.

Most importantly and crucially, stigma can deter someone from being tested. Ignorance makes people very frightened of being tested in case they then have to face the consequences that go with it. Preventing the spread of HIV has to involve the promotion of early testing and the widening of the scope of venues where testing can take place in order dramatically to reduce the estimated 22,000 people who have HIV but do not know it—the 25 per cent who are undiagnosed but might be furthering transmission.

As the Select Committee Report states, HIV testing must become normalised. An offer should be made to newly registered patients in general practice as well as to general and acute medical admissions. The Department of Health’s important screening pilots have shown that staff and patients welcome more HIV testing in hospitals and in primary care and community settings. However, for the future, it will be for healthcare professionals and local authorities, when they take over in 2013, to follow that work through. I am putting a positive slant on the Government’s response that they will consider favourably the Time to Test report. Perhaps the Minister can confirm that I am right to be optimistic.

The evidence of success of this approach is made forcibly by the success rate of antenatal clinics where an offer is automatically made and, as a consequence, mother-to-child transmission is at a very low level. I heard this morning at a meeting of how, when the fathers turn up at the clinics, staff can try to persuade them to have an HIV test. Many have previously been resistant to that. They are examples to learn from. The high level of acceptance of an offered test makes economic as well as medical sense and that message needs to be repeated. Prevention of half those undiagnosed cases would save the country £1.2 billion in healthcare costs. More than half the people are diagnosed late and some are already very ill, which again leads to far higher annual treatment costs. If we could have early testing, we could have early treatment and reduced costs.

The work being undertaken by MedFash, referred to in the Government’s response, will, I am sure, be invaluable in providing an interactive tool to support GPs and primary care staff in offering HIV testing as it will enable those staff, among whom there is great nervousness about making an offer, to do so. That barrier needs to be looked at much earlier and we must think about having discussion of HIV in medical schools and nurse training, so that when staff are faced with such questions, they know the answers. Instead, they are finding it very difficult.

It is also very important that we look for a positive outcome to the public health outcomes framework indicator on late diagnosis. I appreciate that many are being considered in the public health field and I know that the Minister cannot give me an answer. However, I am hoping that she will say that I can be optimistic.

One of my concerns about the new structure—although I am a strong advocate of public health moving into local government—is the design of the new commissioning structure and the inter-relationship between the different elements that make up that structure. This is particularly important for HIV because of the expected split between treatment and care and between prevention and testing. The split of functions may be inevitable, or it may not be; it might still be changed. I understand the case made by the Government in relation to other infectious diseases. I welcome the commitment that prevention work will not become isolated from treatment services. However, I would like to hear a little more about how that will happen in practice. Perhaps the Minister can elaborate on the mechanisms that will ensure that that prevention work does not become isolated from treatment services.

In conclusion, I should like to make three short points. On standards, the response indicates that the provisions set out in the Health and Social Care Bill allow for the development of quality standards for social care and public health, opening up the possibility of quality standards that fully support integrated care pathways. The question that follows, however, is whether comprehensive guidelines will be produced to make that system consistent and effective or will it be left to each locality to determine how that works. In some it might and in others it might not.

The committee recommended that NICE be commissioned to develop treatment and care standards for HIV specifically. While there are excellent standards produced by BHIVA, they do not address the need to co-ordinate specialist health HIV services with other services. I hope that the Government might reconsider and take up the recommendation that was in our report.

My next point relates to charging for HIV treatment and care and the recommendation that HIV should be added to the list of conditions in the NHS (Charges to Overseas Visitors) Regulations 1989. This is a matter which the noble Lord, Lord Fowler, the noble Baroness, Lady Masham, and myself will be raising during the passage of the Health and Social Care Bill. I am not asking for an answer to that today. However, I understand that a review is being undertaken and it might be helpful if we could know when the review is to be concluded.

Finally, I want to say a few words about tariffs. The response indicates that funding methods such as block contracts provide no incentive for organisations to improve patient care. In the light of that clear and positive statement in the response, can the Minister clarify the decision in the Health and Social Care Bill not to allow national tariffs for public health, including sexual health? Not to allow a level of flexibility of tariffs will almost inevitably mean a return to block contracts and therefore, as the response says, diminished patient care. There is a clear contradiction here and I think that it needs clarification.

Much has been achieved in the past. However, if we are to maintain momentum and respond effectively to the challenges of a growing epidemic, we need a national, holistic strategy on HIV, a view endorsed by the HPA in its report earlier this week. We need a strategy that encompasses the findings of the Select Committee report: early diagnosis, effective treatment and social care, HIV prevention and testing in a wide range of settings, laws and policies to eliminate stigma and discrimination, a well-trained workforce and the reduction of health inequalities. That is the approach that I hope we will see in the planned sexual health policy framework, which gets a number of mentions in the response to the report. Only then can we be assured that the momentum that has been achieved can and will be maintained.

Health and Social Care Bill

Baroness Gould of Potternewton Excerpts

Wednesday 16th November 2011 Lords Chamber

The first three amendments are aimed at making explicit the Secretary of State’s central responsibility for public health information and advice campaigns, and explicitly require him to consider the desirability of such campaigns when he draws up the mandate. The final amendment requires the board to include public health information and advice campaigns in its duty to promote education. These are all probing amendments, which are looking, essentially, for two things. First, they seek an assurance that large-scale public health information and advice campaigns will continue to exist and will be an important part of the public health armoury. Secondly, they seek an explanation of how in future public health information and advice campaigns will be originated, how they will be driven and how they will be controlled, funded and assessed. I beg to move.

[Baroness Gould of Potternewton]

My Lords, I support these amendments, which are so relevant to recent proposals in the Select Committee report on HIV/AIDS. The Bill calls for the Secretary of State to take steps to promote public health in England from disease or dangers to health. Without a doubt the most effective way of achieving that aim is through the provision of public information, advice and awareness-raising campaigns, first, in respect of prevention and, secondly, in respect of early treatment and care.

That proposal would mean the promotion of early testing as well as testing for the estimated 22,000 people who have HIV but do not know that they are infected and who, as a consequence, are likely to transmit the disease further. It would also ensure the availability of testing. At the moment the venues for testing are fairly restricted but the Government are considering proposals by the HPA and NICE to widen the range of settings where testing might take place, particularly in areas of high prevalence. We await the Government’s decision on those reports. The need to raise awareness of early testing is crucial to prevent onward transmission of the disease. There is no better example than the evidence obtained from antenatal clinics which have had campaigns and have given information to pregnant women about mother-to-child transmission and where the number of such cases is now extremely low. That advice should be taken by the Government.

I raise these points specifically because the Government’s response to the Select Committee on the need for awareness-raising campaigns did not give the assurances that we might have hoped for. While there are campaigns currently targeted at those most at risk of HIV—we hope that they will continue, but we are not certain that that will be the case—it was very short-sighted that there was no guarantee of the inclusion of HIV on any national sexual health campaigns, if in fact there are to be any. This amendment would be helpful in making that happen. There was a complete rejection of campaigns directed at the general public. Those were not considered to be necessary, yet we know that there is a growing diversification of HIV into other communities. For those people, early diagnosis is essential.

There was, however, a welcome for a web-based campaign run by the National AIDS Trust, which is specifically designed to get prevention and awareness messages to the general public. In a sense, therefore, we have a little contradiction in the need, and the process does go round in a circle. Lack of awareness by the public is one reason why the stigma of HIV persists and why there are so many mistaken beliefs about HIV. It is often the fear of that stigma that deters people who might be at risk from going for HIV testing or even STI testing. Effective awareness-raising campaigns would overcome some of those difficulties and are essential if we are to promote early testing and reduce the levels of HIV, which are growing each year, and thus reduce the levels of transmission.

It seems to me that not to have those campaigns is not only poor health practice but economically short-sighted. The HPA suggests that, if we had prevented the estimated 3,800 or so HIV infections acquired in the UK in 2010, we would have saved over £35 million annually, or £1.2 billion over a lifetime of cost. Treatment is very expensive. That seems to me an enormous amount of money when compared to the cost of running effective and regular public awareness-raising campaigns. Surely common sense tells us that the campaigns should continue.

[Baroness Masham of Ilton]

My Lords, these amendments relating to campaigns are very important. My question is: who will be carrying them out? I would like to highlight the problems of late diagnosis of HIV/AIDS, tuberculosis, hepatitis B and C, and meningitis.

Many people are living with HIV/AIDS who do not know that they are infected. There needs to be sensitive targeting of campaigns. If diagnosis is late, the condition is much more difficult and expensive to treat, as has been said. There are often co-infections of HIV/AIDS and tuberculosis. Late diagnosis in TB is very dangerous. Along with the growing problem of drug-resistant TB, there is extensively drug-resistant tuberculosis, which is very dangerous and much more expensive to treat and takes much longer.

I would like to mention the effective and important work of the group Find & Treat, which goes out to find homeless and other people who are difficult to find, who may have TB, and test them. The group now wants to test for co-infections, which would be much more effective and less expensive in the long run. This type of infection is on the increase. There is a fear that, unless local authorities and the National Health Service work together, there may be fragmentation, and these people, who should be treated early, may fall through the net. Find & Treat needs all the support that it can get to carry on this very important work.

Hepatitis B is very infectious, but there is now a vaccination, which is good. However, there is no vaccination for hepatitis C. Both types of hepatitis have been found to be a huge problem in prisons. There is a problem of liver disease with hepatitis C. Early diagnosis is important for all infections. In the case of meningitis, there have been far too many tragedies because of late diagnosis. The public—and doctors—need to be reminded continually how important this issue is by means of campaigns and guidelines. My GP always waits for guidelines from the Department of Health.

--- Later in debate ---

[Baroness Gould of Potternewton]

My Lords, it is interesting that there is not a universally accepted definition of public health. There are, however, broad domains of public health, be they health improvement, health protection or health services. The Faculty of Public Health defines public health as:

“the science and art of promoting and protecting health and wellbeing, preventing ill-health and prolonging life through the organised efforts of society”.

That is a very broad definition. It could almost include every range of local government services. It seems to me that there is a need for some guidance on what aspects should be included in the ring-fenced budget. We have previously been told that there will be no breakdown of the budget within that ring-fencing, which makes it even more important that some guidelines are laid down. The frequent reply from the Minister has been that we leave it to each local authority to determine what public health is. But while I appreciate that there will be a variation in needs between different authorities in different areas, some guidance and priorities might be useful to them.

I am delighted that my noble friend has highlighted sexual health as being important because there is a great deal of concern that sexual health will not be a favoured issue for many local authorities. Furthermore, as regards HIV for instance, there is no understanding that there is all too often a relationship between the required long-term care and other aspects of local government services. There is also concern that, unless it is highlighted, there will be a lack of understanding by local authorities of the divide within the commissioning arrangements for HIV and contraceptive services between the National Commissioning Board’s responsibilities and their own—for prevention and testing in the case of HIV and for the establishment of clinics for special cases in the case of contraception. Guidance would give local authorities greater clarity of their roles and responsibilities and the fact that they are a key player in this process of integration. I am sorry to refer again to the response to the Select Committee report on HIV and AIDS, but it is so topical. The Government identify that integration where possible—whatever that means—will be by the NHS Commissioning Board, clinical commissioning groups and health and well-being boards. That will apply to all health services so there is no need to have a special duty applying to the integration of specific services, such as sexual health and HIV. However, I think that is a misjudgment. Having some identification priorities would give guidance as to which areas require special duties.

At Second Reading, the Minister referred to the Advisory Committee on Resource Allocation, which is an independent expert committee that has been asked to advise on a public health formula to inform the distribution of the public health grant across local authorities, saying that it intends to publish further detail later this year. So I appreciate that we are not going to get the detail for which I would have asked on the distribution of that grant. If we could get some detail, that would be very helpful, but perhaps I may remind the Minister that there is only two months left this year and I hope that we will get that response before the end of it. The calculation of spend on public health, including sexual health services, must be based on robust and accurate data, so can the Minister identify how that can be achieved without a specific definition of what it should include? I appreciate that the Minister has so far always rejected the idea of coming up with a definition and he certainly might not agree with the list that is before him. Nevertheless, I would be grateful if he could rethink this. There needs to be some principle laid down to make sure that local authorities understand what public health actually means.

[Baroness Northover]

My Lords, Amendment 66 would add alcohol services to the list of examples that the Secretary of State may take under his new duty to protect health and Amendment 74B would add a number of steps, including one on alcohol, to the equivalent list of steps for local authorities to take up under their new duty. I appreciate the decision by the noble Baroness, Lady Finlay, to regroup and we will discuss her amendments a little later. However, the noble Baroness, Lady Thornton, followed by the noble Baroness, Lady Gould, decided that the group should stay in place.

Adding to the Bill's list of steps that may be taken may highlight an issue but would not materially alter the situation. The noble Baroness, Lady Thornton, with her governmental background, is clearly extremely familiar with the function served by these indicative lists. I appreciate her indication that she is probing on this. Obviously it is extremely important in these different areas.

I also note the definition of public health that the noble Baroness, Lady Gould, quoted. I scribbled down the part about the science and art of promoting health and well-being through the organised efforts of society. That illustrates that this is an evolving and moving area. We hope that it will evolve and move because public health has now been put with local authorities. By joining up all the different areas we wish to join up, we hope that the field of public health will move along. Therefore, it is not appropriate to put in the Bill such a definition, which is set at a particular time, because of the evolution that I hope will expand in a way that the noble Baroness—who clearly is not satisfied—will be happy with.

[Baroness Gould of Potternewton]

We are talking about a ring-fenced budget; we are not talking about a general local government budget. Therefore, there must be some guidance on what should go into that budget. I do not mind whether it is a definition in the Bill or guidance, but something must be done to make sure that we know what is in the ring-fenced budget.

[Baroness Northover]

The noble Baroness is absolutely right. This is not simply philosophy. Therefore, regulations will provide that guidance. In the mean time, I say that this is an issue on which we have spent considerable time working. She is probably aware of the July 2011 update to the public health White Paper. If she is not, I suggest that she looks at it. Paragraph A.10 on page 27 contains a list of the areas in which we expect local authorities to engage. I am sure that the noble Baroness, Lady Thornton, will be pleased that the list starts with tobacco control. The noble Baroness, Lady Finlay, may note that the second item is alcohol and drug-misuse services. Other issues that noble Lords have mentioned are also listed, such as obesity and community nutrition initiatives. The list is long.

Female Genital Mutilation

Baroness Gould of Potternewton Excerpts

Thursday 30th June 2011 Lords Chamber

[Baroness Gould of Potternewton]

I thank my noble friend for initiating this debate and for once again raising the issue of FGM. I start by declaring an interest as patron of FORWARD, the Foundation for Women’s Health, Research and Development. As my noble friend said, two pieces of legislation made FGM illegal, but the question has to be: why have there been no prosecutions? We need to examine the legislation again. Perhaps there have been no prosecutions because the law is applicable only to UK citizens and UK permanent residents; perhaps because the law makes it difficult to prosecute perpetrators as it does not protect temporary residents; or perhaps because, as a recent case review demonstrated, there is a lack of co-ordination, awareness and information-sharing among key professionals.

In February, the Government published practice guidelines aimed as a resource for front-line professionals, but they did not include a plan for disseminating the guidelines to key professionals such as police officers, teachers and social workers. To truly raise awareness we must create an environment of positive change, protective policies, the generation and sharing of knowledge, and the forging of strategic partnerships with policy-makers, statutory bodies and civil society organisations. That procedure was on its way in the form of the cross-government FGM co-ordinator, but the post was abolished by the Government in March this year, leaving individual departments to take on the responsibilities. This makes it even more essential for the Government to set out a clear, comprehensive and long-term strategy for tackling FGM. Will the Minister say whether such a strategy is being proposed, and how it will be financed and co-ordinated across government? The loss of this post is compounded by the fact that many organisations working to eliminate FGM are struggling to survive through lack of financial support, leading to closures—most notably that of the internationally recognised African Well Women's Service.

There are 66,000 women in the UK who live with the consequences of FGM, and 24,000 girls are at risk. The consequences can vary from short-term health implications to serious problems in pregnancy and childbirth and serious psychological damage. An important piece of peer research carried out earlier this year showed that type 4 FGM, known as sunna, which includes pricking, piercing or incision, is widely and erroneously accepted because it does not carry the same health risks as other forms of FGM. This is a significant barrier to elimination.

The research also identified that although the majority of cases happen to young children, there is a wider age range of girls being subject to FGM, including in their late teens and early 20s, and that FGM is not discussed even within practising communities so there are differing and contradictory views between the generations about its prevalence. These barriers clearly identify that projects and language must become more adept, dealing with FGM not only as a health issue but also as one of child protection, gender and human rights. To do that there must be greater awareness raising, greater participation and engagement of key communities, including diaspora communities, funding to support existing outreach programmes, the provision of sustainable specialist health and support services, long-term investment and an FGM action plan.

In conclusion, FGM is not only a dangerous and life-threatening practice but a gross violation of the human rights of girls and women. Everything possible should be done to eliminate the practice and ensure that the perpetrators face the consequences of the law.

Violence Against Women

Baroness Gould of Potternewton Excerpts

Thursday 13th January 2011 Lords Chamber

Moved By

[Baroness Gould of Potternewton]

To call attention to reform of the law, and to the strategy and support services, in relation to violence against women; and to move for papers.

[Baroness Gould of Potternewton]

My Lords, I am pleased to have the opportunity to introduce this debate on violence against women and girls. When I put the question into the ballot some months ago, I had little knowledge of the Government’s intentions. The only reference in the coalition document related to examining ways of funding rape crisis centres from the victim surcharge. Not to take anything away from the invaluable work of rape crisis centres, but they cover only one aspect of an extremely wide and complex subject. I was surprised, having read a number of statements written by the Conservatives when in opposition. However, last November, the Government produced a policy document, Strategic Vision: Call to End Violence against Women and Girls. This answers some of the questions I would have raised, but certainly not all. Maybe we will hear more of the detail today and more will come when the action plan accompanying the strategy is issued in March; also, when we have the response to the Stern review into how rape complaints are handled by public authorities in England and Wales. I am pleased that the noble Baroness, Lady Stern, who is back from her holidays, is participating in the debate.

It has been fascinating to put the Labour Government’s cross-government strategy alongside this Government’s strategy paper. There are parallels in concept although perhaps not in detail in respect, for instance, of prevention, reduction of risk, provision of support when violence occurs, the importance of partnership working, ensuring that perpetrators are brought to justice and the importance of the training of front-line staff. I also welcome the reference to international work, following the work already started by my noble friend Lady Kinnock.

Before examining some of the details, I want to look at the breadth of the issue which any strategy has to respond to. Both of the strategies that were produced in 2009, and this Government’s in 2010, use the definition determined by the UN Convention on the Elimination of All Forms of Discrimination Against Women that,

“violence against women is any action of gender-based violence that results in or is likely to result in, physical, sexual and psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or private”.

It is a pity that the Government have resorted to the inaccurate statement that it is the first time that a Government have agreed to work to a single criterion to eliminate violence against women and girls. The previous Government also adopted the wider criteria established at the 1995 UN Women’s Conference in Beijing, which included violence resulting through the use of technology and through economic harm. This cohesive and co-ordinated approach ensures that violence against women encompasses but is not limited to, domestic abuse, including financial abuse, sexual violence, rape, exploitation including commercial exploitation, sexual harassment and bullying, pornography, stalking, trafficking, forced prostitution in adults, all child exploitation, female genital mutilation, forced marriages, and crimes said to be committed in the name of honour. There are many connections that can cut across all these forms of violence against women. Some seem to sustain it, while others indicate common impacts and consequences.

While I appreciate that there is to be a review relating to prostitution and a new strategy on human trafficking, their non-inclusion in the Government’s strategy sends out a negative message that these issues are not forms of violence against women and girls as others are and means that policies will be less effective, such as those which overlap between trafficking, sexual exploitation or domestic violence. For instance, a young woman in prostitution may have a history of childhood abuse, a recent rape, or violent boyfriend or pimp to deal with. All those connections need to be made.

I have two other queries in respect of the strategy. While I appreciate the introduction of domestic violence orders, there is no reference to how, during the period that a ban is imposed on the perpetrator, the victim is going to be protected. I had hoped that the crucial review of the conviction rate for rape would have been reinstated, as in financial terms it will save only £441,000, which I have been told is the reason why it is being removed.

Many research studies continue to find alarming and unwavering levels of violence against women and girls in the UK, and I make no apology for repeating the figures since awareness is a crucial part of achieving change. Some 33 per cent of girls in an intimate partner relationship aged 13 to 17 have experienced some form of partner violence. Every year, a million women experience at least one incident of domestic abuse—nearly 20,000 cases a week, and 3.7 million women have been sexually assaulted at some point since the age of 16. There are 377 cases of forced marriage, many under the age of 16, and 12 so-called “honour” murders a year. In 2003, there were up to 4,000 women trafficked for sexual exploitation. Some 20 per cent of women say they have experienced stalking. Sixty-six thousand women have experienced FGM, and it is estimated by FORWARD, of which I am patron, that 24,000 girls are at risk every year.

Violence against women and girls will not be eliminated until the attitudes that excuse and normalise violence are challenged and transformed. For instance, 36 per cent of people believe that a woman is wholly or partly responsible for being sexually assaulted or raped if she is drunk and 26 per cent if she is wearing sexy clothes. One in five people think it would be acceptable in certain circumstances for a man to hit or slap a female partner. What I think is even more distressing is that one in two boys and one in three girls believe that in some circumstances it is all right to hit a woman or force her to have sex. It has to be made clear that the responsibility for any form of violence or abuse lies with the perpetrator.

Early intervention is a vital part of prevention, and has been key to both strategies, setting out which attitudes are acceptable and which are not. Schools and other institutions such as children’s homes are important in challenging the formation of violence and in fostering positive attitudes towards respectful and equal relationships. Prevention of violence against women and girls needs to be deeply embedded across all aspects of the school curriculum, policy and practices, which prompts me to ask if the guidance produced by the Labour Government for teaching and non-teaching staff continues to be circulated and used, and when we will get confirmation that SRE and PSHE are to be included in the schools’ curriculum. For while the coalition Government’s commitment to teaching sexual consent in schools is welcome, this is not enough to create a safe school environment for girls and to tackle effectively attitudes that condone and normalise violence against women.

Equally, violence against women and girls must be a part of the work on sexualisation of children, child protection and parenting. Every day, all across the country, women and children are to be found in accident and emergency units, at doctors’ surgeries, at sexual health clinics and drug and alcohol clinics bearing the impact of violence and abuse. The findings of the task force under Sir George Alberti, incorporating the focus groups undertaken by the Women’s National Commission reinforced the importance of raising the profile of violence against women and girls, resulting in guidance being circulated to NHS staff. This was reinforced by the inclusion of violence against women and girls in the Operating Framework for the NHS in England 2010/11. Can the Minister assure the House that it will be a part of any new NHS operating framework?

Violence against women cuts across every aspect of public policy and every department of government and local government. There are links between violence against women and fear of crime, rape, assault or stalking, creating the fear of going out at night. Cuts in street lighting costs which are being proposed by some local authorities will only exacerbate that fear. Similarly, big sporting events are a target for increased trafficking and sexual violence, which requires the co-ordination of services both nationally and locally. Perhaps we could hear how that has been achieved. There is clearly value in the Government’s cross-government committee on violence against women, but can the Minister indicate its role and membership, and how it will work with local government and the third sector, which will bear the brunt of implementation at a time when they are experiencing budget cuts?

As well as the long-term physical, psychological and social costs, violence against women also represents a significant cost to the economy—£40 billion per year. The direct cost of domestic violence in one year is £6 billion, the human and emotional costs being estimated at £17 billion and each case of rape is estimated to cost £76,000.

The Government are to allocate in total £28 million for specialist services over the next four years, of which £20 million will be funding for the Multi Agency Risk Assessment Conference, and both sexual violence and domestic violence independent advisers, as well as the National Domestic Violence Helpline. However, the Government strategy refers to initiatives such as MARACs and the IDVA as services, but they are not services as such. Will the Minister clarify that statement?

There is also a sustainable model of funding for rape crisis centres. However, no other women’s services are included, particularly for the most vulnerable, and BME services are lacking in the policy almost entirely. It is also disappointing that there are no targets, milestones, measurements, monitoring and so forth in the document, but again, can we expect them to appear in the action plan?

Violence against women is not inevitable. In 2002, the World Health Organisation's ground-breaking research World Report on Violence and Health found that,

“violence can be prevented and its impact reduced … The factors that contribute to violent responses—whether they are factors of attitude and behaviour or related to larger social, economic, political and cultural conditions—can be changed”.

That means that the prevention of violence against women requires identifying and challenging the root causes and drivers of violence against women, be it the unequal power relations between women and men, including gender inequality in social, cultural, economic and political spheres or the persistence of rigid gender stereotyping. Such interventions to address violence against women will be effective only if they are part of an embedded prevention strategy that challenges broader attitudes, practices and unequal power relations between women and men.

Leadership at all levels is needed to strongly challenge violence against women and to promote non-violent norms and respect for women. In addition to high-level political leadership, community mobilisation and leadership at a grass-roots level is important for transforming attitudes and driving social change at local level. I am proud to have been involved in my own local community in Brighton and Hove for some years now, where we have been doing that work. That means increasing the capacity of women’s services, providing resources for women-only services and local communities to challenge violence against women at a local level and develop models of community-based prevention of violence against women.

Therefore, the prevention of violence against women needs to be located in policy frameworks that promote gender equality and tackle unequal power relations between women and men We must ensure that violence against women is included in the public sector equality duty objectives by public authorities under the Equality Act 2010, which I hope will be retained, and by regular public reporting on progress on key indicators of gender inequality—for example, the gender pay gap, gender division of paid and unpaid work, as well as women’s representation in public decision-making.

To summarise, violence against women is one of the main causes and consequences of women's inequality. It represents a violation of women's rights, including the right to gender equality and non-discrimination, the right not to be treated in an inhuman and degrading way, the right to respect for private and family life, including the right to physical and psychological integrity, and the right to life. It will only be by providing adequate resources, support mechanisms and the necessary machinery that the vision that I am sure we all seek of a society where women and girls can lead lives free of the threat and reality of violence can be achieved. I beg to move.

--- Later in debate ---

[Baroness Gould of Potternewton]

My Lords, I thank everybody who has spoken in this debate, which has been very wide-ranging. One of the things that I always find fascinating about debates like this is how much you learn from other people. The expertise that there is around your Lordships’ House has been offered today in this debate. It has shown the breadth of the subject that we are talking about, which makes it more difficult and complicated to solve. Certainly the solutions are in many ways very complex, but I do think these problems are solvable.

Many noble Lords mentioned the international situation. That is right and may be a subject for another debate, which I would very much appreciate, not least because I have been actively involved with both the UN and the Commonwealth Institute on the question of widows. I would like to have a debate on that subject.

The noble Baroness, Lady Hamwee, said that this was not just an issue for women. She is perfectly right: it is not just for women but for the whole of society. We have to raise awareness, talk about the issue as much as we can and work to find solutions. I look forward, as I am sure other noble Lords do, to working with the noble Baroness, Lady Verma, to make the strategy work so that we obtain a real solution to this very serious problem. In the mean time, I beg leave to withdraw the Motion.

Motion withdrawn.