Sexually Transmitted Infections: England

Lord Black of Brentwood Excerpts

Thursday 5th September 2019 Lords Chamber

Asked by

[Lord Black of Brentwood]

To ask Her Majesty’s Government how the prevalence of sexually transmitted infections in England has changed over the last 10 years.

[Lord Black of Brentwood (Con)]

My Lords, I beg to move the Question standing in my name on the Order Paper. In doing so, I declare an interest as a trustee of the Bloomsbury Network and patron of the Terrence Higgins Trust.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Blackwood of North Oxford) (Con)]

My Lords, we are seeing a mixed picture in relation to trends in sexually transmitted infections. There have been increases in some infections such as syphilis, gonorrhoea and chlamydia, but diagnoses of first-episode genital warts have fallen. We are also seeing a steep decline in new HIV diagnoses among gay and bisexual men. Condoms remain the most effective way of reducing the risk of STDs.

[Lord Black of Brentwood]

I thank my noble friend for that Answer. While the news on HIV is obviously very welcome, is it not the truth that other STIs are now on the rampage, with rates of increase for gonorrhoea, syphilis and chlamydia sky-rocketing ferociously? Does my noble friend agree that what is needed is a cross-sector sexual health strategy and some vision and ambition for what we, as a country, want to achieve around sexual health? Can my noble friend, who I know cares deeply about these issues, tell us exactly what yesterday’s spending announcements mean for sexual health funding, which has been cut by £700 million in the last few years, with appalling consequences?

[Baroness Blackwood of North Oxford]

I thank my noble friend for his Question and I congratulate him on his important work in this area. He is absolutely right that the Health and Social Care Committee recommended a new sexual health strategy and we will respond to its report shortly. In addition to that, the Green Paper consultation on prevention sought views on priorities for a possible new strategy and we will consider those responses very carefully. As he rightly says, the spending review yesterday announced 1% real-terms growth for the public health grant, which I know will be very welcome because it means that local authorities can continue to invest in prevention and essential front-line health services, including sexual health services.

Atrial Fibrillation

Lord Black of Brentwood Excerpts

Tuesday 7th May 2019 Lords Chamber

Asked by

[Lord Black of Brentwood]

To ask Her Majesty’s Government what progress they have made towards Public Health England’s target to increase the proportion of known atrial fibrillation patients who are offered and started on appropriate treatment to 89% by 2021.

[Lord Black of Brentwood (Con)]

My Lords, I am most grateful to all noble Lords taking part in this important debate this evening.

Atrial fibrillation is a heart condition which causes an irregular and often unusually fast heart rate as a result of abnormal electrical signals in the heart. Because of the irregular rhythm, diagnosis is straightforward, through a manual pulse check at an ordinary GP appointment. It is easy to detect, the examination takes seconds and a range of effective treatments, including, where appropriate, anticoagulation, can be deployed.

Although sometimes uncomfortable, in itself AF is not fatal, but its sinister mischief is that it can lead to blood clots forming in the heart that can then enter general circulation and block arteries in the brain, causing stroke. As a result, AF is the root cause of one in five strokes in the UK, and people with this condition are five times more likely to suffer one than those with a regular heartbeat.

Strokes which arise from AF also tend to be more severe than other types of stroke and are associated with significant mortality and morbidity. In addition to the enormous human consequences of an AF-related stroke—for the patient as well, of course, as their families —treating and managing strokes places a huge financial burden on the National Health Service. The average health and social care cost of stroke in the first year after onset is estimated at £22,175, with accumulated costs of over £45,000 after five years. AF illnesses overall cost the NHS about £2.2 billion each year.

I have an interest in this subject as a result of personal experience. I was diagnosed 16 years ago with a form of AF, known as paroxysmal atrial fibrillation. It is brought on by sudden exertion such as running, which I therefore avoid. It happens to me but rarely; the last time it occurred was here in the House of Lords, when I was rushing too quickly up the stairs for a vote. Such is my devotion to my noble friend the Chief Whip that I am prepared to risk ill health for him. I am one of the fortunate ones, though, in that I was aware of the problem because it manifested itself with unpleasant symptoms. I received a swift diagnosis and have been on effective treatment ever since. My condition is well managed and monitored but some people are not so fortunate. For some, the condition is symptomless and undiagnosed, which is when it is at its most dangerous. For others, a diagnosis is made but they then receive inadequate treatment; the consequences of that can be cataclysmic. The debate today is about those people and what can be done to ensure that their condition is diagnosed and managed.

At the end of the day, while AF is a common condition with potentially serious consequences—it affects around 2.5% of the population in England—it can, with proactive diagnosis and effective treatment, be dealt with in a way which reduces the risk of stroke and minimises health and social care costs for the taxpayer. It is estimated that appropriate treatment with effective anticoagulation remedies averts one stroke in every 25. That is why clinical guidelines from NICE make it clear that people with AF should have their risk of stroke assessed and be offered anticoagulation remedies to help prevent the formation of potentially lethal blood clots.

We last had a substantive debate on this issue four years ago, I think. Since then we have seen good progress, to the credit of the Government and the NHS. In 2016, a menu of preventive interventions published by Public Health England set out an ambition to increase the optimal management of people with AF from 74% to 89% by 2021. More recently, the NHS Long Term Plan identified cardiovascular diseases as,

“the single biggest area where the NHS can save lives over the next 10 years”,

not least through better detection and treatment of high-risk conditions including AF, high cholesterol and high blood pressure in order to prevent 150,000 strokes.

As part of that process, NHS England and Public Health England have committed to new national goals for AF, the aim being to ensure that 85% of the expected number of people with AF are detected by 2029 and that 90% of those diagnosed with high risk are adequately anticoagulated by then. Those aims are absolutely laudable but as yet we have little clarity on how such ambitions are to be translated into local action within the NHS to improve patient outcomes. Can my noble friend the Minister let us know how the upcoming national implementation framework will support delivery against the cardiovascular disease prevention ambitions for AF, and how NHS England and Public Health England will measure progress against the goals for detection and management, and report on them?

Key to that ambition are two issues: diagnosis and treatment. I should like to say a word about each. First, it is estimated that in England about 1.4 million people suffer from AF, of whom 1.11 million have been diagnosed. That figure has improved significantly since 2015 but it still means that one in five people with a condition that has potentially fatal consequences is unaware of the fact. Ensuring that they are identified and risk-assessed is absolutely fundamental to reducing the number of avoidable strokes. A quick examination can have a huge impact on an individual’s life. In the absence of a national screening programme for AF, we need to ensure that GPs and healthcare professionals take every opportunity to undertake manual pulse checks, especially among at-risk groups such as the elderly. Can my noble friend tell us what steps are being taken to ensure that that happens, and what Public Health England and NHS England are doing systematically to ensure that individuals at risk of AF are diagnosed?

Once that crucial diagnosis is made, the next hurdle is effective treatment through anticoagulation, particularly for those at the highest risk of stroke. The enormous benefits of anticoagulation are well recognised and clinical guidelines underline its importance. NICE recommends that people with AF at risk of stroke should be offered either warfarin or a non-vitamin K oral anticoagulant—a NOAC. All treatment options should be available to patients where clinically appropriate, but the terrible truth is that many high-risk patients are not receiving adequate treatment because they are getting no medication at all or an ineffective treatment such as aspirin. That has profound consequences.

National clinical audit data for stroke shows that in England in 2017-18 nearly 16,000 people were admitted to hospital with potentially avoidable AF-related strokes. Many of these incidents arose because there had been no diagnosis. Tragically, however, over 40% of these strokes affected people who had been diagnosed with AF but were not receiving an appropriate therapy at the time of their admission to hospital. This means that in the space of 12 months there were 6,703 AF-related strokes that were potentially preventable. Just think for a moment of the shocking human consequences of that failure. The data shows that of those potentially avoidable strokes, because of a failure to anticoagulate, one quarter—1,723 souls—died in hospital. Another 46%, or 3,077 people, were discharged with a severe or moderate disability of a kind which will have changed their lives, and those of the loved ones who care for them, for ever.

To address what is, I believe, an extremely grave issue of undertreatment, the national clinical directors for stroke and cardiovascular disease have made it clear that failure to prescribe an important treatment such as an anticoagulant needs to be seen as an error as serious as prescribing the wrong treatment. What consideration has been given by NHS Improvement to classifying stroke cases that occur in patients with diagnosed AF who were not receiving an appropriate treatment as a “Never event” that requires further investigation? Ensuring increased accountability and transparency in this area could be a vital step in addressing the problem of undertreatment.

My final point relates to the sub-optimal treatment of patients who have been diagnosed and are on an appropriate treatment. Regrettably, strokes among this group can, and still do, occur as a result of poor-quality anticoagulation control and poor adherence to medication. At the moment, warfarin continues to be the most commonly prescribed therapy for AF: some two-thirds of patients are treated with it, compared to around one-third for NOACs. Whereas treatment of AF through a NOAC significantly improves a patient’s quality of life because it does not require routine monitoring or ongoing dose changes, treatment with warfarin—alongside a risk of bleeding—can be unpredictable and unstable if not carefully monitored.

Estimates suggest that even well-monitored warfarin patients are outside the therapeutic range which gives them effective protection about one-third of the time, meaning that they are then at risk of stroke. Indeed, a report by Anticoagulation UK last year showed that 37,000 patients in England are known to have sub-optimal warfarin control. We know that is a problem but we do not know enough about it because of a lack of data. We need to remedy that. Will my noble friend say what steps are being taken to enable local NHS services to identify those whose AF treatment is sub-optimally managed? Will she engage with NHS England and Public Health England with a view to putting in place a system for the routine collection and publication of INR and therapeutic range data to measure the effectiveness of anticoagulation management and to inform quality improvement strategies?

I am conscious that I have sought to cover a lot of ground today but this is a big issue which impacts on many hundreds of thousands of people, and is one where we can make a real difference. I look forward to contributions from other noble Lords, and to hearing from the Minister.

Health: HIV

Lord Black of Brentwood Excerpts

Monday 25th March 2019 Lords Chamber

Asked by

[Lord Black of Brentwood]

To ask Her Majesty’s Government what steps they are taking to bring an end to new transmission of HIV infection by 2030.

[Lord Black of Brentwood (Con)]

My Lords, I beg leave to ask the Question standing in my name on the Order Paper. In doing so, I declare an interest as a trustee of the Bloomsbury Network.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Blackwood of North Oxford) (Con)]

My Lords, due to increased access to testing and other measures, there has been a welcome 28% decline in new HIV diagnoses since 2015. We are also one of the first countries in the world to meet the UNAIDS 90-90-90 HIV targets. To build on this progress, the Secretary of State for Health and Social Care has announced the Government’s commitment to end new transmissions of HIV in England by 2030. Work is under way to take this forward.

[Lord Black of Brentwood]

I thank my noble friend for that Answer. I know that noble Lords across the House who have long campaigned for this moment—I am hazarding a guess that I might include the Lord Speaker in view of his exceptional leadership in this area—will applaud the Secretary of State’s commitment to eliminating new HIV transmissions by 2030. In the certain knowledge that those with HIV on effective treatment cannot pass it on, it is now in our power to bring an end to this cruel illness. Does my noble friend agree that what is needed now is a comprehensive national HIV strategy, which brings together all of the steps that we need to take: prevention through both sustainable access to PrEP and effective treatment for those diagnosed; more testing to stop late diagnosis; greater investment in sexual health services; education about HIV in schools; an end to the fragmentation of HIV services; and a commitment to tackle stigma?

[Baroness Blackwood of North Oxford]

I thank my noble friend for that Question and pay tribute to the work of the Lord Speaker. I agree with the premise of his Question. Public Health England has attributed the success that we have had, with 92% of people with HIV now diagnosed, 98% of patients receiving treatment and 97% virally suppressed to a combination of HIV prevention, including expanded HIV testing, prompt initiation of antiretroviral therapy after diagnosis, condom provision and PrEP, all of which we will need to build on as we develop plans to achieve zero infections by 2030. He is absolutely right that these will all need to go into development of that plan.

Sexual Health Services

Lord Black of Brentwood Excerpts

Thursday 29th November 2018 Lords Chamber

[Lord O’Shaughnessy]

As I have just said to the noble Lord, Lord Cashman, we are seeing a change in services. More services are going online, for example. An e-service for sexual health was launched in January 2018, with 20,000 kits being distributed. So there is a change in the health services being provided. I can tell the noble Lord that there has been no impact on the PrEP trial; indeed, we have already recruited nearly 10,000 of the 13,000 people to that trial, and we are hoping it will be successful.

[Lord Black of Brentwood (Con)]

My Lords, I declare an interest as a trustee of the Bloomsbury Network. Does my noble friend agree that, with the advent of PrEP and the certain knowledge that people on effective medication cannot pass on HIV, we now have within our grasp the possibility of eliminating new HIV infections, and therefore the burden on sexual health services? Will the Government make a clear commitment to achieving that noble goal of zero new HIV infections by 2030 and ending once and for all this horrible disease?

[Lord O’Shaughnessy]

My noble friend makes an excellent point: we have cause for optimism not least because of the work that he, the noble Lord, Lord Cashman, and so many others have done. I mentioned the decline in diagnoses year on year. The UK has met the UN’s 90-90-90 ambition in every part of the country, including London. Having done that, which is a huge achievement, of course we should set our sights higher. I should be very happy to discuss with noble Lords exactly what our target should be. Clearly, a zero infection rate must be where we want to get to in the end.

Health: Atrial Fibrillation and Stroke

Lord Black of Brentwood Excerpts

Tuesday 12th December 2017 Lords Chamber

Asked by

[Lord Black of Brentwood]

To ask Her Majesty’s Government how many people with a diagnosis of atrial fibrillation who were admitted to hospital with a stroke in 2016-17 were not on an appropriate anti-coagulation therapy prior to admission.

[The Parliamentary Under-Secretary of State, Department of Health (Lord O'Shaughnessy) (Con)]

My Lords, audit data shows that around half of patients with known atrial fibrillation who have a stroke have not received anti-coagulation treatment before their stroke. Figures for last year show that this varies from 25% in some clinical commissioning group areas to almost 100% in others. More than 300,000 people in England have undiagnosed atrial fibrillation.

[Lord Black of Brentwood (Con)]

I thank my noble friend for that Answer. As he knows, atrial fibrillation is a significant cause of stroke but it is also avoidable, because it is easily diagnosable and easily treatable with anti-coagulant medication. Yet as the figures he just gave us show, more than 7,000 people in England who were admitted to hospital with a stroke last year were known to have AF but were not receiving proper therapy. Is my noble friend aware that the National Clinical Directors for cardiovascular disease prevention and stroke recently stated:

“Failure to prescribe an important treatment”,


such as this,

“needs to be seen as an error that is equally as serious as prescribing the wrong treatment”?

What action can the Government take to ensure that all eligible patients with AF are prescribed anti-coagulation to help protect them from stroke and the devastating consequences that flow from that for them and their families?

[Lord O’Shaughnessy]

I thank my noble friend for making that point. He is quite right that atrial fibrillation is easily diagnosable and treatable. In the end, it has to be a clinical judgment on what kind of medicine is appropriate for any given patient, but the variation in the prescription of anti-coagulants demonstrates that there is not uniform understanding of the options. There are a number of things I could point my noble friend to, such as the NICE guideline which promotes not only self-monitoring systems, which are typically what we have had, but encourage patient choice for the new types of anti-coagulants which have a lower risk of bleeding and are much more popular with patients.

HIV: Barriers to Treatment

Lord Black of Brentwood Excerpts

Thursday 1st December 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, I think the noble Lord will agree that there is a clinically driven process, through the specialised commissioning groups and the clinical priorities group within NHS England, that attempts to look at all these drugs in an objective, clinical way. Surely it is better that these decisions on priorities should be made by clinicians acting in that way than by politicians, who are subject to all the pressures of which we are all only too well aware. Of course affordability is an issue in assessing whether a new drug should be commissioned; it always has been and always will be. The £2 billion, which the noble Lord has mentioned before and which I think comes from the PPRS, is taken into account when setting the overall budget for NHS England.

[Lord Black of Brentwood (Con)]

My Lords, one of the significant barriers to effective HIV treatment is that it is often present with a co-infection such as hepatitis. What steps are the Government taking to identify, diagnose and treat people who are co-infected with HIV and hepatitis C, the most deadly form of the infection?

[Lord Prior of Brampton]

My Lords, I am afraid I cannot answer that question, or at least I could answer it in only a very inadequate way. I would like to reflect on it and write to my noble friend as soon as I can.

HIV Diagnosis: Clinical Guidance

Lord Black of Brentwood Excerpts

Thursday 1st December 2016 Lords Chamber

[Baroness Gould of Potternewton]

My Lords, I must declare that I was on the innovation panel for Public Health England.

[Lord Black of Brentwood (Con)]

My Lords, all those living with HIV, particularly those diagnosed late, require significant levels of care for both their physical and mental health. Does my noble friend agree that specialist doctors and nurses in the NHS provide exceptional care for those living with the virus, and join me in paying particular tribute to the work of pioneering centres, such as the Ian Charleson Day Centre at London’s Royal Free Hospital, which have made a real difference to the lives of thousands of patients?

[Lord Prior of Brampton]

My Lords, I am very happy to do that. It is extraordinary how healthcare has changed a fatal disease into a chronic disease in just 20 years. I have a quote from the PHE report that was produced today, from a white lady who has HIV. She says:

“Just a few words from someone who has been living with HIV for nearly 20 years: it’s not that bad and there are times when you forget you have HIV. Eventually, even when you remember you’re positive, it’s no longer an issue”.

That is an illustration of just how far we have come in 20 years.

Health: HIV

Lord Black of Brentwood Excerpts

Monday 5th September 2016 Lords Chamber

Asked by

[Lord Black of Brentwood]

To ask Her Majesty’s Government what plans they have to move toward the elimination of HIV infection in the United Kingdom.

[Lord Black of Brentwood (Con)]

My Lords, I am honoured to lead this debate on what remains a profoundly important issue of public health: tackling the spread of HIV and doing so in a way that over time would allow us to eliminate the virus, which has been responsible for so many deaths and so much suffering. I thank all noble Lords for taking part.

It is just over 35 years since the first reports in the US media of an unidentified illness that seemed disproportionately to affect gay men and to kill them. What was identified as the human immunodeficiency virus, an incurable disease, left a generation of those infected facing certain death. Many more living in its shadows had their lives shaped by it. However, 35 years on we have turned the horror of HIV/AIDS from a death sentence into a manageable chronic condition through the use of antiretroviral treatment. That we can today even begin to contemplate its elimination is a tribute to many brave and visionary people. There is not time to name them all tonight but I want to make two exceptions. The first is to praise the campaigning groups, especially the National AIDS Trust and the Terrence Higgins Trust, which fought tirelessly to keep this issue on the front line of the public health agenda. The second, on this very important day for him, is to recall the vital role that our new Lord Speaker played in the earliest days of this epidemic. As Secretary of State Fowler, he showed enormous courage in tackling the issue, and in doing so saved thousands of lives. Our gratitude to him is eternal.

As we know, HIV is a massive global issue, but it also continues to be one of the fastest-growing serious health conditions here in the UK, with an estimated 6,000 new diagnoses—115 a week—and the rate of new infection is increasing. The year 2014 saw the highest ever number of men who have sex with men diagnosed with HIV. Some two-fifths of people were diagnosed late, long after they should have started treatment. One in six of those with the virus still does not know their status and, for many of the 104,000 people living with HIV, economic hardship, stigma and discrimination are all too real.

So if anything, despite the huge life-saving advances in treatment and care globally, the situation here in our own back yard, particularly with regard to testing and prevention, is deteriorating. We need to take tough and determined action to reverse the tide, and that will require a strategic approach from the Government to tackling every aspect of HIV, with the aim of eliminating the transmission of the virus in the UK and bringing its reign of terror to an end.

For the first time we have the ability to do just that because we have at our disposal the means to stop transmission. As a study published last month showed, it is nearly impossible for someone living with HIV to pass on the virus if they are undergoing effective antiretroviral therapy and have an undetectable viral load. This is of profound importance in producing a strategy for tackling HIV, as we have seen in other countries. A recent study about HIV in Denmark, from the University of California and Copenhagen University Hospital, provided the first unambiguous evidence of the link between high rates of viral suppression and falling HIV incidence. Because of the Danish policy of treatment as prevention, HIV incidence among gay men—still the group most at risk—is now so low, at 0.14% a year, that it almost meets the annual incidence rate that the World Health Organization has set as the threshold for eventually eliminating the epidemic.

There is no reason why such a remarkable success should not happen here, given that we have exactly the same tools to use. To do so, however, three things must happen. First, self-evidently, to cut transmission through the effective use of antiretrovirals, those who have the virus need to know about it and get on treatment. Far too many still do not, with devastating consequences. It is a terrible statistic that over 80% of all HIV transmissions in the UK are from the undiagnosed. We need a step change in the volume of tests that are undertaken regularly by those at greatest risk, and in access to testing. Yes, there has been much good progress and innovation—the introduction of home-testing kits, for example—but it is not enough. There should be much more routine testing of populations at risk, and more support needs to be given to GPs and primary care providers, and indeed to local authorities, to deliver it. Of course there is the continuing need for publicity to explain its importance. I pay real tribute to the extraordinary example set by His Royal Highness Prince Harry, whose live broadcast of his own HIV test has done more than anything else in recent times to raise the profile and make HIV testing the norm.

Secondly, one of the major reasons why people do not get tested is that they fear the stigma of a positive result. The 2015 People Living with HIV Stigma Index revealed a continuing problem with HIV stigma and discrimination, with too many people reporting everything from verbal harassment or physical assault to exclusion by their families. Given the crucial role of stigma in encouraging testing, there is a strong case for a public information campaign to raise awareness and tackle some of the myths that still exist. I also commend to the Government the recent NAT report Tackling HIV Stigma, which draws together international best practice.

Improving education about HIV and sexually transmitted illnesses more generally would also be of real benefit, especially as the increase in HIV incidence among young people is particularly sharp, up 70% in the last three years. It is time to look again at what is being taught about this issue, particularly as Department for Education guidance is now 16 years old. It is really important for young people to understand about HIV and to learn how to avoid it through condom use, but also to be taught the importance of being supportive of those living with HIV and not to fear or stigmatise them.

Finally, while improved testing and tackling stigma would help to identify those who have the virus and get them on treatment, the flip side of the same coin is preventing HIV by using medication to protect HIV-negative people from acquiring it. Again, we have the tools to hand in the shape of pre-exposure prophylaxis, or PrEP. Two studies, including the PROUD trial here in the UK, show PrEP to be highly effective at preventing HIV infection in men who have sex with men. Properly taken, the success rate is well over 90%. This is a revolutionary development in the fight against HIV which can transform the public health landscape. Only this week, new statistics from San Francisco showed that it had cut its rate of new infection by a third in the past three years as a result of PrEP.

Inevitably, as PrEP is a drug linked with sex, it has become the subject of controversy and misinformation. It is argued that contracting HIV results from a lifestyle choice and that it is not appropriate for the NHS to pick up the pieces from such actions. This ignores the point that the NHS is treating, curing and preventing illnesses diagnosed from lifestyle choices all the time—cigarette smoking, overeating, overdrinking or riding a bike without a helmet—and PrEP should be no different.

The other argument, of course, is money, and it is estimated that it could cost up to £20 million each year to provide. However, that figure is dwarfed by the existing cost of HIV to the NHS. The lifetime cost of treating someone with HIV is now in the region of £380,000. As people live longer, that figure will only increase. It is Mickey Mouse economics to refuse to fund effective prevention measures for those most at risk at the cost of just £400 a month—a sum soon likely significantly to reduce—when you set that against the huge cost of treating someone who contracts HIV. If PrEP prevented just a handful of infections each year, it would easily be saving money for the NHS and the taxpayer.

Regrettably, that is now a matter before the courts, but I hope that common sense will prevail and that the original decision in the case—that there is no legal impediment to NHS England providing PrEP—will be upheld. That is vital because it is the last element in the jigsaw alongside effective treatment, more testing, tackling stigma and promoting condom use, which will allow us finally to move towards the elimination of HIV transmission, something genuinely within our grasp.

Earlier this year, the UK, as a member of the World Health Organization, committed to the goal of eliminating hepatitis C—another deadly condition—by 2030. NHS England is now working on plans to make that goal a reality through prevention, testing and treatment. We must have the same ambition for HIV. I ask my noble friend whether the Government will be as bold with HIV as they have been with hepatitis C, commit to the elimination of new transmissions by 2030 at the latest and work with NHS England on a strategy to achieve that.

Thanks to the miracles of genetic science, we now know where and when HIV began. We do not yet know when it will end, but end it must, and tonight’s debate should be a staging post on that journey. In memory of the countless millions who have died, in deep honour of those who have pioneered treatment and dispensed loving care and in solidarity with those living with the virus, let this country have the ambition to show the way in consigning the greatest public health peril of our age to the history books.

Atrial Fibrillation

Lord Black of Brentwood Excerpts

Wednesday 4th November 2015 Lords Chamber

Asked by

[Lord Black of Brentwood]

To ask Her Majesty’s Government what action they are taking to improve the diagnosis and management of atrial fibrillation.

[Lord Black of Brentwood (Con)]

My Lords, I am honoured to have the opportunity to lead a debate on an issue which affects hundreds of thousands of our citizens, and I am grateful to all noble Lords who are taking part.

I have an interest to declare in this subject, but not one you can find in the register. It is that for many years I have had a form of AF known as paroxysmal atrial fibrillation. It is brought on by a significant rush of adrenalin—not the sort, of course, which comes from listening to debates in your Lordships’ House but the sort which comes from sudden exertion. I am lucky, however. A doctor diagnosed AF when I was in the midst of an episode and referred me to a specialist. Regular monitoring and medication ensure that, so long as I am careful, I have no problems. Today’s debate is about those who are not so lucky, either because they are not diagnosed or because they are not getting the right treatment.

Atrial fibrillation is a heart condition that causes an irregular and often unusually fast heartbeat. It happens when abnormal electrical signals fire from the top chambers of the heart in a way which overrides the heart’s natural pacemaker. The causes of AF are not fully understood, but it affects up to 1.5 million people in the UK, including around one in 10 people aged over 65. It often runs alongside other cardiac conditions such as high blood pressure or clogged arteries.

There are various ways to manage the condition, including drug therapy, cardioversion from electric shocks and, if all else fails, ablation, where areas of the heart causing the abnormal heart rate are destroyed by radio frequency pulses. The use of one or all of these methods makes AF a condition that is manageable provided it is diagnosed—and that is a key point for this debate. For while AF can be extremely uncomfortable, producing palpitations, chest pains and dizziness as a result of the heart racing at well over 100 beats a minute, it can present no symptoms at all. That is when it is at its most dangerous. Undiagnosed and untreated, a heart that is not beating regularly can lead to the formation of blood clots inside it which can then enter the general circulation in a way that blocks arteries in the brain; in other words, the cause of a stroke.

Diagnosis of AF is therefore a crucial public health issue, as many people—perhaps up to 750,000 in the UK—are simply not aware they have it, significantly increasing their risk of a stroke. According to NICE, around 7,000 strokes a year, and 2,000 premature deaths, are likely to result from the failure to detect AF and treat it with anticoagulant drugs. As Professor Mark Baker, NICE’s director of clinical practice, said:

“This needs to change if we are to reduce the numbers of people with AF who die needlessly or suffer life-changing disability as a result of avoidable strokes”.

A good deal of progress has been made in recent years in dealing with this problem and I know how seriously the Department of Health and NHS England take it. I was enormously grateful to the former Health Minister, the noble Earl, Lord Howe, who met me to discuss it last year. I know that the Minister will take that work forward, and I look forward to hearing from him this evening what progress has been made in a number of areas, three of which I will highlight.

The first is improving diagnosis. In many ways, this could not be simpler, because it can be done through a plain old manual pulse check at an ordinary GP appointment. The irregular heartbeat is easy to feel; the examination takes seconds to do; and it is of course completely painless—one of those genuine occasions when, when the GP says, “This will not hurt”, it does not.

Given that there is nothing like a practical demonstration, I can even show noble Lords how quick and easy it is. Next Tuesday morning, I shall host a drop-in event in association with AntiCoagulation Europe and Bayer HealthCare, where parliamentarians can come and get their pulse checked by an expert doctor who will be able to talk about this issue and advise on any irregularities in colleagues’ pulses. I hope that there will not be many of them, but it pays to be on the safe side, so I invite noble Lords to come along to Room G between 10 am and l pm to see what I mean.

Given that diagnosis is so easy and effective, why is a manual pulse check not routine, especially for over-65s? The reason is that the UK National Screening Committee, part of Public Health England, recommended in a report in June 2014 that it is,

“uncertain that screening will do more good than harm … because … treatment and care for people with AF is not optimal”.

Given that we are talking about a simple test that saves lives, I do not believe that the quality of existing services—which have been improving but perhaps not rapidly enough—should be cited as a compelling reason not to introduce screening for AF. We need to do what we can, of course, to ensure that care becomes “optimal”, but, in the mean time, we should not endanger people who are unaware that they have this condition by failing to test them. Will the Minister join me in calling on Public Health England and the National Screening Committee to review this recommendation?

Once AF is diagnosed, it needs effectively to be treated. Some patients with AF need anticoagulation therapy to stop their blood clotting and reduce their risk of an AF-related stroke. Identifying those patients is not always straightforward but has been made much easier by the introduction of a new tool for GP practices called GRASP-AF, which helps identify patients at risk by assisting GPs to interrogate their clinical data. GRASP-AF is being rolled out across England, but data suggest that only about one-third of GP practices are using it. I would be grateful if the Minister could update us on the rollout of this programme and on what his department is doing to ensure that GPs most effectively assess AF patients’ risk of stroke.

My final point relates to the anticoagulant drugs that are used to treat AF where this is judged necessary by a GP or consultant. The most widely used treatment option in this area is warfarin, which has been deployed for over 50 years and has undoubtedly saved many lives. However, as many noble Lords will know, it is not an ideal drug, as it requires regular monitoring and dose adjustments to ensure that it is working properly, usually in a specialist anticoagulation clinic. This is a problem for those in full-time work, and often difficult for elderly or immobile people. My late father was on warfarin for the last few years of his life, and, as he was to all intents and purposes housebound, his regular tests became very complex and stressful for both my parents.

On top of that, many foods can interfere with warfarin or alter its effects, along with alcohol and some medicines. In other words, it is far from ideal. Warfarin is one of the most common causes of drug-related adverse events and is responsible for about 6% of all fatal and severe drug-related incidents. This is a terrible cost in lives and a substantial financial cost to the NHS. Many GPs therefore do not like prescribing it, and I can understand why. As a result, they either do not treat the condition at all—and audit data suggest that 46% of AF patients who should be on treatment to prevent blood clots are not—or they treat it with aspirin, which is not recommended by NICE.

Yet there is an effective alternative to warfarin in the form of novel oral anticoagulants, or NOACs. These drugs were developed specifically to overcome the limitations of warfarin which I have just described and are recommended by NICE as clinically effective for stroke prevention in AF as well as being cost-effective for the taxpayer. Treatment of AF through NOACs significantly improves a patient’s quality of life because it does not require routine monitoring or ongoing dose changes; it does not entail dietary restrictions; and it provides predictable, stable and regular levels of anticoagulation. Against that background, it would be advantageous both for patients and for the taxpayer if the use of NOACs was more widespread. However, at the moment, data from NHS England show that only 11% of anticoagulants prescribed are NOACs—possibly because of lack of clinical awareness and confidence in using them rather than warfarin, or because NICE guidance is being implemented too slowly.

Under the NHS constitution, patients should have access to the full range of treatment options recommended by NICE, but at the moment that does not seem to be the case. Will the Minister tell us what action is being taken to ensure that more patients have access to NOACs, in line with NICE guidance, and to reduce variations in their use across the country? For instance, might he consider providing specific support for clinical commissioning groups with the lowest rate of NOAC use, to ensure that patients in those areas have better access to treatment?

I greatly look forward greatly to the contributions of noble Lords this evening. This is no peripheral health issue, but one of real importance to the lives of hundreds of thousands of individuals and their families. Great progress has been made in recent years, but, thanks to the development of new drugs and new technology, more can be done. This is an occasion when a tiny hand on the tiller by my noble friend could mean significant further advances in diagnosis and treatment, with real public health benefits. I hope that our debate tonight will gently nudge the noble Lord in the direction of that tiller and lead to life-saving changes.

HIV/AIDS

Lord Black of Brentwood Excerpts

Thursday 5th March 2015 Grand Committee

[Lord Black of Brentwood (Con)]

My Lords, like other noble Lords, I am indebted to my noble friend Lord Fowler for securing this debate today and for giving us, as he said, what is probably the last opportunity before Dissolution to discuss the issue of HIV and AIDS.

It is therefore a fitting moment to pay him the warmest of tributes, as other noble Lords have done, for everything that he has done throughout this Parliament to keep this subject right up at the top of the political agenda, focusing on not just the impact of HIV and AIDS in the United Kingdom but on the terrible scourge of the epidemic in so much of the developing world, which the noble Lord, Lord Crisp, spoke about so eloquently just now. I only hope that at the end of the next Parliament in five years’ time, we will have seen more progress at home but also some of the incredibly important changes that need to take place in the developing world as a prerequisite to tackling HIV and AIDS. I absolutely agree with the noble Lord that the most crucial is the rapid decriminalisation of homosexuality in many Commonwealth countries. Criminalisation is not just a moral outrage; it is a public health disaster, and we must do everything that we can to stop it. I do not want to dwell on that subject today, but it would be good to hear from the Minister that the Government are continuing to put pressure on Commonwealth institutions to live up to their obligations under the Commonwealth charter.

I do not know whether it is a coincidence or whether my noble friend has engineered it this way, but this very week is the 30th anniversary of the approval of the first commercial HIV blood test on 2 March 1985. That was a seminal moment in the battle against what was then an unstoppable horror. Testing meant that the blood supply could essentially be freed of HIV. It also helped scientists and other public health officials to determine the extent of the epidemic. For the first time, it empowered individuals by allowing them to know their status and to protect their partners if they had been infected. What a change 30 years have made. Today, HIV testing is at an all-time high. As I understand it, in the United States, 86% of people who are infected know their status, although that means that an eye-watering 186,000 people in the United States of America do not know that they are infected.

Despite that success, however, rates of infection are still disturbingly high, as we have heard, with 6,000 people in the UK diagnosed in 2013. That figure crosses every age group. I am grateful to the Minister for providing information on that point in a Written Answer to me in the past few weeks. While the majority of people diagnosed in 2013 were in the 35 to 50 age group, 462 new cases of HIV among gay men were in those aged under 24 and 308 were in those aged over 50. Among heterosexuals, 105 women and 47 men were aged between 15 and 24 and 439 were over 50. This is still a virus that respects no boundary of age or background.

Despite the fact that an HIV diagnosis is no longer, as it was 30 years ago, a death sentence—indeed, those infected and properly treated will probably have a normal, healthy lifespan—problems, as we heard during the debate, remain. One is prevention, as my noble friend pointed out, and the other is ensuring ever-higher levels of testing. On prevention, there is a great deal of hope and optimism with the development of pre-exposure prophylaxis presenting incredibly exciting opportunities. Although it has been available in the US for some time, it is not yet here, but should, I believe, be available to all those at risk in the UK as soon as possible. As Yusef Azad at the National AIDS Trust—and I pay tribute to its work—put it to me, the very recent PROUD trial looking at the impact of pre-exposure prophylaxis here,

“is a prevention game-changer which we cannot afford to ignore. As a much needed addition to—not substitute for—condom use, its costs are modest when compared with the lifelong costs of treating someone with HIV if we fail to prevent their infection”.

He is absolutely right, and I hope that NHS England will heed those wise words. Action sooner rather than later will save not just lives, but money too. I support everything that my noble friend said. It must be Mickey Mouse economics to spend so much on treatment and so little on prevention.

Similarly, there has been much progress on testing, as we have heard, but the figures for late diagnosis—still above 40%—are shockingly high. To tackle that, I hope that, among other things, the NICE public health guidance recommending that high-prevalence local authorities commission HIV testing to be offered to all those admitted to a hospital and all those registering with a GP is implemented soon. The Government and Public Health England can play a powerful leadership role, and I would be grateful if the Minister could take the lead today in calling for such important initiatives to be implemented.

Of course, key to both testing and prevention is the ongoing problem of stigma. The National AIDS Trust survey on public attitudes published in December last year still makes very depressing reading. If anything, public knowledge and attitudes seem to be deteriorating, and we need to take action to reverse that, otherwise, all the good work on testing and prevention could be in vain. This is, of course, a matter that goes well beyond central government, but local government, the NHS and schools all have a role to play. The Government can, again, take a lead, and I know that the Minister, who has done so much to help in this area in the past, will take up that challenge and this afternoon energise all those involved to redouble their efforts to tackle stigma.

I am conscious that there are no noble Baronesses speaking this afternoon, undoubtedly because of the clash with the debate on International Women’s Day, but I want to say a word or two about the special issues still faced by women with HIV and to cast a quick glance beyond our own shores to where the situation for people with HIV is still incredibly difficult and in some cases horrific. I commend an excellent report published in the past few months by the Salamander Trust, which last summer conducted a global survey on the sexual and reproductive health and human rights of women living with HIV. Of those who responded in a survey that took place in 94 countries, a shocking 89% reported that they had experienced violence or fear of violence since or because of their diagnosis— in their homes, in their communities and even, most appallingly of all, in healthcare settings. Only 50% of respondents found their healthcare service providers to be well trained and knowledgeable about their condition. A significant number emphasised the challenges of poverty and the resulting strain that it places on mental as well as physical and sexual health. It is little wonder that 80% of respondents reported experiences of depression, shame, loneliness and feelings of rejection.

The report contains a wealth of recommendations about how to improve the specific condition of many women across the globe living with HIV. I hope that the Government will be prepared to support such recommendations. It is an initiative that the Commonwealth in particular could pursue. Progress may be slow—I think that we all understand that—but this is a tangible way in which we could help improve the lot of thousands of lonely, frightened and vulnerable people across the globe.

As so often in debates on this subject, there is much significant progress to applaud and great hope and optimism, but there are problems, too: in tackling stigma in particular. There are serious challenges beyond our shores in tackling the criminalisation of homosexuality, which is turbo-charging the HIV epidemic in much of the world, in dealing with the special problems faced by women with HIV and in ensuring access to healthcare for all who need it. As I said earlier, some of those issues will take time to tackle, but I hope that this debate will again spur us to redouble our efforts both here in the UK and in the wider world one day to bring to an end a horrific epidemic which has already claimed too many lives and will yet claim many more.