HIV and AIDS in the UK

Lord Rea Excerpts

Thursday 1st December 2011 Lords Chamber

[Lord Rea]

I thank the noble Lord, Lord Lexden, for his contribution and congratulate him on it. It was very refreshing to have someone who was not on the committee bring us some fresh insights and information from a part of the world which we did not visit.

Like all speakers, I congratulate the noble Lord, Lord Fowler, not only on his excellent introductory speech and on securing this debate on this day, but, more than this, on his dogged persistence with this issue over the past quarter of a century and his courage and correct judgment in putting HIV/AIDS so startlingly on the map in the mid- 1980s. As my noble professional friend Lady Tonge said, he faced strong disapproval and opposition from powerful members of the establishment, despite getting all-party support. He wisely persisted with the tombstone public education campaign as well as the controversial but highly successful needle exchange scheme which he has told us about. As result, the UK became the most successful country in the world in curbing the epidemic. In the developing world and some developed countries, the epidemic has continued to spread and, in sub-Saharan Africa, has resulted in the expectation of life for the whole population being reduced by 10 to 15 years with serious socioeconomic effects. But that is another debate, although a highly important one.

It was a privilege to serve on the Select Committee. I thank not only our chairman and our specialist adviser, Professor Anne Johnson, but also our two brilliant, dedicated clerks and, last but not least, our highly efficient secretary Deborah Bonfante, who handled the mountains of printed paper which passed before our eyes smoothly and effectively. Our witnesses, whether scientists, clinicians, voluntary sector workers or patients, were always knowledgeable and helpful.

I shall concentrate on some clinical and epidemiological aspects of the epidemic, emphasising, as all speakers have done, the imperative need for better prevention. This was the common thread which drew all our witnesses together and is the theme of the report. It is often said that the persistence of HIV in the developed world is at least partly due, as the noble Baroness, Lady Tonge, said, to the availability since the mid-1990s of antiretroviral treatment that prevents HIV developing into AIDS, and that this has resulted in greater risks being taken by some sections of the sexually active population now that HIV is no longer a death sentence. Even if this was only partly true, it indicates widespread ignorance of the burden that living with HIV can cause, as several noble Lords have most vividly described, even when ARV treatment is being correctly given. Though some of them will live a full lifespan, others will not be so fortunate. There are often unpleasant side-effects, though they are now less common since combination antiretrovirals have become more refined.

The future health and lifespan of HIV-infected people receiving ARV depends very much on the stage that the infection has reached when treatment is started. Early diagnosis after infection is thus extremely important. ARV drugs are much less effective when there is a high viral load, so that full blown AIDS symptoms which are difficult and expensive to treat can develop, even when the subject is on ARV treatment. Fifty per cent of newly diagnosed cases in the UK are classified by the HPA as being at a late stage of infection, with a CD4 cell count of less than 350 per cubic millimetre, just over half of which are severely immunocompromised, with a CD4 count of less than 200. The late diagnosis rate varies from group to group, being highest among heterosexual men—63 per cent of them. It is estimated by the HPA that 22,200 people are living with HIV infection in the UK who are undiagnosed. Most of them are unaware of their condition; some of them are developing high viral loads which means that they will respond less well eventually to treatment as well as acting as a reservoir of infection.

HIV carriers who are being successfully treated, on the other hand, have a very low infectivity of 1 per cent or 2 per cent but even this low rate means that they must still use a condom or take other steps to reduce the chance of passing on their infection. So while acquiring HIV infection is no longer an automatic death sentence it is still a life sentence—it means a lifetime of medication and the other serious drawbacks I have described—a much worse fate than that of other sexually transmitted diseases which can now mostly be treated and cured.

In addition, as the noble Lord pointed out so vividly, people living with HIV are subject to a number of social consequences. We heard from several of our HIV-positive witnesses examples of stigma against people with HIV in employment and in social settings, despite successful ongoing treatment. Frequently there are psychological symptoms, sometimes very severe, including suicide. Life insurance policies and mortgages are difficult or impossible to obtain by HIV-positive people, according to the Terrence Higgins Trust. If after perseverance a policy is agreed, the premium is highly loaded and no cover will be given for illness or death from an HIV-related condition. That puts people at a huge disadvantage when attempting to live a full life, and buying a house, for instance.

The noble Lord, Lord Fowler, and others have described the increasing financial burden caused by HIV infection, particularly the cost of drugs. This cost is increased if HIV is detected late and complications have to be treated in hospital. But the main cost of HIV comes from the persistence and spread of the epidemic through sexual contact with HIV carriers who are not aware of their HIV status. As other noble Lords have pointed out, this is why one of the main messages from our witnesses and the report is the need to widen the screening net by testing in more settings than previously. In fact I suggest testing wherever a blood test is being carried out for any reason and on certain other occasions, for instance when a patient is having a health assessment or being registered at a general practice, for hospital out-patients or in-patients and in STD clinics even when a blood test was not originally planned.

The case for this policy is very well argued in the Time to Test for HIV report, mentioned by the noble Baroness, Lady Gould, published this year—or was it last year?—by the HPA. We visited a group practice in Brighton where routine HIV testing was done as well as the carrying out of general healthcare of HIV patients being followed for their HIV and treated by at the HIV unit at Royal Sussex County Hospital. When a positive test result meant that someone had a fatal disease there was a policy of only testing when suitable counselling for this eventuality was made available. Now that a positive test does not have quite such a dramatic meaning, it is acceptable for the test to be carried out by any suitably trained professional, providing of course that the consent of the patient is first obtained; an opt-out possibility must always be offered.

I have not covered our recommendations at all systematically. There are 53 of them; each has been covered by the Government’s response and many of the report’s recommendations have been accepted. I am particularly pleased that the recommendation to make home testing legal and quality controlled has been accepted. This was the suggestion of many of our witnesses. Also welcome is the lifting of the requirement for all overseas visitors to have to pay for HIV treatment. Lifting this charge makes good public health sense.

I was, however, disappointed in the Government’s response—other noble Lords have mentioned this—to paragraphs 236 and 237 of the report, which called for the integration of HIV and sexually transmitted disease services. This is particularly relevant in the light of the changes envisaged in the Health and Social Care Bill now in Committee in your Lordships’ House. I hope that the noble Baroness who is replying to this debate will be able to raise in Committee some of the issues that I am about to describe.

We heard justifiable concerns about the split between HIV treatment services to be commissioned by the National Commissioning Board, and the provision of prevention services for HIV and other STIs in genitourinary medicine clinics to be provided by local authorities—through their ring-fenced public health budgets, presumably. The proposed changes claim to enable integration between the services, but in this case it seems that the reverse is being proposed. Many PCTs have increasingly brought HIV and STI services together under the same roof, as they logically should be. In this case the opposite seems most likely to occur. Perhaps the noble Baroness can tell us the department’s latest thinking on this particular problem.

I was going to speak also about the future of the HPA, but that has been covered extremely well by the noble Baroness, Lady Masham, and, as I have now been speaking for 12 minutes, I shall end on that point.

Health and Social Care Bill

Lord Rea Excerpts

Wednesday 16th November 2011 Lords Chamber

[Lord Whitty]

My Lords, I will leave that question for the Minister, because it clearly raises wider issues. I totally agree with the noble Lord, Lord Greaves, that one of the most acute effects of all this will be at the district level, where the funds are less protected, and where there is already some difficulty and some serious variability in performance and resourcing.

Given the Government’s support for the establishment of a chief environmental health officer at the centre to help co-ordinate all these issues and—if you like—to punch the weight of environmental health in the other range of priorities which the Department of Health has to pursue, I would ask the Minister this. Will the assessment of public health and the ongoing process she described in trying to defend the Bill from not spelling this out in great detail, lists or no lists, be available to us before we complete the consideration of this Bill, the exact timescale of which looks ever lengthier? Nevertheless, before we reach final conclusions on this, we need to have greater clarity on the direction in which the Government are going on public health, and, I would argue, on environmental health in particular.

I shall mention one other issue that relates to this. The abolition of the HPA also has significant implications in this area. I intend to come back to this at a later stage, but some of the functions of what are currently statutory authorities are going to go to Public Health England, as I understand it, and there is some confusion there as to how that will be carried out, what authority those roles will have and what their local manifestations will be. Under the new structure we will have health protection units around the country. So that is just one more complication here. By Report we ought to have some greater clarity in the strategy of the Government. I ask the Minister to give us an indication of that.

[Lord Rea]

My Lords, I had not intended to intervene on this amendment, but just from memory, I can think of several areas where the presence of an environmental health officer at the centre would perhaps have speeded things up. The noble Baroness, Lady Finlay, alluded to air quality, but there are other examples as well. I am old enough to remember the smog of 1951 and the enormous benefit of the Clean Air Act which followed a few years later. I was also in your Lordships’ House when lead-free petrol was debated, and when that became law nationally. There is also the question of food safety—the noble Lord, Lord Rooker, will know all about this—particularly the BSE epidemic, when it became necessary to ban animal-sourced feed for ruminant animals. Again, that required national legislation. Local environmental health officers, who do a fantastically important job, would not have been able to deal with these things on a local basis.

--- Later in debate ---

[Lord Northbourne]

I rise to support the amendment moved by the noble Baroness, Lady Finlay. One thing that has so far not been mentioned is that it is important to think about the alternatives to alcohol and to regular alcohol use. I used to spend a certain amount of time with very disadvantaged young people, and a great deal of their problem was boredom, inferiority complexes and no belief that there was any real future for them, so let us also think about all sorts of other things that they might be doing.

[Lord Rea]

My Lords, as a former GP, I echo the words of my noble friend Lord MacKenzie. Screening for alcoholism should be added to the QAF measures in view of all the reasons that have been eloquently adumbrated by other people. I want to raise a fairly basic problem which is the cost of alcohol services. At the moment, a lot of these are funded as outreach programmes by PCTs, and those are going to be transferred to local authorities. They will have to be paid for out of the index-linked £4 billion-odd that is going to be given to local authorities for this purpose. Perhaps the Minister could say whether the actual cost of running these alcohol services is being taken into account when considering how that £4 billion is going to be calculated. There are also plenty of other services being transferred to local authorities.

[Baroness Thornton]

My Lords, I rise to comment on these excellent amendments, and to support my noble friend Lord Beecham who has his name against Amendment 71. Amendment 71 is one of those very small amendments that changes “may” to “must” but it is actually at the heart of this discussion. What we are talking about here is how national campaigns will be linked to local action, and how they will be funded.

I start by reminding the Committee of some of the key components of this Government’s health policy on the harmful use of alcohol: banning the sale of alcohol below cost price; reviewing alcohol taxation and pricing to ensure that it tackles binge drinking without unfairly penalising responsible drinkers, pubs and important local industries; overhauling the Licensing Act; local authorities having more powers to remove licences and refuse grants that are causing problems; allowing councils and police to shut down establishments; doubling the fines for underage alcohol sales; and local councils being able to charge more for late-night licences.

My noble friend Lord Brooke put his finger on it, as did my noble friend Lord Turnberg, when he expressed scepticism as to the efficacy of these when you link them to the responsibility deal pledges on labelling. As part of the public health responsibility deal agreed with the Government in March 2011, UK alcohol beverage companies have pledged—that is an interesting word to use in this context—to implement a health labelling scheme to better inform consumers about responsible drinking. This pledge is in line with the industry’s response to the Department of Health’s consultation in May 2010 on options for improving information on the labels of alcoholic drinks to support consumers in making healthier choices in the UK. I do not think this is going to work.

Will the Government be reviewing their national campaign on alcohol and the misuse of alcohol in the light of this Bill? We have a national policy and a campaign, presumably run and directed by the Secretary of State for Health through the public health agency within the department. We have to look at what will actually happen on the ground and indeed address the dangers or risks that are posed by this Bill. A key question is the distinction between primary prevention and secondary prevention, which is complex in relation to the prevention of alcohol misuse. It is a concern when interventions cannot be clearly delineated as primary and secondary prevention. It seems that the reforms being proposed here will make that worse, not better.

Multiple commissions across one therapy, such as alcohol misuse, may cause uncertainty over who is responsible for funding services considered for both primary and secondary prevention. The worst case scenario is that neither the directors of public health nor the GP consortia commission secondary prevention services because the directors of public health are focused on primary prevention, awareness and information, the GPs are focused on treating the physical complications and harms relating to alcohol, and the hospitals are mopping up the people who turn up needing treatment for alcohol abuse.

If we are to tackle the fact that the number of hospital admissions was over a million in the last year, and that it is estimated to cost the NHS £2.7 billion a year—almost twice the equivalent figure for 2001, with the costs to society being even greater—there has to be co-ordination between national and local, and some direction about how these programmes will be carried through at local level. On these Benches we are therefore very sympathetic to what we see as a series of rather modest and focused amendments. We hope that the Minister will be able to look upon them with some sympathy.

Population Growth

Lord Rea Excerpts

Monday 13th December 2010 Lords Chamber

[Lord Rea]

My Lords, I think that the whole House will be grateful to the noble Lord, Lord Hodgson, for raising this Question and for his thoughtful and thought-provoking speech. The fact that 11 speakers have put their names down for this one-hour slot gives an indication of the importance of the issue.

I am going to talk mainly about population and economic migration but, on the way, I should like to flag up briefly the way in which rapid population growth will affect not only this country but the rest of the world through its impact on the environment by accelerating resource depletion and climate change. We are already faced with a time bomb since, although the output of greenhouse gases per head in the developing world is low at present—about one-20th of ours per head—this will inevitably increase with rising standards of living. China is already providing us with an example.

I should declare an interest in that I am a long-standing member of the All-Party Parliamentary Group on Population, Development and Reproductive Health. In January 2007, we published a report, Return of the Population Growth Factor, Its Impact upon the Millennium Development Goals. This was a distillation of a series of parliamentary hearings of experts in the fields of population and demography. Its conclusions, in brief, were that each of the first seven MDGs was adversely affected by population growth when it exceeded the rate of economic development. This applied particularly to sub-Saharan Africa, where population growth rates are the highest in the world and economic development the slowest. With regard to MDG 1, which is to,

“eradicate extreme poverty and hunger”,

the report says on page 21 under the heading “Running to stand still”:

“In sub-Saharan Africa, GDP per capita has been falling at nearly one percent a year, and those living in poverty … rose modestly from 44.6% to 46.4% between 1990 and 2001”.

Annual economic growth is expected to be 1.6 per cent between 2006 and 2015 but,

“due to the countervailing effect of rapid population growth, the World Bank predicts that by 2015, 340 million people in Africa will be living in extreme poverty, compared with 318 million in 2001”—

an increase of 22 million. The pressure to seek a better life in another country comes not so much from overcrowding and population growth per se but from lack of employment and poverty—in other words, “the economy, stupid”. Initially, employment is sought in the rapidly increasing slum cities of the developing world, but when this is not forthcoming the most enterprising citizens seek it elsewhere—perhaps in the El Dorado of the prosperous north and west. As the noble Lord said, the populations of some of those countries are in decline with a shortage of young people, so inward migration may not always be a bad thing.

Of course, there are reasons other than poverty for migration—conflict and political persecution are two. In the past, this country has benefited greatly from migrants from Europe fleeing political persecution. The largest number of immigrants, as the noble Lord pointed out, are seeking their way out of poverty.

There are two approaches to the problem, which are equally important. We must make more efforts to boost the economies of the developing world and diminish poverty. This in itself will result in fertility rates coming down. We all accept that that is a gargantuan task and inevitably slow. In the mean time, much can be done to assist mothers to have fewer children. The two most important are to aim to boost female education and to ensure that contraceptive supplies are made available to the 220 million women who wish to use them but at present cannot obtain them. There is no time to develop these themes. Suffice it to say that DfID is well aware of the needs of the developing world in reproductive health and family planning—not least because our group makes sure that they are aware. DfID devotes a greater proportion of its budget to it than most other countries. I am sure that the noble Baroness in her answer will take the opportunity to describe DfID’s work in this field.

[Baroness Northover]

I remind noble Lords that this is a tight time-limited debate, and when you hit four minutes you have already exceeded your time.