HIV

David Cairns Excerpts

Wednesday 1st December 2010 Westminster Hall

[Hon. Members]

Hear, hear!

[David Cairns (Inverclyde) (Lab)]

That might be the best cheer I get all day. I welcome you to the Chair, Mr Leigh. It is a pleasure to serve under your chairmanship in this important debate. I also thank Mr Speaker for allowing this debate on HIV services in the UK to take place on world AIDS day. I have been in Parliament for nine years, but I am still ignorant about how debates are selected—whether there is a lottery or whether Mr Speaker has a say in the matter. If he does, I thank him; if it was a lottery, I thank the Fates for timetabling this debate on 1 December.

I begin with a point of clarification. This is not for the benefit of hon. Members present in the Chamber, as they are well aware of the procedures of this place, but for those who are watching the debate on television or the internet, and those who will read the account of the debate in days to come. This debate will focus mainly on HIV in the UK, but that is not because we think that HIV outside the UK is not a problem, or because we are unaware of the scale of HIV in the developing world.

Africa has 10% of the world’s population but 72% of the deaths from AIDS, and we are aware of that. However, parliamentary procedure means that different Departments respond to the debates on different days, and today it is the turn of the Department of Health, not the Department for International Development. Therefore, although an enormous number of points could be raised about the global AIDS epidemic, I will in the main restrict my comments to HIV in the UK. With your indulgence, Mr Leigh, I might also sneak in a few comments about the international scene; I alerted the Minister about that in advance.

If colleagues are anxious to hear about the international aspects of the HIV epidemic, I should say that a world AIDS day reception will be held this evening at 7 pm in the Commonwealth Parliamentary Association Room. You are invited, Mr Leigh, as are all hon. Members, friends and colleagues.

[Mr Gareth Thomas (Harrow West) (Lab/Co-op)]

My hon. Friend is performing a service by raising the issue of HIV/AIDS in the UK. Does he also recognise that many people, both inside and outside the country, want to know what the UK Government intend to do about the future funding of the Global Fund to Fight AIDS, Tuberculosis and Malaria? That body has an excellent record in getting drugs to people with TB, malaria and particularly AIDS, many of whom are still in desperate need.

[David Cairns]

I am grateful to my hon. Friend, who was a distinguished and long-serving Minister at DFID. In a sense, it is a false dichotomy to say that there is an AIDS epidemic in the UK and an AIDS epidemic in Africa and never the twain shall meet. One of the largest at-risk populations in the UK is the African community––people who come from Africa and are HIV positive, or those who contract the disease in the UK within the African community. I will speak about that in a moment.

My hon. Friend is correct to highlight the need to address the problem of the AIDS epidemic in Africa. Over the past few years, one of the most effective ways of doing that has been through the Global Fund to Fight AIDS, Tuberculosis and Malaria. The last Government had a good record in ensuring that the global fund was initiated, then adequately resourced. During the most recent meeting of the fund in October, high, medium and low targets were set for the level of replenishment. Unfortunately, the global community failed to hit the low target, let alone the medium or high targets.

I understand why the Government do not come forward and state the exact figures for the replenishment of the fund. Through DFID, they are conducting a multilateral aid review, and until they decide their priorities, they cannot say how much will be made available for the global fund. Until we can provide a figure, I encourage Ministers to let the world know, at least with rhetoric, that we remain committed to the global fund.

Much of the world looks to the UK for an international lead in tackling AIDS, and other countries will be looking to our figures for the replenishment of the global fund before making their commitments. The Government have an excellent opportunity to set a global lead. I was going to make those points about the international community at the end of my speech, but I have made them now.

Let me return to matters for which the Minister is responsible—she will be pleased to hear that—rather than the rest of the world. I will make three points about how we should respond to the ongoing HIV epidemic in the UK and our public policy; priorities. First, I will speak a little about prevention, secondly I will discuss testing and treatment; and thirdly, I will say something about care and support. Those three things do not exist in isolation; they are not, to use fabled management-speak, in “silos.” One point leads into another, but for the purposes of the debate I will say a little about each issue in turn.

The backdrop to this debate is not only the ongoing financial constraints under which all Governments around the world are operating, but the NHS reconstruction and reconfiguration that the Government have embarked on, as well as the messages contained in the public health White Paper, launched yesterday by the Secretary of State. Because the national health service is undergoing a process of change and transition, there is some uncertainty. Until we get answers to some of the questions that we raise, that uncertainty will continue.

As I pointed out in the main Chamber this afternoon, although the Minister’s responsibility on such matters is constrained to the NHS in England, the HIV virus does not respect geographical borders. It is incredibly important for the Government to work closely with the devolved Administrations in Edinburgh, Cardiff and Belfast to ensure a coherent, joined-up approach. That is the only way to tackle the virus in a way that will see a reduction in the number of people affected and reverse the rate of increase in new cases of the disease. Therefore, although I am addressing the NHS in England, the message must be heard by those who configure the NHS in the devolved Administrations. I was pleased to hear that the Secretary of State for Scotland will meet the Minister responsible for health in Scotland tomorrow, and will put that important issue on the agenda.

The first issue that I mentioned was prevention. In the early days of the epidemic, not much was known about the virus. There were no drugs and no effective treatment. Messaging was, by necessity, extensive and untargeted. Those of us old enough will remember the adverts with the collapsing tombstones and the gravelly voice telling us about the new virus—AIDS—and how dangerous it was. We remember the posters and the radio adverts, which were essentially blanket advertising for the whole UK. People debate the relative impact of those messages, but we remember that campaign many years after it happened, so it did have some impact.

The situation of those who have HIV in the UK today means that that type of mass media advertising is not perhaps the best way of getting a message to those most at risk. That point was made in the foreword to the “Halve It” document, by Lord Fowler, about which I will speak shortly. Lord Fowler was a distinguished former Secretary of State for Health and Social Security, and he is remembered very fondly by people who work on behalf of and alongside those with HIV and AIDS for the forward-looking approach that he took. As he acknowledges, such mass communication messages are no longer relevant, and the campaign must be more targeted.

Will the Minister tell us whether the Government’s strategies on sexual health and HIV propose to target messages on specific, at-risk communities, and particularly but not exclusively on younger gay men, for whom some of the safe sex messages may have been lost in time, and the African community? Those communities are not mutually exclusive, of course, but the messaging to each will have to be different. Particularly now that more heterosexual people are contracting the virus, many of whom are in the African community, there is a pressing need to develop messaging that speaks to that community and to its values and structures, whether through Church or faith networks or whatever, so that we can overcome some of the ignorance and stigma in the black African community in this country. I would be grateful for the Minister’s comments on what she proposes to do about that.

[Pauline Latham (Mid Derbyshire) (Con)]

rose—

[David Cairns]

I am happy to give way to a vice-chair of the all-party group on HIV and AIDS.

[Pauline Latham]

Does the hon. Gentleman accept that, in addition, white heterosexual people who perhaps have got divorced recently, after having had a monogamous relationship for many years, are now going out into the world of single dating and getting into a mess because they do not realise that HIV/AIDS is out there in the heterosexual community? Is that not an expanding area that we should also be targeting?

[David Cairns]

The hon. Lady is right. I was saying that the messaging should not go exclusively to gay men and to people in the African community. There must be a message for everyone, but the messaging needs to be differentiated. There will need to be different messages to different people, within relative constraints. I hope that the Minister will deal with her point.

There is concern. I am of the generation that came to maturity at the time when the AIDS epidemic—well, I might not have come to maturity yet; it is probably up for debate whether I have reached maturity.

[Mr Thomas]

Don’t do yourself down.

[David Cairns]

Yes, I am doing myself down here. I am of the generation that came to adulthood when the virus was making its first big impact, so those messages really stayed with me. I wonder whether that is the same today, particularly, although not exclusively, for young gay men of 17, 18 or 19. We cannot be squeamish about this issue. We must speak a language that they hear and will listen and respond to. I do not expect the Minister necessarily to go into that in detail today, but I want an assurance from her in that regard. I know, particularly given her former career, that she is not squeamish about these things, and we cannot be squeamish when people’s lives are at stake.

Of course, one way to prevent the spread of the virus is to ensure that everyone who is HIV-positive knows that they are HIV-positive—knows their status—and is receiving the correct drug treatment. It is not widely appreciated that when someone who is HIV-positive is on the correct level of antiretroviral drug treatment, they become significantly less infectious. I had not appreciated that—I must confess that that was ignorance on my part—until fairly recently. It means that treatment for one person is prevention for another.

When an individual is on ARVs and is less infectious, that helps to constrain the spread of the epidemic and when people know their HIV status, it alters their sexual practices. Most of the evidence and studies show that. The more people we can test and the more HIV-positive people who know their status and are receiving the right treatment, the more we will do to prevent the spread of the virus.

[Jenny Willott (Cardiff Central) (LD)]

rose—

[David Cairns]

I am happy to give way to another vice-chair of the all-party group.

[Jenny Willott]

I have just had a baby and I was tested automatically for HIV during my pregnancy. Does the hon. Gentleman agree that extending such automatic testing could play a valuable role in identifying cases very early, so that people can receive the treatment that, as he said, will not only help them with their own medical needs, but prevent them from spreading the condition?

[David Cairns]

The hon. Lady makes an excellent point. I think that it was my right hon. Friend the Member for Holborn and St Pancras (Frank Dobson), when he was Secretary of State for Health, who introduced automatic testing in pregnancy. If we look at the graph, we see that the tail-off is quite astonishing: once opt-out testing was introduced for pregnant women, the numbers of babies being born HIV-positive plummeted.

Of course, the issue is not just about babies. Quite often when we are talking about the prevention of mother-to-child transmission, we focus on the baby, but a woman is involved as well. As the hon. Lady rightly says, if a woman’s own HIV-positive status has been diagnosed at the beginning of pregnancy, she can be put on the correct course of ARVs. That is why, in the northern world, mother-to-child transmission has been, if not completely eliminated, massively reduced— because not only ARVs but the correct education about breastfeeding are making an enormous difference. However, almost 500,000 babies born in Africa every year are HIV-positive. That is completely preventable—entirely avoidable. If pregnant women are tested and put on ARVs, they do not need to pass on the virus. It is one of the great scandals of our age that something that is solvable—we have solved it here—could be solved throughout the world with the correct financial support and the political will, but it has not been.

[Mr Thomas]

Is not one of the conclusions that can be drawn from the comments made by the hon. Member for Cardiff Central (Jenny Willott), as well as from my hon. Friend’s point about mother-to-child transmission, that we need to ensure that the Department of Health and DFID work closely together, so that the lessons of success in dealing with HIV in this country can be properly worked into our development policy abroad? Is it not therefore a concern that DFID’s HIV/AIDS team seems to have shrunk very small—if indeed any cadre of skills in this area is left in the Department at all?

[David Cairns]

I am grateful to my hon. Friend. He has far greater knowledge of these matters from within DFID than I have. If what he says is true, clearly it is a very worrying development. I was fortunate enough to meet some members of the HIV/AIDS team in DFID a few weeks ago. Whether or not the team is smaller than it used to be, it is certainly very committed. I also met some DFID workers when I was in Kenya a few months ago, and they are doing a tremendous job.

It is to the credit of the Government that they have protected the international development budget, but of course there will be reprioritising within that budget. Part of what we are doing as an all-party group is ensuring that these issues are not lost in the reprioritisation. This is what people find very frustrating about the international dimension of this issue. Enormous progress has been made and the tide is beginning to turn. If we withdrew funding or support or lost the political will at this stage, it would be a disaster and a tragedy, not least because in five years’ time we would have to return to the matter, because we could not let the number of deaths and new infections let rip, as we saw happen in the 1980s and 1990s.

[Mr Thomas]

Will the all-party group, as part of its thinking about the Government’s multilateral aid review, also consider funding for the new UN women’s agency? I ask that in the context of the comments from a previous UN Secretary-General, who said that AIDS in many parts of the developing world has an increasingly female face and that we need to ensure that we continue to champion efforts to tackle issues relating to gender equality—for many reasons, of course, but in particular to help with the fight against AIDS.

[David Cairns]

My hon. Friend makes an excellent point. The new agency has real potential to make a difference. We are all relieved that some of the world’s appalling, oppressive, anti-women regimes that were muscling in have been set to one side, which will allow the agency to focus on the issues that he mentioned.

A saying that we hear over and again now in Africa is that the face of the epidemic is female. That is not just because of mother-to-child transmissions, but because of the disempowerment of women and the limiting of women’s ability to make choices about their own sexual and reproductive health. Of course, that is not the case solely in Africa; it is the case elsewhere in the world as well. However, it is a particularly pressing problem in Africa and one that we must not lose sight of.

I was talking about the need to ensure that people who are HIV-positive know that they are HIV-positive. That is why the all-party group is pleased to support the Halve It campaign, which is composed of many agencies, clinicians and groups advocating on behalf of people with HIV. It is campaigning to halve the number of late diagnoses by 2015. That is an ambitious target, but the document sets out steps that can be taken to meet it, and I would be grateful for the Minister’s comments on them.

Yesterday, I was pleased that when I urged the Secretary of State for Health, while he was making his statement on the public health White Paper in the House, to look at the Halve It campaign, he gave an undertaking to do so and see whether it could form part of the HIV and sexual health strategy. I would be grateful if the Minister confirmed that she will look at the campaign’s document, particularly at the steps that can be taken to halve the numbers of late diagnoses and of those living with undiagnosed HIV by 2015.

I shall press on because I know other hon. Members are keen to take part and I want to hear the Minister’s reply. Once a person is diagnosed––I shall speak about some of the hurdles in a moment––the virus changes from being in its potentially lethal undiagnosed state, which poses a wide public health risk due to how it can be transmitted, to being a more normal—I use that word advisedly—long-term managed condition. That brings different challenges with it.

One thing that we are looking for in the detail of the NHS restructuring plan is how people will access services in the long-term managed phase of the condition. Who will commission those services, particularly in low-prevalence areas? Until those questions are answered, there will be uncertainty in the community. I want the Minister to answer specifically the question of who will commission HIV services in the new restructured NHS. Will it always be the GP? Is the GP the best placed person to do so? Do GPs have the time and the expertise, particularly in low-prevalence areas? I am sure that GPs in much of London, Brighton, Manchester or Glasgow have the necessary expertise because they have the caseload, but in other areas that might not be the case. Is a one-size-fits-all approach across the NHS the right solution or is something a little more granulated necessary to deal with the full complexity of the issue?

We have to face up to the fact that a lot of people who are HIV-positive simply do not want to access services through their local GP. Whether it is wise or unwise, it is understandable in some areas, particularly in smaller towns or villages, where everyone knows everyone else, and you know who works in your GP’s surgery and they know everybody and everything about you. Under those circumstances and given that the stigma prevails, and the myths, misunderstandings and prejudice that people with HIV face, it is understandable that there are those who will not want their status to be known in their own community. In evidence put forward yesterday by the National AIDS Trust, we saw how many people face discrimination in the workplace due to their HIV status.

AIDS is a complex condition. It affects people physically, emotionally and psychologically. In that complex mix, it is important that the NHS is responsive to that and allows people pathways to treatment that might not always be the same in every place. I would be grateful for the Minister’s views on that.

[Mr Russell Brown (Dumfries and Galloway) (Lab)]

I congratulate my hon. Friend on securing the debate. Because stigma is still attached to this condition, people in rural localities, such as mine, will seek advice and help from further afield, thereby distorting the figures on the prevalence of the condition in certain parts of the country.

[David Cairns]

My hon. Friend is absolutely right. He represents an area that is not only largely rural but on the borders of Scotland and England, which brings me to the point that I mentioned at the very beginning. I imagine that many of his constituents will be accessing HIV services in Carlisle, for all sorts of reasons, but partly due to the stigma still associated with the condition. They do not want to access services in small villages and towns. Ultimately, we have to get to a situation in which there is no stigma, prejudice or discrimination and people can happily access GP services for a long-term managed condition, as people with diabetes, asthma and other long-term managed conditions can. Until such a time, we have to be sensitive to these issues.

Another reason why people are wary about always accessing services through GPs is the lack of awareness and understanding that many GPs demonstrate. Part of the reason why we have so many late diagnoses is that GPs do not pick up the telltale signs often enough. An alarming number of people had seen their GP on many occasions during the 12 months before they were eventually diagnosed as HIV-positive, and it was not picked up that they might have been HIV-positive. An astonishing number of people had been in-patients in the 12 months preceding their diagnosis; they were almost certainly HIV-positive while they were in hospital, but it was not picked up.

A lady recently got in touch with the all-party group—a middle-aged, professional, white lady—who had suffered serious recurrent health problems for two years and had seen numerous clinicians, including a GP on many occasions, before anyone thought to offer her an HIV test, which brings me back to the point that the hon. Member for Cardiff Central made. That lady was a textbook case: she had every symptom and yet her GP never thought to offer her an HIV test. That is clearly happening across the country, which explains why we have 22,000 people who are HIV-positive, but do not know it. It is not the case that none of them ever visits their doctor—they regularly visit their GPs, perhaps they even go into hospital as in-patients, and yet their status is not picked up. That is a public health disaster because the ability of those people to infect others is much greater than it would be if they were receiving the correct course of ARVs.

We need assurance that, within the restructuring, GPs will get very good guidelines and necessary training, and be encouraged to offer people an HIV test in the routine manner suggested earlier, to tackle undiagnosed HIV.

[Jenny Willott]

Will the hon. Gentleman also suggest that we need to tackle the stereotypes about the kind of person who might have HIV? That is one issue for people who do not go to their doctor, or who do go but whose GP does not pick up on it. As the hon. Member for Mid Derbyshire (Pauline Latham) mentioned earlier, GPs may not think that a middle-aged, heterosexual white woman is likely to be HIV-positive. We need to tackle those stereotypes.

[David Cairns]

The hon. Lady is correct. Part of the education of GPs must be about looking at the symptoms, not only what the GP imagines a typical at-risk person would be. Having said that, we need to show that those within high-risk groups of people are being tested as well.

The tremendous progress that has been made in testing in the past few years is truly astonishing. Someone can be tested and have the result in less than a minute. I hope that he will not mind me mentioning it, but the hon. Member for Brighton, Kemptown (Simon Kirby) saw this first-hand last night when he received a test through the services provided by the Terrence Higgins Trust in the House, and he had the result in less than a minute. Testing is not the long drawn-out process that it was years ago, but can be done much more quickly.

Finally, on care and support, people are living longer with the virus, which is a very good thing, but it brings with it challenges and complications—physical, emotional and mental. It is very important that we understand the need to have a strategy for people living longer with HIV. The AIDS support grant is no longer ring-fenced, and I am not arguing that it should be re-ring-fenced, but I am arguing strongly for it to stay within the grants that go to local government as a specified budget line.

In that way, local people can hold their local authority to account in exactly the way that the Secretary of State outlined yesterday. It is his belief that local people should be able to see the services being provided for them, and argue for services. If the AIDS support grant disappears as a title altogether and is subsumed into the general pot of money that local government gets, local people will not be empowered to come forward and demand the kind of services for which money is being made available.

In conclusion, I hope that the Minister will address some of the concerns about the AIDS support grant and the Government’s vision for it. I hope too that she will be able to calm some of the fears and uncertainties out there on how HIV services are to be commissioned, how they will be accessed, and how they will be supported under the new NHS that the Government have in mind.

[Mr Edward Leigh (in the Chair)]

Order. Five Back Benchers have intimated that they wish to take part. I intend to call the wind-ups at about 3.30 pm. Hon. Members can do the maths, so I ask for brief speeches from now on.

--- Later in debate ---

[Anne Milton]

We need to ensure that safer sex messages are clearly communicated and understood by all.

I think that we also have to clamp down a bit on irresponsible marketing. I have been approached by those who are unhappy about the promotion of DVDs and other material promoting “bareback” sex. We need to address such issues and I know that a lot of people and organisations, such as the Terrence Higgins Trust, are doing all they can to stop the promotion of such material. To those who are most at risk of HIV in the UK, I say that the Government work very closely in partnership with the Terrence Higgins Trust, the African Health Network and a huge number of other voluntary and community groups.

Yesterday, we published a White Paper on public health and later this month we will publish a number of supporting documents, including a public health outcomes framework. We will be thinking about what the best outcomes might be for HIV and they will be included in that document. I know that Members will look at that document with care and feed back to us their feelings on it. In the spring, we will publish a position paper on sexual health which will, of course, include HIV. That paper will take into account many of the issues that have emerged this afternoon.

[David Cairns]

I will let the Minister catch her breath and I appreciate that we are really up against the clock. She says that there will be a position paper in the spring. Does she envisage that that will lead to a full new HIV strategy, or will it just remain a position paper?

[Anne Milton]

No, it will be a sexual health strategy. The Government and the NHS need to play their part, and we need to support individuals to make responsible lifestyle choices. We continue to provide the very best HIV treatment services, but others have a role to play and they are often better placed than the Government to make a difference. The hon. Member for Hackney North and Stoke Newington mentioned the role of churches in that regard and they can have a significant impact.

Voluntary community groups, industry, responsible media, churches and faith groups all have a part to play. That collaboration is so important in tackling stigma and discrimination, which is still a very real issue for many people affected by HIV. That is particularly important within those communities who find sexual health issues more challenging than other communities.

Stigma means that people refuse tests, do not take precautions and do not go for treatment. I was delighted to see that the Prime Minister highlighted the issue of stigma in his world AIDS day podcast. Tackling HIV is everyone’s business and we can all make a difference to reduce stigma, reduce new infections and enable people living with HIV to lead full and productive lives.

The hon. Member for Inverclyde raised issues about global funds. I am sure that he will also raise those issues with my colleagues in the Department for International Development. However, as my ministerial brief also covers EU health, it may be of note for him to realise that such issues are recognised by many people within Europe and across the world, and we continue to work both nationally—within our own member states—and internationally, because collectively we can do a great deal to help each other.

The hon. Gentleman also said that generally a one-size-fits-all approach does not work and, as my hon. Friend the Member for Hove said, anonymous testing and treatment is often crucial. We will announce our commissioning intentions soon. However, the hon. Gentleman’s point is well made.

I think that it was the hon. Member for Dumfries and Galloway (Mr Brown) who mentioned the issue of commissioning services in rural areas, which poses particular challenges and very real problems. It is absolutely crucial that we get that commissioning right. We will announce our intentions soon and I hope that they will address some of the points that he raised.

We need to talk about sex. We need to talk about people’s sexual health. We need to talk about people’s responsibilities in looking after their sexual health, and we all have something to offer and we all have something that we can do personally, particularly those of us who are Members of Parliament. As MPs, we have unprecedented access to media, particularly in our local areas. We need to do everything that we can to express the fact that this is everybody’s business and that people need to take responsibility for their sexual health. Their sexual health not only affects them; it affects the others around them and their families too. Only then will we be able to see a future for people living with HIV/AIDS that we all want to see.