HPV Vaccinations for MSM

Jane Ellison Excerpts

Tuesday 7th June 2016 Westminster Hall

[The Parliamentary Under-Secretary of State for Health (Jane Ellison)]

Thank you, Mr Hollobone, for giving me the opportunity to respond to the debate. I have to say at the outset that we are actually announcing good news in this debate. I accept that Members of this House wish to challenge me on a whole range of areas in which we might go further, but this is the announcement of a major pilot, and I will go on to talk about what we are actually doing. I really think that we should see this as an important step forward and an important part of delivering on LGBT health. I just wanted to say that at the outset, because it was a bit hard to get that from some of the contributions. I will talk a bit about the issue of action, which I have been challenged on.

Let me start, as I should, by congratulating my hon. Friend the Member for Finchley and Golders Green (Mike Freer) not only on securing the debate, but on championing the issue so consistently and passionately. The point has been made that we should be talking about these issues more often—well, he has been talking about them consistently over many years and the persistence of parliamentary prioritisation is showing results. It is really good to see him in his place and I congratulate him on what he has done.

As hon. Members know, and as many people have mentioned, we are advised on all immunisation matters by the Joint Committee on Vaccination and Immunisation. Back in 2008, on the advice of the JCVI, an HPV vaccination programme for girls was introduced across the UK. It is worth reminding the House that the primary objective of that programme was to protect against cervical cancer. The latest data—just to remind people—shows that there are about 2,500 cervical cancer cases a year and up to 900 deaths from that terrible disease. To give some sense of comparison, there are around 300 anal cancer cases among all men in a year. Those are the origins of this programme.

The HPV vaccine has been given to more than 3 million teenage girls across the UK since the programme started, and coverage is actually among the highest in the world. Hon. Members have, again, made reference to international comparisons. I was recently in Geneva for the World Health Assembly, discussing HPV vaccination with a small group of other Health Ministers; our rates are the envy of much of the world, so we must accept that this is an important and world-leading programme. The number of young women with pre-cancerous lesions is falling, here and around the world, and we expect protection against cervical cancer to be long term, eventually saving hundreds of lives each year.

The vaccine has been subject to numerous safety reviews and I have gone over that in some detail in other debates. I will write to the shadow Minister, the hon. Member for Denton and Reddish (Andrew Gwynne), about the specific issues that he raised today, but I want to assure him about the EMA reviews and the WHO reviews, which are all publicly available.

Protecting girls against HPV has wider benefits and will result in fewer HPV infections and less disease in heterosexual males. However, I recognise, as the House has today, that men who have sex with men—MSM—receive little or no benefit from the programme for girls. It was the increasing evidence of the link between HPV and oral, throat, anal and penile cancers, alongside the incidence of genital warts, that led the JCVI to decide to consider the possibility of HPV vaccination for MSM, and to reconsider the case for HPV vaccination of boys. I will come to the issue of boys, which has been raised by several hon. Members, if there is time—I think and hope there will be. However, I want to focus most of my time on MSM, which is the subject of the debate.

I do not intend to include a lot of statistics in my speech, as my hon. Friend the Member for Finchley and Golders Green has set them out and described the context well. However, I want to point out, with regard to the detail behind the figures he quotes, that some of it is not directly relevant to an HPV/MSM programme, as the figures include both male and female cases and cases of cancer unrelated to HPV.

MSM are one of the groups at highest risk of sexually transmitted infections in the UK and the Government are already taking a number of steps to improve their health and wellbeing. Again, I reject any suggestion that this issue is not a priority. It is quite the opposite: there has been a focus in the last year or so on MSM health and on LGBT health—that is something that we had previously not even begun to do. That includes, for example, the first LGBT health conference run by Public Health England and a number of other things that we have done. I am happy to speak to the hon. Member for Glasgow South (Stewart Malcolm McDonald) about that separately on another occasion.

The JCVI’s advice was that a targeted HPV vaccination should be introduced for MSM aged up to 45 who attend genito-urinary medicine and HIV clinics, if procurement of the vaccine and delivery of the programme is possible at a cost-effective price. Everything in that sentence is the JCVI’s advice. It is not just about the vaccine but about the delivery of the programme and the interrelationship between vaccination and attendance at GUM and HIV clinics, which is germane to the way that we are introducing this pilot.

In the JCVI’s formal advice to us, it acknowledged that commissioning and delivering such a programme would be complex and challenging. It made it clear that the Department of Health and Public Health England would need to work together, and with others, to consider the commissioning and delivery routes for the programme. Over the last few months that is exactly what we have been considering with stakeholders, and on several issues. Demand is one such issue, and we have had to consider whether the programme will result in a greater than expected increase in attendance by MSM at GUM clinics, and the impact of that on broader sexual health services.

We have also had to consider administration costs and what is a reasonable and realistic price to pay for administration of this vaccine in GUM and HIV clinics. Stakeholders raised that during the consultation on the original JCVI advice. How do we monitor the success of a three-dose programme when data collected in GUM clinics are anonymised and MSM could go to different GUM clinics for each dose? There are complexities in this programme that are not present in, for example, the school-based HPV programme for girls.

[Stewart Malcolm McDonald]

Briefly, can the Minister tell me why those complexities exist here in England but not, presumably, in Scotland and Wales?

[Jane Ellison]

They do exist in other nations. I am making a statement of fact of how the system operates and how people access sexual health clinics. I will come to the devolved Administrations.

We have decided that the best way to resolve these and other issues is to pilot the programme. My hon. Friend the Member for Finchley and Golders Green asked who the vaccine will be available to under the pilot. The JCVI recommended a targeted programme aimed at MSM already attending GUM and HIV clinics, so under the pilot, MSM will be offered the vaccine during their existing appointment if they are at a participating clinic. Public Health England is running the pilot, which should confirm whether such a programme can be delivered at a cost-effective price.

In terms of evaluation, which my hon. Friend also referred to, data collected by clinics will be used to monitor coverage of the HPV vaccine and the proportion of MSM completing the course of vaccine. The impact of the vaccine on HPV-related cancers will obviously take many years to emerge, but the impact on the diagnosis of genital warts will be a useful proxy for that and will be seen much sooner. I expect to be updated regularly on the pilot’s progress. My hon. Friend knows that I have taken a strong personal interest in this programme, and I will of course consider how best to share the information.

I understand that some stakeholders are disappointed that we are not rolling out the programme nationally immediately and some hon. Members here today have noted that Scotland and Wales have committed to implementing the JCVI’s advice in full. However, they have yet to confirm how or when they will start. Scotland has not started yet, and we are happy to share lessons from the pilot as it is no doubt considering how to move forward. Officials from the Department, Public Health England and the devolved Administrations meet regularly on this issue and will continue to do so to share experience and learning. Health is a devolved matter.

I confirm that Northern Ireland officials are on our project board, but they do not yet have a ministerial decision on how they will respond to the JCVI advice on MSM. Obviously there are issues to be raised with that devolved Administration.

The key thing to stress is that this is a large-scale pilot and I was somewhat disappointed by some of the stakeholders’ comments, particularly talk of stalling or of small pilots. This is a large-scale pilot that should eventually reach up to 40,000 MSM— more than 35% of those who attend GUM and HIV clinics annually. It will have a good geographical spread, including areas with the highest MSM populations, as well as rural areas with smaller MSM populations. That is relevant because, although there has been some piloting of vaccination in some clinics, it has been in a very limited geographical area and would not tell us enough about how this would work in practice in a national roll-out. The pilots will have a much broader spread. I can also confirm that the pilot will use the vaccine Gardasil-4 which was successful in the recent HPV procurement exercise.

I am pleased to announce that the pilot in England has already started. Two clinics went live in the pilot yesterday and others will come on board as soon as they are ready, hopefully over the next few months. There has been a positive and enthusiastic response from clinics invited to participate, and I am grateful to all those working on the ground to make this happen.

My hon. Friend asked how long the pilot will run. It will run during 2016-17 and decisions on next steps will be dependent on the progress and outcome of the pilot.

[Jonathan Lord (Woking) (Con)]

Like other Members, I pay tribute to the leadership on this issue of my hon. Friend the Member for Finchley and Golders Green (Mike Freer) whose work is appreciated across the House.

I have been following the debate very carefully, but it is not clear in my mind how a pilot of MSM will act as some sort of proxy or in any way affect the decision on immunising schoolboys. I do not see how one will inform the other.

[Jane Ellison]

I have not claimed that one is dependent on the other. They are two separate recommendations from the JCVI, and I will explain what is happening with boys. There are many questions about extending the HPV vaccine to boys and I understand the wish for it to be available to all adolescents regardless of gender. The JCVI is reconsidering its initial advice on this and modelling is under way to inform its consideration. Public Health England expects to complete the modelling by early 2017 and the JCVI’s advice is expected to follow soon after that, after which we can respond. We will look at that as a priority when we get it.

We have discussed in this Chamber whether we can speed that up. I recognise the frustration that people have expressed and I have talked personally to Public Health England officials who are involved in the modelling work. It would be a huge programme to roll out to adolescent boys and JCVI needs to base its advice on very robust analysis of cost-effectiveness. To do that, a complex model is being built. I have been assured that this is not about additional resource. I have asked whether it is a case of needing additional resource to speed the work up, but I am assured that it is not. It is because of the complexity of the model development and the fact that some of the models are time-consuming to run. Essentially, they are modelling behaviour over time, and to do that, one needs time in order to be able to understand how different aspects of the model interact with one another. I have been told—I have no reason to doubt this, because I have asked experts involved in it—that shortcuts could undermine the validity of the results and could not be supported by the JCVI. The model is building on the cervical screening model to create an integrated model of both HPV screening and vaccination, so that we get an understanding of what the interplay is between vaccination and screening programmes in the prevention, diagnosis and treatment of HPV.

I am happy to write with more detail to hon. Members, but I hope that I have given them a sense of the fact that this is complex work: it is under way and we will look to respond to it as soon as we can. However, these are important decisions that the JCVI will take and, because the Government have always acted on its recommendations, it is important that it gets them right and they are based on the right data. This is a significant programme, but the work is well under way and I will look to report back to the House at every opportunity I can.

The HPV vaccination programme for girls is going very well, and there is now scope for an additional programme to make a difference to the lives of MSM, which this will. The pilot will provide answers to the questions that we still have and the answers that we need for a programme of this nature—I have hinted at some of the delivery complexities. We expect to see benefits from the pilot emerge relatively soon through the reduction in genital warts cases and through treatment in MSM, particularly by targeting higher risk MSM.

I hope that that updates the House as fully as possible at this stage. As I said, I will be happy to update it in the future on how the pilots are going. I want to end by again congratulating my hon. Friend the Member for Finchley and Golders Green on initiating the debate and on his persistent campaigning, and to reassure and commit to the House my determination to improve the health and wellbeing of MSM and to see this pilot as a significant step forward in that task.