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.

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.

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.