HIV Treatment

Mike Freer Excerpts

Wednesday 29th March 2017 Westminster Hall

[Mrs Anne Main (in the Chair)]

Before I call Mike Freer to move the motion, I want to say that our thoughts are with the victims of last Wednesday’s atrocities. I do not think that the House is pausing in its proceedings, but our thoughts are with them today.

[Mike Freer (Finchley and Golders Green) (Con)]

I beg to move,

That this House has considered the all-party parliamentary group report Impact of Health and Social Care Act on HIV treatment.

I associate myself with your comments, Mrs Main, which are exactly right, and it is a pleasure to serve under your chairmanship. I also put on the record my appreciation of the Minister and other colleagues, but especially the Minister, who has been extremely supportive of the all-party parliamentary group on HIV and AIDS and who has always been helpful when I have raised issues to do with HIV/AIDS. I am grateful, too, to other Members on what is a busy day, with other demands on their time. Their attendance at this debate is much appreciated.

Since 2015, when I was elected chair of the all-party parliamentary group on HIV and AIDS, our main objective has been to draw on evidence from clinicians, patients, HIV charities and research groups concerned about the potential impact of the Health and Social Care Act 2012 on HIV treatment in England. In December 2015, therefore, we started to collect written evidence so that we could investigate whether such concerns were based on reality.

Our inquiry took about a year to conclude. We heard from clinicians, local authorities, public health officials, people living with HIV, and the charity sector. We took both written and oral evidence. After a year of gathering evidence, it is fair to say that we concluded that fragmentation has occurred, creating a degree of uncertainty and presenting opportunities for aspects of HIV care to fall through the gaps between the commissioning bodies. I will outline that later.

The purpose of our report, “The HIV puzzle: Piecing together HIV care since the Health and Social Care Act”, was not to turn back the clock, but to reach out to the sector for evidence and recommendations so that we may make tangible improvements to the commissioning of HIV services. We need to work together to make such changes to ensure that people continue to maximise the benefits of the world-class treatment and clinical care service available in the UK.

I emphasise that the majority of the report recommendations focus on the need for clarity and accountability in all parts of the HIV care pathway, because the lack of clarity in the 2012 Act is what came into sharp focus. It was exemplified by the debate surrounding the provision of PrEP—pre-exposure prophylaxis—and the uncertain future of HIV support services. I and my APPG colleagues who advocate central funding for PrEP welcome NHS England’s announcement of a new PrEP trial to reach 10,000 people.

Our report concluded that the Health and Social Care Act increased fragmentation to many aspects of the care pathway, from prevention to long-term condition management. For example, fragmentation has created risks for HIV support services. The separation of sexual health and HIV is another example. There are new potential barriers to testing and prevention. Most importantly, there is confusion over the commissioning of new prevention techniques. I will highlight some of our key findings and offer suggestions as to how the APPG believes the report’s recommendations can help address them.

HIV support services—non-clinical services—have long been considered a vital part of the care pathway for people living with HIV. The British HIV Association, BHIVA, which is accredited by the National Institute for Health and Care Excellence, provides official guidance on HIV treatment and care. BHIVA states that the following are necessary for effective long-term condition management: peer support; support from other trained professionals; and information about HIV treatment, healthy living with HIV, diet and lifestyle, and optimisation of general health issues. People living with HIV also need support to access general health services, financial advice, and housing and employment support.

That view is endorsed by NHS England:

“The effectiveness of specialised HIV services depends on other elements of the HIV care pathway being in place and effectively coordinated”,

Those elements include:

“Third sector HIV care and support services for treatment adherence, peer support and self management…Social care, mental health and community services for rehabilitation, personal care or housing”.

Not everyone living with HIV requires support, and most will only need to use those services periodically, such as when they are newly diagnosed, experiencing employment issues, pregnant or considering disclosing their status to others, and if they are experiencing discrimination. The UK stigma survey identified that 28% of people diagnosed within the previous 12 months reported suicidal thoughts. Sadly, the suicide rate for HIV-positive men in the first year after diagnosis is more than five times higher than for men in the general population.

Similarly, while the side effects of treatment have improved in recent years, many people still have real difficulty in managing them, especially when starting medication or transferring regimens. People who are long-term diagnosed may experience ongoing and irreversible side effects of older HIV treatments, such as neuropathy and lipodystrophy. Most recently, there is emerging evidence on diabetes.

Support services in those instances not only ensure that people have access to a trained professional or volunteer at the point of crisis, but reduce the pressure on healthcare professionals. The National AIDS Trust reported that 50% of attendees at expert patient groups subsequently reported fewer GP visits. For an investment of £400 per attendee, the average net saving to the NHS for each patient with a long-term condition was £1,800. In addition, Positively UK reports that 88% of people reported that peer support has helped them to adhere better to their treatment plans.

Unfortunately, however, we have heard from the National AIDS Trust and other local support organisations that HIV support services are vulnerable under the 2012 Act, because commissioning responsibility has not been clearly defined. Therefore, the clearly mandated service provision has instead taken priority, in particular where there have been reductions to public health grants for local authorities. Last year, for example, HIV services in Berkshire and Oxfordshire were reduced by more than £100,000. In Berkshire, that equates to a loss of a third of the funding, which will directly affect 300 people living with HIV in Slough and Bracknell.

In Public Health England’s guidance to commissioners, “Making it work”, HIV support services are the only part of the care pathway left “to be determined locally”. That means that either the clinical commissioning group or the local authority can provide such services, but in a number of cases it appears that no one is commissioning services such as community-based HIV clinical nurse specialists.

The value of support services in other disease areas is well recognised. CCGs already commission cancer care, peer support for mental health services and the DESMOND —diabetes education and self-management for ongoing and newly diagnosed—programme for diabetes. The APPG has therefore recommended that the responsibility for providing HIV support services is met by NHS England and CCGs as part of the patient care pathway provided for long-term condition management.

Local authorities have a responsibility to provide public health and social care services, but the ambiguity in the 2012 Act and reduced funding mean that the responsibility has been deprioritised. Support services sit comfortably within the mandate that CCGs and NHS England already have to provide HIV treatment and care. Importantly, what we are asking is that the Department of Health reiterate the need for a mandated whole-treatment plan, from start to finish.

[Dr Daniel Poulter (Central Suffolk and North Ipswich) (Con)]

My hon. Friend is making some good points, and I commend him for bringing forward this important debate. Does he agree that one of the fundamental challenges thrown up by the Health and Social Care Act 2012 is the fragmentation of services? As a clinician, it is strange to me—I made this point when I was on the Health Committee—that sexual health services are now commissioned by local authorities and a lot of HIV diagnoses are first discovered by contact with sexual health services.

[Mike Freer]

My hon. Friend makes a good point. I will go on to identify what is almost a lottery or a roulette, where people can access testing only if the parts of the health service or social care services that they come into contact with know what to do. I will also comment on the problem that some services—particularly GP services—feel that they are under so much pressure that they do not always know how to refer people for testing. One of the implications of the rationalisation of genito-urinary medicine clinics—GUM clinics—is that people risk falling through the cracks. My hon. Friend makes a good point that because services are provided in a number of places by a number of parts of the health service and it is not clear who is responsible for doing what, there is a great danger that people will think, “Someone else is doing it,” or, “Someone else is paying for it,” and we end up with no one doing it or no one having the funds to do it.

Civil society groups have highlighted that, under the Health and Social Care Act, some HIV services have been separated from sexual health services, which seems to have had the unintended consequence of creating different commissioning responsibilities for different aspects of caring for people living with HIV. HIV clinical services are commissioned by NHS England. HIV clinics traditionally sit in or next to sexual health or GUM clinics. That is the logical place for them to be; it helps with referrals and the continuation of care. Most HIV diagnoses are picked up during routine sexual health check-ups.

For example, the team at the Marlborough clinic at the Royal Free hospital, which serves my constituency, offer HIV testing and treatment alongside sexual health advice, testing and treatment for sexually transmitted infections, and contraception services. Where an HIV-positive diagnosis is made, staff can quickly link the newly diagnosed person into care at the adjacent Ian Charleson day centre, almost by walking them from one part of the building to the next, to ensure that there is continuation of care and no gap between someone being diagnosed and referred. In every part of the health service, whatever the illness or condition, if there is a gap between diagnosis and referral to a specialist service, some patients simply do not turn up. The collocation of services improves the continuation of care. The threatened merging of GUM clinics, which might take them away from HIV clinics, is therefore a cause for concern. I fear that it will make fragmentation worse.

Although local authorities are entirely responsible for providing sexual health services, they are not responsible for the entire HIV care pathway. That has resulted in sexual health services being put out to tender without a plan for the HIV service. That disruption of care presents a real problem for keeping track of patients and ensuring that they remain in the care pathway.

[Dr Poulter]

One of the other practical problems that was not thought through very well in the run-up to 2012 is communication between services, which my hon. Friend rightly mentioned. IT systems in the NHS often do not talk to one another very well, and they certainly do not communicate well with local authority databases or those of private sector providers, which may store information about the same person. That is at the core of the problem, and I wonder whether he might look at that issue when he makes recommendations to the Minister in the future.

[Mike Freer]

My hon. Friend makes a good point. The APPG is currently considering an informal report about the future of social care. Because HIV is no longer a death sentence but a manageable condition, people are living to ages by which they expected to be dead, or by which the health service expected them to be dead. We have early indications that the social care sector simply is not geared up for handling admissions or placements of HIV-positive people into care homes and nursing homes. Some care workers are simply uneducated about how to provide support. My hon. Friend is right: as people are moved into private placements, whether they are funded by the local authority or self-funded, we will have the problem of a lack of joined-up support—not just in IT, but between social care, which is a local authority responsibility, and care for health conditions, which is the responsibility of HIV clinics with NHS support. He makes a very good point.

The disruption caused by dislocating HIV and sexual health clinics presents a real problem in keeping track of patients. As I said, collocation ensures that patients stay in the care pathway. Integrated HIV and sexual health services support young people living with HIV as they transition from paediatric care into adult services. Navigating adult HIV services for the first time can be challenging for young people. Including those services alongside sexual health services ensures that they have a one-stop shop for their HIV care and other tools for ensuring good sexual health.

The reality is that, in many cases, sexual health has become fragmented from HIV. Sexual health is the more profitable aspect of tenders, so some providers have purchased only the sexual health service, leaving no provision for HIV. In oral evidence to the APPG last year, the British Association for Sexual Health and HIV—BASHH—said that it believed that that had been a genuine oversight in the tendering process. Its president said:

“I don’t think the connection of what would happen if, particularly in a small service, the sexual health element of the tender was won by another provider. I don’t think anybody thought what would happen to the HIV service that was there. I think they thought it would just continue to be provided…and of course that may well be the case if it’s a large HIV unit, but in many cases it isn’t and it’s financially not viable, and that’s where the problem lies”.

Others report that when sexual health tenders were purchased without the HIV service, HIV clinics were left understaffed and with little certainty about the commissioning of the service. That means that people living with HIV have been required to access services elsewhere, which has led to small but significant numbers being lost to care. In its written evidence to the APPG’s inquiry, BASHH also noted:

“In a sexual health service that went out to tender a few years ago the contract was awarded to a community NHS provider. The outreach HIV clinic that had been well established was not sustainable and the service was discontinued. The majority of the service users transferred their care to other HIV providers some miles away but 9% were presumed to have disengaged in care.”

With that in mind, the APPG’s report, “The HIV puzzle”, recommends co-commissioning of HIV and sexual health services by local authorities and NHS England. Those two commissioning bodies should work collaboratively to ensure that a service assessment is in place so that the new provider, whoever it is, has a responsibility to ensure that the HIV service is maintained and not lost. The Department of Health needs to ensure that there is mandatory guidance for sexual health service bidders to undertake risk assessments and produce action plans detailing how the HIV treatment service will be transitioned and implemented.

The separation of HIV clinics from sexual health clinics is an unintended consequence of the Health and Social Care Act that needs to be addressed. The split of responsibility for different aspects of HIV care between local authorities and NHS England is leading to confusion in commissioning, and as I mentioned, early indications are that a small but significant proportion of HIV patients have fallen out of the care pathway as a result. Previously, sexual health services were all commissioned by primary care trusts and the separation of HIV services from sexual health services was unheard of.

The inquiry also identified that there remains no whole service specification for HIV and sexual health, which we believe is causing health professionals to deprioritise the service. The service specifications that do exist relate to either sexual health or HIV services through “Integrated sexual health services: national service specification” and the NHS England service specification for adult HIV services, and it is the same for paediatric HIV. Those guidelines are useful, but what is really lacking is a comprehensive service specification for HIV and sexual health that encompasses all aspects of the HIV care pathway.

That is why we recommended that the Government develop a whole service specification for HIV and sexual health, bringing together the various existing strands of clinical guidance to ensure clear and consistent advice is available to all local authorities, CCGs and NHS England. A clear service specification for HIV and sexual health would mean that there is a one-stop shop for local authorities or CCGs, which would help to remove the sense of fragmentation experienced by both patients and health professionals.

We recognise that public health is a devolved issue, but the Secretary of State must ensure that local authorities have enough guidance to ensure that there is a minimum service requirement that they must provide. At the moment, the 2012 Act does not provide enough clarity or accountability to any one commissioning body. The nature of HIV as an infectious disease means that HIV services do not start at the point of diagnosis.

Let me turn to testing and prevention, which are a critical part of encouraging safe sex. The APPG is extremely pleased with the Government’s recent announcement that relationships and sexuality education will be made compulsory in all secondary schools. Properly informed and sensitively taught, that will go a long way to ensuring that young people are able to make informed decisions about safe sex and preventing the transmission of sexually transmitted infections and HIV.

None the less, testing and prevention are subject to similar fragmentation of commissioning responsibility, so confusion over commissioning responsibilities remains. As an example, HIV testing can be paid for by any of three commissioning arms—local authorities, NHS England and CCGs—depending on the setting and context in which the test is offered. HIV testing—including community outreach—for most-affected groups and routine population screening in areas of high prevalence is the responsibility of local authorities. HIV testing clinically indicated in a hospital—and termination of pregnancy services—is paid for by CCGs. Testing and treatment for STIs, including HIV testing, provided in general practice when clinically indicated or requested by individual patients, is covered by NHS England as an essential service under the GP contract. Different settings, different funding, total confusion.

In short, if someone is offered an HIV test by a hospital doctor because they arrive in A&E with shingles, it is paid for by the CCG. If they are offered the same test for the same reason by their GP, it is paid for by the NHS primary services contract. If they are offered a test by the same GP simply because they live in an area of high prevalence, as NICE recommends, it is paid for by local authority.

The evidence for prevention and early diagnosis is overwhelming. People living with HIV can expect a near-normal lifespan if they are diagnosed early, but people diagnosed late continue to have a tenfold increased risk of death in the year following diagnosis. NICE also estimates that the costs of HIV care remain 50% higher for each year after diagnosis if the diagnosis is late. Likewise, preventing onward transmission is crucial not only for individual and public health but in terms of the sizeable lifetime costs of treatment. In 2011, PHE estimated that each infection prevented would save between £280,000 and £360,000 in lifetime treatment costs. NICE estimates that, if national testing guidance is implemented fully, 3,500 cases of onward transmission could be prevented in the next five years, saving the NHS more than £18 million a year in treatment costs.

I mentioned that GPs say they are under time pressure, and for a number of health issues that is widely reported as a barrier to proper intervention. The availability of education for GPs on offering HIV tests remains a problem. GPs feel they do not have enough information about the most appropriate time at which to intervene on HIV testing. As the Royal College of General Practitioners notes,

“There is...the issue of effective implementation—including training and support for practices to adopt these schemes...GPs and our teams are already under immense resource and workforce pressures making it incredibly difficult to implement any new programme”.

Many in primary care will therefore refer patients to GUM services for testing. However, that has the potential to entrench existing inequalities in late diagnosis rates, given that high-risk communities—particularly black African communities—are far less likely to access sexual health clinics and much more likely to access primary care.

Although healthcare professionals’ knowledge of when to offer an HIV test is not directly related to the Health and Social Care Act, the expectations from patients and the NHS England to mandate commission testing based on clinical indicators mean that educating healthcare professionals on the subject in line with NICE public health guidance must be a priority. The APPG has also called for protection of local authority public health grants from further funding reductions, in line with the Government’s commitment to ring-fencing the NHS budget. I would be grateful if the Minister could outline what plans she has to ensure that public health investment is not lost under further changes to local authority funding.

Finally, arguments over commissioning responsibilities have led to a stalemate on the introduction of innovation in HIV prevention. In 2015, studies from the UK, France and the US reported that, when taken regularly, PrEP can reduce the risk of HIV transmission by up to 86%. As the National AIDS Trust notes:

“PrEP is exciting, new, and currently, unique. It is not a vaccine, although it has a similar impact. We can draw comparisons to statins, in terms of preventing illness, or contraception, in terms of preventing unwanted consequences of sex. But actually, there is nothing quite like it. It is the definition of healthcare innovation.”

I do not wish to repeat the arguments made for and against the centralised commissioning of PrEP, but it does serve as an important case study in highlighting how the fragmentation outlined already risks HIV services that are focused on both lifelong condition management and preventing onward transmission.

As I mentioned at the beginning of my comments, I am enormously grateful to the Minister and NHS England for the announcement of an expanded clinical trial phase, including at least 10,000 participants, which will be launched early in 2017-18. I hope she will be able to update us on that trial in her response. I thank everyone who participated in the inquiry, particularly those who travelled across the country to attend our oral evidence sessions, and all the members of the APPG who took enormous time out of their diaries to support the inquiry.

--- Later in debate ---

[Nicola Blackwood]

The whole point of developing a much more systematic process and having a commissioning programme that does not allow the fragmentation of services, but instead is much more integrated, is that it will take into account more ageing people living with HIV. We believe that that will deal with the issue.

The hon. Gentleman also asked how we will tackle the issue of undiagnosed people living with HIV in the community. We believe that the strategy of increasing education and introducing compulsory sex and relationships education will be part of that, as will improving our performance, testing and early diagnosis. The work being done through the innovation fund is a key plank of that. Having clear specifications in commissioning guidelines so that we have coherent services for all who seek them is the strategy. We think that is a coherent response.

[Mike Freer]

Could the Minister write to hon. Members to clarify what will happen to those who are currently on the PROUD trial? What will happen while there is a gap between the drug stopping and the new trial starting? That would be appreciated.

--- Later in debate ---

[Mike Freer]

I thank right hon. and hon. Members for their time this afternoon. This has been a constructive debate, and I thank the Minister specifically for the commitments on extending the ring fence, for recognising that work needs to be done on the commissioning model and with regard to the work that PHE will be doing on a new action plan to support the pilots in addressing fragmentation and specification. Those announcements were all very welcome.

We have come a long way from HIV/AIDS being a death sentence. It is now a manageable condition. That is largely to do with drug breakthroughs but, importantly, it has been delivered through a co-ordinated response both from Public Health England and the NHS. I hope that this debate will help to avoid undoing the progress that we have made.

Question put and agreed to.

Resolved,

That this House has considered the all-party parliamentary group report Impact of Health and Social Care Act on HIV treatment.

NHS Commissioning (Pre-Exposure Prophylaxis)

Mike Freer Excerpts

Tuesday 7th June 2016 Commons Chamber

[Jane Ellison]

No, that is not the case. There has been an important study—the PROUD study—but that looked at clinical effectiveness. There is a wider piece of work to be done—of which the pilot programme that we have announced is part—to enable us to understand where PrEP fits in in terms of clinical and cost-effectiveness, and how it fits into the HIV prevention landscape more broadly, alongside other HIV interventions that are commissioned. There is work yet to do, but we are not standing still. We have announced this important pilot and committed money to it, and we have asked NICE for an evidence review. All this will go into our consideration.

[Mike Freer (Finchley and Golders Green) (Con)]

I agree with the shadow Minister apart from on one thing, which is his asking my hon. Friend the Minister to show leadership. Having campaigned on many male sexual health issues as chair of the all-party parliamentary group on HIV and AIDS, I can say that this Minister has been unfailingly supportive in addressing many of the issues facing not just men’s sexual health, but particularly gay men’s sexual health. I therefore take issue with that call for leadership.

Having said that, I have lost too many friends to AIDS over the years not to challenge NHS England’s decision not to fund PrEP. HIV infection rates in this country are on the increase and existing strategies are not working. It is not acceptable to suggest that we simply continue to do the same. I have a meeting with the Minister on 13 June. Will she agree to widen that to other stakeholders?

[Jane Ellison]

I thank my hon. Friend for his kind words. I take this issue extremely seriously. He is right to say that we face a challenge in relation to HIV rates, and particularly, as I said, STI rates in the high-risk MSM community. I stress again that while it will no doubt have an important part to play, PrEP is not a silver bullet for sexual infections, particularly in some of those high-risk groups. It is important to understand that. We have to continue to look at a whole range of measures. When I recently met the chief executive of the Terrence Higgins Trust, we touched on this.

As my hon. Friend says, we have a meeting coming up. I apologise for not responding to the shadow Minister’s question about meeting stakeholder groups. Of course I will meet all the key stakeholder groups. I have already had some formal and some informal discussions on this, but of course I am very open to having further such discussions. Stakeholders were involved in the process that NHS England has been involved in. NHS England has made its position clear, and there is a matter due to go before the courts on which I will not comment further. Yes, I will engage on this. Yes, of course I accept that we need to do more, and of course we all share the concerns about rising HIV infection rates, particularly among the MSM community. I too lost friends to the AIDS epidemic that my hon. Friend mentions. I take this issue extremely seriously, but we have to follow a sensible process, and that is what the Government are doing.

HPV Vaccinations for MSM

Mike Freer Excerpts

Tuesday 7th June 2016 Westminster Hall

[Mike Freer (Finchley and Golders Green) (Con)]

I beg to move,

That this House has considered HPV vaccinations for men who have sex with men.

Thank you for chairing this debate, Mr Hollobone; it is always a pleasure to serve under your chairmanship. This debate is a continuation of those that we have had over the past few years. The extension of the human papilloma virus vaccination programme to men who have sex with men—MSM—has been three years to the day in the making.

I first raised this issue in an Adjournment debate on 2 July 2013. I thank the then Minister for Public Health, my right hon. Friend the Member for Broxtowe (Anna Soubry), who, in responding to that debate, said that the issue could no longer be ignored. However, I reserve my heartiest thanks for the Under-Secretary of State for Health, my hon. Friend for Battersea (Jane Ellison), who is in her place today, for her unswerving support to ensure that HPV vaccinations are finally available for MSM. I have no doubt that without her personal support and her forbearance of my cajoling on a regular basis the new programme may not have happened.

Before turning to issues relating to the pilot of the new vaccination programme, it is worth reminding ourselves why such a programme is needed. I make no apology for raising yet again what some might regard as unsavoury issues—sometimes we do not like to talk about sexual health. HPV is responsible for nine out of 10 cases of genital warts, and men are six times more likely than women to have an oral HPV-related infection, which increases the risk of cancers of the mouth, throat, neck and head. Then there is HPV-related penile and anal cancer. HPV is associated with 80% to 85% of all anal cancer in men. In 2009, just after the general HPV vaccination programme started, there were more than 6,500 cases of these cancers. Some 47% of penile cancers and 16% of head and neck cancers are thought to be HPV related. The latest incidence data show that in 2010 there were 437 incidences of anal cancer, 5,637 incidences of oropharyngeal cancer, 515 incidences of penile cancer and 90,000 incidences of genital warts. Rates of some HPV-related cancers are on the increase in the UK and throat cancer has overtaken cervical cancer as the leading HPV-related cancer.

It is worth looking at the costs incurred in treating these cancers, which could now be avoided. Each HPV vaccination for the three-dose programme costs an estimated £260 on the open market—I appreciate that the NHS will, I hope, have negotiated a lower price. That compares with the £13,000 cost of treating anal cancer, the £11,500 cost of treating penile cancer, the £15,000 cost of treating oropharyngeal cancer or the £13,600 cost of treating vulva and vaginal cancer transmitted by an infected male. In 2010, the cost of treating genital warts was £52.4 million. The clinical and financial reasons are self-evident. That is why we started this debate three years ago, and today we have a pilot for making vaccinations available for MSM through sexual health clinics.

I will not detain hon. Members for long; this is really an update request. I have several questions for the Minister. How long will the pilot be for? Who exactly will the pilot vaccination programme be available to? Is it to men identifying as MSM or men identifying as MSM who request the vaccine? What if a man who does not identify as MSM asks for the vaccine? Will it be available to heterosexual males?

How will the pilot be evaluated? For example, will it simply be from the take-up of MSM patients registered, or will it measure the adherence rate, because the programme requires three doses, and for all three to be taken, to be effective? So will the evaluation include adherence to the dosage requirements? Is there a timescale to measure the impact on HPV-related cancers and genital warts? Will the results and any mid-pilot indicators be reported to the Minister and, eventually, made public?

I must also ask whether the vaccination programme will include adolescent boys if they turn up at a sexual health clinic. They might not technically or legally be men, but if they are at risk and go to a sexual health clinic, will the HPV vaccination be available to them because they are at risk, and if a clinician deems it necessary? Finally, I cannot miss the opportunity to nudge the Minister on whether we may have an update on when HPV vaccinations will be widely available to all boys in the UK.

[Several hon. Members rose—]

--- Later in debate ---

[Mike Freer]

First, I would like to put it on the record that this pilot is a success. Hon. Members need only go back and read the previous debates to see how the JCVI had simply set its face against extending HPV vaccinations to boys and MSM. It was implacably opposed, and it took a lot of badgering from Members of this House and from Ministers to get the JCVI to change its terms of reference. It has taken us three years to get to this point, but I welcome the pilot and I welcome the Minister’s explanation of the complexities and why we have to ensure that the pilot is robustly monitored before we can take the extension of the vaccinations any further.

I finish by thanking colleagues for joining the debate today and for the broad cross-party support. We covered all perspectives, including MSM, boys, the minority known as heterosexual men and dental health practitioners—have I missed anyone out? Men are notoriously bad at seeking help with their health, especially sexual health. Vaccination is the way forward. I welcome this positive step forward and thank colleagues for their attendance today.

Question put and agreed to.

Resolved,

That this House has considered HPV vaccinations for men who have sex with men.

Junior Doctors Contracts

Mike Freer Excerpts

Monday 18th April 2016 Commons Chamber

[Mr Hunt]

Yes.

[Mike Freer (Finchley and Golders Green) (Con)]

In November, the BMA promised to negotiate on Saturday pay. Has it kept that promise?

[Mr Hunt]

No, it has not. If it had, I do not think that we would be having a strike. I think we would have a negotiated settlement, and the NHS would be able to proceed with the contracts, which have important benefits for doctors, such as reducing the number of consecutive nights or consecutive long days that they can be asked to work. The refusal to negotiate on the crucial issue of Saturday pay, which is not a reduction in take-home pay because the reduction in Saturday premiums was made up for with an increase in basic pay, was what led Sir David Dalton to say that a negotiated settlement was not possible. It is a matter of huge regret, but I am afraid that it leaves the Government with no option but to proceed in the way that we are doing.

Junior Doctors: Industrial Action

Mike Freer Excerpts

Thursday 24th March 2016 Commons Chamber

[Ben Gummer]

It is unfortunate that the hon. Gentleman needs to use such language. The Conservative party is achieving better outcomes for patients in every single metric than the Labour party in Wales, which is consistently letting down patients in the Principality—an appalling aspect for people who are in need of care in Wales.

[Mike Freer (Finchley and Golders Green) (Con)]

Will the Minister confirm that the escalation by the BMA makes a settlement less, not more, likely?

[Ben Gummer]

It is hard to have any discussions on any matter with the BMA in good faith when there is an escalation to the withdrawal of emergency cover on a matter of pay only. That unprecedented situation makes our collective bargaining arrangements with the BMA very difficult.

Oral Answers to Questions

Mike Freer Excerpts

Tuesday 22nd March 2016 Commons Chamber

[Jane Ellison]

NHS England’s senior specialised commissioning management team made that decision, and I think NHS England recognises that it could have been made earlier. However, it is also recognised that NHS England has already done valuable work. Some important lessons have been learned, and we do not want to lose that. We must now work with both NHS England and Public Health England to understand how we can continue to learn from, for example, the test sites.

[Mike Freer (Finchley and Golders Green) (Con)]

I share some of the concerns expressed by the hon. Member for Hornsey and Wood Green (Catherine West) about the roll-out of PrEP, but it is only one tool in HIV prevention. Will my hon. Friend update the House on the progress of the HIV prevention innovation fund?

[Jane Ellison]

My hon. Friend is right to draw the House’s attention to the fact that PrEP is only one part of prevention, although obviously we understand its importance. He is also right to mention the innovation fund, which, of course, he championed. We have invested up to £500,000 in new and innovative ways to tackle HIV. Some excellent organisations have come forward with some very innovative approaches, and we have also established the first national HIV home sampling service.

Gay Conversion Therapies

Mike Freer Excerpts

Tuesday 3rd November 2015 Westminster Hall

[Mike Freer (Finchley and Golders Green) (Con)]

I beg to move,

That this House has considered gay conversion therapies and the NHS.

It is a pleasure to serve under your chairmanship this afternoon, Mr Bailey.

I am conscious that this subject has been raised before; however, it remains possible for people in the UK to be referred by a national health service professional to a psychotherapist for gay conversion therapy—the so-called gay cure. Being gay is not a disease, it is not an illness and it is not something that I or any other gay man or woman can be cured of. To suggest otherwise is not only demeaning, but morally and medically wrong. Not a single medical body supports the concept of a gay cure. The Royal College of Psychiatrists, the UK Council for Psychotherapy, the British Association for Counselling and Psychotherapy and the British Medical Association have all concluded that such therapy is unethical and potentially harmful.

Various techniques and methods have been used, and I will list a few to give a bit of colour to the level of quackery available. Exorcism is one method—in The Times today is a story about a young man taken to a backstreet exorcist because his parents were concerned that he was gay. Cycling, too, was thought to be a cure for being gay, although as a keen cyclist I can tell colleagues that it does not work. Then there is prayer—pray away the gay, apparently—although that does not appear to work either. An Austrian doctor trialled testicular transplants: he took the testicles of a heterosexual man and transplanted them into a homosexual man to see whether that curbed his homosexual desires. Unfortunately, I could not find the outcome of the trial anywhere on the internet, although I am sure that it was of interest to both recipient and donor of the testicles.

I mention those as examples of how far from the mainstream some so-called cures can be. They are also a far cry from mainstream psychotherapy—I need to put that on the record. However, I want to focus on current techniques and to debunk the thought that so-called cure therapies might simply be gentle counselling, laying on the couch and talking about one’s feelings. They are not gentle therapies.

Such therapies purport to change a person’s sexual orientation or to reduce attraction to people of the same sex. Dr Christian Jessen, for a television programme in only 2014, underwent treatment for homosexuality, including one of the most extreme cures, aversion therapy, which looks to teach patients to associate same-sex attraction with pain or nausea. Patients are given a drug that makes them extremely ill and they are then played pornographic images and sound recordings while they vomit violently. That is not counselling. Usually patients experience a session every two hours, night and day, for three whole days. That is not counselling. Similarly, in electric-shock treatment, people who respond to same-sex stimuli are shocked so that their response is associated with pain. That is not counselling.

Imagine the outcry if Parliament were to give tacit approval to curing heterosexual men and women of their heterosexuality. There would be uproar. Allowing conversion therapy to try to turn our straight colleagues gay would not last a day, yet we allow therapists to peddle the myth that they can cure people of being gay.

If such views were held only by crackpots on the fringe of society, it would be laughable. It is not. Some psychotherapists and some NHS staff hold the view that a gay cure is possible. YouGov polling in 2014 for Stonewall, the excellent lesbian, gay, bisexual, and transgender organisation, found that one in 10 health and social care staff have heard other staff express a belief in gay cure therapy; in London that figure rose to one in five. Only six years ago the BMC Psychiatry journal surveyed over 1,300 accredited medical professionals and found that more than 200 of them—over 15%—had offered some form of conversion therapy. Those 200-plus professionals said that 35% of their patients had been referred to them by GPs, and 40% of the patients receiving the so-called treatment were treated in an NHS practice. For any health professional to refer someone for such therapy is fundamentally abhorrent and it is time to call a halt to it once and for all.

Where are we today? In spite of numerous calls for an outright ban, the practice continues, although I accept that there has been some progress. In January, the “Memorandum of Understanding on Conversion Therapy in the UK” was launched. It was developed by the UK Council for Psychotherapy and signed up to by some major organisations, including the NHS. It is welcome as far as it goes, but a number of regulators have not yet signed up to the memorandum—and it is voluntary. The memorandum seems to cover only sexual orientation, not gender identity—and it is voluntary. The memorandum states that practitioners need to be aware of the ethical issues relating to such cure therapies and that the public should be made aware of the risks of such therapies—and it is voluntary. The memorandum seeks to apply standards to a sector of therapy that has no statutory regulation—because it is voluntary. We regulate dentists, but we have no statutory regulation for psychotherapists.

My hon. Friend the Minister has an impeccable record on LGBT issues, especially in health, and I put on the record that on this issue and many others she has a deep commitment to helping to eradicate flaws in the system and to pursuing equality. So I have to ask: why we are allowing this abuse, this so-called cure therapy, to continue? Why are we allowing the practitioners, the psychotherapists, to have merely a voluntary code of practice—a memorandum of understanding?

I acknowledge that psychotherapy has a role to play for adults who need support when dealing with a range of issues connected with their sexuality and sexual identity. Dealing with conflicting feelings is difficult at the best of times and I do accept the role of proper, regulated counselling.

[Ben Howlett (Bath) (Con)]

I congratulate my hon. Friend on securing the debate. Does he agree that availability of such programmes would have a serious effect on the mental health of LGBT individuals?

[Mike Freer]

My hon. Friend makes a good point, given the evidence. I am about to quote the Royal College of Psychiatrists, which states that such therapies are damaging not only to the physical health, but to the mental health of individuals who have such therapies inflicted upon them.

[Stuart Andrew (Pudsey) (Con)]

I congratulate my hon. Friend on raising this important issue. Is he as disturbed as I am to see figures from the United States on people who have gone through conversion therapy showing that they are 8.9 times more likely to commit suicide, 5.9 times more likely to suffer depression and three times more likely to take illegal substances than their peers as a result of this frankly outdated and cruel method?

[Mike Freer]

My hon. Friend makes an extremely powerful point. I am not surprised to hear those figures.

Anyone who is conflicted and in need of support while coming to terms with their sexuality is experiencing some difficult feelings. If they are told that they can be cured—I am yet to find a case of the cure being proved successful—they then have to deal with those feelings as well.

[Dr Lisa Cameron (East Kilbride, Strathaven and Lesmahagow) (SNP)]

I speak as a Member of Parliament and as a psychologist. In all my experience and practice in the NHS, this is not something I am familiar with, although the hon. Gentleman says that there are a number of cases. It is important to recognise that such therapy is without any evidential basis—not surprisingly, given that most of the research findings indicate an adverse impact on people’s mental health, rather than a cure per se.

[Mike Freer]

The hon. Lady makes a good point. I have to say that no one I know has come forward to support such psychotherapy, yet if there is such violent agreement, why are we struggling to get aversion therapy banned? There is this conundrum: we all agree that it is harmful and that it should not be done, yet we do not seem to be able to get it banned.

I accept that my hon. Friend the Minister has difficulty in regulating the sector in terms of setting legal definitions for what would constitute illegal therapies. The legal situation is fraught, but it is not acceptable to leave vulnerable men and women susceptible to aversion therapy. There can be no justification for pursuing therapies that put a person’s mental health and, in some therapies, their physical health at risk. It is time to say that such therapies have no place in our society and no place in our healthcare system. It is time to say simply that aversion therapy has no medical merit and can be harmful and it is time to say that it is going to be illegal. It is also time to ensure that psychotherapy has statutory regulation, so that those who do not comply and continue to perpetuate such cure therapies face stricter and harsher penalties than those currently available under a voluntary code.

The Royal College of Psychiatrists contacted me last week to reiterate that

“the college remains in favour of legislative efforts to ban such conversion therapies.”

In its letter, it said that

“there is no scientific evidence that sexual orientation can be changed.”

It also said that

“so-called treatments of homosexuality can create a setting in which prejudice and discrimination flourish, and there is evidence that they are potentially harmful.”

[Wes Streeting (Ilford North) (Lab)]

I am grateful to the hon. Gentleman for securing the debate and for all the work he does to champion LGBT equality. I am sure that many of us received the Core Issues Trust’s interesting briefing, which suggested a link between homosexuality and same-sex attraction and mental ill health and other forms of physical illness. Has it not got that the wrong way around? It is discrimination and the suggestion that there could be a gay cure that makes all LGBT people, and young people in particular, feel that they are different and somehow alien. That is what causes them mental ill health, not their homosexuality.

[Mike Freer]

The hon. Gentleman has a track record in this area even though he is new to the House and I am sure that he will be extremely vocal on these issues. He is absolutely right. It is the suggestion that homosexuality is a disease or illness that can be cured that drives mental health problems, not the other way around. Frankly, I wasted no time on reading the Core Issues briefing.

I will finish with a couple of comments from esteemed colleagues. On 29 April, in an interview with Pink News, the Prime Minister said, on banning such therapies,

“if we need to go further…we will.”

As far as I am concerned, we do need to go further. The Secretary of State for Education and Minister for Women and Equalities said a couple of weeks ago to Pink News:

“Let me be clear: gay cure therapies have no place in our countries and we must stamp them out.”

I ask my very good friend the Minister if she will agree to explore how stipulated aversion therapies can be banned and whether the voluntary memorandum of understanding should and can be reviewed to put it on a statutory footing.

Junior Doctors’ Contracts

Mike Freer Excerpts

Wednesday 28th October 2015 Commons Chamber

[Mike Freer (Finchley and Golders Green) (Con)]

Finchley and Golders Green is served by Barnet general hospital and the Royal Free hospital, which is just across the border in the constituency of the hon. Member for Hampstead and Kilburn (Tulip Siddiq). In particular, the Royal Free is the largest hospital serving my constituency, and it is one of the largest and safest acute hospitals in London. It has the high security infectious diseases unit, which has recently been in the news for treating Ebola, and it is a major centre for research into immunology and transplants. Not surprisingly, it is a major teaching hospital.

Many junior doctors who live in my constituency have contacted me and despite my best efforts, using the information provided by NHS employers and the Department of Health’s online pay model, they continue to be confused and believe that their pay will be cut. I have no doubt that the selective information from the BMA has not helped. I welcome the reforms in principle and the commitment to introduce a new absolute limit on the number of extra hours that junior doctors can work. Bringing an end to the week of nights and capping the extra hours are welcome, but most junior doctors in my constituency are simply not aware that that is what we propose.

In fact, most of the junior doctors that I have seen believe that the reforms will increase their working week, leading to more fatigue and therefore jeopardising, not improving, patient safety. They believe that this will hamper the Secretary of State’s quite-right drive to improve weekend mortality rates. I say to my colleagues in the Department of Health that something is going wrong in the communication of this welcome reform.

Let me turn now to a couple of issues that have been raised by junior doctors and that echo some of the concerns mentioned by the hon. Member for Central Ayrshire (Dr Whitford). On retention, the Royal Free is a major centre for research and yet Dr Renee Hoenkampf, who wrote to me, is concerned that those doctors who seek to go into research and to step away from the frontline will be penalised by being held back on their progression pay. Those doctors who choose to have a career break to raise a family will also be penalised. Both those concerns will impact on women more than on men.

[Dr Murrison]

On that point, the BMA is making a case for current increments on the basis of experience gained. A career break will probably mean that there will not be any experience accrued. Does he therefore agree that the BMA needs to get its logic right?

[Mike Freer]

My hon. Friend is right that just getting pay progression for time served is not the right thing to do, and most organisations have scrapped it. However, we must avoid accidental penalties acting as a disincentive for women joining the workforce. We should not encourage this idea that women, or any person, should be penalised for taking career breaks or for stepping away from the frontline by taking part in valuable research. I gently ask the Minister to look again at that matter.

When I met Dr Joseph Machta, a junior doctor in paediatrics, he said that, after consulting the Department of Health’s pay model, his pay would reduce by 15%. Like many junior doctors living in my patch—it is not a cheap part of London—he was concerned that he would no longer be able to pay his mortgage. Will the Minister look into that matter? I suspect that London’s junior doctors rely more than most on premium payments. While average pay across the UK may be neutral under the compensatory increase in basic pay, that may not be true in London. I would be interested to hear whether the Department of Health has done an impact assessment on London’s junior doctors and the amount of premium pay that takes up the wage bill in London hospitals. If many junior doctors in London are over reliant on premium payments to pay their bills—that may be a wrong thing to do because they are working too many hours, but that is a different issue—it is a matter that needs to be considered.

It is not unusual to want to have contract terms changed to meet current needs. On that basis, I support the reforms, but I ask the Minister to look into those two issues that I specifically raised.

HIV Prevention

Mike Freer Excerpts

Thursday 12th March 2015 Commons Chamber

[Mike Freer (Finchley and Golders Green) (Con)]

Thirty years ago we became aware of AIDS. The 1980s saw a ground-breaking public information campaign about AIDS. Leaflets to every household as well as television and radio all made us aware of the illness and the risks. The term “safe sex” and the knowledge of the need to use condoms became established and behaviours changed. I lived through that period and I remember the fear and the stigma. We have made progress in combating the stigma, and we have made progress in challenging the misconception that it is a gay disease. But it is worth reminding ourselves that in fact 55% of people living with HIV in the UK acquired the infection through heterosexual sex.

Having lived through those years and having lost too many friends to AIDS, it saddens me that we continue to have a problem with new HIV infections. Today, it is estimated that 108,000 people live with HIV in the United Kingdom. Today, the infection rate means that an additional 6,000 people a year are diagnosed. Ten years ago, the figure was 7,700 a year, so that reduction of more than 30% is welcome. But if we dig below that headline figure, there are some troubling trends. Among men who have sex with men—MSM—the rates are increasing, up 33% from 2,450 a year in 2004 to 3,250 a year in 2013. So while we are having success on many fronts, we still need to combat the rising levels of infections in those groups where infection rates are increasing.

I have already mentioned one group, MSM. Another group is black Africans. The rates per 1,000 head of population are similar. In the MSM cohort, it is 59 per 1,000, and for black Africans it is 56 per 1,000. I must stress that it would be wrong to stigmatise MSM or black Africans. The majority of both groups do not have HIV, but they are groups in which more work needs to be done, not least because it is thought that 25% are unaware of their HIV status and so are at risk of passing on the infection.

Some of the other issues we need to address are: aversion to safe sex; unwillingness to be open about male-to-male sexual partners; drug use, particularly what is known as chemsex; and a lack of knowledge about how HIV is transmitted and how to protect oneself. Therefore, the key issues appear to be prevention through education, prevention through intervention and medical intervention.

The obvious starting point is to educate when people are becoming sexually aware. I appreciate that that is not in my hon. Friend the Minister’s portfolio, but if we are to be innovative in tackling the problem we need to work across Government. Sex education in schools is always controversial, as Members who were present for the previous debate will have heard, but we have to accept that teenagers will have access to online pornography. Not only does the sexualisation of teenagers mean that they do not learn enough about loving relationships, but the imagery can undermine information on consent and on the health implications of behaviour.

[Mr Ben Bradshaw (Exeter) (Lab)]

Is not the hon. Gentleman making a strong argument for mandatory personal sex and relationship education in schools, which is something the Opposition now support? Sadly, his party has not quite got there yet.

[Mike Freer]

The right hon. Gentleman makes a good point. If he bears with me for just a minute, he might find that I am in agreement.

We have to accept that many teenagers will become sexually active, yet sex and relationship education—SRE—remains poor. The National Aids Trust recently published a report showing that in SRE there is little teaching about, among other things, same-sex awareness or HIV transmission. Teachers can be nervous of sex education full stop, let alone same-sex issues, sexual health or, in particular, HIV. That is compounded when schools struggle with homophobic bullying, which can contribute to teenagers feeling uncomfortable about seeking advice or information about their attractions or about having a safe sexual relationship when the time comes.

[Mr Nigel Evans (Ribble Valley) (Con)]

Is my hon. Friend as alarmed as I am by recent newspaper reports in which it appears that an increasing number of youngsters are being bullied or harassed at school for being gay, and in some cases even being taunted by teachers? Surely there has to be a completely different attitude in the 21st-century UK.

[Mike Freer]

My hon. Friend makes a very good point, and I agree entirely. In the Department for Education—I apologise to my hon. Friend the Minister for straying away from health, but this is a cross-Government issue—work has been done to fund teacher training on dealing with homophobic bullying, but we need to go one step further and make it integral to teacher training, not an add-on paid for by schools and local education authorities. One of the problems is that if gay men or men who declare as MSM are bullied for showing any form of attraction to other men, for seeking advice or for showing that inclination in any shape or form, they will simply not seek that information. In school they may be afraid of being bullied, whether by other schoolchildren, teachers or other members of staff. They will close down and withdraw, and as a result they might make ill-informed decisions about their sex lives.

In my view, therefore, it is time for SRE to be made compulsory and inclusive. I appreciate that that is not the view of my colleagues in the Department for Education, but I think that they are wrong and that they need to reassess that. We are talking about people’s health and future relationships, so this is too important to get hung up about the ideology of compulsion.

There is also the issue of new technology. When I was at school, in the dim and distant past, sex education was skirted around and pupils, if they were lucky, were given a rather dusty old book with some rather dodgy drawings—clearly that did not teach me very much. Today, teenagers have access to technology. They are accessing sex differently, and accessing information differently, so we need to educate and inform differently. The increasing use of dating apps—I use the term loosely —means that increasing numbers of teenagers are finding sexual partners through their phones. Are colleagues in Government and in health authorities nimble enough in using that technology effectively to ensure that appropriate sexual health messages are there too? Are we constantly playing catch-up, or can we innovate too? How can we intervene differently to support those who are HIV-positive? I said that we need to start with education and that we need to use technology, but when people present as HIV-positive, how can we intervene differently?

It is true that new anti-retroviral drug treatments—ARVs—have transformed the lives of those who are HIV-positive, and they help most people to live near-normal lives, but it is still a life-changing diagnosis. ARVs have to be taken every day for the rest of the person’s life. Relationships can be harder to find and to maintain because potential partners often reject someone who is HIV-positive. Despite anti-discrimination laws, few employees volunteer their HIV-positive status. To my knowledge, only one Member in the history of this House has ever declared his HIV-positive status. That former Member is now in another place. People will not volunteer their HIV-positive status for fear of discrimination—not just overt discrimination but the subtle passing over for promotions or snide comments in the workplace. Then there is the fear of shunning or harassment by co-workers. Despite all the work over the years, some people still believe that HIV can be transmitted through saliva or through sharing crockery and cutlery— 30 years after a major education programme.

All these factors combine such that the human cost of HIV-positive status can be significant. Despite the medical breakthroughs and ARVs, the costs of depression, isolation and the fear of being open remain. We still have work to do to ensure that health education is provided in the workplace, and not just in health education teaching or clinics. The impact on mental health is often missed by health services and sexual health clinics. Sexual health clinics should be more about general well-being and not just sexual health. It should not just be about treating a symptom. If someone goes in with gonorrhoea and comes out with a pill, it is “Job done” for many clinics, but what if they are treating someone who is presenting as HIV-positive? What is the back-up? What about their mental health? Are we providing that total well-being package?

I mentioned chemsex, where men use drugs that enhance sexual performance combined with drugs such as crystal, methedrone or GHB. This can lead to reduced sexual inhibitions and so increased risk-taking. I understand that someone presenting at a sexual health clinic who has chemsex is more likely to have broad sexual issues, and the clinic will deal only with those issues, while the drug-related issues will often be subject to referral to a drug treatment facility. That is often a separate facility and the referral may take six, eight, 10 or 12 weeks, during which time the person who has been interested in seeking treatment falls through the cracks. The separation of treatments, particularly for those involved in chemsex, not only breaks the treatment plan but increases the chance that the patient will not take up the treatment referral, and so behaviours are not changed.

Only this week I had the chance to visit 56 Dean Street and Dean Street Express in Soho. They are absolutely stunning facilities that look nothing like what we imagine the NHS to look like. It was not clinical and there was no plastic seating—it looked for all the world like an attractive boutique hotel. Dean Street Express has harnessed technology. Rather than someone having to go into a clinic, stand at a counter and announce to the world why they are there, or having to sit in an open waiting room, with everyone looking sheepish because they may recognise somebody else, they can book in using technology. They can also swab themselves, and then use the technology. That is the way forward if we are to make the system friendly and receptive, to innovate and to make it worth while and easy for people to seek help and treatment. Most importantly, it provides help on total well-being, not just sexual health. In my view, the Department of Heath should look at rolling out that innovative technique.

I have mentioned the black African community. It is a difficult community to reach, and I do not have any answers, but we need to work harder to reach it, whatever the method—perhaps through its community groups or churches—both to educate and to support those who disclose themselves as MSM or those who are afraid of doing so for fear that their own community will reject them.

We have to accept that people will make poor choices and have unprotected sex, which leads me on to intervention. I pay tribute to the PROUD report. Its initial studies show that post-exposure prophylaxis and pre-exposure prophylaxis—treatments taken immediately after suspected exposure to HIV or as a preventive measure—work. The initial findings show that they are cost-effective approaches to the prevention of transmission, or at least to ensuring that infection rates drop dramatically.

I accept the fact that the use of PEP and PrEP has cost implications. I understand that PrEP costs up to £6,000 a year, but we should compare that with cost of treating someone who is HIV-positive. The lifetime cost of treatment for a person with HIV is between £250,000 and £330,000 a year, so a £6,000 investment could save between a quarter and a third of a million pounds a year.

I have outlined some of the human and financial reasons for understanding what is driving up infection rates, and the action we could take. That brings me to my last point, which is that we need to increase testing. We need to make it easier and less clinical so that people do not fear that it means always having to go into clinics. A clinic is not a friendly—to overuse the pun—environment.

If clinics are used, they should at least make routine tests for HIV across the board so that people who are HIV-positive can have early intervention. Early diagnosis and early treatment dramatically improve the lives of individuals and reduce transmission rates. Let us remember that 25% of those who are HIV-positive do not know it. Easier and faster testing will help to reduce the number of transmissions and new infections. That should include the roll-out of home testing, because it must be right to make testing accessible and easy.

We often shy away from talking about sex, and we certainly find it uncomfortable to learn about sexual practices outside our own experience. Yet if we are to tackle the issues, we have to deal with the problems that exist and with the world as it is, not as we might like it to be. That is why I call on my hon. Friend the Minister to explain how we can redouble our efforts to educate and innovate in HIV prevention.

--- Later in debate ---

[Mike Freer]

I am grateful to the Minister for that announcement. Is she able to give us any indication of how quickly the expert panel will report?

[Jane Ellison]

I am sure we would all want the panel to do that work in a timely fashion. I am not able to provide a date tonight, but I will convey the sense of urgency here in the Chamber to NHS England.

Hon. Members made important points about stigma and discrimination. I can only support everything they said. There is some encouragement: in the latest Ipsos MORI poll in 2014, the National AIDS Trust reports that overall public support for people with HIV is higher than ever, with 79% agreeing that people with HIV deserve the same level of support and respect as people with cancer. That is up from 2010. There is room for improvement, however, and a need for engagement across the spectrum. The NHS, local authorities, the Government, community and faith groups, the media—everyone has a part to play in eliminating HIV-related stigma. I note the comments about the role of schools—I will convey them to my right hon. Friend the Secretary of State—and the intervention about homophobic bullying. The Government have invested money in tackling such bullying and take it extremely seriously. It remains a concern for all of us.

It is positive that the number of new HIV infections overall continues to fall, and I believe that the Government can be proud of their record in this area, but the rise in the number of new MSM infections and the high levels of late diagnosis among black African populations are of great concern. Today I have set out how we will be more bold and innovative with the HIV prevention programme, including through a new national home sampling programme—one of the first of its kind in the world—increased use of social and digital media platforms and the setting up of an innovation fund to trial new approaches. Importantly, we are working in partnership with local authorities in taking this work forward. I see this as a transition to a long-term plan for HIV prevention and sexual and reproductive health promotion, and it is our ambition to see infection rates falling, not rising, and late diagnosis becoming a much rarer event. I thank all right hon. and hon. Members for their contributions to this excellent debate.

Question put and agreed to.

Joint Committee on Vaccination and Immunisation

Mike Freer Excerpts

Wednesday 8th January 2014 Westminster Hall

[Mike Freer (Finchley and Golders Green) (Con)]

It is a pleasure to be here today under your chairmanship, Mr Gray. I am grateful to Mr Speaker for granting this debate on the work of the Joint Committee on Vaccination and Immunisation. I requested this debate following the JCVI’s decision on the 2 October 2013 to undertake further work on key issues surrounding the human papillomavirus, or HPV, vaccination programme. I understand that some colleagues may wish to comment on other aspects of the JCVI’s work. I want to focus particularly on the Committee’s decision to consider—I use its word—“urgently” vaccinating men who have sex with men, on attendance at sexual health services, and adolescent males. I intend to focus my remarks on that work now being undertaken with regard to the HPV vaccination programme, specifically in terms of exposure to HPV-related cancers, which are increasing in boys who have sex with females and the MSM community.

The decision of the JCVI to prioritise consideration of vaccinating MSM is noteworthy, not least because the minutes of its October meeting accept that a full economic model might not be necessary where sexual health clinicians can develop independent guidelines. Historically, the JCVI has often rejected vaccination of adolescent boys and MSM on economic grounds, so it is a major step forward for it to say that heath clinicians with expertise—particularly at sexual health clinics—can take such a decision on clinical grounds. That is welcome.

It is important—I have no doubt that my hon. Friend the Minister will need to ensure it—that any decision on extending vaccinations is clinically and financially sound. I do not seek to undermine that decision. I wish to stress the economic benefits of extending the vaccination swiftly, rather than stress other issues of equality, which I raised in an Adjournment debate last year.

[Jim Shannon (Strangford) (DUP)]

I thank the hon. Gentleman for bringing this important health matter to Westminster Hall for consideration. There have been significant positive results from vaccinating women and girls for HPV, so clearly there is an advantage shown in doing that. That consolidates the hon. Gentleman’s request for the same vaccination to take place in men and boys as well. Does he agree that the same should happen with regard to men as has happened for women and girls?

[Mike Freer]

The hon. Gentleman makes a good point that repeats some of the discussion we had in last year’s Adjournment debate. The success of the vaccination programme among girls has had a dramatic impact on HPV-related cancers among women. However, the flaw was that it assumed herd immunity for boys who were having sex either with girls or within the herd. But of course, not all boys have sex with girls: some—shock, horror!—have sex with other boys, and not all boys have sex within the herd. Increasingly, in a global economy, and particularly in Europe where the vaccination programme is not the same, adolescent boys in this country are exposed to women who have not been vaccinated. It is important to close the loophole for adolescent boys having sex with unvaccinated girls and those having sex with unvaccinated boys, who, obviously, grow to be unvaccinated men.

If the JCVI has agreed to urgently review the economic case for extending the vaccination programme, why is this debate needed? Before I discuss that, it is worth reminding ourselves what health problems we are trying to prevent. I recall, during the Adjournment debate, seeing the duty Whip sink ever further on the Bench as we discussed certain topics and cancers. This is not a pleasant subject, but I would rather discuss an unpleasant subject than have to deal with it in our hospitals.

Nine out of 10 cases of genital warts are HPV-related; oral-related HPV infections—men are six times more likely than women to have oral infections—increase the risk of cancers of the mouth, throat, neck and head cancers; and there are HPV-related penile and anal cancers: HPV is associated with 80% to 85% of anal cancer in men. In 2009, just after the HPV vaccination programme started, there were more than 6,500 cases of these cancers, with 47% of penile cancer and 16% of head and neck cancers thought to be HPV-related. The latest incidence data show that in 2010 there were 437 incidences of anal cancer and 5,637 of oropharyngeal cancer, 515 instances of penile cancer and 180,000 instances of genital warts. Rates of HPV-related cancers are on the rise in the UK. Throat cancer has overtaken cervical cancer as the leading HPV-related cancer. I am pleased that the JCVI has accepted that there is an urgent need to review the clinical and economic case for extending the programme to adolescent boys and MSM.

I should like to put on record my thanks to the Minister’s predecessor, my hon. Friend the Member for Broxtowe (Anna Soubry),for her support in this matter and for facilitating a teleconference, which she and I and representatives of the Terrence Higgins Trust had with the Chairman of the JCVI, which I believe gave some impetus to this change of heart and the speeding up of the work by the JCVI. That was a significant breakthrough.

The key point in this debate is that although the JCVI’s urgent report is due at some unspecified point later this year, the procurement of the next round of HPV vaccinations will commence in October or November this year. I am concerned that if the JCVI does not report in time and this procurement round is missed, we may have to wait four more years—I believe it is a four-year procurement round—before the HPV vaccination programme is extended to adolescent boys and MSM, if that is the recommendation.

[Alison Seabeck (Plymouth, Moor View) (Lab)]

I congratulate the hon. Gentleman on bringing this subject to the House. I share his concerns. Is he also concerned that although the JCVI undoubtedly does some excellent work, it does not share the flexibilities of the National Institute for Health and Clinical Excellence, in terms of its medical and health assessment processes? Would he welcome some movement there, which might in turn help bring this vaccine forward more quickly?

[Mike Freer]

The hon. Lady makes a good point and speaks, probably, with more knowledge than I have. If NICE is able to react more swiftly than the JCVI, I am sure that my hon. Friend the Minister will take that point away and consider whether the two organisations could share best practice. Clearly, as new drugs come on the market and new issues arise, we must ensure that the health advisers are able to respond quickly to changes.

The key point I was making is that if we miss the procurement window, and if we have to wait four more years, boys and the MSM community would be unnecessarily exposed to HPV-related cancers. There is not just a personal cost to those who become exposed to HPV-related cancers: the NHS would be exposed to treatment costs that might be mitigated or avoided if we get the JCVI to report in time for the procurement round later this year.

If we look at the costs, we can start to see the scale of the savings. To put that into perspective, the three-dose HPV vaccination programme currently costs some £260. I understand that the JCVI is also considering whether that may be reduced to a two-dose vaccination, which would reduce the outlay. Let us compare that with the £13,000 cost per patient of treating anal cancer, the £11,500 cost per patient of treating penile cancer, the £15,000 cost per patient of treating oropharyngeal cancer, or the £13,600 cost per patient of treating vulvar and vaginal cancer transmitted by an infected male. In 2010, the total cost to the NHS of treating genital warts was £52.4 million. If we multiply those figures by four, we can see the clear economic benefits of bringing forward the decision to coincide with the next procurement round.

The clinical reasons and the economic benefits are evident, and I hope that my hon. Friend the Minister will confirm today that, at best, the JCVI will be able to report in time for the procurement round later this year or, at worst, that any contract procured later this year will have flexibility built in to allow the Minister and the Department of Health to extend the vaccination programme to adolescent boys and MSM at some point after the report.