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Volume 468: debated on Wednesday 28 November 2007

Mr. Cook, as you know, I have had the privilege of being a Member of this House for a good many years. Indeed, I was a Member of Parliament when HIV/AIDS first became an issue in this country. The world first became aware of AIDS at the beginning of the 1980s, when it was observed that young gay men in the US were dying from rare illnesses. The first documented case in the UK was in 1981. While scientists worked to piece together how the condition was caused, Governments had to work out how to respond to the new public health challenge.

My right hon. Friend the Minister of State, Department of Health, who is replying to this debate, will remember the huge campaigns mounted by the Government: the “Don’t die of ignorance” leaflet distributed to every household in this country, the newspaper adverts and the public information film. Of course, there was such an outcry at the time because of the fact that to become infected was a death sentence. Infection with the HIV virus resulted within a short time in the breakdown in the human body’s immunity to diseases, such as pneumonia. In Scotland in the 1980s, diagnosis with HIV was followed by death with AIDS within an average of two years.

The main sources of infection varied in different parts of the country. In some places, AIDS was very much a disease among the gay population. In other areas, HIV/AIDS was primarily a problem among injecting drug misusers. That was the situation in Edinburgh, where we had a major epidemic in the 1980s, predominantly among our injecting drug users. It is thought that a clampdown on the availability of needles led to an increase in needle-sharing, and that that in turn led to the explosion of HIV infection among Edinburgh’s drug-taking population.

It was because of the scale of the problem in Edinburgh that I developed an interest in the subject and, under the private Member’s Bill procedure, successfully introduced the AIDS (Control) Act 1987. That Act requires health authorities to publish reports annually, setting out the numbers diagnosed with HIV/AIDS, and to provide details of the work being done in their area on prevention, treatment and care. In the past year, the Government have indicated their intention to discontinue the central requirement of the Act. Health authorities would no longer be required to produce annual reports.

I understand that the epidemiological information provided by the reports is now provided centrally. However, without the reporting requirement in the 1987 Act, health authorities would no longer have to publish details of their work in the field of prevention, treatment and care. I am worried that that may reflect a wish—conscious or unconscious—on the part of the authorities to downplay the continuing incidence of HIV/AIDS as a major challenge in this country. I would be grateful if my right hon. Friend set out for me how health authorities are to be held to account for their HIV/AIDS work, if the reporting requirements of the AIDS (Control) Act are to be dropped.

The nature of the epidemic in the UK has changed over the decades. The numbers of new cases diagnosed declined into the 1990s. However, from 1995, increases in heterosexual and homosexual transmission in the UK, alongside increased numbers of people infected abroad, led to a decade of steep rises. An estimated 7,800 people were newly diagnosed with HIV in the UK in 2006. The most common route of transmission is heterosexual sex abroad, while the highest number of new cases actually transmitted within the UK is among gay men.

The total annual number of new diagnoses shows signs of stabilising, which is welcome, but within the total there remain some disturbing trends. Levels of transmission among men who have sex with men remain high, there are worrying signs of increased transmission among drug users, and the number of people becoming infected through heterosexual sex in the UK is steadily climbing—from 232 in 2000 to 750 last year. It is wholly unsatisfactory that so many people are becoming infected and have to depend on antiretroviral therapy for the rest of their lives. We know how HIV is caused and how to prevent it from being transmitted, yet thousands of people every year still become infected with HIV in the UK.

Public knowledge of HIV and AIDS appears to have declined. While 91 per cent. of people in the UK knew that HIV was transmitted through unprotected sex in 2000, that figure fell to 79 per cent. by 2005. Our education system has a role to play here. HIV/AIDS is not a compulsory part of school education in any part of the United Kingdom. Ofsted reported this year that schools in England give insufficient emphasis to teaching about HIV/AIDS and that pupils appear less concerned about HIV/AIDS than in the past.

Funding is also key. While HIV prevention money in Scotland is still ring-fenced by the Scottish Executive, prevention funding in England and Wales can be spent at the discretion of the health authorities. Money that should be spent on HIV prevention is vulnerable to other pressures within the NHS. A survey conducted by the National AIDS Trust in 2006 indicates that, despite increasing rates of transmission, HIV prevention funding has at best stagnated and probably declined in real terms over the last decade. My right hon. Friend will be aware that there is considerable support for a return to some form of protected funding for HIV prevention work that is not at the mercy of other short-term budgetary needs. I urge her to consider those calls carefully. I would also be grateful if she could set out for me details of the implementation of the commitment in the 2004 “Choosing Health” White Paper to a £50 million mass sexual health awareness programme for young people.

Targeted action is also needed. One in 20 gay men in the UK is now living with HIV. The Health Protection Agency warns that prevention work among men who have sex with men is not succeeding adequately. In its annual report published last week, the HPA called for an assessment of the progress made within the NHS in commissioning soundly based services. The HPA also called for action to address the rising problem of heterosexual transmission within the UK. Such action would include targeted prevention activities alongside work to reduce stigma and discrimination within black ethnic minority communities, which are disproportionately affected.

Another aspect of prevention work is the uptake of post-exposure prophylaxis, or PEP. The number of people seeking PEP is far smaller than the number of people who are at risk. Just over one in 100 men who responded to the 2005 gay men's sex survey had sought PEP, even though almost a third of respondents who had not tested positive had been at risk of infection. Clearly, awareness campaigns need to be continued. Furthermore, PEP is not always easy to obtain. I would be grateful for my right hon. Friend’s observations on the extent to which the NHS is now meeting the chief medical officer's recommendations that all primary care trusts should make PEP available.

Of the 73,000 people in the UK estimated to be living with HIV, about a third are unaware of their status. That means that over 20,000 people in the UK are HIV positive but do not know it; many of them will assume that they are HIV negative. That level of unawareness has two implications. The first is for individuals' own health, as people who do not know that they are HIV positive are not getting the treatment that they need to keep them well. At least a quarter of HIV-related deaths are among people who are tested and diagnosed too late for effective treatment. The second implication is for the spread of HIV, because people who mistakenly believe themselves to be HIV negative may be less likely to take all the steps that they should to protect their partners.

There have been improvements in this area. We have routine opt-out screening for pregnant women, and everybody attending sexual health clinics should now be offered an HIV test on their first screening, and subsequently according to risk. The Health Protection Agency's report, “Testing Times”, which was published last Friday, sets out the welcome increase in the number of people tested and the reduction in waiting times.

However, I am sure that my right hon. Friend will agree that there is a great deal of work still to be done in reducing the number of people who are unaware of their HIV positive status. Some 37 per cent. of HIV positive people visiting a genito-urinary medicine, or GUM, clinic still leave the clinic unaware that they have the virus. My right hon. Friend will be aware of calls for GUM clinic HIV tests to be conducted on an opt-out basis universally, and to be provided for every attendee every time they attend with a new condition.

There is considerable scope for non-HIV specialties to expand their contribution to HIV testing. The Minister will be aware of calls for routine HIV testing to be considered in certain relevant secondary care specialty centres such as TB clinics. Just last month, Scotland and England's chief medical and nursing officers wrote to all doctors and nurses seeking their help in getting more people diagnosed. As the Health Protection Agency notes:

“Perceived and real HIV-related stigma and discrimination by non-HIV specialists continues to be a major barrier to both the offer and uptake of HIV testing in wider healthcare services.”

There is also a funding issue. The 2004 “Choosing Health” White Paper pledged an additional £300 million over three years to transform England's sexual health services. In a survey of primary care trusts and clinicians in 2006, just under two thirds indicated that all or part of their “Choosing Health” funds had been diverted from sexual health services. The professional body, the British Association for Sexual Health and HIV, advises that most of the “Choosing Health” funding has been diverted to alternative causes unrelated to sexual health, notably paying off PCT financial deficits.

There has, however, been a welcome focus on GUM clinics in recent years. A target was set for March 2008 that all patients should be offered an appointment within 48 hours of contacting a GUM service, and by August this year 86 per cent. of patients in England were being offered an appointment within 48 hours. I ask my right hon. Friend to consider retaining the target for a further three years, as it is vital that the progress in improving GUM services is sustained. Quite apart from the direct benefits of improved access, the target also serves to focus primary care trusts on sexual health—an area that we know might otherwise drop down the agenda.

In the early days, a positive HIV test was a death sentence. From the mid-1990s, however, the lives of people with HIV have been transformed by highly active antiretroviral therapy. An emerging issue in the past year or so has been whether financial constraints within the NHS have had an effect upon the availability of drugs. The organisations representing the main providers of sexual health and HIV services in England conduct an annual survey of primary care trusts and clinicians. In the 2006 survey, participants were asked whether their organisation had restricted prescribing of any specific HIV medications or tests because of cost. Of those that answered, 13 per cent. said that there had been restrictions, and 22 per cent. said that there had not been any yet, but that discussions had taken place. The authors conclude that that represented a significant move towards drug rationing within HIV services, and was of serious concern. I would be grateful for any insight that my right hon. Friend has on those findings.

Of course, not everybody in the UK is allowed free treatment. People who are not recognised as being entitled to be in this country do not have the right to ongoing treatment on the NHS. That includes people who have been refused asylum but who are allowed to stay because they cannot return to their own country. The Terence Higgins Trust and the National AIDS Trust each report that pregnant women with HIV have been refused free treatment to prevent transmission to their unborn baby. People with TB or other sexually transmitted infections receive free treatment, but if they also have HIV they can be billed for their HIV treatment. The Terence Higgins Trust reports that people have consequently walked out in the middle of their TB treatment, creating a public health risk.

My right hon. Friend will be aware of the recommendation from the Joint Committee on Human Rights that HIV be included with all other sexually transmitted infections that are exempt from charging. I support that call. Quite apart from the compelling humanitarian argument, it seems likely that the costs of allowing those people HIV treatment is unlikely substantially to exceed the cost of treating them on an emergency basis, as we do now when they succumb to HIV-related illnesses. The Government are conducting a review of foreign nationals' access to the NHS, and I urge them to consider allowing such people access to HIV treatment.

The approach of World AIDS day makes this an opportune time to discuss HIV and AIDS-related matters. The independent advisory group is leading a review into the Government's current strategy on sexual health and HIV, and there is widespread support for the view that once the review is published Ministers should go ahead and consult on a new strategy. I am grateful to have had the opportunity to put to my right hon. Friend some of the issues concerning HIV and AIDS in the UK today, and very much look forward to hearing her thoughts on those important questions.

I start by expressing my gratitude to my right hon. Friend the Member for Edinburgh, East (Dr. Strang) for initiating this important debate, and I pay tribute to his continuing interest in HIV both nationally and internationally. He mentioned his sponsorship of the private Member’s Bill that went on to become law as the AIDS (Control) Act 1987. That set out reporting and monitoring requirements for the NHS at a time when there were no effective treatments, and when today’s detailed surveillance and monitoring were in their infancy.

Let me address the points that my right hon. Friend made on that Act. With his extensive knowledge, he will recognise that the understanding of HIV is now much greater than when he introduced the Bill that led to that Act, which was at a time when the nature of HIV transmission routes was unclear. In prevention, we now focus on the particular sections of our community that are most at risk: gay men and African communities—the groups most at risk of sexual transmission of HIV.

My right hon. Friend referred also to the investments that have been made in relation to HIV and AIDS and sexually transmitted infections. He will realise that in the early days, the mass advertising that was necessary—both on television and in leaflets—was far more expensive. We now have very focused delivery of treatments. He also mentioned ring-fencing. He has followed the subject closely, so he will know that funds that were previously ring-fenced for prevention are now in the baseline for the national health service, and have been since 2002. Later in my remarks, I shall indicate the huge benefits that that has provided.

I am sure that my right hon. Friend would agree that it is important that World AIDS day, in three days’ time, gives us an opportunity to take stock of achievements, while recognising that we need to do more, as he rightly said. Last week, two major HIV reports were published: one is from the UN on the global picture and the other is the Health Protection Agency’s 2006 annual report on HIV and other sexually transmitted infections. Both make sobering reading. Despite global estimates having been revised downwards, the UNAIDS figures are still shocking, with 33.2 million people estimated to be living with HIV in 2007, 2.5 million new HIV diagnoses and 2.1 million deaths.

However, if we examine the situation in the UK, we have reason to be proud of our successes during the very long period for which my right hon. Friend has been following this issue. Deaths among HIV-infected persons fell from 749 in 1997 to 497 in 2006. That is a direct result of ART—antiretroviral therapy. AIDS diagnoses dropped from 1,080 in 1997 to 666 in 2006. Introducing routine HIV screening for all pregnant women has been a success. Today, 90 per cent. of HIV-infected women, up from 70 per cent. in 1999, are diagnosed before delivery, enabling treatment to be given to prevent HIV transmission to the child.

The offer and acceptance of HIV testing in sexual health clinics is now much more widespread. In all United Kingdom genito-urinary medicine clinics, voluntary confidential testing for HIV among men who have sex with men increased from 61 per cent. in 2001 to 85 per cent. in 2006. In heterosexuals, take-up increased from 41 per cent. in 2001 to 72 per cent. in 2006.

The huge success in screening people and therefore in identifying those at risk is the start of the answer to the question that my right hon. Friend posed about the information that it is now necessary to collect to inform treatment. I want to come on to that. Clearly, improving access to GUM clinics has been a top priority for the national health service. In September, 88 per cent. of patients were offered an appointment to be seen within 48 hours, up from 45 per cent. in May 2005. There is clear evidence that early access to services facilitates quicker diagnosis of infections, including HIV, and can break the cycle of onward transmission.

My right hon. Friend touched on the need to ensure proper education and access to counselling in our education system, including schools. He may have touched on the Ofsted report published in January 2005. The Department continues to provide funding for teachers and community nurses, who contribute to the provision of advice and support for our young people. We are developing specialist teams to improve their ability to ensure that such advice is clearly provided, but I recognise my right hon. Friend’s point that it is important to do more and, working with the Department for Children, Schools and Families, we are ensuring that that collaboration takes place.

As my right hon. Friend said, however, we still face significant challenges. I want to deal with those and some of the other points that he raised. Last Friday, the Health Protection Agency published “Testing Times”, its HIV and sexually transmitted infection report for 2006. It reported that although overall, the number of new HIV diagnoses appeared to be stabilising, they were still increasing in gay men. They remain the group most at risk of HIV transmission in the UK. Once all the reports for 2006 are received, the HPA expects a figure of 2,700 for new diagnoses among gay men in 2006.

To take forward the work on prevention and promotion of information that my right hon. Friend clearly identified as very important, we have to understand to whom exactly we are directing our messages and support. Our response involves looking specifically, although not exclusively, at the groups at highest risk; we are recognising the higher-risk groups. Those are gay men and African communities, who continue to bear the brunt of HIV in the UK and remain the focus of our national health promotion work. During the past two years, we have strengthened our national response by investing an additional £2 million in work by the Terrence Higgins Trust and the African HIV Policy Network. For African communities, we are working on interventions to increase awareness of the benefits of HIV testing and the importance of using condoms. We are working to achieve consensus on prevention priorities, as well as strengthening the evidence base for HIV health promotion in African communities in England.

My right hon. Friend recognises that, through that work, we are trying to ensure that we are using our resources to maximum effect to get information to those who need it. He will appreciate that the issue that we are still seeking to address in particular is late diagnosis. I am referring to people who either are unaware of their infection or are not coming forward for testing. However, we have made considerable progress on testing and we need to continue to invest in that.

My right hon. Friend touched on the question of automatic entitlement to free HIV treatment in the UK. HIV treatment is not included in the list of treatments exempt from charges under regulations. As he knows, people who are illegally here have no automatic right to free HIV treatment, but I am sure that he would acknowledge that that does not include asylum seekers, who do receive NHS services, including HIV treatment, without charge, and that treatment is not withdrawn from people whose asylum applications subsequently fail. They will continue to receive that treatment. Guidance on charging provides a number of safeguards specifically for maternity services and immediately necessary treatment, which is always based on clinical decisions. I am aware of the reports to which my right hon. Friend referred. There are difficult issues in this area, but I am sure that he would agree that all those who are ordinarily resident in the UK are entitled to access the treatment.

In conclusion, the action to prevent and address HIV in the UK continues to be a priority for the Department of Health. We have very good treatment outcomes for HIV and some of our health promotion work has been used as a model in other countries. However, we recognise the continuing challenges posed by HIV and sexual health. We are determined to continue to focus and prioritise the resources on that important matter. We are working with the expert advisory group on AIDS and the independent advisory group on sexual health and AIDS. As my right hon. Friend rightly said, we are undertaking a review of our strategies in consultation with others to ensure that we continue to take forward those measures.

We have made a great deal of progress since my right hon. Friend introduced his Bill. We are much clearer about the treatments that are available, about ensuring that we get advice through to the right people and about supporting those people. There is more to do, but as we approach World AIDS day we can be satisfied with the progress that we have made. I hope that my right hon. Friend agrees with that conclusion.

Question put and agreed to.

Adjourned accordingly at eleven minutes past Five o’clock.