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Volume 700: debated on Thursday 3 April 2008

rose to call attention to the trend in the incidence of HIV/AIDS; and to move for Papers.

The noble Lord said: My Lords, I begin this timely and important debate by declaring my interest. I was the co-author, with two colleagues, of the first published estimate of the likely future demographic impact of HIV in Africa. I was living in the United States at the time of that study, which was then regarded by the World Health Organisation and the World Population Council as excessively pessimistic, but which, sadly, was accurate. It had much less demographic detail, but it got the transmission dynamics and epidemiology right.

As a result of that study, I was involved through the US National Academy of Sciences in its expert advisory committees, while my co-authors, Roy Anderson, who is about to succeed Richard Sykes as the Rector of Imperial College, and the third author and junior colleague, Angela McLean, who was then a graduate student and is now a professorial colleague in Oxford, were involved here with the All-Party Group on AIDS, several of whose members will speak in this debate.

We made similar recommendations on a range of pragmatic and effective things to be done, such as distributing needles among drug users who were in the habit of sharing needles, aggressive campaigns to raise awareness and so forth. In the US, all such advice was disregarded by the Reagan Administration as being morally improper, whereas in the UK, under the wise leadership of the noble Lord, Lord Fowler, and others who will speak, the recommendations were implemented. The outcome was summarised very well in a recent report from the Australian Lowy Institute; a foreign policy think tank. It states:

“Generally, countries adopting pragmatic HIV containment policies tended to secure substantially better HIV outcomes than those countries that promoted HIV/AIDS responses based on sexual abstinence, criminalisation of prostitution and zero tolerance for injecting drug use. This was certainly so in the case of Australia and the US which from the early 1980s followed highly dissimilar … AIDS containment policies. After 25 years, the per capita prevalence of HIV … in the United States is well over 10 times”,

that in Australia.

Until quite recently, you could have said, “Similarly for the United Kingdom”. But although the per capita incidence of HIV in the United Kingdom is still markedly less than in the United States, it has recently seen a notable upsurge—that is, in the number of new infections per unit time. It is an upsurge that has evoked remarkably little public attention and concern. In what follows I will first sketch that history and recent events. Secondly, I will say a few words about the causes and our uncertainties about them. Thirdly, and most importantly, I will comment on what we might do about it. In all of this, I am drawing, in a ruthlessly compressed manner, interlarded with opinionated comment, on such things as the Government’s excellent 2001 National Strategy for Sexual Health and HIV; the very recently published Health Protection Agency Testing TimesHIV and Other Sexually Transmitted Infections 2007; the European Academies Science Advisory Council recent report on the impact of migration on infectious diseases in Europe, the Lowy Institute, which I mentioned; primary research literature; and, in many ways most importantly, on a variety of reports and recommendations from UK charities and NGOs such as the National Aids Trust, the Terrence Higgins Trust, the British HIV Association and the African HIV Policy Network. I have no formal association with any of those organisations, but I am a great admirer of all of their work.

I trust that the day will never come when PowerPoint intrudes into this Chamber, but for a quick history of what has happened it would be a help. I shall attempt a verbal sketch accompanied by arm waving.

In the early days when we did not know what was happening, there was an exponential rise in the incidence of HIV and AIDS. In this country, about a third of it was in the drug-using community and some two-thirds was in the male gay community. In future, I will use the term from the technical jargon of my profession, “men who have sex with men”. Once we realised what was happening—again, under the leadership of the noble Lord, Lord Fowler, and others—the pragmatic things that were implemented saw that rise not merely halt, but come down a bit. Then, through the late 1980s and throughout the 1990s, the number of new cases each year ticked over at about 2,000 a year. There was a decline in the number of cases arising from drug use and within the men-who-have-sex-with-men community, but that was somewhat counterbalanced by a slow rise in cases in the heterosexual community. Indeed, at approximately the end of the 1990s the incidence among heterosexuals rose to exceed that among men who have sex with men.

At that time, there set in a marked rise in the number of cases among drug users—a slow reversal which still represented a small fraction of cases at much less than 10 per cent. About a third of cases were among men who have sex with men; from a decline there was a slow rise that shows no sign of turning over. In the heterosexual community, there was a really steep rise that has turned over in the past few years, but, overall, the annual incidence has roughly trebled.

I am afraid that there must be a short and inconvenient pause while I put my notes, which I have dropped, back in order.

What are the explanations for the rise? To some extent, it is the praiseworthy outcome of better testing by the Department of Health, but the statistics are very imperfect. It may be that as many as a third of people who are HIV positive remain undiagnosed. There are interesting tests which are anonymised—you ask people to provide a blood sample, but do not tell them the result. The results show some depressing things. For example, the 2007 report showed that among sub-Saharan African heterosexuals visiting genital-urinary medical clinics, of those who were HIV positive but undiagnosed when they went into the clinics, a third emerged still undiagnosed—and that is an underestimate because another anonymised study shows that people who are HIV positive are much less likely to accept the test than those who are HIV negative.

There are also indications of a general rise in sexually transmitted diseases. For example, there were some 3,000 cases of syphilis a year by 1977. The number reduced to 400 or 500 through the decade of the late 1980s and 1990s and has now increased to about 3,500. An increase in migration from sub-Saharan Africa has certainly had an impact. In roughly two-thirds of cases among black Africans the infections were probably acquired before entering the country. On top of all of that, a MORI poll conducted by the National AIDS Trust strongly suggests that lots of people are less worried, because they feel that now there are things that we can do about it—there is treatment.

So what should we be doing? I begin by observing, as Susan Sontag memorably reminded us, that illness is stigmatising, and no illness is more stigmatising than sexually transmitted disease. But our attitude has to be, both for moral and pragmatic reasons, factual. HIV is an illness; it is an illness that we can treat; and the sooner that we get infected people into treatment, the better for them, the better their prognosis, and the better for the community, because those people will be less infectious.

Therefore, the first thing we should do is ensure better screening. In my opinion—and in the opinion of the British HIV Association and of the European Academies Science Advisory Council—we should be much more proactive in screening migrants once they are admitted. However—this is something I wanted to quote and dropped—the European Academies said:

“Detection of disease on screening must not be used as a reason to deny entry to the European Union”—

the UK in particular—

“for that would deter migrants coming to screening and the identification of high-risk patients. Migrants need to be offered the same access to healthcare services as the rest of the population”.

That is right morally, it is right for the infected people and it is right for the British community, because it diminishes the spread of infection. As many charities have strongly urged, the testing should be opt-out, not opt-in.

I refer to another thing that I lost as I dropped my papers; namely, a recent study that is about to be published in a leading AIDS journal by Anne Johnson and her colleagues. It is a study of newly diagnosed HIV-positive Africans attending London HIV treatment centres between 2004 and 2006. By the time that they were diagnosed, roughly half were in an advanced state of HIV, with a CD4 count—for those familiar with it—of less than 200. However, in the year prior to diagnosis, more than three-quarters of the people in this study—76 per cent—had seen their GP and only one in seven had had their GP raise the issue of HIV, much less offer a test.

Once they have been tested, we need to treat people, we need to treat everybody and we need to treat them all for free. At present, undocumented migrants and failed asylum-seekers can be diagnosed for free, but not treated for free. Again, that is wrong morally and it is wrong pragmatically.

Thirdly—and this is perhaps trickiest—not only should we diagnose and treat, but treatment must be accompanied by counselling about safe sex and other behavioural issues. The Terrence Higgins Trust is keen on GPs carrying out testing, but is concerned that GPs currently may be reluctant to offer tests because of a widespread belief that they are then obliged to provide pre-test and post-test counselling. Interestingly, the Chief Medical Officer has responded to this—and I can understand the problem—by saying that a short pre-test explanation from the GP should suffice. That is irresponsible. The question of who should provide counselling is a complicated one, but counselling should be there for the sake of the individual and the community.

Finally, underpinning all this—I may go a minute over, because I dropped my papers—is the question of education. I have a superb quote from our own note on this subject. It says:

“HIV prevention begins with education. Misconceptions about HIV abound”.

The same MORI poll that I mentioned earlier discovered that,

“fewer people were able to identify correctly the ways in which HIV is transmitted in 2005 than in 2000 … only 46 per cent of the respondents replied they always use a condom with a new partner, and 15 per cent would ‘never’ or ‘rarely’ use one”.

With all of this outreach, it is distressing, though understandable, to learn that the £300 million allocated to sexual health by the Department of Health in 2004 was disproportionately spent on treatment rather than education; and that only 30 of 191 primary healthcare trusts spent all the money that was allocated.

Therefore, my strongest recommendation is that we need to make better use of charities in counselling, education and, indeed, testing than we currently do. The Department of Health recently gave £1 million to the African HIV Policy Network for this purpose. That is a good start but, considering the colossal sums of money that slosh around in the Department of Health, often to little effect, £1 million in this context is ridiculous. In my opinion, much more should be spent on making use of charities because they know their communities and are less process-oriented and more action-oriented than most of the primary healthcare trusts and the Department of Health.

I end by simply saying that we need to diagnose, treat and counsel, but that is for the people who are already infected. For them and everyone, we need to do a better job of educating. We need to put our foot back on the pedal. I beg to move for Papers.

My Lords, I express our thanks to the noble Lord, Lord May, for introducing this important debate in such an informative and interesting manner. I give a welcome to the small team of us who have been pushing this argument for some time. We look forward to the noble Lord joining us on other occasions.

A quarter of a century ago, we were confronted with people dying from a new virus—subsequently defined as HIV. The public health campaign launched at that time by the noble Lord, Lord Fowler, who seems to be receiving a lot of praise this morning, made sure that the whole country knew of the threat of HIV. As HIV became a managed illness, the threat to life reduced and those diagnosed with HIV could look forward to an expectancy of life. However, public awareness has not been maintained. Despite the production of the 2001 strategy and the introduction of other strategies and initiatives, people are unaware of the consequences of HIV. The question that must be asked is: why has the country forgotten about HIV?

Successes and advancements in the medical treatment of HIV and AIDS have led to complacency about the condition. That has led to a concern among many people working with HIV-infected people—particularly the smaller HIV groups—that HIV has fallen off the political agenda. That view is supported by the major funders, who are having difficulty in persuading donors that transmissible HIV is still prevalent and needs support. There is no question but that public interest in HIV and AIDS in this country has declined.

For those reasons, the Independent Advisory Group on Sexual Health and HIV, which I chair, turned its attention to public health and HIV/AIDS and invited specialists and experts to discuss this critical issue at a seminar held last year. Represented at the seminar were charities, funders, clinicians, support groups and academics. In devising the key questions to discuss, we tried to relate them to people living with HIV: which issues need to be addressed; what is being done to eliminate stigma and discrimination; to what extent are current policies and practices appropriate and effective; and what changes need to be made to ensure that services, provision and planning are in place to meet the needs and challenges of HIV? As a consequence of that seminar, we have now established a working group, with the help of the department, to look further at the issues.

Any consideration of HIV has to start with the fact that the number of new diagnoses per annum continues, as the noble Lord, Lord May, said, to rise steeply. This week, the HPA announced a figure of 6,840. There are many reasons for the increase. For example, it may be due to the fact that more people who may have been affected for some time are coming forward and it may also be due to heterosexual contact in high-prevalence areas. However, tragically, not all cases are caught in time.

A disturbing statistic was released from a major audit carried out by the British HIV Association, in which it was reported that late diagnoses account for a quarter of HIV-related deaths in adults. There is also significant evidence that a proportion of those diagnosed late with HIV infection had been in contact with healthcare professionals in the preceding year with symptoms that in retrospect were likely to be related to HIV.

The number of undiagnosed cases is still too high, to quote the Terrence Higgins Trust; HIV testing must be made easier, quicker and more accessible for everyone who has a risk of infection. Although infection rates are increasing, HIV does not warrant its own performance indicator within the NHS—even though that is so necessary as HIV is now a countrywide problem. That means that some PCTs are struggling to pay for treatment costs, so checking the levels of performance is essential.

Testing strategies are very relevant to the level of diagnosis. Following a point made by the noble Lord, Lord May, last September, the Chief Medical Officer and the Chief Nursing Officer wrote jointly to all doctors and nurses calling on them to offer an HIV test to their patients if they might have been exposed to HIV infection and to recommend that they should accept testing. However welcome that initiative was, it needed to be followed by some learning/educational opportunity or professional development, otherwise the request would consequently get lost in the GP's general workload—and that seems to be the case.

While there is a need to develop earlier testing and prevention of late diagnosis, there is also a need to intensify HIV prevention. Many of the advantages that the UK has achieved in terms of HIV/AIDS prevention are now considered to be declining when viewed against the best international standards. There has been a decline in availability of proven harm reduction and prevention initiatives; for instance, the withdrawal of needle-sharing provision for infected drug users entering prison. As part of a prevention strategy, targeted campaigns are vital, so the increased funding of £1 million—maybe not enough—given last year to the Terrence Higgins Trust to target gay men and African communities was very welcome. These campaigns need to be accompanied by more outreach work and an increase in behavioural interventions, particularly relating to safe sex. It makes economic sense. It has been estimated that preventing onward transmission of HIV saves the public purse up to £1 million per annum.

HIV and AIDS differ from other long-term chronic conditions. It is a communicable disease, associated with a negative stigma and fear that is not usually associated with other chronic illnesses. It triggers widespread stigma and discrimination. It builds prejudice and intolerance about poverty, gender, sex, sexuality and race. It reinforces existing social stereotypes and inequalities, inequalities that make women seem inferior to men.

Stigma impedes disclosure and remains the most significant barrier to people testing for HIV and so deters people from using healthcare and social care services, thereby contributing to the social exclusion of those living with HIV. It is disturbing that there is clear evidence of discrimination relating to HIV status by some people working in the NHS and in social care. That is shown by expressing inappropriate comments, taking excessive precautions, and in some instances, refusing to treat or failing to refer or test. That is unacceptable and should be a factor in the registration rules under the Health and Social Care Bill currently going through this House.

Good social care is essential. HIV is not only a medical condition but also a social one: HIV patients have complex needs that cut across both health and local government services, whether related to child care, housing, legal or benefit advice. So the continuation of the ring-fenced AIDS support grant is welcome in enabling local authorities to provide improved support and services for people living with HIV. But those services need to recognise the different groups of people disproportionately affected. The needs, for instance, of African women will not be the same as, say, those of gay men. Growing old with HIV is a relatively new reality—people who do so have a range of previously unconsidered needs such as isolation, the long-term effect of medication and living in care homes, with the need for specialist social care teams. Women asylum seekers have complex needs, many having experienced violence, torture or rape.

The problem for asylum seekers is further exacerbated by the NHS charging regulations, which were introduced in April 2004. Previously, anyone who had been in the UK for 12 months or more could access HIV treatment free of charge. The new regulations now require refused asylum seekers to pay for secondary care. This discriminatory treatment has no sound basis, as the Government have been unable to provide any evidence of HIV-related health tourism. For all other serious communicable diseases, including TB and other sexually transmitted infections, such treatment is free of charge. It is clear that these changes to the regulations are causing serious hardship.

These measures actually prevent vulnerable people, including pregnant women, accessing the vital treatment that they need because they cannot afford the charges. I understand that a government review board, jointly led by the Department of Health and the Home Office, is currently looking at the NHS charges that are applied to refused asylum seekers. Will my noble friend explain why HIV is the only serious communicable disease that is not exempt from NHS charges? When can we expect the government review board to report?

Services also need to be based on sound evidence of what works, including an assessment of evidence on self-management and greater patient empowerment. There must be consistency in standards of care, so there needs to be adequate training, awareness raising and financial incentives. That includes investment in the training of GPs and primary care practitioners, which is currently not sufficiently in place.

To guarantee proper management, there has to be a collaborative approach involving both primary and secondary care providers. This means that PCTs and SHAs should ensure that resources for prevention, promotion and treatment are treated in parallel. Prevention should not have to compete with treatment, as is the current position; they are not alternatives. To make that more easily possible, HIV commissioning services should be a single entity.

In conclusion, what is clear is that the effective tackling of HIV and AIDS requires joint efforts, nationally and locally, across politics, education, health, religion, law enforcement, immigration and social services. There has to be a whole-society approach. This means building leadership from all the sections of society, including national and local government, affected communities, NGOs, faith-based organisations, the education sector, the media and the public and private sectors.

The Government have a responsibility to ensure that the associated resource requirements are sustained for the long-term, to co-ordinate multi-agency efforts and leadership. There has to be the same level of leadership shown by the Government to the prevention and treatment of HIV in this country as is shown, quite rightly, in the response to the global epidemic through the policies driven by the Department for International Development. To do that requires strong, informed and committed leadership. HIV has to be a public health priority.

My Lords, it is a great pleasure to follow the noble Baroness, Lady Gould, who has done so much work in this area, so much of which has been immensely valuable. I also congratulate the noble Lord, Lord May, on the way in which he introduced the debate. As the noble Baroness, Lady Gould, mentioned, it is rather nice to have a debate on HIV/AIDS introduced by someone who is not one of the usual suspects, who are here. It was an outstanding speech. We look forward to the presentation with slides, which I think he would have preferred to have given. I say to the Government Whip, whom I welcome, and who will reply to this debate, that I hope the noble Lord’s speech will be referred to the relevant health Minister so that it can be studied.

Both speakers referred to our campaign in the 1980s. The noble Lord, Lord Hayhoe, who is in the Chamber, was in the Department of Health when I, too, was there. I think that he will confirm that the policy was introduced not without its own struggles and oppositions at the time.

I want to concentrate on the national position. That is not because the international position is unimportant—on the contrary; it is a matter of shame that we in the West should have stood by while 20 million or 25 million people have died from AIDS. It remains a matter of shame that men, women and children are still dying on that scale, despite the fact that medicines exist and are available to save their lives. It is a matter of shame not just for Governments but for the churches that have argued against one of the few effective preventive measures—the use of condoms—which in this context could prevent deaths in a major way. I still find it extraordinary that, for example, the Roman Catholic Church can do so much fantastic work dealing with the casualties of AIDS, as I saw in New York, but so little work preventing those casualties. I do not think that history will deal kindly with its policy.

The reason that I shall concentrate on the national position is in a sense related to the international position and the loss of life in sub-Saharan Africa in particular. As we do not face a problem on the same scale, there seems to be a tendency to ignore what is happening inside the United Kingdom; to be, as the noble Baroness, Lady Gould said, complacent about the position here. There is absolutely no justification for such complacency. The figures published by the Health Protection Agency last Friday contain little for our comfort: 7,000 new HIV diagnoses in 2007; more than 80,000 people now living with HIV in this country; the annual number of newly diagnosed people has increased by 182 per cent since 1997; and new diagnoses among gay men are at their highest level since records began, despite all the warnings given about unprotected sex. The cost to the National Health Service is estimated at somewhere between £400 million and half a billion pounds per year. If we add in the cost of the other sexually transmitted diseases—the number of which, as the noble Lord, Lord May, mentioned, has also increased over the past 10 years—the overall cost is massive.

By the Government’s own measure of what they wished to achieve, the current position amounts to a failure. The Government’s policy in The National Strategy for Sexual Health and HIV, which was published in 2001, took four years to produce. One of the key targets was a 25 per cent decrease in newly acquired HIV infections by 2007. As we can all see, it has not happened. There has been a failure of public health policy. There has certainly been a failure to meet the financial needs. Most of all, however, there has been a failure of will, a failure of commitment. To be blunt—and this is not remotely a party political subject—Ministers have successively failed to meet the challenge of HIV in this country. Unless we recognise that, we are not going to achieve any change and nothing is going to improve.

It is always tempting to sweep the issue of HIV/AIDS under the carpet. It is not a popular subject with the public, as any of us who have been involved in the area know only too well. It is probably the least popular cause for voluntary giving in the whole country. It leads to potential embarrassment for politicians who have to go into the area. It almost certainly leads to controversy with the media and the press. It brings no particular penalty if it is ignored. It is an area that is surrounded by prejudice and discrimination. As the noble Lord, Lord May, said, it is an illness that stigmatises.

Despite all that, I should hope, like the noble Lord, Lord May, that we can as a nation give HIV/AIDS a greater priority than we have managed over the past decade. I think that we should ask why the policy has failed as it has. One reason is the current orthodoxy in the health service that everything should be devolved. In so many areas that view is exactly right; in an organisation as massive as the National Health Service, good management means that power should be devolved downwards. But it should not be an inflexible rule. The Department of Health still has a direct responsibility in some areas. One of those areas is public health, certainly when we are dealing with a subject that is as difficult and sensitive as HIV/AIDS.

The Government’s White Paper Choosing Health is an example of what can go wrong. The Government pledged £300 million to sexual health, much of which was to be allocated—devolved—to the primary care trusts. Ministers took credit for doing so and said that the money had been spent. Unfortunately the money had not been spent. As a survey by the independent advisory group made clear, only 30 of 191 primary care trusts had spent all their allocation for the purpose for which it had been allocated. Primary care trusts had the option to spend it on other things and they used that option, despite the fact that the Government had earmarked the money for HIV/AIDS.

Perhaps I may give another example, from my own experience. Most of those who remember our campaign of 1986-87 remember the public education, television adverts, icebergs, tombstones and leaflets sent to every home—and I would defend every one of those—but we also took one important additional step: we took the decision to supply free clean needles for drug users. It led to a permanent improvement in the position which has lasted to this day. The decision was taken at the centre but not everyone at the centre agreed with it. As the House may imagine, we had some fairly fierce debates on the subject, and some fought against it. Ironically, some with the most difficult problems opposed it on the grounds that they did not want to encourage drug use. Had we left the policy to local health authorities, I am fairly certain that it would not have been implemented in remotely the way it has been in the United Kingdom. Some would have done it but others would not, and HIV infection would have continued to spread in that way, as it has been in other countries that have not followed the same policy, based on the same discredited arguments raised then.

If we are serious about tackling HIV we cannot devolve everything down to the PCTs. We should understand that the centre, the Department of Health, has a crucial role and we should go back to ring-fencing some of the resources intended for tackling it.

We should also avoid taking action that appears discriminatory and counterproductive if the aim is to prevent the onward transmission of HIV. Like the noble Lord, Lord May, and the noble Baroness, Lady Gould, I am puzzled by the Government’s HIV policy in relation to the charging regulations introduced in April 2004. I do not think that there is any evidence that HIV tourism is occurring in this country. I do not see why HIV should be the only exception to the general policy. It also does not make sense in terms of cost. It means that people will become vastly ill and then have to go to Accident and Emergency for treatment. It also increases the risk of onward transmission of the HIV infection. So I add to the two previous speakers’ calls for the Minister to make clear the Government’s aim.

The Government have a direct responsibility in tackling HIV/AIDS, and I believe that there are three urgent priorities. First, testing must be improved and increased. About 25,000 of the 80,000 people living with HIV are unaware of their infection. That is obviously bad for them, because they do not get access as quickly as they might to treatment, but it is also bad for others, because onward transmission continues. Improved testing entails faster access for those wanting tests at clinics. We need more opt-out testing—there is no question about that—and we need testing outside the traditional clinic setting. I am a trustee of the Terrence Higgins Trust, which has done some pioneering work in offering testing at university campuses and in community centres. That has been valuable and successful.

Secondly, priority needs to be given to making much more progress in sex and relationship education. At present, we have a patchwork of provision between schools: some are good and some are frankly inadequate. I do not dispute that there is a complex challenge for schools here, particularly because they are already pressed by a tight timetable. I do not dispute that it means better training than we have now; but if more can be done, there are substantial advantages for young people, and there is the prospect that better education will help understanding and reduce the stigma surrounding HIV/AIDS.

The third priority is public education itself. The truth is that public understanding of HIV and its consequences has lessened over the past 10 years; we have gone backwards, not forwards. Fewer people understand how HIV is transmitted. Almost a fifth of the population are not concerned about HIV because they believe that there is an easy treatment available for it. More and more people are ignoring the advice always to use a condom with a new partner.

At the time of the 1986 campaign, we said, “There is no vaccine and there is no cure”. That remains the position today. There is no cure. We now have drugs that preserve and prolong life, but it is a lifelong condition, taking with it a risk and a range of disadvantages with the disease itself. On the progress of the vaccine, the latest news is anything but encouraging. No one believes that we are on the verge of a breakthrough. That is not a reason for abandoning all research, but it is a further reason for underlining the importance of public education.

We need to put much more effort, imagination and commitment into public education. We have heard pledges from the Government before that serious money will be spent in this area, but they have not been followed through. Instead, we have had a debate, which has now lasted for a decade, on whether there should be a general campaign on HIV and sexual disease or a targeted campaign. The blunt truth is that we have had neither of those campaigns. At times, we have gone back to the old, tired debate about whether, if we advertise, we introduce people to areas about which they know nothing.

I would say only that when we held our campaign, we received very few complaints. Young people and parents valued the advice and, what is more, they acted on it. The advice came with the authority of the Department of Health, which was a fantastic advantage. It is utterly absurd that, at a time when modern communications allow us to get messages directly through to the public better than ever before, we are all but ignoring that course. We need to tell people, young people, about the dangers of HIV/AIDS, for unless we do, the figures will continue to rise. The tragedy is that it is not inevitable that the figures rise year by year, as they have done, but if we are to prevent that happening, the Government have to take a clear lead. I regret to say that this, at present, they are failing to do.

My Lords, I thank my noble friend Lord May of Oxford for this very timely debate. The Times on Saturday last week stated that HIV infection is continuing to grow, according to figures from the Health Protection Agency, and gay men are being urged to practise safe sex and have an annual HIV test in an attempt to halt the rise in infections in the UK. That is supported by the Terrence Higgins Trust, which stated:

“But the fact remains that gay men are still at highest risk of HIV infection in the UK. For those numbers to come down, we need to step up resources for targeted HIV prevention programmes”.

I have been a member of the All-Party Parliamentary Group on AIDS since its inception in 1985 or 1986, when HIV began to present as something to be aware of globally. When the noble Lord, Lord Fowler, was a Minister, he promoted a hard-hitting publicity campaign, which made the public realise that HIV/AIDS was a new danger that could kill. I remember the advertisements to this day. To have an impact now is more difficult. With new drugs keeping HIV at bay and people keeping in better health and living longer, it does not seem so important to be careful. Some people even think that HIV is no longer a problem. That is very dangerous. There is an ever-increasing danger of multiresistance to drugs. There is a need for ongoing publicity so that people at risk realise that there are still dangers around. Campaigns need to be updated from time to time.

Human immunodeficiency virus attacks and destroys the body’s natural defence mechanisms, exposing it to certain infections. HIV can be found in blood, the rectal mucosa, semen and seminal fluids, vaginal fluids and breast milk. The amount of virus present in these tissues is enough to infect a person. While HIV can also be found in sweat and saliva, the amount is too small for an infection to happen. The destruction of a person’s immune system makes them more susceptible to other illnesses, especially infections such as tuberculosis, pneumonia and cancers, many of which are not so dangerous a threat to a healthy person. When the immune system has reached a certain low level of CD4 cells, or when some of the associated infections have happened, AIDS—acquired immunodeficiency syndrome—has developed. This is a condition that needs specialist experts to care for patients.

In 2006, there were an estimated 73,000 people aged 15 to 59 living with HIV in the UK. While London remains the main focus of care for people living with HIV, with nearly 24,000 residents accessing HIV-related care, the largest proportional increase was seen in Yorkshire and the Humber, where 2,475 people were accessing treatment in 2006—a 21 per cent increase.

The Royal College of Nursing, with a membership of nearly 400,000, launched its Think Positive campaign in 2007. I was pleased to be able to attend the launch at Cavendish Square. The campaign was introduced in response to the growing need for nurses working outside HIV and sexual health services to be familiar with the changing needs of people living with HIV and to ensure that they practise and communicate sensitively. The Royal College of Nursing is encouraging a change in attitude that will end the stigma that continues to surround HIV/AIDS. HIV/AIDS is not only a sexual health issue but a chronic long-term condition with which people are now living into their 50s and 60s. The Royal College of Nursing would like to see an updated strategy that takes into account the wider needs of people living with HIV. Perhaps this could be included in the Health and Social Care Bill.

The Government and the NHS must end the existing postcode lottery for HIV care and ensure that everyone has fair and equal access to high-quality treatment, care and support wherever they live. I hope that all people living with any long-term condition would also have that. Trusts should be encouraged to assess, monitor and forecast the needs of people with HIV living in their communities and utilise this information to ensure that sufficient funding and resources are allocated to services in their area.

As more people with HIV are living longer, there is a greater need to increase the number of specialist nurses working in HIV care to provide the high-quality care and expert support that they need. Sexual health and HIV services were particularly badly affected by financial deficits in the NHS, with many specialist nursing posts remaining unfilled. The Royal College of Nursing would like to see training extended to nurses working in primary care so that they can offer HIV testing to their local communities.

Last week I was interested to see a Telehealth Solutions system for monitoring people living with HIV/AIDS. Telehealth Solutions has developed the “pocket pod”, which is specially designed for people taking combination therapies. It is set by a GP to remind patients of what drugs to take and at what time and when to take viral load tests and to monitor vital signs such as temperature, blood pressure and weight. In the event of abnormal responses, an alert system is incorporated through SMS and e-mail services. This ensures prompt responses to adverse events. I am told that the pocket pod provides an essential and cost-effective tool in managing HIV/AIDS treatment, prolonging life and relieving the pressure on the NHS and patients. It should be investigated and assessed.

Some months ago, when the noble Baroness, Lady Royall of Blaisdon, was a Whip in the Department of Health, we visited the Mildmay Hospital in Tower Hamlets, which I have known for many years. There is still considerable stigma attached to a diagnosis of HIV/AIDS, as has been said, especially in many ethnic-minority groups. There is much fear of disclosure to friends, family or church because of this stigma, and patients often present late with an already advanced HIV disease because of this fear. Many people now have much better life expectancy and a good quality of life, but there are still significant numbers for whom services are far from widely or easily accessible.

The Mildmay is the only specialist centre in the UK that provides rehabilitation through in-patient and daycare services for patients with advanced HIV dementia, neuropsychological and other complex HIV-related problems. Its essential and unique services are under threat because of funding issues. As the only such hospital in the country, it is important that it is funded and enabled to continue to provide these services, while teaching and demonstrating to others how to apply its approach.

I end by asking a question that concerns the National Aids Trust: why has HIV/AIDS been singled out, in a most discriminatory way, from all other serious communicable diseases, including TB and all other sexually transmitted infections? Treatment is always provided free of charge irrespective of residency status, but HIV is explicitly excluded from this provision, so that refused asylum seekers and undocumented migrants are required to pay for secondary care. The result is that they are unable to pay if diagnosed with HIV. In almost all cases they are destitute and have to present, gravely ill, in A&E departments, risking having infected others in the mean time, as the noble Lord, Lord Fowler, said. If that includes pregnant women putting the babies at risk too, that is simply appalling.

Britain has been generous to the Global Fund to Fight AIDS, Tuberculosis and Malaria. Many other European countries should do likewise. I therefore hope that the Government will pursue this through the European committees.

My Lords, I must confess that when I put my name down for this debate I expected to hear what have already been referred to as the usual suspects, but it has not been like that at all. I thank the noble Lord, Lord May, for educating me to a great extent, the noble Baroness, Lady Gould, who added to that, and my noble friend Lord Fowler. It has been an amazing combination of speakers—certainly not the usual suspects or the type of debate that we could expect on a subject about which people feel that they have talked a lot. This is where the House of Lords shows its competence; you see people who know what they are talking about. But now your Lordships are going to hear from someone who does not know very much about HIV/AIDS.

I am a latecomer to this subject. I started taking an interest because I am deeply concerned about the situation of the poorest women in Africa and the Indian subcontinent. One cannot look at the situation of these women without focusing on HIV/AIDS. A DfID document says that, in 2007, 22.5 million were living with HIV in sub-Saharan Africa. Around 1.7 million were newly infected and 1.6 million had died, making AIDS the leading cause of death.

In sub-Saharan Africa, the HIV/AIDS epidemic is increasingly feminised. That is very frightening. It is not only in that region; look at South Africa, where AIDS is also increasing. The incidence of rape is unbelievable. In sub-Saharan Africa even little baby girls and old women get raped, and not just by strangers; it is people in the family, their priests, their doctors, their teachers. The lives that these females have to put up with—you cannot say “women” because they are also children—are unbelievable. That alone is terrifying.

UNAIDS has now said that 70 per cent of the world’s infected are women. Women have no way of protecting themselves. We have to take that important point into account. My noble friend Lord Fowler touched on the Catholic Church’s doctrine. The Catholic Church is breaching the most basic human rights of women all over the world. Condoms are the only way by which a woman can be protected from infection. If the church were to say, “Use condoms”, I think that we would see an instantaneous change.

I do not know whether noble Lords have learnt about PEPFAR, the President’s Emergency Plan for AIDS Relief, which devotes many billions of dollars to AIDS relief in Africa. I heard on the World Service, to my shock and horror, that it is being administered in Africa by the Catholic churches. We need to ask them whether they are allowing the use of condoms. If they are not, there is no point in the programme; nothing can be done. Cardinal Murphy-O’Connor said, “Send antiretrovirals to Africa; do not send condoms, because that would breed promiscuity”. What is promiscuity when no woman is safe from rape day to day, not just once in a lifetime? I do not know what “promiscuity” means in Africa.

I have also been shocked by the issue of the arrival of microbicides, which is supposedly around the corner. The National AIDS Trust says that microbicides will come online in two or three years, the Bill & Melinda Gates Foundation says that we are 60 per cent there and the International Partnership for Microbicides tries to fudge the issue by saying two to three years. These “two years” and “three years” have been said for at least three years already. There is no breakthrough. At present, the only way a woman can be protected is by the use of a condom; there is no other way.

DfID is investing a huge sum on trials in Africa. I have had a long talk with Professor Jonathan Weber, who is involved in those trials, and there has been nothing so far that gives any hope for a quick breakthrough. Conducting trials in Africa or India is also extremely difficult, because the women are not used to such things. They have to be monitored and looked after very rigidly, which is not an easy task.

I say again that I have come to HIV/AIDS through the needs of women, which are so unbelievably overlooked, especially in places such as Africa and south Asia. Women are not important; if one woman dies, you get another one. They have very little value. That is what we need to change. We need to start thinking about how women’s lives can be improved. They have no power to force their partners to use condoms. I can speak for India: you have to go quite a way up the social ladder before you find a woman who can ask her husband, or whomever, to use a condom. It is a serious issue.

The world is facing two major problems. I consider HIV/AIDS to be a major world problem. The other one is global warming, which is closely connected with population increase worldwide. It is no use our pretending that the two have no connection. If we are not allowed to use condoms or operate family planning, where are we going to end? I hope that some pressure will be applied to the Catholic Church to rethink the needs of everyone instead of just concentrating on a doctrine that is so out of date. The world is drowning in population. It is not as though we have a shortage of people, although, actually, Italy does: the Italian birth rate is 1.2 per couple. That is interesting because people there do what they want; they are not subject to doctrines. That is what happens in western countries because people can take their own decisions, but the poor have faith in their church and believe what they are told. That is where the Catholic Church needs to help—and to help the women particularly.

All the speakers today have touched on the stigma of HIV/AIDS. Nothing can really change unless people are able to say, “Yes, I am sick. Please see what’s wrong with me”. People get hidden in houses when health visitors come. In poor countries such as India, monogamous women who become infected by their husbands are not allowed to go to clinics because then everybody will know that the husband has infected them. There are many cases where women are hidden, or simply allowed to die, because there is no problem in getting another one.

So give a thought to women when thinking of HIV/AIDS and give a thought to the global situation. I know that we have 80,000 infected people in this country but I think that they are irresponsible. We need to be much more directive. Perhaps we need more education in schools; we have been ambivalent about these issues in schools and we need to be more proactive and more directive.

My Lords, I would like mainly to focus on the issue of HIV prevention in the UK, and how that can be assisted.

I am grateful to the noble Lord, Lord May, for giving us this opportunity and for bringing the benefit of his intense and forensic analysis to this subject. His speech was a compelling tour de force and I hope he continues to harass both the Government and us on the subject. I apply the term tour de force also to the speech of the noble Lord, Lord Fowler, who continues to fire on all cylinders on the subject; we are grateful for that. Many of the issues I was going to raise have been covered in those two speeches, so mine will be quite brief. I also praise the noble Baroness, Lady Flather, for her characteristic forthrightness on the subject. We should all read her speech and take it in. I shall, however, concentrate on the UK.

We are fortunate to have from the Health Protection Agency the figures for 2007, which were published just last week. They were available in a very accessible form, a press release with an accompanying article and graphs. That is just the format needed to help people begin to grasp the current underlying picture and trends. I am grateful also for excellent, highly comprehensible briefing generally from the National Aids Trust.

With my interest in international development, specifically in the field of reproductive health, I have always been aware of the huge—usually horrific—shadow of HIV/AIDS in many parts of the world, particularly in Africa. I very much echo the way in which the noble Lord, Lord Fowler, characterises the shame we should feel over the 20 million or 25 million who have died, with this country and the western world generally ignoring it. The situation was given even more colour by the noble Baroness, Lady Flather.

I have for many years been a slightly detached member of the All-Party Group on AIDS—but I have not been a committee member, as the noble Lord, Lord May, may have implied. I get the impression that the subject seems rather to go in and out of fashion in this building according to what other winds may be blowing and the extent to which what one might call “occasional fatigue” on the HIV/AIDS issue has set in. But however imperfectly the All-Party Group on AIDS may struggle to draw the attention of Members of both Houses to this key subject, I commend the group for its valuable efforts and for what it has achieved in keeping the subject in front of Parliament. I pay tribute especially to the recent and ongoing achievements of its chair, Neil Gerrard MP. We should be grateful also to the noble Lord, Lord Fowler, for continuing to serve as an officer of the group. He has done so over a very long period when, as an elder statesman, he could have retired to slightly higher things.

The noble Lord, Lord May, mentioned the recent valuable POSTnote—an excellent document entitled HIV in the UK produced by the Parliamentary Office of Science and Technology, which Parliament has benefited from. It summarises, in the customary four-page format, all the current aspects of the subject, in a form which is digestible and authoritative and is exactly what Members of both Houses need. I hope that it can occasionally be updated.

The recent survey and report from the National Aids Trust, assisted by the Health Protection Agency, confirmed that there had been a real reduction in spend on HIV prevention over the past 10 years. It has occurred at a time when the number of those living with HIV has steadily increased. The conclusion was arrived at mainly by surveying primary care trusts where the real amount spent on HIV prevention is often not clear. This trend of relative under-spending continues, sometimes in areas with the greatest local need, areas which would benefit from tailored prevention services and whose attempts are failing.

I advocate more focus on prevention. In my experience, there is always a temptation in the international field to follow the immediate treatment needed by those who are visibly suffering, and sometimes to follow the blandishments of the drug companies. As in international areas, we should aim to have measurable targets for HIV prevention, both nationally and locally. One report refers to “aspirational” targets. I would prefer the aim to be more realistic.

If the Government could devote more funds to prevention, it should be clearly identifiable how the funds are to be spent and they should be ring-fenced. The noble Lord, Lord May, said that not all the money allocated has been spent on the intended purpose and that there was disproportionate spending on treatment. I agree with the noble Baroness, Lady Gould, that the elements should be treated in parallel.

I understand that there has been some success in improving access to HIV testing and take-up. As the noble Lord, Lord May, emphasised, there has been a welcome, though possibly slow, move towards opting out rather than opting in to testing. Ready access to diagnostic services is a key part of infection surveillance and we should be more proactive in this field. I recognise the sensitivities that will have to be overcome in achieving that.

A recent excellent, very human television programme gave us Stephen Fry’s take on HIV. It showed a testing centre in Middlesbrough, I believe, which had stripped away many of the disincentives to visiting such a place. It showed how a 15-minute test can be conducted in a most sympathetic way. It deserves praise for not being heavy-handed and for not browbeating the audience. It showed what happens in real life, and it let us judge how we and others might respond. It illustrated the shame and stigma that can still be visited on those affected. It showed how physically unpleasant and draining it can be for some to be on even one pill a day for the rest of one’s life. It also showed how changes in the HIV virus create real uncertainty for some.

Slow progress is being made in this field in the UK, but in years to come we will be found to have not treated it with the seriousness and urgency it deserves.

My Lords, I, too, congratulate the noble Lord, Lord May, on introducing the debate with such clarity and passion. I invite him to join my PowerPoint Liberation Front. There are days when I think I will scream if I see another bullet point. More to the point, PowerPoint stops people making the sorts of speeches that the noble Lord made, speeches which communicate and convey issues in a way that computers never can.

I thank all noble Lords who have taken part in the debate. Every noble Lord who spoke has approached the subject in a slightly different way and added something very important. I want to pick up one of the first things the noble Lord, Lord May, said—that we need longitudinal work to draw attention to what happens with HIV. One of the lessons I always draw from our frequent debates on the subject is the need for persistence and repetition: persistence in looking at the issue and repetition in raising it. That is what we are doing today.

In preparing for the debate, I was taken back to the late 1980s when the virus and the illnesses first emerged. I remember talking to a group of people who worked with and were users of an HIV service at that time. It was a time when people put a brave face on what was a devastating diagnosis. One of those to whom I spoke did an excellent job of putting on a brave face, but he said something terribly important. He said: “I know it sounds strange to say it, but I actually feel quite lucky that I live here. I live in a country where there is a National Health Service. The reason I feel lucky is not only that I know I will be treated but that, as we have a National Health Service and it can look at the incidence of the illness across the whole population, there must be hope that it will find a cure quicker than in other circumstances”. He was right. The National Health Service has a unique opportunity to study the virus and transmission, and to do research at a population and sub-population level. The noble Lord, Lord Fowler, was right that the great tragedy of the past 25 years is that we have wasted that unique opportunity to learn. We have failed to learn some very simple lessons.

I am one of the Front-Benchers in this place who frequently lay into the Government and castigate them for having too many targets and centralised policies. However, I agree with the noble Earl, Lord Howe, who often speaks on health, that public health is an exception to that. Public health targets and nationally determined programmes—which need not be the same all over the country—are a wise way in which to develop public health policy and to make use of the fact that we have a National Health Service.

Other noble Lords have quoted statistics from the survey which came out last week. There are just two on which I wish to focus: the fact that approximately one-third of all cases of HIV are undiagnosed, which is a very high comparative level; and the accompanying statistic that nearly 40 per cent of gay men in the UK have never had an HIV test. There are public health and clinical concerns about such a high level of undiagnosed people, because they are most at risk of transmitting HIV to others. They are far more at risk of doing so than are those in care. Good evidence suggests that people with an undiagnosed HIV infection are responsible for between one-third and one-half of all new HIV infections. I echo a point made by the noble Lord, Lord Fowler, and the noble Baroness, Lady Gould. We should have learned by now, 25 years later, that HIV testing has to occur in a number of different settings, some of which are not identified as having anything to do with HIV, so that a range of different people can be tested in a place where they feel comfortable.

In 2006, the Health Protection Agency produced an excellent report entitled A Complex Picture. It was a very good title because the situation is complex. The document set out how the surveillance systems established in the UK have served the population well during the past two decades. However, it also highlighted the rise in all STIs and drew to the attention of policymakers the key issue of cross-infection. When somebody has another sort of sexually transmitted infection, they are more at risk of developing HIV because they have a compromised immune system. That is part of the issue in Third World countries to which the noble Baroness, Lady Flather, drew our attention. The coincidence of HIV with other STIs makes managing people’s health more difficult. That is important. We have had debates in this House about the rise in the incidence of chlamydia, for example.

I contrast that with the findings of a survey on clinics carried out at the same time by my honourable friend in another place, Sandra Gidley. That showed that fewer than 33 per cent of clinics reached the target of giving appointments within 48 hours, with more than half of all patients having to wait more than seven days for a diagnosis. Many clinics were working with restricted opening hours, some to fewer than 20 hours a week. Many opened irregularly. That is not the way to enable and encourage people to come forward for testing. Other noble Lords are right that cuts to community, outreach and voluntary-sector sexual health services happened in 2006. Those happened because word came from the Department of Health that the overall NHS target was to meet its budget for that year. Therefore, in PCTs across the land, all sorts of other budgets, including for sexual health, were raided. It was a false economy.

A number of noble Lords have spoken about the work of the noble Lord, Lord Fowler. Although the noble Lord, Lord Newton, is rarely mentioned, he was similarly important in that work back in 1986. I do not know whether noble Lords know it, but the noble Lords, Lord Fowler and Lord Newton, were responsible for one of the top 100 adverts of all time, and we all remember its importance.

Around about that time, I was engaged in some of the very first work in Europe on older people and HIV. We noted in statistics that more than 10 per cent of those who were infected were aged over 50, yet, at that time, for very understandable reasons, everything was targeted at young people. For older people who had become infected or who were their carers or relatives, nothing was being done. I remember going along with a colleague to talk to a bunch of older gay men one night in about 1992—so it was after that advert. We assumed that they would have a level of knowledge about infection and safe sex, but we were wrong. They wanted to hear some very basic messages about safe sex, the reason being that, although the gay community as a whole had been given an awful lot of information, it was inappropriate to them. They did not feel that they could go and get it; they did not feel that they could take it home; they did not feel that they could use it; and they missed out on those messages.

The noble Lord, Lord Fowler, said that we are stuck in that argument about global/population-level or targeted adverts. We need both. That is what we have learned in 20 years. We have learned more than anything else that health and information campaigns need to be repeated over and again. The one agency that can do that is government. It is the role of government to be there when everybody else has gone and to bang out those messages until they get right through to the population.

The noble Baroness, Lady Gould, raised the important issue of why HIV has been singled out as the only transmissible disease for which people have to pay for their care. The National Aids Trust, too, has raised it with us. I return to the fact that we have a National Health Service. I am one of the biggest defenders of the National Health Service; it is one of the things about this country of which I am most proud. I pay my taxes to fund the National Health Service, and do so not because I want to be treated—although I am—but because I want a National Health Service that will treat other people. I want a National Health Service that will ensure that the whole population enjoys good health. I want to see my taxes to the NHS going towards those interventions which are not popular and may be open to political criticism from time to time but which are fundamentally necessary to the health of the population.

I enjoyed greatly and agreed with almost all that the noble Baroness, Lady Flather, had to say—not quite all, but most of it. She reminded me that following the US mid-term elections, one of the first things to happen when the composition of the Congress and the Senate had changed was that the policy of the US Government towards funding only abstinence programmes was challenged. Given that the Bush era is coming to an end, given that change on the part of one of the biggest donors and players on the international scene, could the Minister tell us what the Government are doing to make sure that all the lost time which the noble Lord, Lord Fowler, talked about in international work on HIV is regained and that we move towards far more effective policies? Once again, I thank the noble Lord, Lord May, and I say to him, “Do not give up and do not let us give up”.

My Lords, I, too, thank the noble Lord, Lord May, for initiating this debate and for his brilliant speech. I am going to follow the example of the noble Viscount, Lord Craigavon, who did not repeat everything that has been said. All the statistics I was going to give have already been given so I will limit my remarks to a few things.

The director of the Health Protection Agency, commenting on the statistics in November 2007, said that the sooner HIV and other sexually transmitted illnesses are diagnosed and treated, the less likely they are to be passed on. That is certainly true, as the noble Lord, Lord May, said, but it is important that the diagnosis is given in the right and sensitive way, together with correct HIV prevention information and coupled with ongoing support and monitoring. There is, as has been mentioned by several speakers, considerable stigma attached to the diagnosis of HIV and AIDS, especially in many ethnic minority groups, which produces a great fear of disclosure to friends, family and community. Patients often present late, already with advanced HIV disease, because of this fear.

The free availability in the United Kingdom of highly active antiretroviral therapy—HAART—has made some people complacent about HIV transmission and there is now a misconception, as has been mentioned, that HIV can be easily treated. There is still no cure. Treatment is complex and it is given for life. The development of resistant and possible long-term side effects means that regular monitoring at HIV specialist clinics is essential. Many are now living with a much better life expectancy and with a good quality of life but there are still significant numbers with chronic and very complex HIV-related problems. For them, services are far from widely or easily accessible. An editorial in the journal AIDS published in 2007—vol. 21, 1965-66—regarding AIDS dementia commented that there is a common impression that HIV dementia is no longer important as we have these high-powered drugs. However, the prevalence of AIDS dementia has increased in spite of high-powered drugs and this widespread lack of awareness, even among clinicians, has to be remedied.

I need to declare an interest in that I have been associated with the first hospice for people dying of AIDS in Europe—namely the Mildmay centre in Tower Hamlets, which was established in 1985. We remain very grateful to a junior Minister of Health—one Kenneth Clarke. The matron, the chairman of the board of governors and the medical superintendent went to see him because the Mildmay had been closed, being surplus to requirement. These three ladies asked for the hospital back: “It is our hospital and you have taken it away”. Kenneth Clarke, in his usual jolly way, said: “Yes, of course you can have it, no problem at all, but you will never find any money to run it”. He has been a great supporter ever since and we have always been grateful to him. It is the only specialist centre in the UK to provide rehabilitation through in-patient and daycare services for patients with advanced AIDS dementia, together with other neuropsychological and complex HIV problems. Its approach has shown very good outcomes, with many patients being rehabilitated to the point of being able to be discharged to independent or semi-independent living in the community, which saves the NHS significant sums of money. Its essential and unique services are now under threat because of funding issues. It is the only such centre in the country and it is very important that it be properly funded and enabled to continue to provide these services.

The Mildmay has extended its work with AIDS over the past 15 years into many countries in Africa. I shall never forget one day in the Mildmay centre in Uganda when we saw nearly 100 orphaned children, all with HIV and AIDS, 80 per cent of whom had TB and many other infections, including scabies. Scabies presents just a few spots on the body, but with their immune system destroyed, they are covered with scabies and suffer terribly. That, of course, can be treated.

I would like to draw attention to the plight of children with HIV and AIDS. Currently there are 2.5 million children with HIV in the world. Last year new infections amounted to nearly 500,000 and deaths among children amounted to 330,000. Only 15 per cent of the 780,000 children who are in need of treatment with these high-powered drugs are currently being treated in low- and middle-income countries. Children living with HIV are often neglected or ignored and are the last to access care and treatment. Quite rightly, many donor agencies have in the past two years or so included the development of services and support for orphans and vulnerable children in their agenda, especially since UNICEF and Save the Children called for more attention to the needs of the 15 million or so AIDS orphans in the world. The issue must be fully acknowledged and included in any national and international aid programmes and government policies and strategies and plans.

It is also important to be aware of the needs of the large number of children who are HIV positive and in need of comprehensive holistic medical care. Of those who access treatment, many are living into adolescence and early adulthood with all the challenges that that brings in terms of increasing sexual awareness and expression.

During the celebrations last year to mark the bicentenary of the abolition of slavery, attention was rightly drawn to the existence throughout the world, including the United Kingdom, of a form of slavery more prevalent now than it was 200 years ago. Human trafficking is responsible for the spreading of HIV/AIDS and many other sexually transmitted diseases. It is reckoned that 80 per cent of women in United Kingdom brothels have been trafficked. Therefore most of the activity in these places is rape. As Her Majesty’s Government have insisted that all public places, including churches, display “No Smoking” notices, should they not find a similar way to warn customers in brothels that they may run the risk of being charged with rape? The amendment tabled by the noble Lord, Lord Anderson of Swansea, to the Criminal Justice and Immigration Bill a few weeks ago to make all purchasers of prostitution services liable for prosecution would certainly go some way to reducing the spread of all sexually transmitted diseases, including AIDS. Something drastic has to be done, as the demand for paid sex has more than doubled in the past 17 years. The solution may well be to criminalise demand, as has been done successfully in Sweden.

A recent “Panorama” programme drew attention to the appalling fact that 5,000 children are being trafficked into the United Kingdom and having unprotected sex. This is not only rape but a sure way of spreading disease, including AIDS. Lyndon Whitehouse, a former detective sergeant in Wolverhampton, said in the documentary that this activity is occurring in all major cities, but only two police forces have dedicated teams to deal with this scourge. He was involved in a pilot project that successfully dealt with the problem in Wolverhampton and secured 35 convictions, but the lessons learnt have not been implemented elsewhere. Apparently there are targets for reducing gun crime and burglary, but no targets for child prostitution reduction. Children are much more frightened of the pimps than they are of the law, and the violence that they suffer is terrible. One girl had boiling water held above her throat; another had her tongue nailed to a table. Will the Minister look into the reason why this successful Wolverhampton project has not been repeated elsewhere?

Care and prevention programmes really must go hand in hand, as the availability of good medical care and treatment encourages people to come forward for testing. Both HIV positive and negative individuals can then be taught about good prevention, with an emphasis on a balanced ABC approach—abstain, be faithful, use condoms—the successful programme in Uganda that resulted in a reduction in the incidence of AIDS from 31 per cent to 5 per cent in pregnant women. We do not know how far one can extrapolate that to the rest of the population, but the noble Baroness, Lady Royall, has confirmed that the Government support this ABC philosophy.

HIV infection is as least as devastating to the individual as a diagnosis of cancer, and although there is a cure for some cancers, there is no cure for HIV infection. So much more remains to be done.

My Lords, I am most grateful to the noble Lord, Lord May, for leading this important debate today. As several noble Lords have said, it has been a fascinating debate, which has embraced a wide range of issues in a sensitive and informative manner. The noble Lord has such an outstanding reputation in this area that it is a privilege to be in a position to respond to the debate.

Thanks in part to the contribution and leadership of the noble Lord, Lord Fowler, in the 1980s, to which noble Lords referred, and to his early action in introducing needle exchange schemes and other preventive measures, we in the UK have not experienced the rates of HIV seen in many other European countries. I hope that I can convince him that the Government’s policy has not failed and, indeed, that sexual health, including HIV, continues to be a priority for the Department of Health and the NHS. We are well aware of the challenges that HIV presents for people who are infected and affected by and vulnerable to the virus. I will set out later how we are responding to some of these challenges.

Last week, the HPA published on its website its provisional HIV data for the UK for 2007, which were based on reports received up to the end of December. The HPA estimates that there were 6,840 new HIV cases in 2007, which is lower than the figures for 2005 and 2006. We welcome this modest downward trend. Gay men continue to be the group that is most at risk of HIV transmission in the UK, as outlined by the noble Lord, Lord May, and others. The HPA estimated that there were 2,630 diagnoses in 2007, which is similar to the 2,640 diagnoses in 2006. Gay men’s increased risk of HIV is the reason why the Department of Health continues to prioritise them as a population group that requires focused and targeted HIV health promotion programmes. Like many other European countries, the UK is not immune from the global epidemic, and since 1999 an increasing number of infections have been acquired in high HIV-prevalence countries, mainly in Africa, from people who migrate to the UK, although the latest HPA estimates indicate that the numbers are declining, having been stable for a number of years.

Published in 2001, our national strategy for sexual health and HIV sets out the Government’s response to the challenges presented by increasing sexual ill health, the changing HIV epidemic and the need to modernise and improve sexual health services. Four of the five aims address HIV, and include work on stigma and social care, to which I shall return later. The strategy has been effective in driving our national response and driving change. The noble Lord, Lord Fowler, and the noble Baroness, Lady Barker, mentioned ease of access to sexual health clinics, which has been improved by reducing waiting times. The latest data for January 2008 show that 96 per cent of patients were offered an appointment within 48 hours, which is up from only 45 per cent in May 2005.

We have also increased dramatically the offer and uptake of voluntary and confidential HIV testing in sexual health or GUM clinics. Among gay men, this has increased to 85 per cent in 2006, from 61 per cent in 2001, and among heterosexuals to 72 per cent, from 41 per cent in 2001. This builds on excellent progress in diagnosing HIV in pregnancy and offering interventions that prevent-mother-to child HIV transmission. Today, the HPA estimates that at least 90 per cent of HIV- infected pregnant women are diagnosed before delivery, which is an increase from about 70 per cent in 1999.

On the last World AIDS Day on 1 December, we announced a major increase—20 per cent over three years, or £17.6 million—in the AIDS support grant paid to local authorities, recognising the often complex social care packages required especially for women, children and families. I very much welcome the review of the strategy which the Independent Advisory Group on Sexual Health and HIV is conducting. The IAG was established by the Department of Health to monitor progress on the implementation of the strategy. It is currently finalising the review and will present its report to the Department of Health shortly. I pay tribute to the work of my noble friend Lady Gould in chairing this group and to her long-standing role as an advocate for good-quality sexual and reproductive healthcare services for all, as well as to her keen interest in HIV prevention and care.

HIV prevention and care promotion are key elements of our response to HIV. We know from the data, as outlined by the noble Lord, Lord May, with significantly more eloquence than me, that gay men and African communities continue to bear the brunt of HIV in the UK, which is why they remain the focus for our national health promotion work. Over the past two years we have strengthened this work by investing an additional £2 million in the work delivered by the Terrence Higgins Trust and the African HIV Policy Network. This is in addition to the sustained investment we have provided over the past 10 years or so.

New work for gay men includes work with men who use recreational drugs, owners of social venues—in other words, sex-on-the-premises venues—gay men with diagnosed HIV, and work to increase and improve the evidence base for gay men with HIV. The Department of Health has commissioned Sigma Research to do a retrospective analysis of the data amassed in the past 10 years of the Gay Men’s Sex Survey. We are keen for this work to look at trends and changes over time and drill down to the subpopulations of gay men at increased risk of HIV. In the early summer of 2008 we will make the findings, including regional and local information, accessible to NHS commissioners, who will then have up-to-date information to support their provision of local services.

For African communities we are working on interventions to increase awareness of the benefits of HIV testing and the importance of using condoms. Last week, at its national conference, the African HIV Policy Network launched a new campaign, funded by the Department of Health, called “Do it right” which addresses gender issues and how they impact on prevention, an issue mentioned by several noble Lords. We are also working to achieve consensus on prevention priorities as well as strengthening the evidence base for HIV health promotion in African communities in England. This is a challenge. It certainly cuts across a variety of issues to do with culture, migration, the movement of populations and, indeed, the place of women. We are also supporting innovative work in supporting faith leaders and communities to engage in HIV prevention and social care. Later this year the African HIV Policy Network will publish the outcome of this in the form of a toolkit and supporting materials.

I turn briefly to some of the issues raised by the noble Lord, Lord May, and other noble Lords. On the screening of migrants for HIV, the current routine screening of migrants involves screening for TB in those from high-incidence countries. TB has been targeted as a serious airborne infection. Over time, around 10 per cent of those in close contact with a person with infectious TB can expect to become infected. Screening for other infections is being kept under review. However, HIV and hepatitis do not pose the same risk and screening for them might be discriminatory and stigmatising. As the noble Lord said, testing should be opt-out, not opt-in. That poses some very difficult issues for us. We are considering the recommendations from the Europe HIV conference, held last November, in which a number of UK experts participated. We welcomed the focus on making confidential and voluntary HIV testing more accessible. However, there are no current plans to introduce universal testing for HIV in the UK, as was done in the USA.

The noble Lord, Lord May, the noble Baroness, Lady Gould, and other noble Lords raised the issue of counselling and HIV testing. Moving from pre-test HIV counselling to pre-test discussion, unless a person asks for, or needs, counselling, aims to make HIV testing more routine and more normal, especially in more mainstream healthcare settings, including primary care and hospital settings. If a person seeks, or a clinician feels, that there is a need for, counselling, it is available following a positive test result. This approach has been supported for some time by the British HIV Association, the British Association for Sexual Health and HIV and others, including HIV voluntary sector organisations.

The noble Lord, Lord May, the noble Baroness, Lady Gould, and other noble Lords raised the issue of educating people. For the past 10 years, and in line with the epidemiology, which identifies the groups most at risk of HIV in the UK, our prevention and HIV health promotion has focused on gay men, or men who have sex with men, and people from, or with close links to, high-prevalence countries overseas, especially in Africa. This targeted approach is supported by the Health Protection Agency and organisations such as the Terrence Higgins Trust.

The noble Lord, Lord May, raised the issue of the money that is not being spent by PCTs on sexual health. The noble Lord, Lord Fowler, also raised this issue. Ultimately, funding arrangements are a matter for the NHS and the primary care trusts, which must be free to prioritise their local funding in accordance with local needs. However, we recognise the need for improvement in this area, which is why we produced the national strategy for sexual health in 2001, and why sexual health is a key element in the public health White Paper. It has been a priority for the NHS, over the past two years, to take action on reducing waiting times in GUM and chlamydia screening. The 2008-09 NHS operating framework and the national planning guidance confirm that sexual health will continue to be a priority for the NHS. Our targeted HIV work is additional to our new sexual health campaign, Condom Essential Wear, launched in November 2006, which tackles the five major acute sexually transmitted infections, as well as HIV. Evaluation is showing high levels of awareness.

I turn to the important area of HIV stigma and discrimination, touched on by the noble Baronesses, Lady Gould, and Lady Flather, the noble Lord, Lord McColl, and others. The national strategy for sexual health and HIV recognised the importance of tackling this, since it can have negative health and other outcomes for people with, or affected by, HIV. Last May the Department of Health published Tackling Stigma, setting out action on HIV stigma. This includes Department of Health funding for three new projects over the next two years. These are: funding the National AIDS Trust for a project to address stigmatising behaviour in the media, workplaces and the NHS; a project by the national AIDS manual to produce a booklet, HIV and You, for people living with HIV, setting out how they can respond to, and challenge, stigma; funding the Medical Foundation for AIDS and Sexual Health for a project to increase awareness of HIV among non-HIV professionals, so that they can offer the appropriate guidance, counselling and testing where they need to.

In the UK we provide some of the best quality HIV treatment and care in the world, underpinned by strong clinical guidelines and standards, and supported by excellent surveillance. AIDS diagnoses and deaths have fallen markedly following the introduction of anti-retroviral therapies in the mid-1990s, and have remained relatively constant in recent years. Deaths among HIV-infected persons fell from 749 in 1997 to an estimated 540 in 2007. AIDS diagnoses dropped from 1,083 in 1997 to an estimated 750 in 2007.

Despite these successes, we certainly are not complacent about the challenges that we face. I have mentioned the impact of stigma, which we never underestimate. Our other challenges include the persistently high numbers of HIV transmission among gay men in the UK; increasing rates of STIs; the evidence we see of the late diagnosis of HIV; and the proportion of those with HIV who remain unaware of their diagnoses. One of the challenges for gay men’s health promoters is how to keep fresh and relevant the long-standing health promotion messages for those gay men exposed to them since the 1980s, while addressing the needs of those who have become sexually active in an age of effective HIV treatments and more risk-taking behaviour generally. It is therefore essential that our national work, delivered by the Terrence Higgins Trust and its partners, gets the balance right.

We need to recognise, too, that for all groups, changing behaviour is not an area where government action alone is sufficient. We need to work with the NHS, the voluntary and commercial sectors, and individuals to promote a sustained and focused effort to improve sexual health. Action on sexual health is required through the joint Department of Health and DCSF PSA on teenage pregnancy. The target for improving access, and the inclusion of sexual health in new priority indicators, as well as detailed monitoring and reporting by the HPA of HIV have all helped to prioritise local action on sexual health and, importantly, focus action on improving sexual health outcomes, rather than focusing solely on inputs. The new NHS operating framework and national planning guidance identifies action on sexual health for 2008-09 focusing on chlamydia screening. I understand that the review of the strategy will also recommend some suggested performance indicators for HIV, sexual and reproductive health.

I now turn briefly to some of the points raised by noble Lords during the debate. I promise that I will write to reply to those that I do not deal with. The noble Baronesses, Lady Gould and Lady Barker, asked about late diagnosis of HIV. It is not clear why some groups, particularly Africans, delay testing or choose not to test. We can speculate about what those reasons might be, but they might include denial of HIV risk, lack of familiarity with the NHS—on confidentiality and open access services, for example—and concerns, as has been mentioned, about the stigma of being HIV positive. Our national HIV health promotion work is trying to address some of those issues.

On the issue of social care, which was mentioned by the noble Baroness, Lady Gould, and other noble Lords, over the past two years we have invested an additional £2 million, as I already said. That is an additional £2 million to our national HIV health promotion programme for gay men and African communities, the groups most at risk. We published an action plan on HIV-related stigma and funded new work, and last December announced the additional funding.

The noble Baroness, Lady Gould, and the noble Lord, Lord Fowler, mentioned the needle exchange schemes. In recognition of the importance of harm reduction services in preventing blood-borne virus transmission among infected drug users, the Department of Health published only in the past year an action plan to address that.

The noble Baronesses, Lady Barker, Lady Gould and Lady Masham, and the noble Lord, Lord Fowler, all mentioned, as did others, the issue of asylum seekers. The NHS is first and foremost designed for people living legally in the United Kingdom. We believe that the majority of people with HIV are living here legally and are entitled to receive free of charge the excellent NHS treatment for HIV. Asylum seekers are entitled to full NHS care without charge, including for HIV services. Those asylum seekers whose application and any appeal subsequently fails and who have started treatment continue to receive free NHS treatment while they remain in the UK. Following publication of the Home Office strategy Enforcing the Rules: A New Strategy to Ensure and Enforce Compliance with our Immigration Laws, the Department of Health and the Home Office are jointly reviewing the rules on access to the NHS by foreign nationals. That includes treatment for HIV.

The noble Lord, Lord Fowler, raised the issue of education in schools. Action to improve PSHE includes funding a training programme for teachers and community nurses who input into that programme, providing guidance to schools to help them better assess what pupils learn, provide support for PSHE teachers and share best practice.

I now turn to issues raised by the noble Lord, Lord Fowler, the noble Baroness, Lady Flather, and the noble Viscount, Lord Craigavon, about our international contribution. DfID provides substantial support through country programmes, multinational organisations and Global Partnerships. Under Global Partnerships, DfID is a key donor to the global fund to fight AIDS, TB and malaria, pledging £1 billion for 2008-15, which is an unprecedented contribution. DfID supports the Stop TB Partnership—nearly £9 million. We are funding programmes throughout the world to help reduce AIDS and address the issues of sexual health.

I am not able to deal with all the issues raised, but I should like to make one point to the noble Baroness, Lady Flather, because she knows that I have a lot of sympathy with the points she made. I agree with her about condoms and their usage and about the importance of sexual health education. I should also like to add a point to the noble Baroness, Lady Barker, about the upcoming elections in the United States. We provide a huge amount of help and supply condoms throughout the world. We will continue to do that, whatever Administration there is in the United States. We are committed to their use. DfID recently committed £100 million to the United Nations Population Fund to ensure the availability of reproductive health products, supplying both male and female condoms.

I very much welcome this debate and the attention that it has given to HIV. We have seen tremendous progress, particularly on treatment issues, but we are well aware of the continuing challenges around the world. I thank all noble Lords, particularly the noble Lord, Lord May, for their fascinating contributions.

My Lords, noble Lords who were here earlier will be reassured to discover that I have only three bits of paper in my hand, although if they could see the first bit of paper they would perhaps be less reassured. I want to thank all those who have spoken in the debate, which, it is fair to say, has been one of very high quality.

I began by saying that I find it rather surprising that this remarkable upsurge in the incidence of HIV in the UK has not received more attention. The noble Viscount, Lord Craigavon, pointed out that the issue is not fashionable. I hope that this debate, among other things, might help make it a bit more fashionable. We were reminded by several noble Lords that there are currently between 70,000 and 85,000 people—the numbers are uncertain, as I emphasised earlier—living with HIV in this country. We can keep them alive, but there is no cure and no vaccine, and I am shamelessly going to digress and mount a hobby horse for an instant.

The molecular biology that describes in molecular detail how individual strains of HIV virus interact with individual immune system cells in the human body is beyond imagination. That descriptive material has enabled us to design drugs that suppress viral replication and keep people alive. I would be willing to bet that probably nine out of 10 of the frontier researchers—the UK plays a disproportionately important role in research into the molecular cellular biology of this problem—never consciously reflect that we still have no agreed explanation of how HIV actually ends up causing AIDS. Personally, I do not believe that we will have one until we have a better understanding of the complex, non-linear dynamical system that is an invasive viral agent and the immune system. The immune system itself—questions of allergy—are still open because we have no agreed explanation of how it works. The immune system is not coded in the DNA. It is self-assembled in the first few years of life, reaches a level of complexity, and turns off. That is not understood in fundamental terms. It is described brilliantly, but we are still Tycho Brahe, getting toward Kepler and nowhere near Newton. It is unlikely that we will have a vaccine or a cure until we have understood those things.

An immunology text of today looks like an ecology text of the 1960s—the description is important and it is practically applicable, but it lacks an understanding of many of the complicated dynamical workings that knit communities together. Today, an ecology text has that analytic component. Immunology texts are still descriptive. Twenty years from now they will be different and that difference, I believe, is a prerequisite to having a cure or a vaccine.

What should we be doing in the mean time? We should be diagnosing, treating and counselling—three legs of a stool. Yes, we should diagnose people, and we heard from the Minister that we are doing a better job of that: it is possibly partly contributing to the rise in our knowledge of the incidence. At the same time, I again urge and stress that we will do better if we shift and bite the politically incorrect bullet of moving to opt-out testing, rather than basing voluntary testing on opt-in. I hope that the Minister will take that away and consider it.

The second leg of the stool is that once we have diagnosed we must treat. As the noble Lord, Lord Fowler, the noble Viscount, Lord Craigavon, and the noble Baroness, Lady Barker, strongly emphasised, it is not merely immoral, in my view, but just plain stupid that people who get into the country are freely diagnosed, but cannot be freely treated. Not only is that morally wrong, but in practical terms it is not a good idea—not just for the individuals, but for the community. I trust that the noble Baroness, Lady Thornton, will take that away, too, and I hope that we will hear well of its consequences.

On the subject of treatment, I particularly enjoyed the contribution from the noble Lord, Lord McColl—

My Lords, I really hesitate to interrupt the noble Lord, Lord May, because this is such an interesting lecture, but—

My Lords, we still have to keep to our times and everyone has done that. If the noble Lord would wind up, we would appreciate it.

My Lords, I will be very good about doing that. The noble Lord, Lord McColl, greatly widened the debate. I will have to be dragged from the Chamber before I leave out the third leg of the stool, which is that treatment must be accompanied by counselling. I would have wittered on at greater length on this as I misunderstood and thought that I had 15 minutes to close, particularly given that we have not used up our two and a half hours. I will not go on, save to say only that I particularly welcomed the detailed comments of many speakers, and the specific comments that addressed the question that there are powerful forces in the world, led by the United States and the Vatican, that are deliberately opposed to doing effective things. There is even an office in the Vatican, led by Archbishop Trujillo, committed to telling lies about the inefficacy of condoms.

I wish to leave four recommendations with your Lordships. We should do a better job of treating; we should make counselling an integral part of everything that we do; we should engage charities more and give them more than the few millions of pounds that we are giving them—the charities are the most effective way of delivering much of this; and, finally, the Foreign Office should do more proactively in combating the faith-based ignorance that trumps scientific fact in trying to halt the pandemic. I beg leave to withdraw the Motion for Papers.

Motion for Papers, by leave, withdrawn.