That this House takes note of the report of the Select Committee on HIV and AIDS in the United Kingdom (HL Paper 188).
My Lords, I am grateful to the authorities for finding room for this debate on World AIDS Day. Perhaps I may first offer some thanks. I thank the committee, which was a mixture of old campaigners— I must be careful how I say that these days, but the noble Baroness, Lady Trumpington, is not here—and Members who were very much new to the area but who made a major contribution. I am delighted to see so many of the committee here, late on a Thursday afternoon, including my noble friend Lady Ritchie. I thank the clerks, Mark Davies and Matt Smith, for their invaluable work and tremendous effort. I also thank all those people who were witnesses, many of whom are the heroes of the struggle against HIV and AIDS—the clinicians, the Health Protection Agency, the department and voluntary organisations, without which, frankly, we would not be able to manage in this country.
It is 25 years almost to the week that we had our first debate on HIV and AIDS in Parliament. It was on Friday 21 November 1986. Reading that debate, I see that, as Health Secretary, I had the support of Michael Meacher for Labour and of Archy Kirkwood for the Liberal Democrats. I even had the support of Bill Cash—I have not often been able to say that in my political career. All the parties combined to make it an entirely non-partisan debate, and so it has remained—as, too, have many of the issues raised in it; public education, treatment and research are still the issues today.
However, there is of course one enormous difference between now and then. At that stage, AIDS was a death sentence. We had neither drugs nor vaccines. In the hospital wards, we found young men dying as doctors and nurses looked on helplessly. That was why we took the decision then to mount a very high-profile public education campaign using television, radio and press, while sending leaflets to every household in the country. If we wanted the public to know of the dangers, it was the only course open to us.
Of course, not everyone at that time agreed. They said that it would offend the public—there was little evidence afterwards that it had done that—and that the Government should stand well clear of such a controversial and, to them, distasteful error. My view and that of my colleagues on the special Cabinet committee that we had set up under the brilliant chairmanship of Willie Whitelaw was that that was not the case. Disease was disease, suffering was suffering, and we had a moral and human obligation to treat sexual disease just like any other and, above all, to try to prevent its spread.
The aim of our Select Committee has been to examine the progress that has been made in the 25 years that have intervened. The greatest change in every meaning of that word is the availability of effective drugs. Antiretroviral drugs have transformed the life expectancy of those with HIV. Provided that people are treated early, there is no reason why they cannot live long lives. In this country we are fortunate that such drugs are freely available, a position that even today after more than 25 million deaths worldwide is still not the case in many parts of the world. In Britain the drugs are there and the death toll has been drastically reduced. Perhaps that is why one of the most common questions that I get asked today is, “Is it still a problem?”. The answer is an unequivocal yes. It is not only a problem, it is a growing problem. The evidence that the Select Committee received on this was utterly clear. Today almost 100,000 people in this country are living with HIV, the number of HIV patients has trebled in the past 10 years, a quarter of those with HIV do not know that they are infected and continue to spread the disease, and although we have drugs to prolong life there is still no cure and no vaccine.
This point should be emphasised; those with HIV, despite the drugs, face a lifetime of treatment and, even worse, the threat of discrimination in jobs and normal social life. The stigma has not been removed. It is not consequence free. A few months ago I received a letter from a man who had just been diagnosed with HIV. He said: “Last year I was diagnosed with the disease and it almost drove me to suicide. I would not want someone else to go through the pain I have. I am now seeing a psychiatrist and talking through how to deal with the disease”. More happily he went on to say that he had now started the medication and his viral level was almost undetectable. That gives some indication of the kind of pressure and suffering that can be caused, even today, to those with HIV.
The real tragedy is that HIV is entirely preventable. Thanks to medical advance, very few babies in this country are now born with the condition. It is not like asthma or epilepsy. To be blunt, we have seen in the past decade a failure in our efforts to reduce the spread. One reason for that failure is clear enough; as a nation we spend more than £750 million a year on drugs to treat HIV, and in contrast the Government spend a miserable £2.9 million trying to prevent it. That is the failure of the policy and the direct and unavoidable challenge to this Government.
The basis of our report is that priority should be given to preventing HIV and AIDS in the United Kingdom. So far, the effort has been wholly inadequate over the past decade and a new priority must now be given to prevention policies if the epidemic is to be stemmed. Our belief is that HIV and AIDS remain one of the most serious public health issues confronting the Government at the start of the 21st century.
In principle I am encouraged by the Government’s proposals to set up a new public health body with a ring-fenced budget; it is an excellent idea, although we will obviously have to ensure that the detail of the proposal lives up to the promise. However, I say to them that it is essential that much greater priority is given to prevention in areas such as HIV. At the moment we have a health system that is financed to treat the casualties but is simply not resourced to prevent those casualties coming about. Before Ministers say that this is simply a plea for money, let me remind them what can be saved by successful prevention policy. It is estimated that a lifetime’s treatment costs between £280,000 and £360,000 for every patient. If we can prevent just 1,000 new infections, we are talking about savings of around £300 million. That is good news for the NHS budget, and it is exceptional news for the people spared a lifetime of treatment.
In entirely practical terms, I refer Ministers to paragraph 229 of our report, where we challenge the local procurement policies at present being pursued inside the health service and propose that antiretroviral drugs should be purchased on a national scale using the purchasing clout of the health service. The Government should reconsider their position and, in so doing, they would do well to read the debate in this House last Thursday, particularly the speech of the noble Lord, Lord Sugar, who made exactly that point about purchasing generally.
Of course, not everything costs vast amounts of new money. One of the undoubted reasons why HIV is spreading is that too many people are not tested; a quarter of the 100,000 with HIV do not know that that is their condition. That is obviously bad for the people who do not test, because the longer it goes on undiagnosed the worse the outcome for the individual. It is certainly bad for the country, because every undiagnosed person represents a public health hazard. It is a sure way of spreading the virus.
We have a series of proposals, but I shall pick out only three. Home testing kits are already available on the internet, but it is a trade that is unregulated and unchecked. The committee took the view that home testing was a sensible extension of testing generally, provided that such tests were accurate and under a licensing system. I am glad that the Government agree with that and I congratulate them on accepting it.
The second proposal concerns general practitioner testing. We should involve general practitioners much more and certainly ensure that people who sign up with GPs for the first time are tested. That point was made this week also by the Health Protection Agency, which points out that of the 680 people with HIV who died in 2010, two-thirds were diagnosed late.
The third area concerns prisons. I am less sure, to be frank, what the Government’s attitude is here, having read their response. We know that the incidence of HIV in prisons is above the average. It would seem almost an automatic step for prisoners to be tested for their own sake so that treatment can be given, and certainly for the health of other prisoners. I will welcome the Minister’s guidance on this. Overall, the aim of policy should be that HIV testing should be a normal part of medical care.
Let me return to 1986 and make a comparison between one feature that has improved markedly and another that has not improved to anything like the same extent. The good news comes from drugs. It was not entirely unanimous inside the Thatcher Government that we should introduce clean needle exchanges for injecting drug users. I could put it more strongly than that. There were fears that it might be seen as condoning criminality and that drug crime would rise. Nevertheless, we went ahead and the result has been consistently successful. Only about 2 per cent of HIV cases in the United Kingdom come from injecting drugs and we have received no evidence from the police that it has led to any increase in criminality.
I add this; we were set up certainly to look at HIV/AIDS in the United Kingdom, but we cannot ignore what is happening in the rest of the world—not only in sub-Saharan Africa but in countries such as Russia and Ukraine. There the HIV epidemic is driven by injecting drug users and is at an alarming level. In Russia, more than one-third of drug users are living with HIV; in Ukraine the position is even worse. Conceivably, our experience here might be of help. Can the Minister say what efforts we are making to make our experience available overseas?
The part of our experience that is less encouraging is that the stigma and discrimination that surround HIV testing have not remotely disappeared. We were told of examples in employment and even of graffiti being daubed on homes and people being forced to move away. I do not say that this is general but I do say that it occurs too often. Noble Lords will know, of course, the teaching of the Christian Church—and, indeed, of every other religion—of love thy neighbour. In that context, it is interesting to look at the Ipsos MORI poll carried out in 2010 for the National AIDS Trust. Respondents were asked whether they agreed with the statement, “If I found my neighbour was HIV positive it would not damage my relationship with them”. Thirty-three per cent strongly agreed with that, while 30 per cent tended to agree, but 23 per cent either disagreed or strongly disagreed. That position had actually got worse since 2007.
The stigma surrounding HIV is one further reason why the whole issue should be tackled early, and we should take relationship education seriously and not be dictated to by the bigots who say that it is all a plot to force explicit sex education down the throats of four year-olds. People who campaign on that sort of falsehood should hang their heads in shame.
It is interesting to see from the same survey that young people in particular are interested in hearing more about the reality of HIV and that many confess to ignorance in this area. In 1986, the campaign was “AIDS: Don't Die of Ignorance”. Of course, the challenge today is different, but no one can dispute that there is a challenge or that ignorance of HIV remains an issue. Frankly, I do not agree with the Government that no new campaign in this area is worth while. There is a real danger that we drift into worse problems by our complacency. Of course, I understand the restraints on spending. It may come as a surprise to the Front Bench that in Margaret Thatcher’s Government we also had restraints on public spending. What we did not have was a budget of £120 billion. Prevention, either against HIV or in any other area, is not one of the most costly programmes for the health service. We need a new prevention initiative. That is good financial investment for the health service, but above all it is a good human investment in that it can avoid so much avoidable suffering and distress.
My Lords, I start by thanking the noble Lord, Lord Fowler, for making the meetings enjoyable, friendly and determined. We were absolutely sure that we were going to come to the right conclusions. The people out there who work in the field have welcomed the report. I have not heard one negative remark about the report and that says an awful lot, in many ways, about how the noble Lord, Lord Fowler, guided us through those many days. I support the noble Lord in his thanks for the staff. Sometimes we overburdened them but nevertheless they were absolutely wonderful with us. It was certainly a very concerted effort—every Tuesday morning for eight months. As one noble Lord said to me when it was over, he was suffering from Tuesday morning withdrawal symptoms—I am looking straight at him. I think that that applied to many others. If I raise any criticism of the response, this is in no way a criticism of the officials in the Department of Health, with whom I have worked for many years, and all of whom are fully committed to building the sexual health services, including for HIV, from the Cinderella service that it was to the improved service that we have today. Even the response goes in the right direction of travel. At this point, I declare an interest, among many, as chair of the Sexual Health Forum and as chair of the All-Party Parliamentary Group on Sexual and Reproductive Health.
I reiterate what the noble Lord, Lord Fowler, said—that the Select Committee was right to focus on prevention as a theme of the report, whether relating it to raising awareness, education, testing or treatment. It cannot be said too often that HIV remains the most serious infectious disease affecting the UK and prevention is the only way we will make that change. We had an interesting short debate during the passage of the Health and Social Care Bill on the need for national sponsored awareness-raising campaigns. But as with the response to the Select Committee report, I did not get any real assurance that national campaigns were on the agenda. While accepting the need in some instances for targeted campaigns—£2.9 million has been spent on those campaigns—there appeared to be a complete rejection of the idea of campaigns directed at the general public. That is a serious mistake as it does not take into account the rising number of UK-acquired infections among people not in the high-risk groups, who now account for more than 25 per cent of newly diagnosed infections each year. However, I was pleased to see the welcome given to the National Aids Trust website, HIV Aware, which directs its messages of prevention and awareness specifically to the general public. This is a classic example of the important role that the third sector plays in the alleviation of HIV and support for those affected. Has thought been given by the department or the Government as to how we could nationally disseminate the themes of the HIV Aware campaign more locally so that there is uniformity of message throughout the country? It would cover high prevalence groups as well as the wider audience. It would raise awareness and provide information and advice at very little cost. I do not think the argument against that can relate to cost.
Also in terms of awareness-raising, I was pleased to note the work taking place among faith leaders. As our visit to Leeds highlighted, it was possible to have dialogue with some faiths, but in other instances it proved to be very difficult. It is terribly important that this work is expanded for us to influence what is happening among some of the groups who find it difficult to accept HIV.
Overall, the public have become less aware of HIV and that has created widespread public ignorance. As the noble Lord, Lord Fowler, said, the lack of awareness by the public is one of the reasons why stigma persists and why there are so many mistaken beliefs on the supposed dangers of HIV. This creates a negative and judgmental attitude towards people with HIV. Stigma is still a daily reality for many people living with HIV. As in the instance given by the noble Lord, Lord Fowler, it can have a devastating effect on the life of someone with HIV and can often be compounded by profound health inequalities—for HIV is also about health inequalities.
Most importantly and crucially, stigma can deter someone from being tested. Ignorance makes people very frightened of being tested in case they then have to face the consequences that go with it. Preventing the spread of HIV has to involve the promotion of early testing and the widening of the scope of venues where testing can take place in order dramatically to reduce the estimated 22,000 people who have HIV but do not know it—the 25 per cent who are undiagnosed but might be furthering transmission.
As the Select Committee Report states, HIV testing must become normalised. An offer should be made to newly registered patients in general practice as well as to general and acute medical admissions. The Department of Health’s important screening pilots have shown that staff and patients welcome more HIV testing in hospitals and in primary care and community settings. However, for the future, it will be for healthcare professionals and local authorities, when they take over in 2013, to follow that work through. I am putting a positive slant on the Government’s response that they will consider favourably the Time to Test report. Perhaps the Minister can confirm that I am right to be optimistic.
The evidence of success of this approach is made forcibly by the success rate of antenatal clinics where an offer is automatically made and, as a consequence, mother-to-child transmission is at a very low level. I heard this morning at a meeting of how, when the fathers turn up at the clinics, staff can try to persuade them to have an HIV test. Many have previously been resistant to that. They are examples to learn from. The high level of acceptance of an offered test makes economic as well as medical sense and that message needs to be repeated. Prevention of half those undiagnosed cases would save the country £1.2 billion in healthcare costs. More than half the people are diagnosed late and some are already very ill, which again leads to far higher annual treatment costs. If we could have early testing, we could have early treatment and reduced costs.
The work being undertaken by MedFash, referred to in the Government’s response, will, I am sure, be invaluable in providing an interactive tool to support GPs and primary care staff in offering HIV testing as it will enable those staff, among whom there is great nervousness about making an offer, to do so. That barrier needs to be looked at much earlier and we must think about having discussion of HIV in medical schools and nurse training, so that when staff are faced with such questions, they know the answers. Instead, they are finding it very difficult.
It is also very important that we look for a positive outcome to the public health outcomes framework indicator on late diagnosis. I appreciate that many are being considered in the public health field and I know that the Minister cannot give me an answer. However, I am hoping that she will say that I can be optimistic.
One of my concerns about the new structure—although I am a strong advocate of public health moving into local government—is the design of the new commissioning structure and the inter-relationship between the different elements that make up that structure. This is particularly important for HIV because of the expected split between treatment and care and between prevention and testing. The split of functions may be inevitable, or it may not be; it might still be changed. I understand the case made by the Government in relation to other infectious diseases. I welcome the commitment that prevention work will not become isolated from treatment services. However, I would like to hear a little more about how that will happen in practice. Perhaps the Minister can elaborate on the mechanisms that will ensure that that prevention work does not become isolated from treatment services.
In conclusion, I should like to make three short points. On standards, the response indicates that the provisions set out in the Health and Social Care Bill allow for the development of quality standards for social care and public health, opening up the possibility of quality standards that fully support integrated care pathways. The question that follows, however, is whether comprehensive guidelines will be produced to make that system consistent and effective or will it be left to each locality to determine how that works. In some it might and in others it might not.
The committee recommended that NICE be commissioned to develop treatment and care standards for HIV specifically. While there are excellent standards produced by BHIVA, they do not address the need to co-ordinate specialist health HIV services with other services. I hope that the Government might reconsider and take up the recommendation that was in our report.
My next point relates to charging for HIV treatment and care and the recommendation that HIV should be added to the list of conditions in the NHS (Charges to Overseas Visitors) Regulations 1989. This is a matter which the noble Lord, Lord Fowler, the noble Baroness, Lady Masham, and myself will be raising during the passage of the Health and Social Care Bill. I am not asking for an answer to that today. However, I understand that a review is being undertaken and it might be helpful if we could know when the review is to be concluded.
Finally, I want to say a few words about tariffs. The response indicates that funding methods such as block contracts provide no incentive for organisations to improve patient care. In the light of that clear and positive statement in the response, can the Minister clarify the decision in the Health and Social Care Bill not to allow national tariffs for public health, including sexual health? Not to allow a level of flexibility of tariffs will almost inevitably mean a return to block contracts and therefore, as the response says, diminished patient care. There is a clear contradiction here and I think that it needs clarification.
Much has been achieved in the past. However, if we are to maintain momentum and respond effectively to the challenges of a growing epidemic, we need a national, holistic strategy on HIV, a view endorsed by the HPA in its report earlier this week. We need a strategy that encompasses the findings of the Select Committee report: early diagnosis, effective treatment and social care, HIV prevention and testing in a wide range of settings, laws and policies to eliminate stigma and discrimination, a well-trained workforce and the reduction of health inequalities. That is the approach that I hope we will see in the planned sexual health policy framework, which gets a number of mentions in the response to the report. Only then can we be assured that the momentum that has been achieved can and will be maintained.
My Lords, I begin by congratulating the noble Lord, Lord Fowler, and the committee, of which I was a member, on this report. I consider it to be a very important piece of work and I would have hoped that the Government would have accepted all of our recommendations. Perhaps that was a bit too much to ask for; sadly, we have a little more persuading to do. I want to talk about two or three aspects of the report and I make no apology for repeating some figures that we have already heard, because they are very important and need to be engrained on everyone's mind.
HIV infection is growing in the United Kingdom. By next year, there will be more than 100,000 people living with the disease in this country and in AIDS treatment, one of the great medical successes in recent years—a quite fantastic medical success—the costs are now approaching £1 billion a year. Yet we still have to remember the title of the committee’s report: No Vaccine, No Cure. It is not curable but for the fortunate people who are diagnosed early, this disease has become a rather nasty long-term condition, which can be controlled with the right treatment, so that people can go on to live a relatively normal lifespan. We have already heard about early testing being desirable. Unfortunately, this has led to a young generation growing up now who think that AIDS can be cured, like any other STD. It is, “No worries, then”—you go to the doctor.
It was 25 years ago that the noble Lord, Lord Fowler, as Secretary of State for Health, launched the never-to-be-forgotten “Don't Die of Ignorance” campaign, with its collapsing tombstones. My children trembled in front of the television set during that campaign. It had impact. They have never forgotten it, and it certainly slowed the spread of that disease in the UK. The noble Lord should always be remembered for his courage in pushing through that campaign, against what I know was some pretty tough opposition.
I do not know how much that campaign cost, but I know how inadequate spending on prevention is today. We have heard that £2.9 million is being spent on prevention—the cost of a house in my old constituency—despite the Government using “prevention” 35 times in their response to the report. I counted each mention because I am a pretty sad person sometimes. Despite those 35 times, only £2.9 million has been spent on prevention yet, as we have heard, nearly £1 billion is spent on treatment in one year. On another preventable statistic, as we have heard, a lifetime of treatment is estimated to cost between £250,000 and £350,000. For the individual and for the Treasury, prevention has to be and is better than cure.
I want to emphasise a few more aspects of prevention, which may not have occurred to some people. AIDS is one of many sexually transmitted diseases and in my view we should not single out one disease for a campaign, as we did recently with chlamydia. That was a wasted opportunity. AIDS is a very serious disease, but I repeat that we have a sexually active population. Sexual images are everywhere and much advertising uses them. Heterosexual and homosexual activity is on our TV screens, in the cinema, and on the internet and YouTube. I do not watch YouTube but I know that young people watch it a lot. That activity is everywhere and young people are immersed in it, but whoever has seen an actor talk about condoms or sexually transmitted disease before hopping into bed with the leading lady? I never have in my lifetime.
I do not want to sound like an old prude but we have to accept that this is the way people behave. They must have the freedom to live their lives, heterosexual or homosexual, as they wish—so long as their actions do not affect others, which sexually transmitted disease does. That is good John Stuart Mill stuff: they are limiting the freedom of people to enjoy their lives. Therefore, people must be given the right warnings and information, and they must be given to all sections of the population, not just the target groups. I have talked to some AIDS campaigning groups about this, and I can say that a spin-off from this more generalised approach to the whole population may help to diminish the stigma which AIDS sufferers have to contend with. I repeat: it is a sexually transmitted disease like gonorrhoea, syphilis, trichomonas, chlamydia and even warts. Are your Lordships feeling uneasy yet, sitting on your red Benches? They are all sexually transmitted diseases and can be prevented. Let us be open about them all and push preventive messages for all of them, especially AIDS.
In their response to the report, the Government said at page 8 that they do,
“not support the Committee's recommendations on the need for a national campaign aimed at the general public, as there is little evidence that this would be effective”.
Where is the evidence? I do not think we saw that evidence and we should if it exists. There should be no ifs and buts from the Government. We must massively increase preventive campaigns or face huge bills and destroyed lives. We must also have statutory sex-and-relationships education in our schools, covering all aspects of sexual activity. Stop caving in to the religious lobbies—state education must provide this.
We have another problem however—I hope on a lighter note—even if we got the Government to agree on these issues. It is the reorganisation of the health service which, as noble Lords probably know, is not one of my favourite topics. The Health and Social Care Bill will have a huge impact on the treatment, care and prevention of AIDS and every other sexually transmitted disease, because everything is being broken up. Treatment of the disease is to be commissioned by the national Commissioning Board and provided nationally. HIV prevention will be commissioned by Public Health England, I think either via or with local authorities. Sexual health promotion generally will become the responsibility of local authorities. Genito-urinary clinics, many of which treat AIDS patients too at the moment, will be the responsibility of local authorities, but the AIDS bit will somehow have to be funded by the national Commissioning Board.
AIDS testing will be done by local authorities. GPs will be encouraged to monitor and maintain AIDS patients already being treated, but the cost of their drugs will be commissioned nationally. Failed asylum seekers with AIDS, still sexually active in the population, are currently denied free treatment. Who will be responsible for them? Do noble Lords get my drift? Said quickly, it all begins to sound like a Gilbert and Sullivan patter song. During the Christmas holidays, I am going to work on the NHS reorganisation plans to make a nice little ditty out of all those various quangos and the way in which they will connect with one another.
For example, why should cash-strapped local authorities—I have been a member of one—or Public Health England get excited about testing for AIDS or prevention of AIDS if the budget for treatment lies with another body? In reality, they will be one phase removed. Arguments about savings “in the long term” in my experience in management, fall on deaf ears because all budgets are short term and even Governments seldom look beyond the next election. Ah, but I hear you cry, we shall encourage integration and co-operation. This, I suppose, is where the health and well-being boards come in, but without representation on those boards from the national Commissioning Board responsible for AIDS treatment, how will they integrate? What about a local authority which has a particular religious majority, or just plain old-fashioned stigma, prejudice, ideology or disapproval? What about that authority? This may severely restrict the choices made and the services it provides.
As well as the health and well-being boards, health services require full staffing and plenty of resources for those staff to find the time to contact colleagues in other services to integrate and co-operate with. Call me an old cynic but I was in the thick of it for many years in the NHS and I know the reality. These words and phrases are pushed out so easily but are so difficult to implement in practice. Noble Lords will have gathered that I am disappointed by the Government’s response, but I am prepared to accept that it may be different once they get to grips with the consequences of their own health reforms.
My Lords, I should like to congratulate the noble Lord, Lord Fowler, on securing the Select Committee on HIV and AIDS in the UK. Now we have the Government’s response to the committee’s report and this debate on 1 December. I think the noble Lord is Lord Fix-it. I was pleased to be a member of the Select Committee and thank the staff for their very hard work.
I have been a member of the All-Party Group on HIV/AIDS since its formation in 1987. In the early days of HIV/AIDS, the noble Lord, Lord Fowler, was Secretary of State for Health and instigated the campaign to warn people against the dangers of HIV/AIDS. To this day, many of us remember the lilies and the tombstones. Some of us, who were in at the beginning of this serious virus, know that there is no vaccine and no cure, and that great effort should be put into prevention and research. The USA undertakes a huge amount of research but there is still no vaccine.
Spending on prevention is seriously inadequate. HIV is entirely preventable but the latest figures show that the Government spent only £2.9 million on national prevention programmes, compared with £762 million on treatment. In a number of cases, general sex or health campaigns have made no mention of HIV, so the public think that it is not a problem. There has been little in the press that confirms their idea that the virus has gone away. This disparity of spending persists despite the fact that preventing one infection avoids a lifetime of treatment, estimated to cost between £280,000 and £360,000. We recommend that a new national campaign should be mounted to tackle the ignorance and misunderstanding that still exist.
As I said, many members of the public think that HIV/AIDS is no longer a problem; they are wrong. There are many people living in the community who are HIV positive and do not know it. They may be infecting others unknowingly. Late diagnosis is a huge problem. People are diagnosed when they are seriously ill and often die within a year or are very expensive to treat. Our Select Committee suggested that there should be wider testing facilities, for example in GPs’ surgeries.
A few years ago the very good GP surgery Lambeth Walk, which I visited, conducted a pilot scheme in testing for HIV. It was ideally suited because the surgery is close to St Thomas’s Hospital, which has an HIV/AIDS unit for secondary care. I have heard that the pilot scheme ended and the testing did not continue. Will the Minister please look into why this project did not continue? Perhaps she would write to me.
We took evidence from many people who work for organisations that are involved with HIV/AIDS. One such body was the Health Protection Agency, which does an excellent job, working with infections. There is concern because in the Health and Social Care Bill now before your Lordships' House nobody seems to know what is happening to this independent body, which advises the Government and is well thought of throughout the world. I think the HPA falls into the category of, “If it ain’t broke, don’t fix it”. Could the Minister please tell the House what will happen to the HPA? We have the very difficult situation of drug resistance and the very problematical HIV virus which mutates. Research is so important and should be shared with the rest of the world in order to find a vaccine.
The HPA, or whatever it becomes, should still be able to do research and receive grants. There was concern that if it is absorbed into the Department of Health or Public Health England its independence may be lost. People with HIV can be very susceptible to tuberculosis and again there are strains of TB which are resistant to antibiotics. This is an increasing danger. Our report says that data on HIV in prisons must be improved. The Health Protection Agency should utilise surveillance and profile HIV within the prison population. At the same time a review exercise into offender health services in public prisons is under way. The Government should supplement this with a review of the extent and nature of HIV prevention, testing and treatment services within the public prisons to determine the levels of provision across the country.
The Government’s answer is that the Department of Health has worked with the Health Protection Agency to improve disease surveillance in prisons and provide prison-specific data on STIs, including HIV. The department and the HPA are aiming to disaggregate data on prison diagnoses next year. What will happen if the HPA is disbanded? I need an answer, being a member of the All-Party Parliamentary Group on Prison Health.
Throughout the process of taking evidence we found that stigma kept on coming up. HIV stigma is still a daily reality for many people living with HIV. A recent National AIDS Trust survey revealed that 69 per cent of people agree that there is still a great deal of HIV stigma in the UK. In a large-scale east London study, one in three people living with HIV had experienced discrimination. Half of all discrimination was in healthcare. The Department of Health must take a lead on this and develop training resources aimed at stopping such discrimination to be used by all current and new NHS and professional bodies.
One of our recommendations is that the Government, local authorities and health commissioners build on work already taking place within faith groups to enlist their support for the effective and truthful communication of HIV prevention messages. The Government agree but I read in the Evening Standard of 25 November that the London Church has been putting lives at risk by telling HIV-positive worshippers to stop taking their medication because God had cured them. After a healing process in which the pastor sprayed water in their faces and shouted over them, asking for the devil to come out, the patients were told that they could discard their medication. This is a death sentence but illustrates that there are many problems still to be overcome.
We found some excellent services and dedicated staff and volunteers when we visited Leeds, the Chelsea and Westminster Hospital, the Homerton Hospital and Brighton. I want to mention a gem that some of us visited in Brighton. High up on a hill overlooking the city, with a wonderful view, is the Beacon: a splendid, beautifully adapted house where people with HIV/AIDS can stay after they have been in hospital for a short time to rehabilitate before they go home. There should be more Beacons across the country for all sorts of long-term conditions. One finds good ideas often come out of HIV/AIDS treatment, and there are many aspects that would have been good for us to look at, such as children’s facilities—children can become HIV positive from mothers giving breast milk—and end-of-life resources, but time did not allow for this..
I hope the report will be of use. There is something special about HIV/AIDS, as the virus and drugs are complicated. The priority aim should always be prevention. We must not forget that last year there were an estimated 3,800 UK-acquired HIV cases diagnosed.
My Lords, I am particularly nervous to follow the comments on the particular church background that the noble Baroness mentioned a moment ago. I would like to start with an example of where the church and church agencies have been rather more positive. Almost 20 years ago when I was in Rome for a series of meetings, I was taken to two or three projects in Trastevere, in the heart of the city. These included a language school for illegal immigrants, a soup kitchen and a hostel for children born with HIV/AIDS. It was a powerful experience, meeting the children and their mothers. The unit had been opened about a year before by Desmond Tutu and was entirely the initiative of the Community of Sant’Egidio, a lay community which now works throughout the world on the same sort of projects.
This commitment to HIV and AIDS was mirrored in this country by the churches in the early days of the Mildmay Hospital, the London Lighthouse and other early AIDS projects. Of course, there was some element of enlightened self-interest in this work. The churches, not least through their priests, have been affected by these diseases just as much as other organisations and agencies. Looking back to my experience in Rome, I was stimulated to think further about the complexity of this task and the way that that agency had found itself dealing with illegal immigrants at the same time as HIV/AIDS, and so on. Migration and the spread of the disease and other viruses have been a key part of all this, as indeed has the enormous growth in international travel. This automatically presents us with issues about the treatment of all people with HIV, regardless of where they come from or indeed their present resident status. Humanitarian concern places an imperative on us to make sure that all who are living with HIV/AIDS receive proper care and treatment. This point has already been made by noble Lords in this debate. Again, there is, of course, an element of enlightened self-interest in this. If we are selective in the way we face this continuing issue, we may indeed be storing up further trouble for our own society in the coming years. Disease and infection know no boundaries, either morally or internationally.
Just two months ago I welcomed representatives from across the Anglican Communion, and especially from Africa, to a day consultation at Lambeth Palace on this very subject. I had been well briefed having spent two weeks in Tanzania only a month earlier, where I was introduced to projects. The focus at this consultation at Lambeth was particularly on sub-Saharan Africa, to which the noble Lord, Lord Fowler, referred earlier. It struck me at the time that in what I was saying to that consultation, I could equally well have been speaking to myself and to our own situation here in the UK. The situation is not something that we can take for granted, and that seems to have been made perfectly clear in all the speeches that we have heard so far in this debate. The situation here is as serious as it ever was. The figure of 100,000 that we heard at the beginning is terrifying, and it is increasing.
The Church of England is committed to the fight against HIV/AIDS through its community work in many places. In my own neck of the woods in the diocese of Wakefield, the St Augustine’s project in Halifax provides help for asylum seekers, refugees and EU migrants, and to all those resident in the local community who need assistance. HIV and AIDS is, of course, an integral part of this, so we do work from first-hand knowledge in each locality.
In 2004, the Church of England produced a report which we called simply Telling the Story: Being Positive about HIV/AIDS. In a useful and concise manner it focused on many of the problems that we still face—for example, the question of openness about the crisis. It read:
“At the heart of the AIDS crisis lies the sin of stigmatization. Unless and until we address this central issue, whether it is manifested in our communities, expressed in our personal or national attitudes or, as in the case of Africa, is directed towards an entire continent, stigmatization will remain the single most resistant defence against any fulfilment of our promise to future generations”.
What the report said remains just as true now as it was then. It went on to say:
“If the Church’s response is to be effective ... then we will need to understand that the only way that we can work for an AIDS-free world is to work for stigma-free hearts, individually, nationally and globally”.
Any one of us who has encountered people living with HIV/AIDS will know only too well of the difficulties that they have in finding the courage to be open about what has afflicted them and is threatening their lives.
Earlier, I noted that our attitudes to AIDS are related not simply to stigmatisation but to enlightened self-interest. This means that there are at least three practical ways in which we must respond to be effective. First, with regard to public health, new evidence shows that effective HIV treatment results in a 96 per cent reduction in onward transmission. Therefore, ensuring that everyone who needs treatment receives it is the key to tackling the UK HIV epidemic. Charging for such treatment deters people both from being tested for HIV and from seeking treatment.
Secondly, ending charging for HIV will, in the end, save the NHS money by preventing new infections and identifying HIV early, as the noble Lord, Lord Fowler, noted in his introductory speech. Then it can be effectively treated. This will reduce hospital costs and, indeed, expensive high-tech treatment. Thirdly, there is no evidence to support the claim that there is a market in HIV “health tourism”, or indeed to suggest that the ending of charging in this country would lead in that direction.
I have mentioned once or twice issues of enlightened self-interest but ultimately the issues behind this debate take us to a far deeper level—to what is essential to our common humanity. Universally we owe it to each other to offer free and effective care in response to an epidemic which has wiped out whole populations in sub-Saharan Africa but which has also been, and remains, critical within our own society. Such fear still exists, so people are unprepared to talk about their condition and others are too frightened to face it when dealing with people pastorally or medically.
I remember, as I am sure do many other noble Lords, that some 25 years ago people whispered about the terrifying implications of the growth of AIDS. Such whispering began on the boundaries of some of the homosexual communities in North America. Now, a generation on, this is no matter for whispering about, nor indeed is it the rumour of an impending crisis. The crisis is already upon us and it is also no longer an issue for homosexuals alone; it affects all parts of our community. The crisis is upon us and we owe it to each other as a society to respond with all the resources that we can effectively muster.
First, I congratulate the noble Lord, Lord Fowler, on securing this important debate on World Aids Day and must say how privileged I was to have served on the Select Committee that was so expertly chaired by him.
The report calls for urgent action by the Government and I wish to highlight two recommendations in particular. Recommendation 72 states:
“HIV awareness should be incorporated into wider national sexual health campaigns, both to promote public health and to prevent stigmatisation of groups at highest risk of infection. We recommend that there should be a presumption in favour of including HIV prevention in all sexual health campaigns commissioned by the Department of Health”.
Recommendation 139 states:
“Ensuring that as many young people as possible can access good quality SRE”—
sex and relationship education—
“is crucial. We recommend that the Government’s internal review of PSHE”—
personal, social, health and economic education—
“considers the issue of access to SRE as a central theme. Teaching on the biological and social aspects of HIV and AIDS should be integrated into SRE”.
The report makes it clear that although there is a widespread assumption that the danger has gone away, nothing could be further from the truth. Thousands of people are still being infected every year and the number of those diagnosed with HIV continues to grow relentlessly. Next year it is estimated that there will be 100,000 people with HIV in the UK. Although medical advances have ensured much better treatment and enabled those diagnosed with the illness to live much longer thankfully, serious medical and mental health problems remain for many with HIV.
As the report states:
“Patients can now live with HIV, but all those infected would prefer to be without a disease, which can still cut short life and cast a shadow over their everyday living”.
I highlight those two recommendations as part of the way forward to help prevent the disease and to increase understanding and tolerance by the public for those who have contracted the virus. The problem of stigma has already been raised by the noble Lord, Lord Fowler. It leads to isolation and fear of getting treatment and possibly prevents people seeking a test in case they are found positive and excluded by their community. Our report argues that the awareness of responsibility and risk must extend to the population as a whole, and general campaigns may be necessary to educate the wider population. Evidence from charities noted by the Select Committee suggests that a general HIV prevention campaign would be valuable. As the report says in paragraph 100:
“Discrimination against those affected by HIV is based, at best, on ignorance and, at worst, on prejudice, and we unreservedly condemn it. This underlines the need for a general public awareness campaign on HIV”.
I am particularly disappointed that the Government have responded to this by saying:
“We do not support the Committee’s recommendations on the need for a national campaign aimed at the general public as there is little evidence that this would be effective”.
I hope they will think further on this and that with the publication of their new sexual health policy framework planned for 2012 they will have reassessed,
“where further work is needed to ensure a strong and sustained response to tackling HIV”.
Complacency is not an option when looking at the scale of infection in the UK. As the report states:
“There has also been a dramatic increase in the yearly number of new HIV diagnoses since the late 1990s. This peaked in 2005, with more than 7,800 new diagnoses ... In 2010, there was a year-on-year increase for the first time since then, with an estimated 6,750 people diagnosed”.
By next year, the report states, and I repeat, that the figure for people living with HIV is likely to be above 100,000.
The need to increase awareness remains, and so does the need to ensure that young people are taught about the illness and how to guard against it. The committee heard evidence of the increase in numbers of young people contracting the virus. The Health Protection Agency report of 6 June 2011 states that,
“a quarter of MSM”—
—men who have sex with men—
“newly diagnosed in 2010 probably acquired their infection 4-5 months prior to diagnosis, with higher recent rates in younger ages”.
According to the HPA, in 2009 10 per cent of diagnoses for HIV were among those aged between 15 and 24 years old. The National AIDS Trust has highlighted that since 2000 new HIV diagnoses among 15 to 24 year-olds have risen by nearly 70 per cent and among young gay men they have more than doubled. As a generation grows up without memories of the widespread health promotion messages of the 1980s, spearheaded by the then Secretary of State, now our formidable chairman of this Select Committee, the noble Lord, Lord Fowler, reliable HIV information for young people remains essential.
Given the lack of either a vaccine or a cure, then,
“prevention is better than cure when there is no cure”,
as Dr John Middleton, vice-president of the UK Faculty of Public Health said. One of the best means of prevention lies in education. Present teaching looks at HIV and AIDS within the science curriculum. However, the separate subject of SRE, with its focus on broader social issues, which can increase levels of safe sexual behaviour according to the Sex Education Forum, should also be considered as part of HIV and AIDS prevention methods. While the report calls for the mandatory teaching of SRE in schools, the Government have indicated that that was,
“not the approach we are taking to education policy”,
and that it was,
“imperative that parents will maintain a right to withdraw their children from SRE lessons”.
Yet a recent survey commissioned by Brook, the charity, found that 43 per cent of young people said that their SRE was unsatisfactory or non-existent. More alarming is the recent Sex Education Forum research, which found that one in four young people did not learn about HIV in school, which was described by a government Minister, Nick Gibb, as “unforgivable”.
The Select Committee report states that,
“ensuring that as many young people as possible can access good quality SRE is crucial”,
and recommends that the internal government review of PSHE considers access to SRE as a central theme. In a report in 2010, Ofsted highlighted SRE as an area for improvement, finding that in a third of schools visited students’ knowledge of SRE was no better than satisfactory. In a previous report, Ofsted expressed concerns about teaching around HIV and stated specifically:
“In particular, schools gave insufficient emphasis to teaching about HIV/AIDS. Despite the fact that it remains a significant health problem, pupils appear to be less concerned about HIV/AIDS than in the past”.
I am pleased to see that the government response to this report states:
“The reviews of the National Curriculum and of PSHE by the Department for Education will take account of the Committee's recommendation”,
but where compulsion is not appropriate I return to the report's call for a national sexual health campaign. We cannot afford to let public awareness of HIV and AIDS fade away, and young people must be given the information either through such a campaign or by better education in schools or preferably both. It will help young people to learn to look after themselves and their health better and to increase their understanding and tolerance of those who live with the illness. The success of the “Don't Die of Ignorance” campaign in the 1980s should serve as a lesson to the Government to ensure that young people do not live in ignorance today.
My Lords, I join other noble Lords in congratulating my noble friend Lord Fowler most fervently on the excellent work of the Select Committee that he has chaired and on securing this debate on World AIDS Day. I approach any event involving my noble friend with trepidation. To my shame, I did not always have the answers to the perfectly straightforward questions that he asked me at Conservative Central Office, where I worked when he was party chairman nearly 20 years ago, yet with his customary kindness he always seemed to forgive me.
This is an immensely important occasion that should be noted by people and organisations that share the deep concerns that have been expressed so movingly in this House today. The Motion before us refers to the whole United Kingdom. The matters that we are considering affect all parts of our country. I am above all conscious of their impact on Northern Ireland, the place that has been closest to my heart since the 1960s when I began to study its history and went on to teach, along with British history, at Queen’s University Belfast. Political responsibility for all health services rests of course with the devolved Northern Ireland Executive, but on this day above all the interests of those suffering as a result of HIV/AIDS in the Province should surely form part of our general UK deliberations.
Northern Ireland has just one laboratory dealing with the results of tests carried out throughout the Province. It therefore enjoys a high degree of accuracy in its data. Equally importantly, the lab can gather evidence of rates of testing from all sources, enabling it to pinpoint areas where the most rapid improvement can be made. Over the years, Northern Ireland has enjoyed a relatively low prevalence of diagnosed HIV, but recent trends suggest that this may well be changing. The Health Protection Agency recorded 79 new diagnoses of HIV in Northern Ireland in 2010, which is a 316 per cent increase on new diagnoses in 2001. The increase for the United Kingdom as a whole over the same period was around 20 per cent. Rates of testing in Northern Ireland are not increasing in response to the state of affairs as rapidly as they should. Less than 10 per cent of all HIV tests are being performed in primary care settings. The vast majority are being done in clinics or in hospital.
As our Select Committee’s report has made clear in comments endorsed so firmly by noble Lords speaking in this debate, the stigma and discrimination that continues to surround HIV must be eliminated. That is absolutely crucial in Northern Ireland if the number of tests performed in GP surgeries is to increase significantly. As my noble friend Lord Fowler stressed, and as other noble Lords have said, early diagnosis improves the chances of more effective management of this disease. Too many deaths of HIV positive adults are due to the diagnosis coming too late for effective treatment. As has also been pointed out, early diagnosis of a patient is also of major importance in preventing the spread of infection to others.
How might earlier diagnosis be promoted in Northern Ireland? First, there is a strong case for the increased availability and accessibility of testing in areas where people might otherwise go untested. Almost one-fifth of GP practices in Northern Ireland did not perform a single HIV test last year. Of those that did, half performed three or fewer. In some places, the story is more encouraging. Northern Ireland’s south-eastern trust has made particularly good progress in increasing primary care testing, with a new clinic being established to serve the local community. It will be instructive to take note of the successes of the south-eastern trust and to consider how its innovations might best be extended to the rest of the Province.
There is also a strong case for the advocacy of point-of-care testing among targeted groups. Point-of-care tests such as the well known “determine” are easy to perform and can offer results within 15 minutes, which can be life-saving where time is of the essence. At-risk groups, such as the homeless, are not easy to contact and help if longer tests are employed, but we will not get the major increases in testing and early diagnosis that are needed in Northern Ireland without increased awareness among clinicians and staff of the issues surrounding HIV and AIDS, which often include the difference between them and the dispelling of misinformation.
Here too, there is some good news in the Province. The in-service HIV awareness training project began in Belfast during the hard-hitting campaigns of the 1980s initiated by noble friend when he was Secretary of State for Health. The project has made steady progress ever since. Around 60 HIV awareness trainers help staff and practitioners to understand the basic issues surrounding HIV and AIDS. They promote methods of early detection and diagnosis and address the changing character of the virus.
Since the project began, more than 40,000 staff have received training and the project has expanded to take in the south-eastern and southern trusts. The Belfast trust hopes that by 2013 the entire Province will be able to benefit from the training, which is devised in consultation with a wide range of organisations. In areas such as healthcare, which can have a high turnover of staff, projects such as this are vital in securing the quality and, importantly, the continuity of care that patients faced with an HIV diagnosis need.
In Northern Ireland, as in the rest of the United Kingdom, the advances that we have seen in medicines that help people to cope with HIV and AIDS must be accompanied by similar advances in the public understanding of the disease. If that does not happen, the disgraceful social stigmas that surround the issue will persist. The social aspects of HIV and AIDS are central if the goals advocated by this widely applauded report are to be met.
Public understanding, as we have heard, has certainly increased, but many of the stigmas that campaigns during the 1980s highlighted still persist for those with a positive diagnosis. Research carried out by the HIV support centre in Belfast on 40 of its clients reveals that over half have been verbally assaulted, harassed or threatened in the past 12 months as a result of their HIV status, and over 25 per cent had felt suicidal. One respondent to the 2010 people living with HIV stigma index said, “We are all afraid of rejection. The moment you tell someone you are HIV positive they just run a mile and never look back”.
These are the attitudes that we must change. Not only are they hurtful and harmful to people with a diagnosis, they are also likely to deter people from seeking a test in the first place. It is shocking to think that someone might prefer to wait until a test is carried out in an intensive care unit than come forward at an early point because of the risk of being stigmatised and rejected by those around them, including their families and friends. Sadly in Northern Ireland this remains all too common.
If only we could create new antiretroviral medicines overnight. Sadly, as we have heard in this debate, it could be many years before the next great leap forward in helping people to live with HIV and AIDS. What we can begin overnight is a redoubled commitment to increasing public education on HIV and AIDS, a commitment to reducing the stigmas that HIV-positive people face, and a commitment to preventative messages and projects such as needle exchanges as highlighted in this report.
We must continue to press for three things. First, more accessible testing is needed in places where people are unlikely to go to a clinic or hospital until it is too late for effective treatment. Secondly, more training is needed for staff and professionals in order to increase the level of testing that is being performed outside hospitals or clinics. Finally, unequivocal support must be given to organisations, voluntary or publicly funded, that are helping to break down the barriers associated with HIV and AIDS today, and helping those struggling with the condition to lead happier lives. We must end the situation in which people considering being tested must perform some kind of social versus medical cost-benefit analysis. Only then will people with HIV receive all the benefits of early diagnosis. Only then will the public at large become fully aware of the true nature of HIV in the United Kingdom and the great steps forward that have been taken. Only then will those who follow us in the next generation be adequately equipped to protect themselves against its threat.
Keats's beautiful poem, To Hope, contains the following poignant lines, which seem particularly apt today, and I conclude with them:
“Whene'er the fate of those I hold most dear
Tells to my fearful breast a tale of sorrow,
O bright-eyed Hope, our morbid fancy cheer;
Let me awhile thy sweetest comforts borrow”.
I thank the noble Lord, Lord Lexden, for his contribution and congratulate him on it. It was very refreshing to have someone who was not on the committee bring us some fresh insights and information from a part of the world which we did not visit.
Like all speakers, I congratulate the noble Lord, Lord Fowler, not only on his excellent introductory speech and on securing this debate on this day, but, more than this, on his dogged persistence with this issue over the past quarter of a century and his courage and correct judgment in putting HIV/AIDS so startlingly on the map in the mid- 1980s. As my noble professional friend Lady Tonge said, he faced strong disapproval and opposition from powerful members of the establishment, despite getting all-party support. He wisely persisted with the tombstone public education campaign as well as the controversial but highly successful needle exchange scheme which he has told us about. As result, the UK became the most successful country in the world in curbing the epidemic. In the developing world and some developed countries, the epidemic has continued to spread and, in sub-Saharan Africa, has resulted in the expectation of life for the whole population being reduced by 10 to 15 years with serious socioeconomic effects. But that is another debate, although a highly important one.
It was a privilege to serve on the Select Committee. I thank not only our chairman and our specialist adviser, Professor Anne Johnson, but also our two brilliant, dedicated clerks and, last but not least, our highly efficient secretary Deborah Bonfante, who handled the mountains of printed paper which passed before our eyes smoothly and effectively. Our witnesses, whether scientists, clinicians, voluntary sector workers or patients, were always knowledgeable and helpful.
I shall concentrate on some clinical and epidemiological aspects of the epidemic, emphasising, as all speakers have done, the imperative need for better prevention. This was the common thread which drew all our witnesses together and is the theme of the report. It is often said that the persistence of HIV in the developed world is at least partly due, as the noble Baroness, Lady Tonge, said, to the availability since the mid-1990s of antiretroviral treatment that prevents HIV developing into AIDS, and that this has resulted in greater risks being taken by some sections of the sexually active population now that HIV is no longer a death sentence. Even if this was only partly true, it indicates widespread ignorance of the burden that living with HIV can cause, as several noble Lords have most vividly described, even when ARV treatment is being correctly given. Though some of them will live a full lifespan, others will not be so fortunate. There are often unpleasant side-effects, though they are now less common since combination antiretrovirals have become more refined.
The future health and lifespan of HIV-infected people receiving ARV depends very much on the stage that the infection has reached when treatment is started. Early diagnosis after infection is thus extremely important. ARV drugs are much less effective when there is a high viral load, so that full blown AIDS symptoms which are difficult and expensive to treat can develop, even when the subject is on ARV treatment. Fifty per cent of newly diagnosed cases in the UK are classified by the HPA as being at a late stage of infection, with a CD4 cell count of less than 350 per cubic millimetre, just over half of which are severely immunocompromised, with a CD4 count of less than 200. The late diagnosis rate varies from group to group, being highest among heterosexual men—63 per cent of them. It is estimated by the HPA that 22,200 people are living with HIV infection in the UK who are undiagnosed. Most of them are unaware of their condition; some of them are developing high viral loads which means that they will respond less well eventually to treatment as well as acting as a reservoir of infection.
HIV carriers who are being successfully treated, on the other hand, have a very low infectivity of 1 per cent or 2 per cent but even this low rate means that they must still use a condom or take other steps to reduce the chance of passing on their infection. So while acquiring HIV infection is no longer an automatic death sentence it is still a life sentence—it means a lifetime of medication and the other serious drawbacks I have described—a much worse fate than that of other sexually transmitted diseases which can now mostly be treated and cured.
In addition, as the noble Lord pointed out so vividly, people living with HIV are subject to a number of social consequences. We heard from several of our HIV-positive witnesses examples of stigma against people with HIV in employment and in social settings, despite successful ongoing treatment. Frequently there are psychological symptoms, sometimes very severe, including suicide. Life insurance policies and mortgages are difficult or impossible to obtain by HIV-positive people, according to the Terrence Higgins Trust. If after perseverance a policy is agreed, the premium is highly loaded and no cover will be given for illness or death from an HIV-related condition. That puts people at a huge disadvantage when attempting to live a full life, and buying a house, for instance.
The noble Lord, Lord Fowler, and others have described the increasing financial burden caused by HIV infection, particularly the cost of drugs. This cost is increased if HIV is detected late and complications have to be treated in hospital. But the main cost of HIV comes from the persistence and spread of the epidemic through sexual contact with HIV carriers who are not aware of their HIV status. As other noble Lords have pointed out, this is why one of the main messages from our witnesses and the report is the need to widen the screening net by testing in more settings than previously. In fact I suggest testing wherever a blood test is being carried out for any reason and on certain other occasions, for instance when a patient is having a health assessment or being registered at a general practice, for hospital out-patients or in-patients and in STD clinics even when a blood test was not originally planned.
The case for this policy is very well argued in the Time to Test for HIV report, mentioned by the noble Baroness, Lady Gould, published this year—or was it last year?—by the HPA. We visited a group practice in Brighton where routine HIV testing was done as well as the carrying out of general healthcare of HIV patients being followed for their HIV and treated by at the HIV unit at Royal Sussex County Hospital. When a positive test result meant that someone had a fatal disease there was a policy of only testing when suitable counselling for this eventuality was made available. Now that a positive test does not have quite such a dramatic meaning, it is acceptable for the test to be carried out by any suitably trained professional, providing of course that the consent of the patient is first obtained; an opt-out possibility must always be offered.
I have not covered our recommendations at all systematically. There are 53 of them; each has been covered by the Government’s response and many of the report’s recommendations have been accepted. I am particularly pleased that the recommendation to make home testing legal and quality controlled has been accepted. This was the suggestion of many of our witnesses. Also welcome is the lifting of the requirement for all overseas visitors to have to pay for HIV treatment. Lifting this charge makes good public health sense.
I was, however, disappointed in the Government’s response—other noble Lords have mentioned this—to paragraphs 236 and 237 of the report, which called for the integration of HIV and sexually transmitted disease services. This is particularly relevant in the light of the changes envisaged in the Health and Social Care Bill now in Committee in your Lordships’ House. I hope that the noble Baroness who is replying to this debate will be able to raise in Committee some of the issues that I am about to describe.
We heard justifiable concerns about the split between HIV treatment services to be commissioned by the National Commissioning Board, and the provision of prevention services for HIV and other STIs in genitourinary medicine clinics to be provided by local authorities—through their ring-fenced public health budgets, presumably. The proposed changes claim to enable integration between the services, but in this case it seems that the reverse is being proposed. Many PCTs have increasingly brought HIV and STI services together under the same roof, as they logically should be. In this case the opposite seems most likely to occur. Perhaps the noble Baroness can tell us the department’s latest thinking on this particular problem.
I was going to speak also about the future of the HPA, but that has been covered extremely well by the noble Baroness, Lady Masham, and, as I have now been speaking for 12 minutes, I shall end on that point.
My Lords, I begin by paying tribute to the noble Lord, Lord Fowler, with sincerity undiminished by the repetition. He did a superb job of chairing an excellent committee. I thought I would be unique in paying tribute to our special adviser, but the noble Lord, Lord Rea, anticipated me. Anne Johnson, with whom I have had the privilege of working and publishing, for that job, was not merely the best person in Europe but the best person, arguably, in the world. She was absolutely superb. She has a connection with this House that is not widely appreciated. If my memory is correct, she is the niece of a very distinguished late Member of the House.
I think the Government’s response to our report was basically a good one. That must be borne in mind as I now go on to air the respects in which I found it disappointing. My speech will be perhaps a little different in that it will be more academic. However, it will be no less impassioned.
I have on a previous occasion drawn a graph with my hand and scattered my papers down the aisle and I risk doing it again. It is worth reminding the House what has happened not only with HIV but with sexually transmitted diseases. When HIV first appeared it was mainly among men who had sex with men and among drug users, and its incidence rapidly went down in this country, Australia and New Zealand because of effective measures such as those we have heard about. It then, for about 15 years, ticked along at a low level, slowly further declining among drug users and men who have sex with men and slowly increasing among heterosexuals to keep it at a roughly constant low level. However, over the past six, seven, eight years it has begun an upswing that shows no sign of diminishing. The question before us, which we have heard a lot about, is: why is this?
It is a fact that many studies of people—particularly young people—reveal that they are less well informed and less concerned about sexual health than was the case 20 years ago. As our report says, this is possibly because diagnosed early the majority of people with HIV can expect a near normal life expectancy. That is true and good and it needs emphasis, not least because it has a complicated and curious association with the stigmatisation initially that HIV was a death sentence. While that is true and good at the moment, it is not quite as simple as it is presented. We do not yet have clear sight of a vaccine. I declare an interest in this subject as I am co-author of the first and contentious prediction of the demographic impact of HIV on sub-Saharan Africa that was grossly pessimistically at odds with the World Health Organisation and others, whose models were much more elaborate but epidemiologically stupid. To my great regret, we were right.
I have a continuing interest in a fact not commonly appreciated in debates such as this. Although our almost magical understanding of the interaction between an individual virus and the immune system cells can enable us to design a drug or sequence of drugs that suppresses viral replication, we still do not have an agreed understanding of the pathogenesis—of how the initial infection is handled. Escape mutants appear and at first they are handled, then finally the immune system goes down. My view is that it will be difficult to have a vaccine before we have an understanding that matches the brilliant descriptive molecular biology with a more complex sense of the incredibly complex dynamics of the immune system and the many escape variants that it is trying to handle.
At first, we could not handle the resistance that quickly evolved to the first antiretrovirals. My research group, among others, was involved in that in the 1990s. We now have a mixture of a richer panoply of drugs, combined with a better understanding of how to use them, and we can keep people alive—but how long that is going to last is not something that anyone can sign off on. It is not a question of whether eventually, as with any set of such agents, we will finally run into a barrier; it is not a question of whether but of when, in relation to the timescale of when we have a vaccine. One thing that we sought in our discussions was an estimate of that. I am pleased to say that very good people working on this are of the view—which I share—that we probably will have a vaccine before we run into the wall. But we do not have a guarantee.
We have a very good reason, well beyond that of simple compassion or the financial details that we have heard about, not to take our foot off the pedal but to keep emphasising the need to slow down and reverse the increase in the incidence. This is a three-pronged thing. We need uninfected people to appreciate the need to be more careful; we need infected people to be diagnosed earlier so that they can be treated earlier, which will make them less infectious to a degree; but to do that, the third prong, we need infected people to know that they are infected. That brings us to some of the key recommendations that did not get the in-your-face affirmation that I would have wished.
The first recommendation is that:
“HIV testing should be routinely offered and recommended, on an opt-out”—
not an opt-in—
“basis, to newly registering patients in general practice, and to general and acute medical admissions”.
I realise that that will not be popular with some groups, but that is what we recommended. We also said that routine and opt-out testing should be offered in other circumstances that are related to the trend in the upward rise of sexually transmitted infections—hepatitis is one, or associated things such as TB. The Government’s response to this was broadly welcoming, but speaking from my five years’ experience as Chief Scientific Adviser first to Major and then to Blair as a permanent secretary embedded as a kind of anthropological tourist in a strange culture. I recognise, I am afraid, in the response to that recommendation, the caution and elevation of process over product that is characteristic of our well meaning and excellent Civil Service. I would like there to be a much more positive and unambiguous affirmation of the need to do that. I have resisted expressing that thought with colourful Australian adjectives.
Another of our recommendations is that we repeal the ban on home testing kits, with appropriate caveats. The Government supported us, but with subtle nuances of language they did not accept the recommendation, and said that they would review the policy. They will think about thinking about it. That is not good enough.
What is totally indefensible on ethical and common-sense grounds is our current policy that visitors or others without the right to live here can be freely diagnosed as having HIV but cannot be treated. This is ridiculous simply on common-sense financial grounds, much less unambiguous ethical grounds, because it demotivates people from even being tested. The government response did not agree with or even support us. It used the dread words “review policy”. That is not good enough.
In general, we also recommended,
“that the Department of Health undertake a new national HIV prevention campaign aimed at the general public”.
Here I shall go off-piste to offer a personal opinion on how best to do this. I am strongly of the view that wherever possible this sort of activity should be delivered though the NGOs, not the NHS. That is because some 10 years ago £400 million was put into a campaign on sexual health by the Department of Health. In the event, only 31 of 191 primary care trusts spent a penny of the money on sexual health, and none spent any of it on awareness campaigns. What fraction of that £400 million was given to NGOs? It was 1 per cent. It would have been much more effective if 1 per cent had been given to the primary care trusts and 99 per cent to the NGOs.
In summary, despite the negative tone of some of the things I have said, the Government have given us a welcoming response and they have a proud record in this, as we have heard. I was living in the United States when the committee of the noble Lord, Lord Fowler, was acting, and we watched in despair and distress as the same recommendations coming out of the US National Academy of Sciences to Ronald Reagan were seen as the kind of immorality you expect of a bunch of academics. I end by emphasising again that we have done well but we are not doing as well now. We have to put our foot back on the pedal and we have to be focused on effective prompt action, not on endless review.
My Lords, like other noble Lords who have spoken, I warmly welcome the publication of this first-class and comprehensive report from the Select Committee, and I am delighted that we have an opportunity to debate it on such an important day.
If I may, I start with a personal tribute to my noble friend Lord Fowler. For nearly a quarter of a century, his name has been inextricably linked with this issue and he has courageously trod an often lonely path. The Don’t Die of Ignorance campaign was a phenomenally bold move. Looking back on it 25 years later, we can see that it was a seminal moment in the history of HIV and AIDS that without any shadow of doubt saved countless thousands of lives. I say to my noble friend that I was just over 20 when the campaign was launched and was therefore part of a generation of gay men who, without the very stark warnings the campaign contained, could have fallen victim to what was then an untreatable disease. My generation owes an enormous debt to the foresight and courage of my noble friend, those who worked with him and the pressure groups that so assiduously supported him. They gave us the gift of life.
I wholeheartedly endorse the conclusions of this compelling report, in particular the emphasis on early and better testing. There is no doubt, as we have heard so often during this excellent debate, that the issue of late diagnosis is now the greatest challenge in dealing with HIV/AIDS. As the report makes clear, delays in dispensing antiretroviral therapy have grave health implications for the person diagnosed, as well as the risk of onward transmission. As the noble Lord, Lord Rea, touched upon, the figure in the report that 52 per cent of adults diagnosed with HIV in 2009 were diagnosed late is shocking. The problem is even higher among those aged over 50, at over 65 per cent. This is becoming not so much a problem of the young but a problem of the middle-aged.
When treatment of HIV is so effective and easily accessed, with rarely any of the problems of unpleasant side effects that once occurred, there can be no excuse for this. We need, therefore, above all else, to get to the roots of this issue. That is what I would like to concentrate upon, drawing heavily on the report.
There are undoubtedly many causes—after all, this is a very personal issue—but I would like to highlight three. One is certainly education. I do not just mean what is taught in schools, where the report has valuable recommendations on incorporating sex and relationships education into the national curriculum to ensure that children are taught about security in intimate relationships; it is more the importance of education throughout life. As the problem of late diagnosis among those aged over 50 is real and pressing, perhaps we need to find, for instance, novel ways to educate older audiences too, by deploying information through the media and the opinion-forming channels which influence those in middle age.
The second is the role of GPs and health professionals. The report rightly highlights how,
“a major obstacle to more widespread testing seems to be with those who could offer the test”.
In other words, some GPs avoid recommending a test to those who might have HIV because of misconceptions about the need for counselling, time constraints and, above all, stigma.
When I was preparing for this debate I visited the excellent Bloomsbury Clinic within the Mortimer Market Centre in Camden a few weeks ago. I heard a dreadful story there of someone who made his way to the clinic after having been ill for two years with a variety of conditions that should have shouted to his GP “HIV” from the rooftops. This person had never been given a test by his GP; by the time it was discovered, when he found his way to the clinic, full-blown AIDS had set in and the person involved lived barely a few weeks.
That sort of situation, rare though it is, is completely unacceptable. I hope that the recommendations in the report on the need for practitioners to become more confident in identifying those at risk of HIV are acted on without delay.
However, perhaps the single most significant problem remains that of stigma, as many noble Lords have said, most movingly, perhaps, in the examples given by my noble friend Lord Lexden. Of course, there have been remarkable strides in addressing the fear and misunderstanding of HIV, which are the wellsprings of stigma. Enormous credit must go to those many organisations—we have heard about the National AIDS Trust and the Terence Higgins Trust, which do remarkable work—which have fought tirelessly to combat HIV, as well as to the wonderful clinicians who work with patients and give them the confidence to deal with it.
However, there is much more to do and it is absolutely central to the issue of diagnosis, because fear of stigma and fear of testing are inextricably linked. Consider this: in the 2009 People Living with HIV Stigma Index, as we have heard, one in eight HIV-positive people living in the UK reported being physically harassed in relation to their HIV status in the previous 12 months. More than one in five had been verbally assaulted or threatened.
My noble friend Lord Fowler quoted from the survey on public knowledge and attitudes undertaken last year by the National AIDS Trust, which does such fantastic work in this area, about how people would regard a neighbour who was diagnosed with HIV, quoting, quite rightly, “Love thy neighbour”. There is an even more shocking figure in that survey that 20 per cent of respondents disagreed with the proposition that,
“if someone in my own family told me they were HIV positive, it wouldn't damage my relationship with them”.
Therefore one in five would have a more negative view of someone in their own family who was diagnosed.
Four areas of action need to be taken to tackle stigma, and the report very helpfully points the way in some of them. The first relates to healthcare professionals; sadly, as the noble Baroness, Lady Masham of Ilton, said, half of all discrimination reported by people with HIV is in healthcare, particularly in the case of dentists and GPs. Yet those are the very people who should be encouraging testing then, when somebody is diagnosed HIV positive, ensuring that they get swift and effective treatment from experts at the brilliant HIV centres around the country. NHS staff need consistent, high-quality and, above all, continual training about not just the basic facts regarding HIV but the unacceptability—indeed, the unlawfulness—of HIV discrimination, and about the actions that need to be taken to ensure that patients with HIV have the respect and support they deserve. Here, the new NHS Commissioning Board has a vital role to play in requiring anti-stigma training, especially in primary care.
The second area relates to general public information. Undoubtedly, “Awareness of HIV”, in the opening words of the report, is “below the public radar”. What that means is that public understanding of HIV transmission has also decreased significantly in the past decade. The Ipsos MORI surveys commissioned by NAT, which we have heard mentioned today, have over the past few years shown an increase in the number of people believing HIV can be transmitted through kissing. Less that half those questioned cite sharing needles as a possible route, although that is actually the second most common transmission method. These misunderstandings foster stigma because of the link between poor understanding of how the disease is transmitted and a judgmental attitude towards people living with it. Education in schools is obviously vital here, but so are local sexual health campaigns and information to ensure that, at the local level, people have accurate information on how HIV is and is not transmitted.
The third area relates to the media; here, I must declare my interest as executive director of the Telegraph Media Group. Undoubtedly, HIV scare stories in some small parts of the media still foster the fear that is the basis of stigma. While HIV and its ramifications are complex issues to report, not least because they can often become entwined with other emotive subjects such as immigration, there is never an excuse for inaccurate reporting when it can have a terrible human cost. Some progress has been made. The National AIDS Trust, working with the help of the Press Complaints Commission, has produced excellent guidelines for reporting HIV which have started to make an impact. They cover the law, the myths, the vocabulary and issues about testing. They are extremely important in tackling stigma and I encourage their wide dissemination in newsrooms across the media.
My fourth point relates to public policy. The Government's recent mental health strategy has, as one of its six objectives:
“Fewer people will experience stigma and discrimination”.
The Government are, rightly, backing this with significant funding. HIV is in many ways comparable to mental health in terms of conditions that arouse fear and foster stigma: yet there is no strategy or funding in place specifically to tackle HIV stigma and its resulting harms to public health. As the noble Baroness, Lady Gould, said earlier, such a strategic policy could work across departments and disciplines, involving education and teachers, the police, social workers, the media and, above all, healthcare professionals to tackle stigma at its roots.
Of course, money is tight but investment in a strategy of this sort would be perhaps the most cost-effective money the Government could ever spend. Various noble Lords have quite rightly pointed out the simple maths, which I am afraid were never a strong point of mine. I would look at it this way: £1 million spent on an HIV stigma strategy would be recouped by preventing just four of the 2,656 confirmed UK-acquired infections diagnosed in 2010. It is just four; once we get to the fifth, we have started saving. If it were successful, the long-term savings to the public purse could be considerable. Taken together, these four steps could significantly help tackle the stigma, encourage more people to get tested early, help prevent onward transmission of the virus, and ensure a better quality of life for the 100,000 people who will soon be living with HIV.
In my closing comments, I want to mention those 100,000 people. Thanks to effective treatment, there is no reason that they should not lead long and healthy lives. However, we have to recognise that HIV is now a chronic illness, that our understanding is relatively new, and that we do not know what its long-term consequences might be, or the long-term effects of the drug therapies, particularly in terms of other conditions that those living with HIV might contract. If you have HIV, every illness that you get could potentially impact on your treatment regime. As people live longer, this is going to become a much more complex issue to deal with and the model of care, as the report notes, will need to change accordingly. That means a holistic approach to treatment, with regular access to specialists in the field for all those with HIV.
For a number of reasons, some of which I mentioned earlier, GPs may not be the best suited to this task. I am cautious of any moves to give them primary responsibility in this area when it is specialist care which is going to be increasingly vital as the health service copes with an increasingly elderly population living with HIV. Ideally under the new commissioning arrangements, designated centres of excellence for HIV treatment and care should be the ones responsible for ensuring the most effective, convenient, continuous and flexible therapy for all HIV patients. I believe this would be likely to offer better longer-term results in quality of care than the strategy of giving GPs shared responsibility with specialists.
In my remarks today, I have tried to touch on a wide range of subjects. I could go into nearly as much detail as the brilliant report that we are considering. That is a point that underlines how complex this issue is in public policy terms. We are fortunate indeed that this report has given us the opportunity for such an important debate. I hope that in its way it can be as effective as the original campaign 25 years ago—this time not just so much about saving lives, but improving the quality of those lives. That is the great and noble task ahead.
My Lords, I, too, thank the noble Lord, Lord Fowler, for securing this debate and I thank the Select Committee for producing such a timely and thorough report. I was not a member of that committee, but I want to make some general comments about prevention campaigns, then focus on prisons and schools and ask the Minister about the Department of Health’s new sexual health policy framework. It is an honour to follow so many well-informed, even poetic, speeches. I know that all those noble Lords who have spoken today have a long-standing commitment to HIV/AIDS prevention and treatment. In thanking Lord Fowler, I have to say that he is one of my public health heroes.
At a time when HIV/AIDS was emerging as a health threat, when the public response was one of fear, confusion and prejudice which sought to stigmatise certain groups, the noble Lord remained calm and reminded us that this was a health issue that needed to be tackled firmly. I know this because I was working in public health at the time, and how glad we were that he was in post. Yes, there were, I believe, icebergs and tombstones—sometimes misinterpreted by the general public—and maybe we would do some things differently now. However, the noble Lord, Lord Fowler, certainly had a great impact on those campaigns of public awareness.
The rampant and unthinking prejudice which emerged then still has echoes in the ignorance and dangerous attitudes of some people who oppose sex education and sexual health promotion today. It is interesting that other public health issues, such as vaccination, smoking, wearing seat belts and so on, are not connected to sex, or are perhaps only marginally, and so are not fraught with the connotations attributed to HIV and AIDS. In the government response, the high cost of treatment is described as a compelling investment. In 2010, prevention could have saved over £32 million annually. I was pleased that the committee recommends both targeted, intensive campaigns and, very importantly, that awareness should be incorporated into wider national sexual health campaigns, with evaluation commissioned by the Department of Health.
There should certainly be a new national HIV prevention campaign targeted at the general public. Let me say briefly why this is important. There has not been such a campaign for a long time. The high profile of HIV/AIDS has decreased and the problem of HIV infection and other sexually transmitted infections is increasing. We are in a new era of communications. We now have the internet, social networking of many kinds and highly sophisticated mobile phone applications. All are wonderful but they can also be misused, as we have seen in grooming and internet and mobile phone bullying. I have sympathy with the support of the noble Lord, Lord May, for NGO involvement in such campaigns.
Apart from HIV and AIDS, there are other dangers, some rather curious. I was in Nottingham last week, discussing substance misuse and public health. I must declare an interest as chair of the National Treatment Agency. As I learnt in Nottingham, there is concern about the injection of steroids in relation not just to bodybuilding but to the desire for the body beautiful. There is also concern about the injection of a substance that will give a body tan that also enhances libido. In Nottingham, people were found who have contracted HIV/AIDS and hepatitis B through these practices. It is very worrying and a call to renew our look at how we campaign.
Prevention campaigns have to be part of general health campaigns, using ever more sophisticated and subtle means of communication with adults and young people. I am also glad that the committee has shown concern for future structures in public health. Such concerns were highlighted by the noble Baroness, Lady Tonge, and many others. As the report points out, sexual health has often been the poor relation of the health service. The voluntary sector has done an enormous and valuable amount to tackle HIV and AIDS. We all wait to see how drug, alcohol and sexual health services will fare in future public health services with a ring-fenced budget. They must not be lost among other demands. I know how ring-fencing has in the past enabled drug treatment to improve the numbers in treatment and waiting times. Health and well-being boards and other local monitoring groups must be vigilant about keeping HIV on the agenda.
The public health White Paper, Healthy Lives, Healthy People, spoke of working,
“towards an integrated model of service delivery to allow easy access to confidential, non-judgemental sexual health services”.
It points out that testing should be a priority of any prevention policy. Prevention has been spoken about a great deal today. The testing of pregnant women has been a success. Other testing, such as by GPs and home testing, could be effective, as many others have pointed out.
I now want to talk about schools, which were referred to by others, including my noble friend Lady Healy. Schools should be considered part of the community and, therefore, connected to community services. There have been good examples of older pupils in schools visiting Brook Advisory Centres as part of the PSHE programme. This encouraged them to seek advice, perhaps after leaving school. Schools should also teach about public health issues. The danger of HIV infection should be taught as a specific issue, not just in sex education—if it exists. I should like to see secondary schools teaching compulsory modules on public health. This would go alongside teaching about respect for oneself and others, decision-making, self-esteem and communication skills. All these skills can reinforce the ability to behave responsibly in relation to sex and substance misuse. I am not talking here about explicit sex education for five year-olds and I do not believe that schools are either. Those who rant about sex and five year-olds should visit some schools and inform themselves about the responsibility of school governors, some of whom are parents, for the curriculum.
We have suffered recently from a barrage of misinformation and prejudice about teaching sex education. Such misinformation is an insult to teachers, parents and school governors and it should have a health warning on it. Primary schools, including five year-olds, can discuss relationships with family, friends and the community. Children have rights and responsibilities. They can learn about keeping themselves and others safe. Later, this foundation of rights and responsibilities can be used to teach about drugs, alcohol and sex. Lack of information and misinformation are highly dangerous.
I turn briefly to offender health. People in prisons are a high-risk group in many ways. Among them there are significant levels of illiteracy and mental health problems. We know that some prisoners use drugs and have sex. But, significantly, prisoners leave prison and may spread infections. The recent report on prisons and drugs chaired by my noble friend Lord Patel of Bradford recommended: a cross-government strategy; a streamlined commissioning system; a framework for service delivery; user and carer involvement—that is very important; and links to the wider criminal justice and health and social care systems. For HIV we need all those things. We need guidance to prison governors and clarity on best practice in managing HIV in prisons, to include provision for prevention, testing and treatment and data collection. I hope that clinical commissioning groups will address, monitor and evaluate the outcomes of interventions in prisons. There must be continuity of care. The programmes to identify substance misuse and provide individual key workers to help with employment, housing and other social issues have proved highly successful.
The report on prisons highlights many significant issues for HIV and AIDS prevention and management of services. I very much look forward to following what happens in the new structures for public health. I hope that the Minister can give us a preview of the sexual health policy framework. I also hope that, perhaps in two years’ time, the noble Lord, Lord Fowler, will reconvene a committee to look at the outcomes of these new structures and the impact of the sexual health policy framework. As usual he has done a great favour to those concerned for public health. I again congratulate him and the committee on this debate.
My Lords, it has been a great privilege to serve on the Select Committee under the chairmanship of my noble friend Lord Fowler. It has been a particular privilege to serve with colleagues across your Lordships' House, our professional adviser and clerks, who all know so much more than I do about this devastating and serious virus.
I fear that I may have asked some all too obvious questions. My first was because I failed to understand—and still do—why antiretroviral drug prices need to vary across the country. I am a supporter of localism but surely it is desirable to procure nationally if this means that more competitive prices can be achieved across the country and significant savings can then be utilised on the front line of treatments or, indeed, on prevention measures. In the Government’s response to the committee's report, it is acknowledged that beyond London regional procurements have been less successful. However, I do not see that rectifying this has been viewed as a priority. I hope that I am wrong. Predominantly, it has been a privilege to hear directly from exceptional professionals, dedicated volunteers and courageous and inspirational people who live with HIV.
Your Lordships have already heard that in this country the stark facts are that the number of people living with HIV is increasing—it is now more than 100,000—with treatment costing £1 billion a year. In the world some 34 million are now living with HIV/AIDS. The rate of infections in the world is thankfully slowing yet in the UK the rate is increasing, so now is the time for the UK to tackle this virus with renewed determination. With early diagnosis we can enable the majority of people with HIV to have as normal a life as possible. The drugs have transformed the prospects for so many. However, we must now concentrate even more tenaciously on prevention. This is the key to all our aspirations to defeat HIV/AIDS and eventually eradicate it.
Some prevention measures in the UK have been outstanding successes. Many noble Lords have already referred to the clean needle programmes and routine antenatal testing of pregnant women. More generally, however, our financial commitment to prevention campaigns for too long has been disproportionately low. The lifetime cost of treatment of a single patient is nearly £360,000. Yet £2.9 million, as has already been referred to, is all we will spend on national prevention programmes in 2011-12. The Government in their response recognise the benefits that investment in prevention would offer. We need to do more than that. We need action. There must be a far more robust attitude, a sense of mission on prevention, which my noble friend Lord Fowler so admirably galvanised and led in the 1980s.
We must be bold about prevention programmes. Is the UK rate of infection increasing because we have not been? Of course our efforts should be focused on the parts of the community most at risk. But should not HIV also be seen as part of the overall sexual health campaign? The more we place it in that context, the wider the message reaches. I do not understand why the Government are so adamant that a national campaign aimed at the general public, which the committee recommended, would not be effective. I apologise to the Minister, but when the national campaign led by my noble friend Lord Fowler is universally acknowledged as having been extremely effective, I do not understand the Government’s initial response. At the same time, the Government quite rightly accept that more needs to be done by all to address behaviour that increases the risk of HIV infection. I urge the department to look at this with urgency as it formulates the new sexual health policy framework. I am sure the department will be widely supported in being robust in considering all the options when prevention contracts end in March next year. I also hope that upon gaining new responsibilities, local authorities will prioritise prevention.
No responsible person underestimates the financial pressures we face in this country; new money is more than hard to find. However, we will fail to be cost effective if we do not direct scarce resources towards prevention. Even with the success of antenatal testing, last year over 70 babies were born HIV positive; that is, 70 children with the prospect of medication all their lives. It is a sobering and distressing thought and we must do better.
One element of serving on the committee which most affected me was learning about the consequences of late diagnosis in terms of quality and expectancy of life. Some 52 per cent of adults in 2009 were deemed as diagnosed late: heterosexual women at 59 per cent and heterosexual men at 66 per cent. Two-thirds of those over 50 were diagnosed late. That may be a profile that is not what many would have expected. Going further, 30 per cent of new diagnoses are in the very late diagnosis category. This is a frightening percentage with many adverse health implications.
In committee we discussed testing at some considerable length and received much evidence. The current situation surely warrants that we should look at the whole issue of testing and its expansion. Antenatal testing is now seen as a routine and uncontroversial procedure. Is this not the route we should now take? As part of tackling stigma and discrimination, should we not be looking to normalise as much as possible our approach to testing? Why cannot HIV testing on an opt-out basis—as the noble Lord, Lord May of Oxford, has already highlighted and as is recommended in our report—be routinely offered and recommended to new registered patients, to general and acute medical admissions and on entry to prisons? The wider we test, the more we can break down stigma. The more we do so, the more likely that people will come forward, be tested and, if necessary, receive medication. Therefore, I endorse the Government’s comments that HIV testing should be within the competence of all doctors and nurses, and I welcome the department’s review of the policy which bans the sale of home-testing kits. Echoing the noble Lord, Lord May of Oxford, I hope that the review will, in turn, move to action.
I came to the deliberations of the committee with a fresh mind. I can see, alas, that we in the UK have been faltering in our national efforts to conquer this dreadful virus despite the supreme dedication of superb professionals and volunteers. We need renewed vigour and courage to seize this moment. Every new infection of a baby, a young person, a man or a women takes its toll on the patient and on their family and friends. Medical advances since the 1980s have been dramatic, yet no cure is in sight. It is on our watch now that we must be innovative and bold on prevention and compassionate to the all too many people who live with HIV.
My Lords, I, too, congratulate the noble Lord, Lord Fowler, on initiating this excellent debate. I have huge respect for the work that he has done and continues to do in raising awareness of HIV and AIDS.
I also pay tribute to all the members of the Select Committee for producing such an excellent and timely study. I say “timely” because only this week the Health Protection Agency warns that the virus is on the rise again in the UK. As we have heard in today’s debate, more than 100,000 people will be living with HIV in the UK by the end of the year, and, as the noble Lord, Lord Fowler, said, more than a quarter of HIV infections remain undiagnosed—that is, in people who have not yet had a test and do not know that they are infected.
The HPA reported that new diagnoses of HIV in men who have sex with men have hit a record high, with around 3,000 men diagnosed in one year. That is the largest annual figure ever recorded. It was 1,820 in 2001, 2,660 in 2005, and 2,790 in 2009. As many noble Lords have said, it is time to break the silence and stigma around HIV, and this report is a very welcome step in helping us to do that.
Early diagnoses and the excellent treatments now available from the NHS mean that many have a chance of avoiding the worst consequences of this virus. As the noble Lord, Lord Fowler, reminded us, when the epidemic began 30 years ago, people with HIV swiftly became sick, developed AIDS and died of infections, such as pneumonia, which their bodies could not fight off. Today, combinations of antiretroviral drugs keep people alive and healthy, and can give them a relatively normal lifespan as long as they stay on the medication. This means, too, that the number living with the virus continues to rise.
Early preventive action not only saves lives but saves money. This is where I also want to amplify the conclusion in the report that a new priority must be given to prevention. As many noble Lords have said, spending on preventing infection is seriously inadequate—just £2.9 million compared with the £762 million treatment bill. I very much regret that the Government dismiss out of hand the committee’s recommendation for an advisory committee for HIV prevention research. Such a committee might give us a clearer indication of the effectiveness of some of the public campaigns.
An area that I want to stress in particular, evidenced in the committee report, is the link between prevention strategies and treatment. As my noble friend Lady Gould and others have said, that link is tested. As I have said, more than a quarter of those with HIV in the UK do not know that they have it, which means that they may be unwittingly passing it on to others and may not be diagnosed until they are ill and treatment is more difficult.
As my noble friend Lord Rea said, in 2010, 50 per cent of all new diagnoses were made late—in other words when the CD4 cell count falls below the level at which treatment is recommended. The proportion diagnosed late is higher in heterosexual men—63 per cent—and heterosexual women—58 per cent—than among gay and bisexual men—39 per cent. Black African and Black Caribbean people are more likely to be diagnosed late than white people. People diagnosed over the age of 50 are more likely to be diagnosed late than younger people. While progress is being made, it is being made very, very slowly. At the current rate it could take 50 years to eradicate the late diagnosis and start treatment on time.
As the noble Lord, Lord Fowler, reminded us, of the 680 people with HIV who died in 2010, two-thirds were people who had been diagnosed late. On the other hand, the outlook for people who are diagnosed promptly is excellent, with life expectancy just a few years shorter than that of people without HIV. Will the Government do more, as the Select Committee and the HPA ask, to increase access to HIV testing? For example, the report advocates that such testing is routinely offered to new patients of GPs and at hospital general admissions in areas of the country where rates of HIV infection are high. While I welcome the Government’s positive comments, including reviewing the ban on the sale of home testing equipment, I believe, as the noble Lord, Lord May, said so effectively, that more needs to be done to incentivise public health commissioners to prioritise HIV testing. With responsibility for HIV prevention moving to local authorities, it is vital to look for ways to ensure they are prioritising this issue and to invest in effective targeted prevention work. It must be a key performance indicator. Like others, I very much hope that it remains in the final public health outcomes framework. However, there are currently no plans to include a specific public health outcome measure on HIV prevention or sexual behaviour. I should like the Minister to respond to that.
This lack of emphasis from central government is exacerbated, as we have heard today, by the distribution of budgets and responsibilities in the new health structure proposed in the Health and Social Care Bill. As local authorities will not be paying for HIV treatment out of their budgets—this will be funded by the NHS Commissioning Board—like others, I am concerned that there is no cost-saving incentive to prevent further transmission. The Bill proposes significantly to increase the power of local authorities through health and well-being boards. While I am not opposed to greater local power in principle, I am concerned that the new structure opens the door for an ever-increasing politicisation of public health, which could have a severe impact on less socially acceptable health conditions, such as HIV. There are still considerable negative associations and stigma attached to HIV and a severe lack of knowledge about HIV among the general public, as the National AIDS Trust's recent Ipsos MORI research study report showed. This makes it particularly vulnerable to prejudice and can silence local voices of people with HIV. Stigma, prejudice, ideology or disapproval can threaten evidence-based interventions which meet the health needs of groups most at risk of HIV. There is potential for the increased role for elected officials to pose a threat to the continuation of the high-quality services needed to tackle the HIV epidemic in the UK. Indeed, in some places, HIV organisations have already begun to experience barriers when working with local politicians. Therefore, I urge the Minister to acknowledge how important it is for the Government to understand this and to build suitable protections into their reforms package. This should be through HIV-related outcomes in the NHS public health and social care outcomes frameworks. There should also, in relation to HIV and sexual health, be a detailed mandate from Public Health England to local authorities which sets out the essential elements of a comprehensive sexual health service, as my noble friend Lady Gould urged. It is vital that the Government ensure that stigmatising views of HIV, and around sexual health more broadly, do not affect decisions about local public health services.
As the Select Committee report said, stigma and lack of understanding can undermine HIV prevention efforts. Misinformation circulated about HIV, suggesting that it is a judgment or that it can be cured through non-medical methods, poses a threat to public health messaging. This is especially the case when such statements are made in faith-based settings, given the significant influence of faith leaders in some communities. As someone who still finds leaflets from local churches in Finsbury Park offering cures for AIDS, I know how important such work is, as the noble Baroness, Lady Masham, reminded us. I am therefore pleased that the Government agree with the Select Committee's recommendation about the valuable contribution that faith leaders and faith groups can make to HIV prevention and care services. When linked to projects such as the African Health Policy Network’s Ffena programme, which has trained more than 100 people living with HIV to become advocates for understanding of the condition, we know the policy can make a real difference in our communities. These sorts of projects involving HIV-positive people as advocates and confident service users are a vital tool in addressing stigma through publicising the condition and encouraging dialogue. It is really important that the Government ensure continued support for this work, especially in these difficult economic times.
After recent research that showed that drugs can protect against the transmission of the virus, I also welcome the report's call for immediate reviews into the possibility of putting people on medication sooner and offering it to their uninfected partners. However, I fully accept that such a policy should be considered after detailed research into the particular circumstances pertaining in this country.
Finally, I want to turn to the Health and Social Care Bill's proposals on health and well-being boards. Many noble Lords have mentioned them in the debate. They will be central to the integration of services. However, I share the concerns expressed by many HIV/AIDS charities that the NHS Commissioning Board will not be routinely represented at all health and well-being board meetings. Without the presence at health and well-being board meetings of those commissioning HIV services, there is a real risk that the importance of HIV prevention, as well as the concerns of people living with HIV, will be sidelined in favour of areas where there is a direct financial benefit, and which, perhaps, are not as potentially controversial. I ask the Government to do more to ensure the presence of representatives from the NHS Commissioning Board at health and well-being board meetings and to guarantee that voices representing the needs of people with HIV are heard in the deliberations of those boards.
My Lords, I congratulate my noble friend Lord Fowler on securing this important debate today, World AIDS Day. He has an outstanding record as the person who very much shocked us into an awareness of AIDS. He also deserves plaudits for his continuing interest in HIV and AIDS nationally and internationally, an interest that has done much to raise awareness inside and outside Parliament. As we know all too well, in issues such as this awareness is a significant part of the battle.
The report by the House of Lords Select Committee on HIV and AIDS in the United Kingdom, No vaccine, No Cure: HIV and AIDS in the United Kingdom, was most timely, given that it was 25 years ago when my noble friend led the Government’s response to HIV and AIDS. I commend the outstanding membership of this Select Committee, many of whom have a long record of work in this area, as I know from when I was an officer of the All-Party Parliamentary Group on HIV and AIDS. This report will help to inform the Department of Health’s new sexual health policy framework planned for next year.
In October, we published the Government’s response to the report and made clear that we agreed with many of the Committee’s recommendations on combating HIV and AIDS. World AIDS Day provides an excellent opportunity to reflect on the progress that we have made. Globally, there has been progress. The epidemic has stabilised in many regions. New infections have fallen by 21 per cent since 1997. Nearly 7 million people are on antiretroviral treatment—a more than tenfold increase over five years.
Today is also an opportunity to recognise the continuing challenges presented by HIV, both globally and at home. More than 34 million people are living with HIV and, as noble Lords have noted, there is no cure or vaccine in sight. Around 10 million people in need of treatment are not getting it. There are more than 7,400 new HIV infections every day, which is two for every person who begins receiving treatment. To compound the problem, HIV funding is flatlining, about which we can read more in today’s papers.
While the scale of the epidemic is very different in countries such as the UK, as my noble friend Lord Fowler pointed out, we are not unaffected by the global picture. Effective treatment from the NHS can transform the lives of those living with HIV or AIDS, but there is no cure or sign of a vaccine and HIV still attracts considerable stigma, which is a huge challenge.
The Government’s early response all those years back, led by my noble friend Lord Fowler, has helped to make sure that the UK has remained a relatively low prevalence country for HIV, particularly compared with some of our European neighbours. The early introduction of needle exchange and harm minimisation programmes, for example, has meant that we have very low rates of HIV in drug users who inject, unlike in other countries, as my noble friend pointed out.
Earlier this week, the Health Protection Agency published its annual HIV report for 2010. There are now around 91,500 people living with HIV, of whom around a quarter are unaware of their infection. This means that they are unable to benefit from highly effective treatment and risk unwittingly transmitting HIV infection to others. The HPA also reported that in 2010, new diagnoses in men who have sex with men—MSM—reached a peak of 3,000, and MSM remain the group most at risk of HIV transmission in the UK.
That is why I very much welcome the report’s focus on the importance of HIV prevention. The Government agree that we need to be more effective in supporting responsible sexual behaviour. HIV prevention makes good economic sense too, as noble Lords have pointed out. The HPA estimated that preventing the estimated 3,800 HIV infections acquired in the UK in 2010 would have saved over £32 million annually, or £1.2 billion over a lifetime, in costs.
This year, the department has invested £2.9 million in a national programme of HIV prevention for men who have sex with men and for African communities, delivered by the Terrence Higgins Trust and African Health Policy Network. On top of that, the NHS provides many HIV prevention services, some funded separately and some funded as part of mainstream services such as testing and distributing information and condoms. The Department of Health is currently considering how national HIV prevention programmes might be taken forward when the current programmes end. The Committee’s comments will help to inform what happens.
Of course, effective prevention requires effective testing. Late diagnosis is the most important factor associated with HIV-related morbidity and mortality in the UK. We agree with the Committee that HIV testing should be offered more widely and in various healthcare settings, particularly in areas of high prevalence. In September 2011, the HPA published its final report on pilots which the department funded in 2009-10 to help to reduce late diagnoses of HIV. The findings were encouraging and patients responded to being offered HIV tests. We are also funding the Medical Foundation for AIDS and Sexual Health to develop ways of helping GPs and primary care staff to offer HIV tests more routinely.
It is vital that the public health system is versatile and proactive enough to deal with HIV and AIDS. Reference has been made to how this is going to be structured in the future. Ring-fenced public health funding is central to our NHS and public health plans. This will allow us to plan spending on prevention without the money being raided for other projects. In today’s restrictive financial climate, this is a very noteworthy commitment in this area.
Finally, I turn to the concerns raised by noble Lords about the current policy to charge some people for HIV treatment. As we made clear in our formal response to the Committee, we are concluding an internal review of our current policy—I know that review does not please the noble Lord, Lord May, but I hope he will be encouraged in the end—and expect this review to be completed by the new year, including any discussions with the other government departments that have an interest. The review is considering many of the issues raised today. These include the increasing evidence on the public health benefits of early diagnosis and the significant role of HIV treatment in reducing the onward transmission of HIV.
Promoting HIV testing to reduce undiagnosed HIV and late diagnosis remain important priorities for HIV prevention. We would be very concerned if our current policy was to deter people from being tested for HIV, even though testing has always remained free of charge to all. I acknowledge that a small number of vulnerable people will not be covered by the current exemptions and that they may be deterred from accessing HIV testing services because they cannot afford treatment or are confused about the entitlement to free NHS treatment. In considering any changes to our current policy we must avoid creating an incentive for people to come to the UK for the purpose of free HIV treatment, without compromising our overriding responsibility for public health. I hear the powerful case made by the right reverend Prelate the Bishop of Wakefield in this regard. The department’s review has considered many of the issues raised today and we will conclude it by the new year.
I turn to some of the questions that noble Lords have put to me. The noble Lord, Lord Fowler, asked about supporting more HIV testing in general practice. I have made reference to the funding that we have provided to the Medical Foundation for AIDS and Sexual Health, which is working on a three-year project to try to support GPs and primary care staff in offering HIV testing. The noble Baroness, Lady Gould, also referred to that.
The noble Lord, Lord Fowler, and the noble Baroness, Lady Masham, asked about prisoner health. As they know, we do not routinely screen people in prison for HIV just because they are prisoners—rather, we have an active case-finding programme which encourages both prisoners and staff to consider whether their behaviour, current or previous, may have put them at risk of infection with HIV and provides them with an opportunity for testing. We respect the rights of prisoners to accept or refuse testing if they so choose, which reflects normal practice in the wider community.
The Department of Health offender health team has worked with the HPA to improve disease surveillance in prisons. We aim in the new year to disaggregate data on diagnosis made on people in prison. Condoms are routinely provided in prisons to prevent the transmission of STIs. NICE evaluated the evidence of effectiveness of needle-exchange programmes in prisons and stated that there was a need for more research on the added value. It felt that the condom programme was useful.
The noble Lord, Lord Fowler, and other noble Lords, including the noble Baroness, Lady Healy, spoke of the need for a new prevention campaign. The awareness campaigns of the 1980s, which targeted the whole population, were effective in raising the public’s awareness of a serious public health threat at a time when we did not know how HIV would develop or the main routes of transmission. By the mid-1990s, it was clear that men who have sex with men and people from sub-Saharan African countries were disproportionately affected by HIV. That is why, since 1996-97, the Department of Health funded programmes that focused on those communities. This approach is supported by community organisations and others including the HPA. The previous Government also subscribed to this. I hear what noble Lords have said and this will no doubt continue to be assessed on an evidence-based approach.
The noble Lord, Lord Fowler, asked about home-testing kits, to which I think I made reference in my speech. We are reviewing our policy on banning the sale of home HIV tests. We recognise anyway that the current ban is probably not sustainable given that home-testing kits are already available from overseas on the internet. It is essential if there is any change that home-testing kits are quality-assured, including the provision of clear patient information on following up positive or unclear results. It is extremely important that those kits are reliable if they are going to be used at home.
The noble Lord, Lord Fowler, asked about national procurement of ARV drugs, as did others. The Department of Health is keeping this under wider review. We are very keen to ensure that we have clinical collaboration in ensuring there is leverage on price and that experience from procurements on a local and regional basis will be used in evaluating the ability to take this forward on a multi-regional or national basis. It will be under review.
Various noble Lords, including the noble Lords, Lord Lexden and Lord Black, and the noble Baroness, Lady Gould, spoke about stigma. It is of course very much the case still that stigma is an enemy to progress. TB was a stigma in the 19th century and cancer in the 20th century and we have a problem here also when people are unwilling to come forward because HIV has the power to define a person in a way that an illness simply should not. Too many people with HIV still experience shame and isolation because of their diagnosis and that can manifest itself, as we have heard, in discrimination in all sorts of places.
The Department of Health’s new sexual health policy framework planned for next year will consider how key partners involved in HIV care work and others can work together to reduce and challenge HIV stigma. The national HIV prevention programme for African communities, funded by the Department of Health, has contributed to toolkits for faith leaders and communities in this area and we want to develop this further; that is a very important message that comes out of this report.
The noble Baroness, Lady Gould, asked whether the Department of Health would consider the HPA’s Time to Test for HIV report. The answer is yes and this will help to inform our forthcoming sexual health policy framework. She also asked about the public outcomes framework; we are considering responses to this, including a proposal on an indicator on late HIV diagnoses and we will publish that framework very soon. The noble Baroness also asked about tariffs on sexual health; as she probably knows there is ongoing work on tariffs and I will write to her in more detail about this.
My noble friend Lady Tonge expressed her reservations about our plans in general and this issue in particular. I can reassure her, at least in one or two areas. The £2.9 million on prevention that was flagged up as being inadequate excludes work done on prevention by the NHS, for example testing, condom distribution and local health promotion. There is more there than she might have felt. I will no doubt address many of her concerns on the health Bill more widely outside this Chamber, otherwise I am sure we will be here again until at least midnight.
My noble friend Lady Tonge, and the noble Baronesses, Lady Healy and Lady Massey, spoke about PSHE in school; I assure noble Lords that we recognise that children benefit enormously from high-quality PSHE which helps them make safe and informed choices. There is a slimming down of the statutory curriculum to give schools more freedom and space to teach a curriculum which engages pupils; however, we have launched a review of PSHE to identify the core body of knowledge pupils need and ways of improving the quality of teaching. I emphasise that we welcome representations, including evidence and examples of good practice, and I strongly urge noble Lords to feed into that process. As a result of the review we will be drawing up proposals, based on the evidence, and consulting on them.
The noble Baroness, Lady Masham, asked about the future of the HPA; we will be having further discussions about this in the health Bill. In fact, we almost came to it last night but I think it will now be discussed on Monday. As she knows, the HPA, along with a number of other organisations, will be brought together into Public Health England, which will be free to carry out research; it is an executive agency of the Department of Health that will be established in April 2013—always assuming your Lordships pass the health Bill. It can carry out research, it must give advice to the Government—it has that independence; those working will be able to apply for grants and so on. We will work to maintain the excellent quality of the HPA’s current HIV surveillance programme when it transfers to Public Health England.
The noble Lord, Lord Lexden, referred to Northern Ireland, and it was extraordinary to hear of the difficulties that he perceived there. It shows how in many areas, not only geographically but by community, some communities can be particularly difficult and harder to reach than others. Nevertheless, I assure him that the Department of Health works with the devolved Administrations to discuss issues that are common across the UK, such as increased testing, and to share good practice on prevention and care.
There was some concern about possible fragmentation because of local authorities being much more involved now in public health and also the NHS Commissioning Board. Again, we will no doubt return to these issues in the Bill, but the Department of Health is already working, and will be working over the coming year, with key stakeholders to map out the integrated sexual health pathway that will address the concerns raised today. This debate will no doubt feed into those concerns to ensure that work on the issue is joined up.
I have referred to the HIV home testing kits, which the noble Lord, Lord May, flagged up. The noble Lord, Lord Black, and other noble Lords spoke about HIV awareness in the general population being very low. Although we wish to seek improvement in all kinds of areas, it is quite interesting to note that, according to NAT’s Ipsos MORI poll, four out of five adults in the communities that are most at risk were aware that HIV can be passed on by having sex without a condom. In other words, the targeting of information, at least to those groups, is having an effect. I am pleased that that is the case.
The noble Baroness, Lady Massey, the noble Lord, Lord Gardiner, and others asked about the sexual health policy framework. We are seeking to take a life course approach—that sounds like a course that we are offering through PSHE—to sexual health needs, for young people through to old people, including people aging with HIV, and we are working with the Sexual Health Forum to agree this framework. That work is being undertaken at the moment.
The noble Lord, Lord Gardiner, asked about introducing HIV testing and learning from antenatal HIV testing. We have asked the UK National Screening Committee to consider the evidence on making HIV testing more routine. We await its response.
I hope that I have covered most of the points raised. If there are points that I have not answered, I will write to noble Lords. Clearly we have a tremendous amount to think about as a result of this report and there is still more to do. We all have a part to play in keeping HIV high on the agenda, and debates such as this and the coverage today in the media all help to raise the profile of the disease. I welcome the report and the extremely important cajoling from noble Lords today. I am aware that we shall return to some of these areas in the discussions on the health Bill. I look forward to being further cajoled and I hope that we can make progress in at least some of the areas that have been flagged up in this important debate.
My Lords, it has been an excellent debate and I thank everyone for taking part in it. I repair one omission and give thanks to our special adviser, Anne Johnson, who was absolutely first class in her advice.
I said at the beginning that we had the first debate on HIV/AIDS 25 years ago this month in the Commons, and today’s debate was very much in that tradition, with outstanding contributions. There was general agreement on the serious increase in HIV, the central importance of early testing and the importance of combating the stigma.
I thank the two Front-Benchers—the Minister and her shadow—for their contributions. On the Minister’s reply, to use the famous words of the noble Lord, Lord May, there were quite a lot of reviews in what she was saying, but I agree with her that a ring-fenced budget is infinitely preferable to one that can be raided and which we have had in the past. I am encouraged by what she says about charges for people from overseas and on home testing. I am not quite so encouraged by what she says about prisons, which we will have to revisit. As for what she says about a general campaign in getting this message over, I will say only that, as I count it, the noble Baroness, Lady Massey, called for one, as did the noble Baroness, Lady Gould, with all her experience, and as did the noble Baroness, Lady Tonge. The noble Lord, Lord Gardiner, agreed that there should be one, as did the noble Baronesses, Lady Masham and Lady Healy. For what it is worth, I think that there should be one as well, so I think she might find herself in a slight minority in this House.
The right reverend Prelate the Bishop of Wakefield made a quite outstanding speech on the work of the Church of England, to which I pay tribute. I also pay tribute to Bob Runcie, who was archbishop at the time of the 1986 campaign. I agreed with everything he said about charging for HIV treatment.
The noble Lord, Lord Lexden, made an important speech and rightly reminded us of the importance of Northern Ireland and the challenge there. The noble Lord, Lord Rea, talked about HIV not being a death sentence any more but certainly being a lifetime of medication. The noble Lord, Lord May, in a masterclass on the background, history and origins of HIV, made an outstanding contribution. I hope he is right in his predictions on the development of a vaccine. Above all, I think his message was that there is no reason to take the foot off the pedal at this point, which I hope that the Minister heard very clearly.
The noble Lord, Lord Gardiner, made a crucial point in passing about purchasing policy on drug costs. The noble Lord, Lord Black, underlined the vast importance of involving general practitioners in the work, which, as his example showed only too well, has not always been the case.
There will be future opportunities for talking about these things. If I could put in a commercial for the right reverend Prelate and the noble Lord, Lord May, we have an amendment down on testing for overseas visitors and we might conceivably put the Minister under rather more pressure than she was under this afternoon. I thank her and indeed everyone for an important debate on World Aids Day. I hope that we can renew our efforts to combat HIV, which seems to be the message that has come through from the whole debate.
House adjourned at 6.49 pm.