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Volume 760: debated on Thursday 5 March 2015

Question for Short Debate

Asked by

To ask Her Majesty’s Government what steps they are taking to meet the continuing challenge of HIV and AIDS.

My Lords, we are nearing the end of a Parliament, which is, perhaps, a good time to assess what progress has been made in this important area, where we are and where we want to be. I start by congratulating the Government on two measures of immense importance. The first was their decision to enable equal marriage, which did a vast amount not only to encourage equality but at the same time to fight prejudice against gay people, which stands against progress in fighting HIV and AIDS literally around the world. The second was to double their contribution to the Global Fund to Fight AIDS, Tuberculosis and Malaria, which brings invaluable help to areas where the death toll has been immense. AIDS alone has been responsible for 35 million deaths around the world since the epidemic began. Frankly, the criticism of the National Audit Office that this was an example of a last-minute decision was about as far from the mark as it was possible to get. It was first promised not by the current Secretary of State but by her predecessor, Andrew Mitchell, and it was, as I say, extraordinarily welcome.

However, in this short debate I want to concentrate on this country and ask whether we are making the progress that we should. In bare statistics, last year there were almost 6,500 new HIV diagnoses. I have just come back from Russia, where I looked at the position there. Indeed, they were kind enough to present me with a medal for 25 years service. It is a damn sight more than I ever get from the Department of Health, I can tell noble Lords, but I fear that it makes me no more sympathetic to their policies, which last year resulted in 85,000 new HIV diagnoses. The figure goes up remorselessly each year.

The temptation is, against that background, to say about Britain, with fewer than 6,500 new HIV diagnoses, what are you worried about and what is the problem? The problem, basically, is that today in Britain there are 100,000 men, women and children living with HIV. That is almost double the number accessing care a decade ago. The National Health Service now spends £860 million a year on treatment and care: almost £1 billion a year. Worst of all, of those 100,000 with HIV, about a quarter are undiagnosed. They do not know that they have the virus and, of course, other things being equal, they spread HIV further. In other words we have, in my view, an undoubted public health crisis and, although we now have antiretroviral drugs which prolong life, we still face the situation which we faced, frankly, in the 1980s, with no cure and no vaccine.

Against such figures, what can we do and what are we doing? The obvious step is to put the maximum effort into prevention. We save £320,000 in lifetime costs for every infection which is prevented. Top of the list in prevention policy is to persuade ever more people to be tested. We are not going to win when we have around 25,000 people untested and undiagnosed in the community. Second to that is that we also need to persuade people to continue with their treatment once they are on it. Too many drop off. The point to recognise, generally, here is that persuasion can work, provided that sufficient imagination is put into the messages and it is backed by sufficient resources. We established that back in 1986-87 with the promotion of condom use and the warnings against shared needles.

The Select Committee that I chaired in 2011—I am glad to see that one of its members, my noble friend Lord Gardiner, is sitting very near me—raised this point with the Government. We said that publicity was inadequate and should be increased, so what did the department do? It cut it further. Today, the department spends about £2.4 million a year nationally on promoting prevention. I repeat that the cost of treatment and care is £860 million a year. It is, frankly, a ludicrous position. We spend hundreds of millions on treating the casualties but next to nothing on trying to prevent those casualties coming about. The defence for this is that, in addition to the national campaign, another £10 million or £11 million is spent by local authorities, although the figures suggest that some of the most affected local authorities are spending next to nothing, if anything at all.

Frankly, making every allowance in the book, the amount we spend on trying to prevent infection is seriously inadequate. Prevention is simply not being given the priority that it deserves. If it were not for the NGOs and the volunteers, our overall national policy would, in my view, be not only in trouble but in tatters.

Therefore, I say to the Government that we need a new campaign to encourage testing, which is the obvious glaring gap in our policy. A few weeks ago, I proposed to the Minister on the Floor of the House that a task force should be set up to explore how to take that forward. The Minister, as is his custom, was courteous—even encouraging—but, frankly, I have heard no more, doubtless because he was planning the detail of the campaign that I set out. Perhaps this afternoon he might come forward with those proposals.

I would like to make two further points. The first is on drugs and harm reduction policy generally. We introduced clean needles and then methadone as a policy back in the 1980s. Methadone is not injected and therefore has an obvious use in reducing transmission. It has been demonstrably successful as a policy. For the last 25 years the number contracting HIV in this country through shared needles has been around 1% of the total—almost imperceptible. Therefore, it is vastly important that that policy is maintained and that there is no lurching away from it. Why do I say, “lurching away from it”? In recent weeks there has been a suggestion that policy is changing. There has been a hint that drug users should be forced into taking treatment—taken not only off injecting drugs but off methadone as well. I say to the Minister that my only advice on this is to go very cautiously indeed.

Of course, we all want to see as many people as possible living a drug-free life, but we should not underestimate the difficulties, which are not going to be reconciled by a speedy review of a few weeks. If you want to see the alternative, again, go to Russia: see the treatment centres there and the attempt at rehabilitation, and look at the figures. They show that after 12 months of treatment and rehabilitation 80% or 90% go back to injecting drugs, and after five years virtually everyone does.

Given that drug users have never really been able to be forced off drugs in the way that seems to be imagined, I think we might also remember that methadone can lead to a recovered life. I remember visiting a clinic in Ukraine, where the doctor in charge basically said just that—that, although some of them had been on methadone for six, seven or eight years, they had at least been restored to society: they held down jobs and were relating to their families again. Basically, I would like an assurance that there is no intention on the part of the Government to turn their back on sensible harm reduction policies.

My last point I make in précis. The latest research shows that the drug Truvada can very substantially cut HIV for men who have sex with men. It prevents HIV infection. Given that men who have sex with men are the group most affected by HIV in this country, it seems obvious that we should develop that policy as quickly as we can. Of course, there are costs to the policy, but there are even greater costs in doing nothing.

My conclusion is this. On a number of issues, such as the increased contribution to the Global Fund, this country has been among the leaders in the world, but I fear that nationally, inside Britain, there are too many gaps in our policy to say that we lead the world. What we can say is that we have some of the finest and most devoted clinicians, NGOs, voluntary organisations and officials. If I had one word of advice for the Government, it would be that Ministers should raise their general policy game to the level of those doctors and volunteers who work so tirelessly in this country to eliminate HIV and AIDS.

My Lords, I begin with what is a normal courtesy but I really mean it. I thank the noble Lord, Lord Fowler, for securing this debate and for his dedication and overwhelming commitment to the issues of HIV/AIDS and non-discrimination. I also want to develop the theme which he outlined. There has been a massive expansion globally of HIV interventions, which has transformed the HIV epidemic and the broader public health landscape, demonstrating that the right to health can be realised even in the most trying circumstances. I remember well the 1980s when, as a gay man, I saw AIDS and HIV portrayed in the media as the gay plague. We have moved further, and onwards, since then. I welcome that move and I welcome this Government’s commitment and their increased funding, particularly for the Global Fund.

There has been much progress in the developing world but I must express my concern at our view, now taken, that we should pull back in those so-called middle-income countries such as South Africa, where there is a high and increasing prevalence of HIV infection. To pull back in those middle-income countries, with this Government leading on asking the Global Fund to pull back in them, will reverse all the good that has been done.

I turn now specifically to the United Kingdom. People with HIV who receive appropriate treatment, as we know, have a near-normal life expectancy and are very unlikely to transmit the virus. Yet the proportion of people receiving a late diagnosis, according to Library statistics, was 47% in 2012. An estimated 22% of people living with HIV in the United Kingdom are unaware of their infection or status. Increasing HIV testing is therefore important so that treatment can be given and onward transmission prevented. Successful prevention depends on a combination of testing, treating and behavioural change. Giving antiretroviral drugs to those at risk could reduce infections. We know that that work is being rolled out in the United States. Work is also being done here on that. I have to express concerns at some parts of the media comparing the cost of this treatment to that of cancer care. When it comes to the health of an individual, comparisons are odious. There are concerns that the separation of commissioning HIV treatment and prevention has negatively impacted patients.

I have specific questions for the Minister but I will come to those shortly. First, let me refer to the National AIDS Trust and its press release of 20 February 2015. In its report, HIV Prevention—Underfunded and Deprioritised, the charity states:

“Not enough money is being spent on HIV prevention to have any impact on the … new HIV infections”—

as was outlined by the noble Lord, Lord Fowler. The trust estimates that,

“in 2014/15 £15 million was spent nationally on HIV prevention compared with £55 million allocated in 2001/02 … In this time the number of people living with HIV has trebled whilst the amount spent on prevention has decreased to less than a third of the original budget”.

This makes no sense whatever. The report continues:

“This estimate is based on information provided to NAT from local authorities in England with a high prevalence of HIV. £10 million was spent in 2014/15 on HIV prevention in these areas—this works out at only 70p per person. The report found that in local authorities with high prevalence of HIV less than 1% of local authority public health allocation is spent on HIV prevention. In 2013 the NHS spent 55 times more on HIV treatment and care in these areas than local authorities spent on HIV prevention”.

According to the chief executive of the NAT:

“Our research found, shockingly, in the 58 areas of highest prevalence of HIV in England, seven local authorities weren’t spending anything on primary HIV prevention or on additional testing services. Worryingly we also found no correlation between level of HIV prevalence in an area and how much was being spent on prevention”.

The report continues:

“The HIV charity is also concerned that more problems are on the horizon when the ring-fencing for the public health budget is removed. Currently, local authorities are given money to provide basic services such as sexual health clinics. In April 2016 they will be able to spend this money on anything”.

To quote the chief executive:

“In the current climate of cuts and pressure on budgets we are extremely worried this money will be used to shore up other areas of council spend. This would be a disaster for public health in this country”.

I now come to my questions. Will the Government address this funding gap, maintain public health ring-fencing and prioritise HIV prevention and testing services? It is three weeks to purdah and the new financial year. The people who are supposed to be managing the national HIV prevention programme, which has been cut in half, have still had no instruction on how the money should be reallocated, let alone spent. They are dependent on getting approval for this from the Department of Health, which means that the charities involved will not even get the four weeks’ notice they need to give notice, in turn, to staff who may lose their jobs. How do the Government intend to ensure continuity of service?

We also need a nationally co-ordinated approach to ensure that we use ever-decreasing resources effectively to reduce undiagnosed HIV and forward transmission. How will the Government ensure a co-ordinated approach when they are not planning and consulting on it? We have a situation where reducing duplication and using money wisely is paramount, yet I am reliably informed that there is a total abdication of any national responsibility for this. Both the Department of Health and Public Health England say they can only advise. It is deeply worrying and I look to the Minister for his replies.

My Lords, I, too, pay tribute to the noble Lord, Lord Fowler, for his leadership on this issue. It was needed right at the beginning of the epidemic, and he gave it, and it is needed again very strongly now and over the next few years. I am going to talk about the situation outside the UK. I have told the Minister that I am not expecting instant replies to the two questions I have, but I hope that they can be passed on to the Department for International Development.

This is, of course a global epidemic and it is in our interest to see that it is contained and managed globally as well as locally. As the noble Lords, Lord Fowler and Lord Cashman, both said, the UK is very influential in this regard. Globally, there has been amazing progress. The epidemic is coming under control in the sense that more people are going on to treatment than there are new infections each year. That is true even in South Africa, thanks to changes in the political leadership there. But it is still devastating and it will be for years to come, so there is much more to do.

In 2013, 35 million people were estimated to be living with HIV/AIDS, of whom less than half had been diagnosed; 13 million were in treatment; 2.3 million more received treatment; 2.1 million more became infected and 1.5 million died. This is an awful picture. In those countries that are particularly badly affected, HIV/AIDS affects everything about health and health services. In South Africa, there is 5% prevalence and there are huge costs to its health system. It will grow and be more costly over the next few years because the WHO has changed its guidelines about when to put people on treatment, and still many people are not yet receiving treatment. This is a big problem. Nevertheless, UNAIDS aims to see what it describes as the end of the epidemic by 2030. That will require increased funding until 2020, and it will decline thereafter.

There are economic issues as well. This is not just about human devastation, illness and death; it is also about the economy. Conservative estimates suggest that the gross national product of South Africa has decreased by at least 1% per year because of the illness of its people. I shall sum up this quick summary of the situation with the South African Government’s vision for 2030—in 15 years’ time—which reflects this reality. They aim to have life expectancy reaching 70 and a generation of under-20s largely free of HIV. That is a great vision from where they are, but it is also rather sad that is what we are talking about. This is a long march. It is a very long-term issue which needs, as I said, champions like the noble Lord, Lord Fowler, to keep the momentum up globally as well as nationally.

What are the key issues? The first is funding. The noble Lord, Lord Cashman, has already pulled out one extremely important point, which is that most people who are affected are now in middle-income countries, and the development agencies of the world, particularly DfID, do not give money to middle-income countries. Even the Global Fund, which is cash strapped, is having to prioritise the poorest countries. This is a wider issue about development because most poor people now live in middle-income countries. Therefore, we cannot think about this as being aid to poor countries; it is much more targeted.

The response of groups such as the International HIV/AIDS Alliance is to try to raise money locally. This is very difficult. I am proud to be the chair of Sightsavers, which works, for example, in India, where we can raise money because you can raise money for elderly people with cataracts or children going blind relatively easily in any society. It is much harder when you are talking about intravenous drug users or men who have sex with men. It is even harder in those countries than it is in our own country. That is the second big point about prejudice and discrimination against the groups that are most at risk. In purely health terms, this affects treatment and prevention and is very counterproductive economically and in health terms—but, of course, there are other profound ethical and human rights issues here that ought to be addressed.

The third issue that people who work in this area tell me about is the loss of priority that is coming to HIV/AIDS because, at the end of this year, we will move on from the millennium development goals to the sustainable development goals, which I support. Let me be very clear: I think that the sustainable development goals, which put an emphasis on the whole of the health system, are exactly what is needed for the future in low and middle-income countries, particularly in the light of things such as Ebola. I think the case is made by Ebola. However, it raises a very serious issue of transition from HIV/AIDS being central to international development to it not being in quite the same position, and how that transition will be managed. The All-Party Parliamentary Group on HIV/AIDS has just published an excellent report, Access Denied, which identifies these and other more detailed issues about problems in the supply chain, monitoring, pricing, R&D and so on.

What should Her Majesty’s Government do? There are many recommendations from that All-Party Parliamentary Group, but I shall draw out three. In asking questions, I want to congratulate the UK on its global leadership on this issue and, indeed, on development in global health generally. It is because DfID is so influential globally that the signals it gives on aid are fundamental. It is supporting the Global Fund. Indeed, it increased its support, and it needs to use its influence to make sure that there is continuing support from other countries. However, its recent decision to stop funding work on an AIDS vaccine is counterproductive. Will Her Majesty’s Government reassess the decision to stop funding an AIDS vaccine, as was proposed by the All-Party Parliamentary Group?

The second issue is that as the needs move to middle-income countries from low-income countries, the funding gap needs to be addressed. It is important not just that external parties such as DfID do something about this but that the countries themselves are encouraged to take up the slack. There were, after all, the Abuja agreements of 2003 and 2001, whereby every African Government committed themselves to spend 15% of their expenditure on health. Only six have yet hit that target. So there is a great challenge that should be put to the middle-income countries.

My second question is: what are Her Majesty’s Government doing to help facilitate continued access to funding for countries moving to middle-income status? That includes encouraging national Governments to play an increased part. My final point is not in the form of a question. The UK is also very influential on civil liberties, and it needs to argue the case about discrimination louder than it has. I know that that is difficult. I have spent a lot of time in Africa. I was recently in Uganda, where I came across a situation where Ugandan doctors were extremely annoyed—with the Americans, I am happy to say, rather than the Brits—because on the one hand Americans from various gay groups were arguing their case and on the other, Americans from various church groups were arguing their case. They said: “The last thing that we need is an American war on our territory”. They likened that to some other things that had happened earlier in their history.

It is difficult to intervene in any other country, but we need to take a stance as a nation about who we are as well as who our friends are and how we work with other people. There is a vital health case to be made here, because this is about health and the economy as well as people’s beliefs about society. The right to health is fundamental. It is also ultimately an economic case. Healthy populations can be productive and prosperous.

Finally, I support the call made by the noble Lord, Lord Fowler, at the end of his excellent book, where he says that there should be some sort of international convention based here in London—something that this Government or a Government formed after May should take up—on protecting the rights of people who are discriminated against in that way.

My Lords, like other noble Lords, I am indebted to my noble friend Lord Fowler for securing this debate today and for giving us, as he said, what is probably the last opportunity before Dissolution to discuss the issue of HIV and AIDS.

It is therefore a fitting moment to pay him the warmest of tributes, as other noble Lords have done, for everything that he has done throughout this Parliament to keep this subject right up at the top of the political agenda, focusing on not just the impact of HIV and AIDS in the United Kingdom but on the terrible scourge of the epidemic in so much of the developing world, which the noble Lord, Lord Crisp, spoke about so eloquently just now. I only hope that at the end of the next Parliament in five years’ time, we will have seen more progress at home but also some of the incredibly important changes that need to take place in the developing world as a prerequisite to tackling HIV and AIDS. I absolutely agree with the noble Lord that the most crucial is the rapid decriminalisation of homosexuality in many Commonwealth countries. Criminalisation is not just a moral outrage; it is a public health disaster, and we must do everything that we can to stop it. I do not want to dwell on that subject today, but it would be good to hear from the Minister that the Government are continuing to put pressure on Commonwealth institutions to live up to their obligations under the Commonwealth charter.

I do not know whether it is a coincidence or whether my noble friend has engineered it this way, but this very week is the 30th anniversary of the approval of the first commercial HIV blood test on 2 March 1985. That was a seminal moment in the battle against what was then an unstoppable horror. Testing meant that the blood supply could essentially be freed of HIV. It also helped scientists and other public health officials to determine the extent of the epidemic. For the first time, it empowered individuals by allowing them to know their status and to protect their partners if they had been infected. What a change 30 years have made. Today, HIV testing is at an all-time high. As I understand it, in the United States, 86% of people who are infected know their status, although that means that an eye-watering 186,000 people in the United States of America do not know that they are infected.

Despite that success, however, rates of infection are still disturbingly high, as we have heard, with 6,000 people in the UK diagnosed in 2013. That figure crosses every age group. I am grateful to the Minister for providing information on that point in a Written Answer to me in the past few weeks. While the majority of people diagnosed in 2013 were in the 35 to 50 age group, 462 new cases of HIV among gay men were in those aged under 24 and 308 were in those aged over 50. Among heterosexuals, 105 women and 47 men were aged between 15 and 24 and 439 were over 50. This is still a virus that respects no boundary of age or background.

Despite the fact that an HIV diagnosis is no longer, as it was 30 years ago, a death sentence—indeed, those infected and properly treated will probably have a normal, healthy lifespan—problems, as we heard during the debate, remain. One is prevention, as my noble friend pointed out, and the other is ensuring ever-higher levels of testing. On prevention, there is a great deal of hope and optimism with the development of pre-exposure prophylaxis presenting incredibly exciting opportunities. Although it has been available in the US for some time, it is not yet here, but should, I believe, be available to all those at risk in the UK as soon as possible. As Yusef Azad at the National AIDS Trust—and I pay tribute to its work—put it to me, the very recent PROUD trial looking at the impact of pre-exposure prophylaxis here,

“is a prevention game-changer which we cannot afford to ignore. As a much needed addition to—not substitute for—condom use, its costs are modest when compared with the lifelong costs of treating someone with HIV if we fail to prevent their infection”.

He is absolutely right, and I hope that NHS England will heed those wise words. Action sooner rather than later will save not just lives, but money too. I support everything that my noble friend said. It must be Mickey Mouse economics to spend so much on treatment and so little on prevention.

Similarly, there has been much progress on testing, as we have heard, but the figures for late diagnosis—still above 40%—are shockingly high. To tackle that, I hope that, among other things, the NICE public health guidance recommending that high-prevalence local authorities commission HIV testing to be offered to all those admitted to a hospital and all those registering with a GP is implemented soon. The Government and Public Health England can play a powerful leadership role, and I would be grateful if the Minister could take the lead today in calling for such important initiatives to be implemented.

Of course, key to both testing and prevention is the ongoing problem of stigma. The National AIDS Trust survey on public attitudes published in December last year still makes very depressing reading. If anything, public knowledge and attitudes seem to be deteriorating, and we need to take action to reverse that, otherwise, all the good work on testing and prevention could be in vain. This is, of course, a matter that goes well beyond central government, but local government, the NHS and schools all have a role to play. The Government can, again, take a lead, and I know that the Minister, who has done so much to help in this area in the past, will take up that challenge and this afternoon energise all those involved to redouble their efforts to tackle stigma.

I am conscious that there are no noble Baronesses speaking this afternoon, undoubtedly because of the clash with the debate on International Women’s Day, but I want to say a word or two about the special issues still faced by women with HIV and to cast a quick glance beyond our own shores to where the situation for people with HIV is still incredibly difficult and in some cases horrific. I commend an excellent report published in the past few months by the Salamander Trust, which last summer conducted a global survey on the sexual and reproductive health and human rights of women living with HIV. Of those who responded in a survey that took place in 94 countries, a shocking 89% reported that they had experienced violence or fear of violence since or because of their diagnosis— in their homes, in their communities and even, most appallingly of all, in healthcare settings. Only 50% of respondents found their healthcare service providers to be well trained and knowledgeable about their condition. A significant number emphasised the challenges of poverty and the resulting strain that it places on mental as well as physical and sexual health. It is little wonder that 80% of respondents reported experiences of depression, shame, loneliness and feelings of rejection.

The report contains a wealth of recommendations about how to improve the specific condition of many women across the globe living with HIV. I hope that the Government will be prepared to support such recommendations. It is an initiative that the Commonwealth in particular could pursue. Progress may be slow—I think that we all understand that—but this is a tangible way in which we could help improve the lot of thousands of lonely, frightened and vulnerable people across the globe.

As so often in debates on this subject, there is much significant progress to applaud and great hope and optimism, but there are problems, too: in tackling stigma in particular. There are serious challenges beyond our shores in tackling the criminalisation of homosexuality, which is turbo-charging the HIV epidemic in much of the world, in dealing with the special problems faced by women with HIV and in ensuring access to healthcare for all who need it. As I said earlier, some of those issues will take time to tackle, but I hope that this debate will again spur us to redouble our efforts both here in the UK and in the wider world one day to bring to an end a horrific epidemic which has already claimed too many lives and will yet claim many more.

My Lords, I, too, pay tribute to the noble Lord, Lord Fowler, for his outstanding work on HIV and AIDS both here and globally, advocating action on prevention, treatment and care while attacking discrimination and stigma. As we have heard in this debate, it is estimated that 35 million people are living with HIV worldwide, with 1.5 million AIDS-related deaths in 2013. Here, 6,000 people were diagnosed as carrying the HIV infection in 2013, and 320 people were reported as having AIDS. An estimated 107,800 people are now living with HIV.

As we have heard in the debate, the UK is one of the world’s leading funders of global health. If we are to move beyond investments to control HIV and towards eradication, we desperately need new tools. Where there is an affluent market, as is the case with adult HIV drugs, we can see significant private investment. By contrast, there are very few formulations of paediatric HIV drugs, where the market is smaller and more heavily based in developing countries. UNAIDS highlights the fact that only 24% of children living with HIV currently have access to HIV treatment. Will the Minister support within government the recommendation from the HIV/AIDS APPG that the UK commissions an economic paper to contrast the total costs of developing and purchasing medical tools using the current R&D model with the costs of a delinked model?

As was asked by other noble Lords, including the noble Lord, Lord Crisp, can the Minister explain how the Government will address the growing problem in middle-income countries whereby funding is being pulled out from all directions, including from the Global Fund, while the pharmaceutical industry continues to expect MIC Governments to afford higher prices for ARV treatment?

In England, the Health and Social Care Act changed the commissioning and monitoring of HIV prevention, testing, treatment and care services. Conditions that require specialist expertise and medication are the responsibility of NHS England, including HIV treatment. In its Five Year Forward View, NHS England states that it plans to let local commissioners share responsibility for commissioning specialised services, incentivising them to direct funding towards local priorities.

Naturally, many patient groups are concerned about the impact on service standards leading to a possible postcode lottery. Their concern is heightened by the fact that there are so many outstanding questions about what co-commissioning will look like and no specific announcements related to HIV. What steps will the Minister take to ensure that the overall responsibility for the provision of services is clearly defined? It is also vital that standards of care are maintained across the country.

As we have heard in this debate, particularly from the noble Lord, Lord Fowler, the Government have funded national HIV prevention programmes since 1996. In recent years, funding for these programmes has been progressively reduced. The current English national prevention programme HIV Prevention England—HPE—has been funded for three years until the end of March 2015. Funding for HPE is £2.4 million per year, which is less than the combined funding received by the previous prevention programmes in 2011 and 2012. In December 2014, the Government indicated that they intended to reduce funding for HPE by 50% to £1.2 million for 2015-16.

That decision was criticised by many organisations, who led a public campaign seeking reconsideration, and shortly afterwards it was reversed and a commitment made to fund the programme at current levels for a further year. Will the reallocated budget support a new programme of work or existing activities that are currently paid for with other budgets?

In addition to the national HPE programme, local authorities should be investing in complementary prevention initiatives as part of their public health responsibilities. However, National Aids Trust research shows that less than 0.1% of local funding allocated to public health in high HIV-prevalence areas is being spent on primary HIV prevention. A total of about 1.2 million men have sex with men and black African adults living in England. A budget of £1.2 million means that the national programme has only £l to spend a year for each person in its target audience. Does the Minister believe that that is enough to achieve the programme’s objectives? The estimated lifetime cost of treating someone with HIV is £360,777. That means that even if a £2.4 million programme prevented only seven new transmissions a year, it would save the NHS money. Is there not a strong case for increasing the funding rather than cutting it?

Finally, I raise the issue of pre-exposure prophylaxis—PrEP—to which the noble Lord, Lord Black, referred. Really impressive research from England was released last week. I read it at the international retrovirus conference in Seattle. The study recruited men who have sex with men and trans women who were at elevated risk of acquiring HIV. They had multiple partners; condom use was inconsistent or irregular; rates of sexually transmitted infections were high; many participants had needed post-exposure prophylaxis before and recreational drug use was common. Participants were generally well-educated and in full-time employment. The fact that the study has demonstrated such a high and statistically significant level of efficacy with a few hundred participants tells us both about how effective PrEP is and how high the rate of infection is in some groups of gay men.

What is being done to ensure that this highly effective HIV-prevention intervention is made available to those who need it without delay? What work is being done to ensure that prescribing of PrEP is appropriately targeted to those who are most likely to benefit from it?

My Lords, I am most grateful to my noble friend for today’s debate on this important issue. All of us know how much he personally has done to ensure that HIV and AIDS remain firmly on agendas, both at home and abroad. I may not be able to give him a medal, but I congratulate him on his book AIDS: Don’t Die of Prejudice, which is very timely and draws on his great experience. It is most welcome given that there is still, as we have heard today, much to do around the world to reduce the stigma and prejudice associated with HIV. I welcome, too, his appointment as a member of the International AIDS Vaccine Initiative.

Compared with many other countries, HIV prevalence in the UK remains relatively low: just under three per 1,000 of the adult population were living with HIV in 2013. Thanks to the Government’s early efforts and the leadership of my noble friend back in the 1980s, we have been spared the higher prevalence rates seen by other European countries and countries in other continents. Our confidential sexual health clinics are doing more and more HIV tests—more than a million in 2013, up 5% from 2012. The NHS continues to provide excellent, high-quality HIV treatment and care for everyone, with 90% having an undetectable viral load. Diagnosed early, the outlook for people with HIV in the UK is very good and most people can expect a near normal life expectancy. We also benefit from government’s sustained investment in Public Health England’s comprehensive HIV surveillance systems.

A 2014 report for the National AIDS Trust by Ipsos MORI reported that overall public support for people with HIV is higher than ever, with 79% of adults agreeing that people with HIV deserve the same level of support as people with cancer. Today, it is much easier to get an HIV test, with virtually all NHS sexual health clinics providing the option of same-day testing results. Like many other countries, we have virtually eliminated mother-to-child transmission of HIV.

However, we are acutely aware that challenges remain in how we tackle HIV. Although overall HIV prevalence in the UK is very low, there are marked variations. In London, HIV prevalence in men who have sex with men—MSM—is much higher, and in 2013 one in eight men were living with HIV, compared to one in 26 outside London. In 2013, the prevalence rate of HIV was approximately 30 times higher for MSM and black African men and women compared to the general population in England. New diagnoses in MSM continue to increase, with 3,250 MSM diagnosed in 2013. Some of this increase will be due to increased testing but there is evidence of increasing risk-taking behaviours, which prevention services and community groups must address, taking into account the latest research and evidence. Achieving sustained changes in risk-taking is challenging for all.

Today, HIV prevention is just as important as it was in the 1980s. Investment in prevention also makes good economic sense, as noble Lords have argued, given that each new HIV infection represents between £280,000 and £360,000 in lifetime treatment costs alone. I will pick up a point made by the noble Lord, Lord Cashman. Although we have excellent NHS HIV treatment and care services, and antiretroviral treatment is highly effective, we are still seeing too many people diagnosed late, after treatment is recommended. This means they are unable to benefit from that treatment and risk transmitting HIV to their partners. Although we have seen improvements, HIV still attracts stigma, which is unacceptable and can deter people from getting tested and, if positive, taking their medication. I listened with care to my noble friend Lord Black on that theme.

In 2013, the department published A Framework for Sexual Health Improvement in England, setting out our ambitions to improve sexual health and well-being for all. These include reducing the rate of sexually transmitted infections, including HIV, using evidence-based prevention and treatment initiatives; tackling HIV through prevention, including increasing access to testing to enable earlier diagnosis and treatment; and tackling the stigma, discrimination and prejudice often associated with sexual health and HIV.

Late diagnosis is included as an indicator in the public health outcomes framework and progress is being monitored. Since we published the framework, we know that HIV testing services are changing and becoming more innovative and focused around the needs of people. A good example of that is self-sampling HIV tests to reduce undiagnosed and late diagnosis of HIV.

Self-sampling HIV test schemes, such as those provided through the HIV Prevention England programme and the 56 Dean Street clinic in Soho, show that new types of tests are acceptable. Importantly, they appeal to people who choose not to use traditional services, and they are picking up undiagnosed HIV. An assessment of more than 4,000 people using self-sampling HIV testing services in November 2013 indicated that the majority had never had an HIV test, yet were reporting high-risk behaviour. It is encouraging that the rates of late diagnosis are improving, albeit slowly—down from 57% in 2004 to 42% in 2013. However, I agree that we need to do more to reduce this. Last year, we removed the ban on the sale of self-testing kits, which will eventually provide further options for testing.

Healthcare services, including general practice, especially in high-prevalence areas, have a key role in offering HIV testing. We were pleased to fund the Medical Foundation for HIV & Sexual Health to produce a web-based interactive tool to make testing easier in primary care. That was launched by MEDFASH last November.

Finally, my noble friend Lord Fowler referred to the prevention budget. We are committed to protecting the national HIV prevention budget for next year. I agree with him that we will need to be more ambitious and innovative in our plans to prevent the spread of HIV. We will be announcing our plans very shortly and these are likely to include a contract with the Terrence Higgins Trust for the HIV Prevention England programme, but we are also keen to be more innovative and ambitious in our response. At that time, the answer to one of the questions posed by the noble Lord, Lord Collins, will become clearer.

I will endeavour to answer as many questions as I can in the time available but I will of course write to noble Lords whose questions I cannot answer today. The noble Lord, Lord Collins, referred to a lack of clarity, as he perceives it, in the overall responsibility for commissioning these services. We recognise that the public health and NHS reforms have presented some challenges for sexual health services, and a number of actions have been taken or are planned. Public Health England has worked with partners, including the Local Government Association, and last summer published Making it Work: A Guide to Whole System Commissioning for Sexual Health, Reproductive Health and HIV. It is planning to undertake a review of commissioning arrangements for sexual health and HIV, similar to the one just published for drugs and alcohol.

My noble friend Lord Fowler called for a new campaign to promote testing. As I mentioned, the level of testing in sexual health clinics is increasing, which is encouraging. More than 1 million tests were carried out in 2013, which was an increase on the previous year. I agree that that level needs to increase, with action by local authorities, especially in high-prevalence areas. We need to offer new ways of testing, as I mentioned—for example, home sampling.

The noble Lord, Lord Cashman, rightly said that engagement with HIV charities was vital in determining the way forward. We see 2015-16 as a transition year towards a longer-term plan for sexual health promotion and HIV prevention. Public Health England will engage with key stakeholders on their new strategy, and my department has been discussing 2015-16 contracts since last November.

My noble friend Lord Black mentioned stigma. I remind us all that it is not just the NHS or the Government who have a role to play here, it is everybody. Community and faith groups, the media and individuals all have a part to play in eliminating HIV-related stigma. We should not forget some of the good news, part of which is that people with HIV are now protected by UK equalities legislation. The department’s framework for sexual health improvement is clear that there is a need to build an honest and open culture, where everyone can make informed decisions and responsible choices about relationships and sex.

The noble Lord, Lord Cashman, referred to the role of local authorities. We believe that local authorities are best placed to make decisions on investment in HIV health promotion services and primary prevention services. Reducing the late diagnosis of HIV is included in the public health outcomes framework, as I mentioned. We have provided local authorities with £8.2 billion of ring-fenced funding for public health, including HIV prevention. I completely understand the arguments in favour of the ring-fence; it has played an important part in ensuring a smooth transition of services and will continue to apply through the next financial year. We have always intended to review the need for it after that. We will do that during discussion on the next spending round, but of course it is for the next Government under the ensuing comprehensive spending review to decide on the continuation of the ring-fence.

In primary care, there is evidence that HIV testing is acceptable to patients and healthcare professionals. My department was pleased to fund the Medical Foundation for HIV & Sexual Health for its HIV testing in primary care project, launched last November.

I just mention the issue of PrEP and Truvada, referred to by my noble friends Lord Fowler and Lord Black and the noble Lord, Lord Collins. The recent results from the trial are encouraging. Further work is needed, and NHS England has set up an expert committee to consider the results of the PROUD study and whether PrEP should be provided by the NHS. Some outstanding issues are being considered in that process which prevent us forging ahead immediately with any action. For example, there is the evidence supporting use in other higher-risk groups, such as black African groups, and whether the recommendation should be for daily treatment, as in the study, or only to protect individuals for a certain high-risk event. The service model is also important here. I can write further on that to noble Lords.

I hope that I can reassure my noble friend Lord Fowler on the continuation of methadone and reducing the harm that drug-taking can cause. Again, I shall write to him on that subject, as I shall to the noble Lord, Lord Crisp, and all those who have spoken about global issues. For now, my time is up. I thank all contributors for their expert speeches, to which I shall respond.

Sitting suspended.