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Volume 768: debated on Monday 18 January 2016

Question for Short Debate

Asked by

To ask Her Majesty’s Government what assessment they have made of the report of the All-Party Parliamentary Group on HIV and AIDS Access Denied.

My Lords, I thank noble Lords who are about to participate in this debate for their patience. Normally when one does that, it relates to a matter of minutes, but in this case noble Lords have had to wait seven weeks. We were originally due to discuss this matter at the beginning of December, but we were bumped—I believe that is the term—because of events in Syria. I will return to that at the end of my speech because there is an interesting point to be made.

However, there is an upside. It means that we waited over the Christmas and new year Recess and one of the more enjoyable things about new year is to open newspapers and discover what has been released under the 30-year rule. This year, it was fascinating to read about everything that the noble Lord, Lord Fowler, did 30 years ago when as Health Minister he had to walk in and explain to Mrs Thatcher why we should spend money to deal with this controversial disease that affected people whom we did not particularly like and so forth. Some of us have long suspected that he was something of a hero in the way that he persuaded one of the most formidable right-wing politicians in the world to do the right thing for public health. I want to look at this report today in that spirit.

The report was compiled by members of the All-Party Parliamentary Group on HIV and AIDS—some of us went to India and others went to South Africa—to look at this key question of access to HIV medicines. It is fair to say that there has been a tremendous success story in the world of HIV in the past 10 years or so. Because of international agreements by Governments and the pooling of resources, we have managed to curtail the impact of this deadly disease in an amazing way. In 2015, we reached a milestone of 15 million people on treatment compared with fewer than 1 million 10 years ago. It is estimated that nearly 16 million people are now accessing anti-retroviral treatments. HIV-related deaths have fallen to 1.2 million in 2014 from 3.2 million in 2005. Modelling—we have to model these things—suggests that nearly 74 million people have avoided acquiring HIV and 36 million HIV deaths were avoided between 1990 and 2013. That is an amazing global public health success. But across the globe, 60% of new infections are among young women, and HIV remains the leading killer of women of reproductive age. Noble Lords will appreciate that the report covers a number of large and in some cases very technical issues, and I will have to skate through just a few of them and hope that other noble Lords in the debate will follow me in.

The aim of the sustainable development goal is to end AIDS as a public health threat by 2030. To do that—to bend the curve of this epidemic—the bulk of progress has to take place over the next five years. If we do not manage to prevent young people, particularly women and girls across the developing world, from contracting the virus, infection rates will get ahead of us. The question for us, as a country that has led the international success to date, is: how will we manage to do that in times of austerity?

I want to highlight some of the things we need to do that emerge from this report. First, we must ensure continued access to affordable treatments. The success that has come about in the past 10 years has partly been due to the work of the Global Fund, but it is also because generic drugs are now widely available across the developing world. As noble Lords will know, the development of new drugs is a very risky business. That is why in highly developed countries it is a long and expensive process, although one of the most interesting things that came out of our evidence sessions is that there is no real relationship between the cost that drug companies attach to new drugs and the cost of producing them. They simply make a market decision about how much money they can make from new products.

However, those generic suppliers have managed to do wonderful things. They have managed to get the cost of the drugs to maintain a person in India for a year down from something like $2,000 per annum to $100 per annum. Those drug manufacturers told us that is now impossible to get those costs down even further. Some parts of the pharmaceutical world need more help. There is no great market for paediatric pharmaceuticals. Therefore, drug companies cannot put any more money into getting the costs of those drugs down. They look to Governments and international players for help in finding ways to make sure that they can keep the supply of those drugs coming.

The second thing is to focus on R&D. This Government have a proud record of making contributions to international research and development. Indeed, in the past few months there has been an announcement from George Osborne that there would be funding via the Ross fund for research into new diseases. It is not clear whether that funding will be in addition to existing HIV funding. Will the Minister commit to making a statement about the transparency of the different parts of funding that DfID and the Government are involved in? This is not a time to start robbing Peter to pay Paul. We have to be absolutely clear about the totals of funding and the projected outcomes.

The third thing that I want to focus on is the replenishment of the Global Fund. As a partnership between Governments, the voluntary sector and the private sector, the Global Fund has done truly remarkable work. One reason why it is so effective is that it focuses much of its work on women and girls. We know that the Government a few years ago led the way internationally by making a commitment of almost £1 billion into the Global Fund. The Global Fund replenishment is due shortly. Will the Government continue to give an international lead to funding that replenishment? It is so important and the most effective way in which to tackle this problem. We need to keep the pressure on other developed countries to continue with their funding and not to let it be dissipated.

I have a final question for the Minister. Middle-income countries have been de-prioritised in terms of UK Government direct aid. We understand the reasons for that. When we were researching the report in India, we heard lots of arguments about how India is now a successful economy that no longer needs to receive UK aid. But as noble Lords are aware, the poorest people on earth live in middle-income countries and the people most marginalised in those societies and most at risk fear greatly that their needs will be missed. I wonder whether the Minister will commit her Government to work with other international donors and funders to find new mechanisms to support those middle-income countries, as they transition away from direct aid from larger countries such as ourselves to a new order in which their own health systems and political systems are better equipped to deal with this ongoing issue. Finally, will the Minister explain to noble Lords where HIV will sit in the DfID strategy from 2016? It seems that it is being folded into a much broader remit on sexual and reproductive health, and there is some considerable concern out there that it is being deprioritised.

If we do not continue to fund public health initiatives such as this one around the world, desperate people will become the migrants that Europe has to help. Please can we maintain what to date has been a very successful track record and not be pushed away from that by the politics of the moment?

My Lords, I congratulate the noble Baroness, Lady Barker, on her speech and on the work that she is doing in this area. I thank her for her remarks and I agree with all the points that she made. Perhaps I may also pay tribute to the chairman of the all-party group at the time, Pamela Nash, who is much missed in Parliament. Many important points are contained in the report on the availability of drugs, on generics and the rest, but the first part sets out the barriers to treatment.

I want to concentrate on one of those, the third barrier which is noted: the ways that key populations are left behind. Those key populations are injecting drug users, men who have sex with men, sex workers and transgender people. The one feature that unites these different groups is that they all suffer discrimination, prejudice, criminalisation and violence, and they are often given little or no political priority. This goes to the heart of the debate, because it all too often defines a position where access to medicine is denied. We are not talking only about developing countries in sub-Saharan Africa. When we talk about injecting drug users, we are quite often talking about countries like Russia, for example.

Globally, and particularly in the developing world, an even more formidable barrier is the discrimination against gay people, which takes its clearest form in the criminalisation of homosexuality. Many countries around the world still have laws, regulations or policies which present obstacles to HIV treatment—more than half the countries of the world, according to UNAIDS—and many of them are, of course, in the Commonwealth. The effect of criminalisation on access to medicine is clear enough. It acts as the strongest possible barrier for the people penalised in this way to come forward, and even more, it acts as a disincentive to prevention.

In their defence some officials around the world, particularly in Africa and India, say that the law is not strictly enforced in some countries, but that does not remotely settle the issue for it ignores the fact that the law also sets standards. That is why we have race relations legislation, for example. The standards in this case, however, are much worse. If the law says that certain acts are criminal, it provides an excuse for people generally to discriminate. It gives the green light to persecution. “The law is on our side”, they say. It encourages whole communities to ostracise gay people and for young men to be forced out of family homes, which happens all too often.

Perhaps I should say in passing, in response to something the noble Baroness said at the beginning of her speech, that I was half amused and half irritated to see in the official papers which were recently released that the internal advice from a civil servant at No. 10 to Margaret Thatcher on the AIDS threat was—I shall précis it—“Leave it to Fowler, Prime Minister. You would do better choosing a children’s cause”. I doubt very much whether that distaste for sexual disease has altogether disappeared in this country.

I want to make one last point. Apart from Governments, the obvious people who should be leading in the effort to fight the kind of discrimination that we face are the churches, and it is sad to note that there is precious little sign of that around the world. Uganda is not the only African country where the church is in fact on the side of repression rather than fighting it. Leaving equal marriage to one side, which we have debated in this House several times, not only would it be refreshing but immensely valuable if the Anglican church could back much more explicitly the right of gay people not to suffer from the injustice and discrimination that at present they do. There are some issues we can debate, but surely not the infringement of the human rights of any individual.

A wind of change in attitude is sweeping through many parts of the world, so surely the aim must be to encourage that wind of change to blow through Africa as well, and at the same time to blow down some of the barriers to treatment that are set out in this valuable report.

My Lords, before I thank the noble Baroness, Lady Barker, and the all-party parliamentary group under the chairmanship of Pamela Nash, I want to make a personal statement of thanks to the noble Lord, Lord Fowler. As a gay man growing up in the 1980s, I think many people on other continents and some in this country thought that we were a group of people who were expendable, but because of the noble Lord’s courage, leadership and determination, we were not seen to be so in this country. There are generations of gay men, lesbians and men who have sex with men, not only here but elsewhere, who owe the noble Lord a deep debt of gratitude, and I am privileged to echo something which, if they had the opportunity to do so, they would say.

I thank the noble Baroness, Lady Barker, for securing this important debate and for her speech, and I will try not to repeat some of the things she has said, but sadly for noble Lords I will repeat much of what the noble Lord, Lord Fowler, has said. Unbeknown to me as I sat down and wrote my speech earlier today, the themes are the same: human rights and civil liberties are at the very core of what we do.

Perhaps I may say, as I have on numerous occasions since I joined your Lordships’ House just over a year ago, that given my experience working with NGOs and UNAIDS and my time as a member of the Committee on Development of the European Parliament, I remain deeply concerned about the Government’s decision to direct ODA away from countries which they define as “middle income” countries. In so doing, and by insisting that the Global Fund should also control and curtail its work in middle-income countries, decades of work and investment in those countries are undermined. Once again, that places marginalised communities and vulnerable key populations, along with women and children, at risk. If we are seriously to make AIDS and HIV history, we will not do so by scaling back our work and our commitments, especially when using such questionable factors as GNI to define general income levels, as referred to by the noble Baroness, Lady Barker. South Africa, a country I know only too well, along with India, are two countries where our approach is unhelpful, to say the least.

Outlined in the excellent material supplied by the House of Lords Library, I note—and, sadly, must confirm that I am deeply alarmed and worried about—the criminalisation of homosexuality in parts of Africa, the Caribbean, the Pacific and Asia, as the noble Lord, Lord Fowler, referred to. These attacks are on fundamental human rights, which in turn affects access to treatment, increases the transmission of the HIV virus, and piles on greater harm with stigma and discrimination, and that it is often done in the name of religious belief is even worse. Those people of all people, preaching tolerance and understanding, should extend it and not control it or rein it in. However, in this regard I welcome the announcement of the most reverend Primate the Archbishop of Canterbury—Justin Welby—who said that he hoped the Anglican community could lead the argument for decriminalisation of homosexuality worldwide. That is not a direct quote. However, I am deeply concerned at the sanctions against the United States Episcopal Church for its open and liberal attitude to homosexuality and its acceptance of same-sex marriage.

My concerns are also, as I said, for other vulnerable groups—men who have sex with men, trans women and trans men, sex workers, women and young children. Access to healthcare, access to medicines and early testing are absolutely necessary if we are to continue the battle against HIV/AIDS, ignorance and stigma. Every year I take the trouble to have myself tested for HIV, and it is incredibly shameful that so many men and women still fail to do so.

We need to create a global research and development fund, as the noble Baroness, Lady Barker, referred to, and transparency, as she said, is key. Where is the funding coming from? Are we robbing HIV/AIDS Peter to pay Paul? We need to invest our way out of this crisis and prepare for the challenges of the future. We need to give access to first-line antiretrovirals and second and third-line treatments. If we ask people to test for HIV, we must assure them that they will receive treatment throughout their lives.

We have seen great progress, but there is much more to be done. There is a new epidemic among men who have sex with men, and it is vital that we make available the preventive method. I can see that the Whip is getting slightly agitated on the Front Bench, so I will move to my conclusion.

Will the Minister outline the plans her department has to ensure that key populations in middle-income countries are not forgotten and are not left behind? Furthermore, can she assure me that the Government will not prevent the Global Fund operating in so-called middle-income countries? I thank your Lordships.

My Lords, of all the issues facing all those concerned with diminishing the spread of AIDS and HIV that are highlighted in this report, one of the most intractable and difficult to deal with is the damage inflicted by stigma. It is, of course, very easy to call for different ways of approaching the problem: more money, for example—the UK is showing a lead in this area, and we should be proud of that—or indeed, bashing the pharmaceutical industry for its charges. I would caution all to remember that these companies are not a public but a private good, however much their drugs may do public good in the end. It is shareholder funds, not government or charitable donations that make such wonderful ground-breaking research possible—going off from paid-for antiretrovirals and spinning off into generics—so we need to work with them, not against them, all the way.

Changing attitudes is just as difficult, expensive and long term as is the research that provides those new drugs and eventually their generic equivalents. This remains a huge challenge, particularly in reaching the poorest and most marginalised, leaving no one behind. Stigma stops people going for HIV tests in the first place, finding support without shame, telling their family and friends or taking the potentially life-saving drugs—all this from the apparent fear of being rejected by those you love the most, of losing your job, of abuse from your community and the rest.

I am told that we urgently need much more systematic stigma-reduction initiatives, particularly in Africa. Who told me this? Well, I listened during the debate on Syria—the one that bumped the noble Baroness’s debate seven weeks forward into a new year—to the most reverend Primate the Archbishop of Canterbury, on the need to do more to protect Christians and other minority non-Christian faith groups in the Near East, citing as his source the work done on the ground by his daughter. Borrowing from the episcopal book, and listening to what the most reverend Primate had to say, I hope that if it is all right for him it is all right for me to lean on briefings that I have had from my daughter who, ever since she came down from university, has worked with the Catholic Agency for Overseas Development. That organisation has been working flat out on trying to help on stigma reduction in Africa since the epidemic began. CAFOD and its partners, of all faiths and none, implement a broad range of HIV-related programmes from providing information on transmission, care, prevention, counselling and spiritual support to those of all faiths and none.

In three African countries—Kenya, Zambia and Ethiopia—back in 2010, CAFOD set up what I believe to be a brilliant and ground-breaking survey into the causes of stigma carried out by local people living with AIDS who, after proper training, asked people about stigma. Its findings were shared very widely. It revealed invaluable information about, say, differences between urban and rural communities or what drives some, rather than taking the antiretrovirals available, to spend what must be to them fabulous sums of money on traditional medicines and on the purveyors of traditional medicines. Our daughter has seen and heard much of the efficiency of this research-based evidence in visits to each of the three countries, going right up to the Eritrean border. She will be there again in March this year, listening and talking in particular to women—Muslim women as well as to Catholic women or those with no religion at all. The more the work of CAFOD and other organisations like it is successful in reducing stigma, the greater will be the parallel reduction in the spread of the epidemic.

Unless stigma is reduced, so that people living with and affected by HIV are helped with advice on how to live—and, most of all, simply how to take their antiretrovirals—then all the money spent and all the scientific advances that are made will be all the less effective. That is for certain. I hope that Her Majesty’s Government take stigma-reduction programmes very seriously indeed.

My Lords, I also thank the noble Baroness, Lady Barker, for initiating this debate as it gives me the opportunity to raise the plight of women with HIV and the particular barriers that they face.

Since the start of the global HIV epidemic, women have remained at a much higher risk of HIV infection than men, with young women and adolescent girls accounting for a disproportionate number of new HIV infections. As the noble Baroness, Lady Barker, said, a consequence is that HIV remains the leading cause of death among women of reproductive age, yet access to HIV treatment remains low. This lack of comprehensive HIV and SRH services means that women are less able to look after their sexual health and are more at risk of HIV infection—a problem that is often made worse for young women as such services are available only for married women with children.

In Kenya, Rwanda and Senegal more than 70% of unmarried sexually active girls cannot receive contraception due to age restrictions. That is not helped by healthcare providers often lacking the necessary training and skills to inform women on how to protect themselves, and on how to use anti-retroviral drugs. While overall access to HIV testing and counselling is improving it is still far too low. Discriminatory social and cultural norms are translated into laws which stop women and girls accessing HIV prevention treatment, care and support services. Women often face stigma and judgmental attitudes to drug use, sex work and homosexuality, resulting in the denial of healthcare.

The situation is that women are being left behind in terms of access to HIV treatment, exacerbated by the high cost of treatment, which creates weak and insufficient health systems and supply chains. This situation could be improved by community and home-based testing as an effective way of reducing costs. There is a correlation between HIV and poverty. Addressing poverty has shown to reduce sexual risk behaviour. A study in Malawi showed how cash transfers that were conditional on keeping girls in schools reduced HIV and STI prevalence, as well as high-risk behaviour. The World Health Organization states that 30% of women worldwide have experienced intimate partner violence or have been physically assaulted. These women are more likely to acquire HIV. Women experiencing abuse are coerced into sex and unable to negotiate practices such as condom use. Very often it seems that the men who are committing the abuse are more likely to engage in risky behaviour. A woman who depends on her partner economically cannot afford to jeopardise the relationship, even when she suspects that he may be HIV positive.

One hundred and twenty five countries have legislation criminalising domestic partner violence, sexual violence, child sex abuse and sexual harassment, but despite this progress the evidence for establishing the crimes is very weak. For instance, only 52 countries recognise rape within marriage as a crime, again making it difficult for women to protect themselves from such sexual violence or negotiate safe sex.

DfID has identified the needs of women and girls as a clear priority for the UK Government, but to date has not explicitly made the connection between the women and girls agenda and the HIV response. I ask the Minister to clarify the position, for addressing HIV and AIDS is not an additional burden or add-on to DfID’s core priorities—rather, it supports them. Will the Minister confirm that HIV is not being deprioritised and absorbed into other conditions? Surely our target has to be to end the epidemic and to increase focus on protection of women with HIV and AIDS, not the reverse. Additionally, the UK aid strategy makes no reference to HIV and AIDS and gives no indication of how the UK intends to contribute to meeting the SDG target.

In conclusion, it is widely recognised that gender equality is vital to an effective HIV response. There needs to be renewed political and financial commitment to eliminate gender inequalities and gender-based violence, and to increase the capacity of women and girls to protect themselves from HIV. We cannot forget, as so often seems to happen, that, in the words of the executive director of UNAIDS:

“This epidemic unfortunately remains an epidemic of women”.

My Lords, I join others in congratulating the noble Baroness, Lady Barker, on securing the debate, which is quite literally about life and death, and therefore one of the most important subjects with which this House can deal. The report is extremely compelling and I support without hesitation its recommendations, particularly on the issue of paediatric treatments, which the noble Baroness mentioned briefly. There is something horribly cruel about babies and infants being infected with HIV, which is compounded by the poor levels of care available. The figures from the WHO and UNICEF, which show that by 2020 some 1.9 million children will require HIV treatment, are heart-breaking. The chances of even a majority of them getting such treatment are slender, but, as UNAIDS makes clear:

“Without treatment, about one third of children living with HIV die by their first birthday”.

New energy and focus need to be brought to bear on this issue, and policy and programming given the same priority as the key populations.

The point I want to highlight is one already raised by my noble friend Lord Fowler and the noble Lord, Lord Cashman, and which we have debated with great passion on a number of occasions in this House: the link between the criminalisation of homosexuality and the spread of HIV. I promise noble Lords that the three of us have not colluded on our homework, but I hope that the message is clear. For, with the best will in the world, HIV treatments, when they are available, are of use only if people are prepared to come forward, get tested and then take the drugs. But in far too many parts of the world—the majority of them, as we have heard, shamefully in the Commonwealth—criminalisation and stigma, which my noble friend talked so powerfully about, mean that HIV spreads more quickly, that safe sex practices never take root because there is no education on the subject, that prevention programmes simply do not exist, that people at risk do not get a test, and that the treatments central to this report are therefore simply not an option.

The evidence is overwhelming, as the Human Dignity Trust and others have documented in compelling work on the subject. The most telling statistic comes from UNAIDS, which found that HIV prevalence among men who have sex with men rises from one in 15 in Caribbean countries where homosexuality is not criminalised to one in four where it is. In countries where homosexuality is unlawful, the risks for the entire community are heightened because trans women and men who have sex with men have concurrent relationships with men and women, with fatal consequences, as the noble Baroness, Lady Gould, said in such a compelling way.

As I have said before on this issue, criminalisation kills. We have heard about the sterling and extraordinarily courageous work of the noble Lord in the mid-1980s, when the phrase that very much came to the fore was, “AIDS: Don’t die of ignorance”. Now it would be “AIDS: criminalisation kills”, so, “AIDS: Don’t die of criminalisation”, might be a better way of looking at it. Whether or not there is widespread access to effective treatments, the HIV/AIDS crisis can never be brought under control and the dream of an AIDS-free world by 2030, which the noble Baroness, Lady Barker, talked about, will remain impossible while consensual same-sex relationships remain criminal in so many parts of the globe.

That has massive implications for public policy and for the brilliant work going on in the area of treatment. The UK is quite rightly investing millions of pounds in managing and ameliorating the HIV/AIDS crisis in the developing world, yet we are still prepared to accept the criminalisation fuelling it. While criminalisation exists, much of this money, invested with the best of intent, is being wasted. Policy needs to be joined up. That needs to start with our leadership role in the Commonwealth since 40 of its 53 members criminalise, in a most shameful breach of human rights. Some 60% of all people with HIV currently live in the Commonwealth, yet it is still a subject which, I say with some irony, dare not speak its name. At a presentation entitled “Getting to Zero” at the Commonwealth Secretariat on World AIDS Day in December, there was not a single mention of the link between criminalisation and HIV, despite the overwhelming empirical evidence, nor even mention of men who have sex with men and trans women as high-risk groups. Progress will never be made while the Commonwealth has its head in the sand, yet until progress is made on this front important issues surrounding access to treatment are, in so many parts of the world, largely academic.

In commending this report, which contains so many vital recommendations that need to be acted on, please let us continue to remember, as we have heard from so many speakers today, that one of the most basic points about why HIV continues to spread and why treatment will never be as effective as it can be is down to criminalisation of gay men and women. Action on treatment will never be sufficient on its own until we make progress on that agenda too.

My Lords, I, too, congratulate my noble friend Lady Barker on eventually securing this debate. I have been getting to know a new friend over this weekend and I have been telling him about my life and my experiences. One of the things that I spoke to him about was the fact that, in the late 1970s and early 1980s, mainly because of social pressure, I was dating women rather than men, and in 1983 I married one. Had it not been for that social pressure, for my marriage to Mary and for living faithfully in that marriage for five years, I probably would not be here addressing noble Lords this evening—that, and the pioneering work of the noble Lord, Lord Fowler, when he was Health Minister. That is personal for me.

Thankfully, medical science has moved on from those days when there were so many—too many—deaths in western countries because antiretroviral drugs were in their infancy and not always effective. The problem then was lack of scientific knowledge. Today, lack of funding is causing unnecessary and completely preventable deaths, together with prejudice and discrimination, as many noble Lords have already said.

The way the pharmaceutical sector works is that new and effective medicines are developed at significant cost on the basis that the companies will see a return on their investment through high drug costs. Once the costs are recovered, there is the opportunity to produce generic drugs at lower cost. This is the situation that we are in generally with primary treatment for HIV. In many cases, people can be successfully treated using primary treatment at low cost, as my noble friend Lady Barker said. But the virus develops resistance and sometimes secondary and third-line treatments are necessary—but these drugs are too expensive for many low and medium-income countries to afford.

As many noble Lords have said, the other issue is high-risk groups where HIV is most prevalent: intravenous drug users, men who have sex with men, sex workers and the transgender community—people who not only face the highest risks but, because of society’s prejudice in some countries, are the least likely to get treatment.

I am sure your Lordships will remember the UK Government campaign, “Don’t die of ignorance”, that the noble Lord, Lord Fowler, spearheaded. In a different sense, perhaps, people are still dying of ignorance: the ignorance that results in prejudice and discrimination. It is not just these high-risk groups that should have an equal right to treatment. The fact is that they infect others, not least unborn and infant children. As my noble friend Lady Barker said, 60% of new infections are among women. The excellent all-party group report on HIV and AIDS put it so well: this is not someone else’s problem; this is everyone’s problem.

Medical science has come a long way. For those who are being successfully treated for HIV, and whose levels of HIV virus in their bloodstream are so suppressed by medication that they do not show up in tests and whose immune system is healthy, it is almost impossible to pass on the infection to others. It is vital that people know whether the treatment they are receiving is effective, so access to regular viral testing is also an essential part of the solution.

There are new developments all the time. I am currently part of a clinical trial in the UK of pre-exposure prophylaxis, or PrEP, where a daily dose of medication can prevent HIV infection in the first place. The results of the trial so far show that it is a highly effective way of preventing further HIV infection—but again, whether it becomes available on the NHS is another cost question.

It is Oscar season and again this year the Elton John Aids Foundation will be holding its annual Oscar viewing party to raise money to fight HIV. But charities such as this—and there are many of them—that are trying to raise funds to eradicate HIV, which is now scientifically possible, cannot win this fight alone. They need Governments’ financial support and willingness to join them in the battle, which will help such charities to raise funds themselves.

This is an important report at a time when we need to renew our commitment to an HIV-free world. All it needs is the political will to bring this about and I urge the Minister to ensure that this Government show leadership in committing the necessary resources and encouraging others to follow their example.

My Lords, I, too, thank the noble Baroness, Lady Barker, for initiating this debate. The APPG report demonstrated progress on access to anti-retroviral therapies. The latest figures released by UNAIDS show that nearly 16 million people now have access compared with fewer than 1 million just 10 years ago. However, 22 million people living with HIV still do not have access to ARTs and an incredible 19 million remain unaware of their status.

Since the report’s publication we have had DfID’s new development strategy and the Government’s strategic defence and security review, which alongside the Autumn Statement pledged significant new funding for global health. These strategies highlight the need for better integration between DfID and the FCO to address human rights abuses and, as noble Lords have pointed out, criminalisation of LGBT groups, which, as the noble Lord, Lord Fowler, said, contributes to access to treatment being denied. Can the Minister outline the process ensuring cross-Whitehall policy coherence so that development needs are not undermined by other political considerations?

SDG objective 3.3 is to end HIV/AIDS, TB and malaria by 2030, and 2016 marks the beginning of the next replenishment phase for the Global Fund. The Global Fund estimates that the combined external funding required to beat the three diseases in line with the SDGs will be $97 billion through to 2019. This will come from affected countries themselves and the countries contributing to the Global Fund, which will need some $13 billion over the period—slightly less than for the last replenishment period. As noble Lords have said, the UK has a proud record on the Global Fund, contributing up to £1 billion over the last replenishment period, making it the third largest contributor.

In addition to the Global Fund commitment, I welcome the Autumn Statement launching the £1 billion Ross fund with the Gates Foundation. The Opposition will hold the Government to account on how that co-operation is working in the months and years ahead. That £1 billion includes a £300 million package on malaria and £115 million to develop new drugs and insecticides for malaria and TB. I welcome that attention given to TB and malaria but, as noble Lords have indicated, the funds do not yet specifically cover new tools for HIV and AIDS, either for treatment or prevention. It is crucial that the Government recognise the importance of new and better tools to prevent and treat HIV to ensure that investments in eliminating the disease are ultimately sustainable and successful.

If the aim of ending AIDS as a public health threat by 2030 is to be achieved, the bulk of the progress must be made in the next five years, as we have heard. The joint UN programme has accepted fast-track targets. These are that 90% of people living with HIV know their status; 90% of those people are accessing treatment; and 90% of those on treatment are virally supressed. That would significantly reduce the number of onward transmissions. Achieving universal access, however, remains a challenge. As my noble friend Lord Cashman said, affordable first-line generic drug treatments are denied to middle-income countries, which are excluded from licensing deals and are forced to buy at inflated prices, making second and third-line ARTs prohibitively expensive. The Global Fund must be allowed to provide critical bridging finance for middle-income countries. We cannot simply pull out and leave Governments to fill the gap when we know that they will not. So will the Minister commit to looking at providing technical support before funding is withdrawn to ensure that programmes do not collapse after withdrawal?

My Lords, I join all noble Lords in thanking the noble Baroness, Lady Barker, for securing this debate. I also thank all noble Lords for their excellent contributions. The noble Baroness referred in her opening remarks to the pioneering approach of my noble friend Lord Fowler in ensuring that the debate around HIV/AIDS had considerable resource at a time when it was very difficult to discuss such matters.

As the noble Lord, Lord Collins, rightly said, UNAIDS estimates that nearly 16 million people are now on treatment but, despite this significant progress, 1.2 million people are still dying every year because they lack the essential drugs and prevention services.

As noble Lords have mentioned, the Access Denied report raised important issues. The UK remains committed to addressing these issues, getting to zero and ensuring that no one is left behind. The scale of the UK’s financial commitment is testament to this. We remain the second largest international donor on HIV prevention, care and treatment and over the period 2014 to 2016 have pledged up to £1 billion to the Global Fund—a commitment that is yielding real results, with the Global Fund providing more than 8.1 million people with life-saving treatment.

As noble Lords have said, no child should be born with HIV, and when this happens it is a clear failure of health systems. In response to this, the UK spent £360 million in 2013-14 investing in strong and resilient health systems. With considerable UK support, the Global Fund has reached 3.1 million women with services to prevent transmission of HIV to their babies.

The APPG’s report expresses concern over the affordability of second and third-line antiretroviral drugs. As a number of noble Lords raised that point, I want to assure them that the UK is heavily investing in tackling this important issue through our support to the Global Fund, UNITAID, the Medicines Patent Pool and the Clinton Health Access Initiative. Our support to the latter has helped secure more than $1 billion-worth of procurement cost savings. These savings have been reinvested to allow millions more to access treatment.

The report also highlights the importance of viral load testing. The cost of viral load testing remains a major challenge, and so my department is supporting a deal with Roche at $9.40 per test, a 40% reduction for many countries. In low and middle-income countries, this equates to an average price cut of more than 40%. While the agreement is by no means the final answer, it does represent an important step.

A number of noble Lords referred to middle-income countries. We agree with the report that the withdrawal of international financial support must be sensitive to the needs of key populations. At present, approximately 50% of the Global Fund’s resources are targeted at middle-income countries, and we continue to use our place on the board to encourage such countries to focus on key populations. At the same time, we must remember the needs of lower-income countries, which simply cannot afford to provide universal access to HIV treatment and HIV prevention services on their own.

It is clearly unacceptable that every two minutes an adolescent girl is infected with HIV and that 1,000 young women are infected every day, the vast majority of whom are in sub-Saharan Africa. DfID—my department—puts the empowerment of girls and women at the heart of everything we do. Nearly 60% of Global Fund resources are invested in programmes that reach women and children, and we have committed more than £100 million to programmes to tackle gender-based violence.

Sadly, stigma and discrimination continue to drive key affected populations underground—populations such as men who have sex with men, sex workers, prisoners and injecting drug users—inhibiting prevention efforts, increasing people’s vulnerability to HIV and reinforcing barriers to accessing medicines. Tackling such stigma, and securing evidence-based HIV prevention and treatment for key populations, remains one of the UK’s HIV policy priorities. The UK is therefore proud to be a founding supporter of the Robert Carr civil society Networks Fund, through which we support these particularly vulnerable groups.

We are also one of the world’s leading funders of research and development into infectious diseases. In 2014-15, we spent at least £86 million on health research. The innovative new Ross fund gives us an opportunity to continue this important investment, developing, testing and delivering a range of new products for infectious diseases which affect the poorest and most vulnerable people in the world.

A number of questions were raised, and I will endeavour to answer as many of them as possible. If I run out of time, I promise to write to noble Lords. I will start by giving noble Lords a personal commitment. I have spent as much of my life as I can remember fighting all kinds of discrimination. For me, any form of discrimination needs to be tackled head on. My role gives me a really privileged position from which I can push hard. I work with the noble Baroness, Lady Barker, and we share some common areas which need a cross-party political response. I hope that, where noble Lords feel they can offer support, they will undertake to come forward. These issues are not for any one political party; they are for us all to come together on.

The noble Baroness, Lady Barker, and other noble Lords asked whether the Ross fund was new money or whether it was robbing Peter to pay Paul. It is a new fund—a new £1 billion research initiative that will focus on malaria and other infectious diseases. It will report regularly to a cross-government assurance board. I do not have enough detail to give much more information at the moment, but as more details come forward I will be very happy to share them with noble Lords who are interested.

A number of noble Lords mentioned the difficulties that middle-income countries will have if funding is taken away. I hope I have demonstrated that we do support those countries—50% of the funding goes there—but we need to ensure that we focus very much on the low-income countries with high burdens. Where the key groups are in middle-income countries, our support must be directed and targeted to them. However, we support the Global Fund’s new funding model, which will focus where the need is greatest. We are pressing the fund to ensure that marginalised groups in middle-income countries are prioritised and that innovative mechanisms are developed to address their needs.

The noble Lord, Lord Collins, spoke about giving assistance to middle-income countries. One area in which we offer programmes is working with the Governments of middle-income countries to ensure that they know how to target those key populations.

The noble Baroness and others asked where HIV sat within the overall strategy. It is a high-level strategy and we do not name every disease. However, I hope it reassures noble Lords that we remain the second biggest international funder of HIV prevention, treatment, care and support. We are not reducing our presence, but we need to focus on how to make others join their pledges and deliver with as much enthusiasm and commitment as the UK.

My noble friend Lord Black and other noble Lords rightly highlighted the issue of paediatric treatment. Besides our contribution to the Global Fund, we have provided €60 million annually to UNITAID to continue its pioneering role in paediatric HIV diagnostics and treatment.

My noble friend—along with my noble friend Lord Fowler and the noble Lord, Lord Cashman—also highlighted the link between the criminalisation of homosexuality and the spread of HIV. We continue to urge all states with laws that criminalise homosexuality and discriminate against people based on sexual orientation or gender identity to urgently review their laws. I was proud to chair a round table on LGBT issues at the Commonwealth Heads of Government Meeting in November. It was really encouraging to see that the meeting was so well attended. I can assure noble Lords that, in my role, I am determined to ensure that we work towards much more inclusive communities. Wherever I go, the issues around inclusive responses and challenging those countries are always on the agenda.

I think that I am fast running out of time. As I have said, approximately 50% of the Global Fund resources go to middle-income countries.

My noble friend Lord Patten talked about stigma, as did other noble Lords. Given the sensitivity of this issue in some countries, our approach to LBGT rights is strongly guided by local civil society in each of those countries. We work on a case-by-case basis, building bottom-up pressure for change.

I have got the message to say that my time is up, so I would just like to reiterate my thanks to the noble Baroness, Lady Barker.