Question for Short Debate
My Lords, I am honoured to lead this debate on what remains a profoundly important issue of public health: tackling the spread of HIV and doing so in a way that over time would allow us to eliminate the virus, which has been responsible for so many deaths and so much suffering. I thank all noble Lords for taking part.
It is just over 35 years since the first reports in the US media of an unidentified illness that seemed disproportionately to affect gay men and to kill them. What was identified as the human immunodeficiency virus, an incurable disease, left a generation of those infected facing certain death. Many more living in its shadows had their lives shaped by it. However, 35 years on we have turned the horror of HIV/AIDS from a death sentence into a manageable chronic condition through the use of antiretroviral treatment. That we can today even begin to contemplate its elimination is a tribute to many brave and visionary people. There is not time to name them all tonight but I want to make two exceptions. The first is to praise the campaigning groups, especially the National AIDS Trust and the Terrence Higgins Trust, which fought tirelessly to keep this issue on the front line of the public health agenda. The second, on this very important day for him, is to recall the vital role that our new Lord Speaker played in the earliest days of this epidemic. As Secretary of State Fowler, he showed enormous courage in tackling the issue, and in doing so saved thousands of lives. Our gratitude to him is eternal.
As we know, HIV is a massive global issue, but it also continues to be one of the fastest-growing serious health conditions here in the UK, with an estimated 6,000 new diagnoses—115 a week—and the rate of new infection is increasing. The year 2014 saw the highest ever number of men who have sex with men diagnosed with HIV. Some two-fifths of people were diagnosed late, long after they should have started treatment. One in six of those with the virus still does not know their status and, for many of the 104,000 people living with HIV, economic hardship, stigma and discrimination are all too real.
So if anything, despite the huge life-saving advances in treatment and care globally, the situation here in our own back yard, particularly with regard to testing and prevention, is deteriorating. We need to take tough and determined action to reverse the tide, and that will require a strategic approach from the Government to tackling every aspect of HIV, with the aim of eliminating the transmission of the virus in the UK and bringing its reign of terror to an end.
For the first time we have the ability to do just that because we have at our disposal the means to stop transmission. As a study published last month showed, it is nearly impossible for someone living with HIV to pass on the virus if they are undergoing effective antiretroviral therapy and have an undetectable viral load. This is of profound importance in producing a strategy for tackling HIV, as we have seen in other countries. A recent study about HIV in Denmark, from the University of California and Copenhagen University Hospital, provided the first unambiguous evidence of the link between high rates of viral suppression and falling HIV incidence. Because of the Danish policy of treatment as prevention, HIV incidence among gay men—still the group most at risk—is now so low, at 0.14% a year, that it almost meets the annual incidence rate that the World Health Organization has set as the threshold for eventually eliminating the epidemic.
There is no reason why such a remarkable success should not happen here, given that we have exactly the same tools to use. To do so, however, three things must happen. First, self-evidently, to cut transmission through the effective use of antiretrovirals, those who have the virus need to know about it and get on treatment. Far too many still do not, with devastating consequences. It is a terrible statistic that over 80% of all HIV transmissions in the UK are from the undiagnosed. We need a step change in the volume of tests that are undertaken regularly by those at greatest risk, and in access to testing. Yes, there has been much good progress and innovation—the introduction of home-testing kits, for example—but it is not enough. There should be much more routine testing of populations at risk, and more support needs to be given to GPs and primary care providers, and indeed to local authorities, to deliver it. Of course there is the continuing need for publicity to explain its importance. I pay real tribute to the extraordinary example set by His Royal Highness Prince Harry, whose live broadcast of his own HIV test has done more than anything else in recent times to raise the profile and make HIV testing the norm.
Secondly, one of the major reasons why people do not get tested is that they fear the stigma of a positive result. The 2015 People Living with HIV Stigma Index revealed a continuing problem with HIV stigma and discrimination, with too many people reporting everything from verbal harassment or physical assault to exclusion by their families. Given the crucial role of stigma in encouraging testing, there is a strong case for a public information campaign to raise awareness and tackle some of the myths that still exist. I also commend to the Government the recent NAT report Tackling HIV Stigma, which draws together international best practice.
Improving education about HIV and sexually transmitted illnesses more generally would also be of real benefit, especially as the increase in HIV incidence among young people is particularly sharp, up 70% in the last three years. It is time to look again at what is being taught about this issue, particularly as Department for Education guidance is now 16 years old. It is really important for young people to understand about HIV and to learn how to avoid it through condom use, but also to be taught the importance of being supportive of those living with HIV and not to fear or stigmatise them.
Finally, while improved testing and tackling stigma would help to identify those who have the virus and get them on treatment, the flip side of the same coin is preventing HIV by using medication to protect HIV-negative people from acquiring it. Again, we have the tools to hand in the shape of pre-exposure prophylaxis, or PrEP. Two studies, including the PROUD trial here in the UK, show PrEP to be highly effective at preventing HIV infection in men who have sex with men. Properly taken, the success rate is well over 90%. This is a revolutionary development in the fight against HIV which can transform the public health landscape. Only this week, new statistics from San Francisco showed that it had cut its rate of new infection by a third in the past three years as a result of PrEP.
Inevitably, as PrEP is a drug linked with sex, it has become the subject of controversy and misinformation. It is argued that contracting HIV results from a lifestyle choice and that it is not appropriate for the NHS to pick up the pieces from such actions. This ignores the point that the NHS is treating, curing and preventing illnesses diagnosed from lifestyle choices all the time—cigarette smoking, overeating, overdrinking or riding a bike without a helmet—and PrEP should be no different.
The other argument, of course, is money, and it is estimated that it could cost up to £20 million each year to provide. However, that figure is dwarfed by the existing cost of HIV to the NHS. The lifetime cost of treating someone with HIV is now in the region of £380,000. As people live longer, that figure will only increase. It is Mickey Mouse economics to refuse to fund effective prevention measures for those most at risk at the cost of just £400 a month—a sum soon likely significantly to reduce—when you set that against the huge cost of treating someone who contracts HIV. If PrEP prevented just a handful of infections each year, it would easily be saving money for the NHS and the taxpayer.
Regrettably, that is now a matter before the courts, but I hope that common sense will prevail and that the original decision in the case—that there is no legal impediment to NHS England providing PrEP—will be upheld. That is vital because it is the last element in the jigsaw alongside effective treatment, more testing, tackling stigma and promoting condom use, which will allow us finally to move towards the elimination of HIV transmission, something genuinely within our grasp.
Earlier this year, the UK, as a member of the World Health Organization, committed to the goal of eliminating hepatitis C—another deadly condition—by 2030. NHS England is now working on plans to make that goal a reality through prevention, testing and treatment. We must have the same ambition for HIV. I ask my noble friend whether the Government will be as bold with HIV as they have been with hepatitis C, commit to the elimination of new transmissions by 2030 at the latest and work with NHS England on a strategy to achieve that.
Thanks to the miracles of genetic science, we now know where and when HIV began. We do not yet know when it will end, but end it must, and tonight’s debate should be a staging post on that journey. In memory of the countless millions who have died, in deep honour of those who have pioneered treatment and dispensed loving care and in solidarity with those living with the virus, let this country have the ambition to show the way in consigning the greatest public health peril of our age to the history books.
My Lords, warmest congratulations are due to my noble friend Lord Black of Brentwood on securing this important and particularly timely debate. The arrival and availability of PrEP, the benefit that it can provide, is something that I hope we all support and strongly urge. Even timelier, as my noble friend pointed out, is the arrival of the first male Lord Speaker. I appreciate that we have had the most distinguished female Lord Speakers, but perhaps it is now time for a male Lord Speaker. We welcome him most warmly to the Woolsack. As my noble friend said, the noble Lord, of all people, deserves enormous credit for his pioneering and courageous campaign, “Don’t die of Ignorance”, the shocking, bold, unstoppable campaign of 1987.
My noble friend mentioned the noble Lord, Lord Fowler, but I want to mention one other person, the then Chief Medical Officer, an eminent physician and epidemiologist, Sir Donald Acheson. Uncompromising, he on the whole thought that Ministers had to be tolerated. As long as he got his way, which he was determined to do, he was happy and easy to work with, and he worked with great principle and distinction. When he first became CMO in 1983, fewer than 30 AIDS cases had been seen. By 1985, two years later, 121 people had died and 10,000 were thought to have the condition. That was the most phenomenal situation: the greatest new public health threat of the 20th century.
Following that was a model of the way in which a Government can decide that they are going on a war footing against a new condition. There was not only the great public health education campaign in the health service. In the voluntary sector, my noble friend paid tribute to the Terrence Higgins Trust and the National AIDS Trust, but there was also London Lighthouse, Mildmay and Landmark. It was extraordinary how the voluntary sector mobilised, rather in the way that all the children’s charities mobilised at the end of the 19th century, holding the Government to account in every area, even in the Diplomatic Service.
I took over at the Department of Health, only being half the man of the Lord Speaker, because he manfully was able to handle both the enormous Department of Health and the then Department of Social Security, now the Department for Work and Pensions. No mere mortal Secretary of State has been able to handle those two enormous responsibilities since then, but he did so with great distinction, so perhaps he will be the man to handle our colleagues’ business here. At the time, there was a real problem internationally because in many African countries, acknowledging the development of HIV and AIDS was thought to be a threat to the tourism industry. I remember going to the World AIDS Conference in Paris in 1990, when the British ambassador to France was proud in his red ribbon, which I think his mother would have been amazed to see him wear. There was a campaign to try to persuade the Russians to accept that HIV/AIDS was a serious problem in Russia. All of us in our different times have had different campaigns to handle this real threat to the human race which so extraordinarily, through the work of our scientists and the pharmaceutical industry, has become a manageable chronic condition, if only it can be identified, diagnosed and treated.
I confess to a tension I held in my term of office, because there was resistance to testing when there was no available cure or treatment. I found it very difficult because, without going into too much detail, any women in the House who have had a baby will know that you are tested for all sorts of different things without any counselling or consent; that is what we are told we have to do. Nevertheless, at the time it was felt that people should not be forced to have assessment or treatment, even if they were going into hospital for a major operation, without counselling.
I tracked down where the source of all that lay and then declared war in the most joyful way on the insurance industry. The ABI used to weight people on their insurance if they had had an HIV test. It did not matter whether the test was negative—the fact that they had been tested meant that they were high risk and therefore should pay the penalty on their insurance premium. Prince Harry would then have been a wonderful example which one could have used. I fear that I was just rather aggressive, insistent and disagreeable, but I am delighted to say that since 1994, ABI policies have been absolutely clear that a negative test is not a barrier to obtaining insurance. All the way through, we see stigma, resistance and obstacles. Together we can unite and work to overcome these many barriers and improve diagnosis and treatment.
There is no doubt that that early campaign was a model which many of us felt proud of internationally. My noble friend has pointed out that we now have more to learn from other parts of the world which are developing their services and approach faster than us, but it remains the case that, as a percentage of the population, France, Spain and Italy each have twice as many people living with HIV as we do in the UK. As my noble friend said, HIV has been responsible for the deaths of over 35 million people worldwide, including 1.1 million in 2015 alone. There is still a long way to go. The WHO reported in 2015 that there were approximately 26.7 million people living with HIV worldwide. In South Africa, Zimbabwe and Uganda, 19%, 14.9% and 7.1% respectively of the adult population is living with HIV. In the UK, it is 0.3% and in the US 0.6%, but any percentage, any number, is something we cannot tolerate without greater effort.
The UN sustainable development goals, established in 2015 to end poverty and fight inequality and injustice, include the commitment to end the epidemic of AIDS by 2030. UNAIDS has set interim targets for 2020 which have been agreed by political declaration by UN members, including the UK. This goes back to the part we can play internationally as well as nationally. Noble Lords may feel that the international is not part of the debate today, but in this extraordinarily permeable world, with mass migration, there is no such thing as looking at the situation in the UK without having regard to the international situation, such is the movement of people. Whatever the outcome of Brexit may be, I doubt we will bring an end to the mass migration of populations.
As my noble friend has pointed out, we are not doing well enough because we are still finding that one in 6 of those 100,000 people living with HIV in the UK now is unaware of it. Only 82% of those with HIV know that they have the condition. If a person is diagnosed a long time after they have been infected with HIV, it is more likely that the virus will already have seriously damaged their immune system. Late diagnosis is a huge contributing factor to illness and death for people with HIV and, if an individual is unaware of the situation, to further transmission. In 2014 it was estimated that 40% of the adults in the UK—
I apologise to the House; such is my enthusiasm to support my noble friend in his excellent work. I had another 40 minutes of speech here, but I will now bring it to an end and simply commend my noble friend and our most distinguished Lord Speaker. I hope to support them in every way that I can.
My Lords, it is a great pleasure to follow my noble friend Lady Bottomley, who is as enthusiastic today as she was when she held office, with such distinction, as Secretary of State for Health.
In the last few years, the House has become accustomed to returning, from time to time, to this grave public health issue. So often the impetus has come from the noble Lord, Lord Fowler, an unwavering friend to all of us, regardless of party, who believe strongly that, though very significant progress has been made, not least as a result of his courageous work in the 1980s, much remains to be done. Above all, the country at large needs to be made aware that the disappearance of stories of heart-rending agony from the front pages of our newspapers does not mean that a great crisis has been almost entirely resolved and that the political agenda no longer needs to make much provision for it. As we have heard, HIV continues to spread rapidly. Public opinion requires a wake-up call. In these circumstances, it surely must be right for us to press the Government to commit themselves firmly to the objective of eliminating this terrible scourge.
My noble friend Lord Black, a close personal friend for exactly 30 years, has performed a signal service by securing this most timely debate. Concerns about the prospects of steady further progress are accumulating to such an extent that serious anxiety now exists among the valiant organisations that work so hard on behalf of actual and potential HIV sufferers. Wide publicity has been given to one of the principal concerns, the delay in introducing a miraculous new drug. It is tragic that protracted action in the courts should have become necessary. It is tragic, too, that some have sought to create tensions between those dedicated to the relief of HIV and others suffering grave hardship from other sources. As my favourite Times columnist, Janice Turner, put it recently, at its heart, the PrEP controversy shows where tolerance of gay lives ends.
I will touch briefly on another of the many sources of concern. It is becoming evident that, as a result of the Health and Social Care Act 2012, the provision of HIV and other sexual health services is in danger of becoming seriously fragmented. The crux of the problem seems to be that the division of commissioning responsibilities between NHS England, clinical commissioning groups and local authorities is confusing and unclear. The damaging implications have been the focus of a detailed inquiry by the All-Party Group on HIV and AIDS. Its report will be published shortly. In the light of it, the Government will surely need to consider how they can ensure that HIV prevention and testing are not set back, particularly at a time of falling local authority budgets. They will also need to clarify where the responsibility for commissioning HIV support services actually rests.
Finally, I will say a word about Northern Ireland, for this debate relates to the whole United Kingdom. I have always been particularly interested in all that happens there, including during the time that my noble friend Lord Prior’s father was its deeply committed Secretary of State, more than 30 years ago. The greatest concern of Positive Life, Northern Ireland’s only HIV-specific charity, is the heavy stigma that still attaches to HIV in the Province. It is pressing for investment in education and the raising of greater awareness in both schools and the wider community. It states:
“There has been little communication with the public since the 1980s and a recent public health advertising campaign did little to address the misinformation and myths that surround the condition”.
There could be no more telling reminder of the continuing need to combat prejudice wherever it arises, a point made repeatedly by the noble Lord, Lord Fowler, and emphasised in his book AIDS: Don’t Die of Prejudice. Policy in Northern Ireland is, of course, determined at Stormont, but its leaders must always be able to look to the Government here for an unwavering, resolute approach to combating HIV and for encouragement to emulate it.
My Lords, I start by thanking the noble Lord, Lord Black of Brentwood, for this timely and important debate. I personally believe that the good work that has happened with HIV prevention and treatment in the UK is now at a crossroads because of public policy. That may not be intentional, but we are at a crossroads. It is going to need political leadership—not the courts—to deal with the increasing number of HIV infections happening in the UK. I shall come back to that in a moment.
It is very nice to see our new Lord Speaker, the noble Lord, Lord Fowler, in his place. His voice has been not just important but critical in the fight against HIV, not just in the UK but across the world, and many thousands and millions of people owe him personal gratitude for the work that he has done.
I am not going to concentrate significantly on the key issues already raised about education, access to testing, treatment and stigma—although I shall come back to the point about stigma. I will major on one issue—that of PrEP, a treatment to stop the replication and transmission of HIV within the UK. It is a treatment widely available in France, the United States, Israel and Kenya, and other countries are using it. It is a treatment that Public Health England modelled: if PrEP were widely available to high-risk groups, particularly men who have sex with men, it could prevent 7,400 cases by 2020.
Noble Lords have already referred to the PROUD study, which showed that the treatment is 86% effective in preventing HIV transmission, and also to the cost. The noble Lord, Lord Black of Brentwood, made it very clear that the lifetime cost of treating somebody with HIV is up to £380,000; the cost of PrEP is £400 a month. That is the equivalent of 83 years’ worth of PrEP to treat one person living with HIV. The economics are not questionable in terms of the costs of PrEP.
So how have we got to the position whereby two parts of government are slugging it out in court over who is going to pay for this preventive treatment? Interestingly, as I am sure the Minister is aware, both parts of government are funded by the Department of Health. Local government’s prevention is funded by the Department of Health, as is NHS England. In July, I asked House of Lords Question 1425—what stops the Secretary of State intervening and asking the Department of Health to commission PrEP? I got a very nice Answer about NICE, but I did not get the answer to my Question. So I will ask the Minister: what legislation stops the Secretary of State tonight telling NHS England that it can commission PrEP? What law stops that? The advice given to NHS England made it very clear that that could actually happen, so I am interested to know why it does not happen, particularly when the NHS national plan puts prevention at the heart of future health care. The whole argument about why NHS England cannot provide PrEP is that it is a prevention measure. If the whole NHS five-year plan is about prevention, why cannot the NHS step up to do this?
There is a lack of political leadership on this issue. It is not a lack of managerial leadership, although there may be with NHS England. There is a lack of direction from the centre to say that PrEP is so important, as the studies have shown, that it should be commissioned by NHS England. I declare an interest in that my partner works for NHS England in specialised commissioning. The work does not have anything to do with this area, but it is an interest that needs to be on the record.
Political leadership is needed because NHS England is taking a particularly aggressive and nasty approach on PrEP and in the arguments for why it cannot be used. A statement by Dr Jonathan Fielden on 2 August, on the day of the judgment—he is the deputy medical director of NHS England and the director of specialised commissioning—was at best unfortunate and at worst showed institutionalised homophobic language by NHS England. I do not use those words simply for effect. I shall read out what the statement said, because it was highly emotive and highly charged and used language that I do not think is worthy of a senior doctor of this country. He said that PrEP is,
“to prevent HIV transmission, particularly for men who have high risk condomless sex with multiple male partners”.
He went on to compare it with not being able to afford treatment for children with cystic fibrosis or children who do not have limbs.
That is clearly an attempt to put it into the public mind that there are deserving and non-deserving people with regard to specialised commissioning, which is not the kind of approach or language we would expect from our National Health Service. As a number of noble Lords have said, it creates a stigma. It is not acceptable for a senior doctor in the commissioning part of one of our national treasures—the National Health Service—to use that kind of language about deserving or non-deserving people. Does the Minister agree with the sentiment or tone of that press release? If not, will he say exactly why he disagrees with what the deputy medical director of NHS England said?
Finally, I will turn to the pharmaceutical company manufacturing the drug Truvada, which is the PrEP drug of choice in the UK. It is clearly about to come off patent, so what discussions have the Government had to reduce the cost? One issue is to do with cost—that NHS England or local government cannot afford the drug. As someone who has been a council leader and is still a councillor, on the issue of local authorities buying the drug, I can go to any sexual health clinic in the country and be anonymous and get PrEP as a preventive measure. If it was down to one local authority to give way on this, everyone would go there, but if it is a national preventive service that we are trying to provide, only one organisation can provide it—the National Health Service. That is why it is important that NHS England is asked to look more seriously and urgently at providing PrEP as part of its National Health Service provision.
I hope that the Government will discuss these matters with the pharmaceutical industry, and in particular with the company promoting the drug, to reduce costs. That way, even if it were to go through NICE, the cost-effectiveness question would be unanswerable.
My Lords, I join other noble Lords in congratulating my noble friend on securing this debate on an incredibly important subject. It is particularly important for me, personally, because just over 23 years ago my parents, my two sisters and I lost my older brother to AIDS. He had contracted HIV some seven years previously, at a time when the whole treatment of HIV and AIDS was at an early stage. I often reflect, as I think of him, that had he contracted HIV even five years later he might very well still be with us today. One thing to celebrate in this otherwise quite gloomy story is that medical advances have meant that HIV is not today the death sentence that it was for my brother Charles but a chronic condition that can be managed successfully.
It is a pleasure to see a new Lord Speaker on the Woolsack and to recall and celebrate what he did at that time in the mid-1980s, in leading that brave campaign of public information on the transmission of HIV. I had a very minor walk-on part as the very young Whip attached to the DHSS, and was in a number of those meetings, although I was not privy to any meetings that the Lord Speaker would have had with the Prime Minister at the time. However, given that the then Prime Minister was a scientist, I like to think that she would have been readily persuaded of the need for urgent action on this issue. At that stage a huge stigma was attached to this condition which undoubtedly deterred many from going through a test. My noble friend Lady Bottomley talked about the action of the ABI and insurance companies, which certainly deterred people from having tests which they would otherwise have done. The role that the current Lord Speaker played at that time is of historic importance and one of which he should be enormously proud.
I wish to make one or two reflections on the points made by other speakers in this important debate. My noble friend Lord Black is completely right: you cannot separate treatment and prevention. In the case of HIV they are very closely linked. We know that the more effective the treatment given to HIV-positive people, the less the condition will spread. There is a huge premium on people with HIV being given effective treatments that are easier for them to take and keep on taking, resulting in the viral load being lowered and therefore lessening transmission. Obviously, the more effective the prevention, the less the need for treatment. We have to think of prevention and treatment not as separate things but the same.
I also have one or two reflections on the vexed issue of PrEP, about which other noble Lords have spoken. I urge my noble friend the Minister to take back to the department the concern of many in this House that this is not a good way for the Government to proceed. We are told that the cost of making PrEP available is some £20 million a year. After the lawyers have had their cut from protracted legal action and several appeals, I doubt whether there would be much change from £20 million. We know for sure that the cost of people becoming infected with HIV is huge, protracted and continuing. Given the way in which our Government operate, we have very much a silo approach to government. This is not a feature of the current Government but goes back to the middle of the 19th century. As the noble Lord, Lord Scriven, said, there is an argument between two different bits of government in this regard but in this case local government is the agent of central government. This is not even a case of different pockets within the taxpayers’ disbursement. The reality is that we are talking about taxpayers’ pounds and they need to be used in the best way possible.
As people live longer, a key factor in the success of our society will be how good we are at keeping people well and living independently at home. As we live longer, more people will live with chronic illnesses. The cost of people being sick and needing active treatment, particularly hospital treatment, is borne not just by the health service as social care costs are involved. As people’s working lives are extended—as they certainly will be—costs will arise from the loss of tax revenues when they are sick. There are additional costs arising from welfare support for carers. These costs are disbursed in different pockets of taxpayers’ funds but also over time. Government is not well equipped to understand or harvest the benefits of savings that will accrue later if we spend modest amounts of money now.
We still suffer from the use of analogue structures. I noticed that Nick Clegg, the former Deputy Prime Minister, was quoted in a newspaper this morning as saying how frustrated he was when he was Deputy Prime Minister to discover that we used analogue structures in the processes of decision-taking that were ill equipped to deal with the pressures and tempo of the digital age. I completely understand and sympathise with that frustration. However, more important in this context is the analogue structure, the model deriving from the mid-19th century, as I say, with a theology of departmental sovereignty that is intolerant of central decision-taking and which makes it unbelievably hard to justify relatively modest expenditure in one part of the state apparatus because the consequential savings are disbursed over many different budgets—in this case both the costs and revenue losses of central government, the cost to the NHS and the cost to local government. We need to find better ways of doing this. I hope that in some way the debate my noble friend has initiated on this subject will help us to make progress towards that.
My Lords, I thank the noble Lord, Lord Black, for initiating this debate. I agree with him and the noble Lord, Lord Maude, that prevention, testing and treatment are part of the same healthcare, which needs to be joined up. We are talking today about prevention, particularly the use of PrEP, the pre-exposure anti-viral treatment to reduce the incidence of HIV. This debate is about the elimination of HIV. We now have the possibility to do that. However, we will fail to do so if we do not address this issue urgently.
Reducing the incidence of and eliminating HIV requires biomedical, behavioural and structural intervention. However, we also have to adopt any new treatments or preventive treatments that come along. I was interested to read what the Health Committee had to say about our public health strategy in its recent report, published last week:
“We welcome the focus on public health but recognise that reducing health inequality will also need to address the wider determinants of health, such as … the environment. This will require cross-Government working. We recommend that a Cabinet Office minister be given specific responsibility … at national level”.
Will the Minister comment on what the Health Committee said? It also said:
“Local authorities face a number of challenges and have had to cope rapidly with major system change. In addition they face real terms cuts … of £200 million … Cuts to public health and the services they deliver are a false economy as they not only add to the future costs of health and social care”,
as exemplified by the cost of treating a patient with HIV as opposed to the cost of prevention, as many others have mentioned.
The committee goes on to say:
“Commissioning for certain services is divided between different bodies, creating the potential for confusion and fragmentation. Where … progress on resolving them is in the best interests of patients and the public. Sexual health provides a clear example of such fragmentation”.
The committee refers to the,
“responsibility for and funding of preexposure prophylaxis, PrEP, for HIV”,
as many other noble Lords have mentioned.
I come back to why PrEP is so important. Others have mentioned the evidence that is now public in two studies, one conducted by PROUD and the other by Ipergay. They both found that PrEP was 86% effective, as has already been mentioned—that is, it stopped 17 out of every 20 HIV infections. They tested different ways of taking PrEP. In the case of the PROUD study, it was a daily dosage. In the Ipergay study it was an intermittent dosage. Despite that, both ways of taking PrEP are effective, so it does not have to be taken daily. Studies with heterosexual men and women equally show that PrEP works well in people who are able to take it consistently. For example, an African study showed that it was 75% effective—that is, it stopped 15 out of 20 HIV infections that would have occurred without PrEP.
PrEP is needed if HIV infections are to start going down in the UK and even to be eliminated, especially in gay men. It is estimated that 2,800 gay men in the UK acquired HIV in 2014—about eight gay men got HIV every day. PrEP is necessary in England because while condoms, testing and treating HIV-positive people are just about containing the HIV epidemic at its current level, infections in gay men are not decreasing, and more and more gay men are living with HIV every year. PrEP will save money, as has already been mentioned, because the cost of treating HIV patients is so high compared to prescribing.
I will also address some of the other issues that have come out in the debate on who pays: NHS England or the local authorities. Instead of having a debate about who pays, we have got confused about the clinical efficacy of PrEP. Absolutely convincing, good studies show that it is highly effective, so that should not cloud judgment about who pays. Concerns have been expressed that it could lead to other unintended consequences; for example, what about condoms and PrEP? There is little evidence that providing PrEP will result in big changes in condom use. People who use condoms carry on using them. People who do not use them, particularly gay men having sex with other men, need to be targeted. Another concern was about other sexually transmitted infections—none of which, by the way, are as serious as HIV. There is little sign that PrEP causes rises in other STIs.
Side-effects were also mentioned, but PrEP rarely causes them. Clinical resistance to the drug was another issue, but there is no evidence that PrEP will lead to many more cases of HIV drug resistance. The cost-effectiveness models have already been mentioned but, in the studies conducted, other, different cost-effectiveness models were used, and all of them were found to be effective.
The bottom line is: given to gay men at high risk of HIV, PrEP will be cost effective or could even start saving money now, especially if it is as effective as it was in the PROUD study and if at least a proportion of users take it intermittently. Even taken intermittently, it is effective. Therefore, there is no reason why we should not introduce this now. The argument about who pays needs to stop. The same taxpayer pays at the end of the day. The only issue is who tells whom to start introducing this treatment. I hope that the Minister will respond positively to that.
My Lords, I too congratulate the noble Lord, Lord Black of Brentwood, on introducing this important debate, and at a particularly serendipitous moment—the very first day of the noble Lord, Lord Fowler, as Lord Speaker. I join with noble Lords who have expressed their admiration for his vision and energy. Not many of us in this House can say that we have saved hundreds, if not thousands of lives; the Lord Speaker did.
One of the subsidiary UN sustainable development goals is to end the epidemic of AIDS—by which is meant HIV—by 2030. UNAIDS has set interim targets for 2020 which have been agreed by UN members, including the UK. Individual nations are expected to develop a national strategy for HIV. However, England has not had one since 2010, which is what we have been exploring in this evening’s debate. Therefore, my first question for the Minister is: why not? We have the tools now. How sad it is to think, as we heard from the noble Lord, Lord Maude, who lost his dear brother many years ago in the early days of HIV infection, that if the tools we have today had been available then, many of us would not have lost close family members and close friends. I too lost a dear friend years ago, in the early days, and I still mourn and remember what a lovely person he was and feel so sad that it happened at a time when research was in its early stages. As we have heard, part of the problem is that although we do quite well on treatment, we are falling behind on diagnosis. Thousands of people have undiagnosed HIV, which means they will pass it on without knowing it. They will also develop associated conditions for which proper treatment will be difficult because of the undiagnosed HIV.
Since April 2013, prevention of ill health generally has been funded from the ring-fenced public health budgets of local authorities. But while NHS funding has been protected, public health has been subject, as we have heard, to repeated government cuts—£200 million in one year—which I and others have lamented in the House many times. We are also told that there will be further cuts of 3.9% a year over the next five years. Government proposals to abandon the ring fence or even fund public health through business rates could further lessen the funds available for this work.
HIV prevention funding is already inadequate to meet changing needs and behaviours and is a fraction of what it was 15 years ago. It is also 55 times less than the amount spent on HIV treatment. In this situation a more effective and widely available prevention strategy is needed. If we can have a strategy on hepatitis C, why can we not have one on HIV? HIV prevention needs a strategy because it requires a combination approach, including traditional forms of outreach, sexual health counselling, condom schemes, harm reduction and of course—I say this particularly because the noble Baroness, Lady Gould of Potternewton, is not able to be with us this evening, and she and I share an interest in this—good sex education in schools, with frank discussion of the risks and of how young people can protect themselves. That is what is needed. Information is power when it comes to health, as the noble Lord, Lord Fowler, proved in his campaign many years ago.
Most HIV sufferers are very responsible about their condition. However, the majority of onward transmissions occur when the transmitter is not aware that he or she has AIDS. The majority of those already diagnosed are in treatment and, since treatment reduces viral load to the point where transmission is almost impossible, new cases are not coming from there; they are coming from people who do not know that they have the disease. Therefore, better diagnosis is essential in defeating the epidemic.
Why, then, when the number of diagnoses is rising, does the NHS refuse to make use of or fund PrEP—the most effective preventive treatment yet devised, as we have heard very clearly—and then appeal the decision of the High Court? I find it very difficult to understand why the NHS wants to spend its money on lawyers instead of treatments. We have to balance the cost of treating a patient pre-infection against the cost of treating the disease if it happens, as well as against the loss to the public purse of the talents of that person and the taxes that would be paid if he or she was fit and healthy and not suffering from HIV.
Prevention has long been at the heart of our NHS. Vaccination was one of the most beneficial discoveries of medical science and has been used over the years to save lives and to save the NHS many billions of pounds. Those of us who were war babies will remember that we had orange juice to increase our vitamin C level when we could not get citrus fruits, as well as cod liver oil to give us vitamins A and D to ensure that we did not get rickets. Programmes such as those prevented a lot of ill health and saved the NHS billions of pounds. Surely, pre-infection prophylaxis of such a dangerous disease corresponds to many of the vaccination and supplement programmes that have saved the lives of babies and children over the years.
For diagnosis to be improved, we need an effective programme of testing, as we have heard, but in 2014-15, contrary to national guidelines, 60% of high-prevalence local authorities did not commission any HIV testing outside the sexual health clinic setting. That is probably because they are so cash-strapped. Putting the financial burden of PrEP on them will not help the diagnosis rate; nor will it help them provide the support that many patients need to take their medication. On the whole, HIV medication requires a high level of adherence and some patients need support and help with that.
So we need a proper strategy, including PrEP being made available on the NHS for people in risk groups, not just for the sake of those at risk but for the sake of the many people to whom those patients might transmit the disease in the future. We must be realistic: risky behaviours happen and we have to live with that fact. Unless we protect from infection those who take part in those behaviours, we fail to protect the whole population. If the international community can help very poor African countries to eliminate a highly infectious disease such as Ebola, why cannot a wealthy country like ours eliminate HIV? We should get on and do it. We know how to do it but, as others have said, it needs leadership.
My Lords, I too very much welcome the debate and the thrust of the argument put forward by the noble Lord, Lord Black, for the elimination of HIV. Like many other noble Lords, I echo the tribute that he made to organisations such as the National AIDS Trust and the Terrence Higgins Trust, as well as, of course, to the noble Lord, Lord Fowler, whom it is marvellous to see in the Speaker’s chair tonight. The noble Baroness, Lady Bottomley, mentioned Sir Donald Acheson, who was the powerful, dynamic Chief Medical Officer at the time, and it is right that we remember the role that Chief Medical Officers have played in this story over many years.
In opening his debate, the noble Lord reminded us that HIV is a global issue. The UK has played a proud role in global efforts but HIV remains a major challenge in this country. The noble Lord, Lord Patel, and the noble Baroness, Lady Walmsley, referred to some of the statistics but, for me, the two most striking are the 2014 statistic showing that more than 6,000 new people in the UK were diagnosed with HIV and that in the same year an estimated 18,000 people were living with HIV but were unaware of their infection. The argument that the noble Lord put forward for testing, and for publicity about testing, is very important, and I hope that the Minister will be able to respond positively in that regard.
That then leads us to the wider issue of tackling stigma. I very much commend the argument that the noble Lord, Lord Black, made for a public information campaign. However, I would link it, as the noble Baroness, Lady Walmsley, did, with sex and relationship education. That is vital but the statistics are frightening. We know that only 40% of secondary schools in the state maintained sector have proper sex and relationship education on the curriculum and that primary schools, academies and free schools do not need to teach SRE. I do not think that that is right. I hope the noble Lord’s department is in earnest discussions with the Department for Education about a proper change in policy in this area.
The noble Lord mentioned that the last government advice around these areas was produced 16 years ago, and it is the same in relation to sex and relationship education and guidance. There is a need for new guidance. A lot of water has flowed under the bridge in those 16 years—not least the introduction of same-sex marriage, the mass use of mobile phones, the internet, and all the issues in social media that that brings in relation to sex and relationships. The Government need to look at these issues very carefully.
I cannot add much in relation to PrEP because noble Lords have covered the subject adequately. The argument for its use is overwhelming, as is the economic case if we look at it in the round rather than from a narrow departmental point of view. It has never been explained why NHS England has taken this perverse point of view. It is equally puzzling why it is carrying on with the case having been comprehensively shown, in the judgment, the error of its ways. I am also puzzled why Ministers have simply not called in the chairman of NHS England and told him to sort his body out. We have had no cohesive explanation as to what this is about.
I completely put aside the argument that this should be for local government. It is a nonsensical argument which no one in the field believes is true. Clearly it is a device for NHS England to avoid committing itself to the expenditure of this money. If it is, it should come clean on it. If you look beneath the emotive language, essentially that is what the press release to which the noble Lord, Lord Scriven, referred is saying. I agree that many of the organisations involved in specialist services feel that blackmail is being undertaken by NHS England at the moment. It is a hard word to use, but when a senior medical official talks about making comparisons between people who indulge in high-risk sex and children with cystic fibrosis, I find it a disgraceful use of words. I am surprised that Ministers have not called that official to account.
We all know that in the current climate hard choices are being made. However, I cannot believe that Ministers do not think that PrEP should be funded. The noble Lord may quote the 2012 Act in terms of the relationship between Ministers and the NHS Executive, but he knows only too well that Ministers are accountable to Parliament and that they should discharge that accountability.
On public health budgets, the noble Lord, Lord Lexden, pointed out one of the problems with the 2012 Act—the fragmentation of effort in this area. There are two issues here: one is that there is fragmentation between local government and the health service; the second is that some local authorities are not taking their responsibilities and that others, particularly those in the big city areas, are having greater pressure put on them because individual patients are going to them because their own local services are not available. This needs review. We should probably work in partnership with the Local Government Association to see whether we can iron out the inconsistencies.
Another problem is the issue of public health budgets, which have taken more than their fair share of reductions as a result of the financial stringency. It makes it difficult to make sense of the overall five-year forward plan of NHS England, which promotes public health and prevention, yet in the budgeting decisions seems to detract from the ability of services to play their full part.
This has been an excellent debate and I endorse the points put forward by all noble Lords. It would be nice if the Minister were to say that it is the Government’s intention and aim to subscribe to the thrust of the noble Lord’s Question and, above all, to sort out some of these problems, particularly the issue of PrEP and the integration of services between health and local government.
My Lords, this has been a very good debate and everyone who contributed to it has had something of interest to say. For me it has been a wake-up call. As has been reflected in a number of speeches, I thought this problem had somehow been sorted out, but clearly it has not been. My noble friend Lord Maude talked about the tragedy of his own brother, and of course for him it was not sorted out. I had thought that since then we had made huge progress, and of course we have done so. I would like also to echo the comments of my noble friend Lady Bottomley about our new Lord Speaker because I can feel his presence glowering down at me on this issue. He said to me not all that long ago that when he took up his new role he would not be able to pester me about the long-term sustainability of the NHS. But I can feel his presence this evening.
My noble friend Lord Black made an outstanding speech, which brought all the threads of the arguments together. Perhaps I may pick out a few of the individual points that have been raised. I know Jonathan Fielden, the deputy medical director at NHS England. He is a very humane, decent and experienced doctor and I think he would be horrified to feel that what he said or how he said it—I have not seen his exact words—would be interpreted in the way it has been. I will write to him with a transcript of this debate and I will leave how he would like to respond to it up to him. I am sure that the last thing he would want to do is leave the impression that he clearly has with the noble Lord, Lord Scriven, and indeed with the noble Lord, Lord Hunt.
My noble friend Lord Maude talked about the cross-government and cross-ministerial issues and how difficult it can be for one department to bear the cost when the benefit is being received by another. It is worth saying that in this case the cost of treatment lies with NHS England, so it seems entirely reasonable that the cost of prevention should also lie with NHS England and that they are kept within the same budget. The noble Lord, Lord Patel, suggested having a cross-government Minister. All my experience of cross-government Ministers has been that they are not all that effective because the silos that we have created in British Government are very strong. The noble Lord also drew a comparison with the strategy for hepatitis C. In a sense we face the same problems dealing with hepatitis C as we do with PrEP and countless other drugs: there is a limit to the money we have available. There is a cost. The noble Lord says that it will all end up with the taxpayer, but the fact is that the taxpayer has given us a certain amount of money for the NHS. We would like to spend a lot of it on treating hepatitis C, on PrEP and on other drugs, but we simply do not always have the money to spend as we would like.
Perhaps I may turn to the speech that I had prepared beforehand. It falls short in some respects of what I have been asked to do this evening. I was struck by that when listening to the quality of the debate, but noble Lords will have to be the judge of my speech more than I can be myself. I am hugely impressed by what has been said this evening and I am sure it will have a big impact outside the Chamber as well as within it.
It is worth restating that the NHS provides excellent treatment and care for people living with HIV. The success of our treatment services means that the UK is already ahead in meeting two of the three ambitions set out in the UNAIDS 90-90-90 target: 90% of people with HIV being diagnosed; 90% on ARV treatment; and 90% viral suppression for those on ARV treatment by 2020. In 2014, of all those attending for care, 91% were on treatment, of whom 95% were virally suppressed and very unlikely to be infectious to others. So we have achieved more than 90% on two of those UN goals.
There are other positive indicators of success. Late diagnosis of HIV, defined as a diagnosis made after the point at which treatment is recommended, has declined from 50% of diagnoses in 2010 to 40% in 2013, but that is still too high. Reducing late diagnoses remains important since people who are diagnosed late have a tenfold increase in the likelihood of death in the first year of diagnosis compared with those diagnosed more promptly. Reducing late diagnosis is included as an indicator in the public health outcomes framework. We are also reducing the proportion of people with undiagnosed HIV, which was down to about 17% in 2014 from an estimated 25% in 2010. More progress is needed to reach the global goal, but things are improving in the right direction.
I had been doing a bit of work with a colleague of the medical director of NHS England, Bruce Keogh. She is a specialist in HIV. She sent me a note. I should say that she is very supportive of PrEP. I would not want to mischaracterise her view. She said that around 80% of HIV infections in men who have sex with men are transmitted by the 20% of individuals who are unaware that they are HIV positive. She tells me that people who are not aware of their diagnosis do not make the same effort to modify their behaviour—for example, the consistent use of condoms—to reduce transmission. Undiagnosed individuals are not on treatment, so have high levels of HIV in their blood, which makes them more likely to pass on the infection to others. There is no dispute between us on the importance of early diagnosis.
Overall, new diagnoses of HIV remain stable, with an estimated 6,151 new diagnoses in 2014, up very slightly from 6,000 in 2013. Of course, we must not be complacent. We know that much more needs to be done to reduce the new number of HIV infections, especially in men who have sex with men, where we continue to see increases in new infections. We also know that transmission is continuing among black African men and women who are acquiring their infection within the UK.
So what are we doing? To really tackle rates of HIV infection we must increase regular HIV testing and promote safer sexual behaviour, particularly condom use. In England, the Government continue to invest £2.4 million each year in national HIV prevention. This funding is allocated across three main areas. First, funding has been allocated to seven new innovative local HIV prevention projects. Activities being undertaken include providing full sexual health screening in saunas and other similar premises, to working with faith leaders to promote HIV prevention and testing among black and minority ethnic communities. A further round of funding for 2016 and 2017 was announced in June this year. The successful projects will be announced in September. We will be building on learning from the year one projects.
Secondly, we know that early testing and diagnosis reduce the risk of onward transmission of HIV. This is the basis of the new HIV home sampling service, which my noble friend Lord Black referred to. It is one of the first of its kind. Some 27,173 HIV self-sampling kits were ordered between November 2015 and May 2016; 13,992 kits were returned, of which 197—1.4%—were reactive. This is encouraging, given the challenge of identifying those living with undiagnosed HIV. Central funding was provided through PHE until January 2016, when the service transitioned to local authorities. Eighty are now signed up to funding the service. PHE will look to build on these numbers.
The third and final strand of funding is from the Terrence Higgins Trust, which has been awarded a new contract to lead and manage a national partnership to deliver information and resources to improve the proportion of individuals in highest-risk populations able to make safe and sustainable sexual health choices and reduce HIV incidence. The programme will focus on social marketing and local HIV prevention activity, as well as monitoring and evaluation activities.
I turn to PrEP, which, as most noble Lords will know, is a new use of HIV drugs that has shown clinical effectiveness in research trials at preventing HIV in people at higher risk of getting HIV. The trials recruited men who have sex with men engaged in high-risk behaviours and people with HIV positive partners—this is the PROUD clinical trial. As noble Lords mentioned, it has been extremely successful. It is important to note that the drug used for PrEP, Truvada, is not yet licensed for this use in the UK. It is licensed only for treatment, not for prevention. However, progress is being made with an application to the EMA and a licence is expected to be granted very shortly.
PrEP should not be seen as a silver bullet. It is only one of a range of activities to tackle HIV. As with any new intervention, PrEP will need to be properly assessed in relation to clinical and cost effectiveness, including how it compares with existing cost-effective approaches, to see how it could be commissioned in the most sustainable and integrated way. The NICE evidence review is considering the published evidence on PrEP and will be published shortly. We know, however, that cost-effectiveness is very sensitive to HIV incidence in the target population and effective targeting; the adherence to taking the medication, which affects clinical effectiveness—although I was interested in the comments of the noble Lord, Lord Patel, about intermittently taking the drug—and the cost of PrEP drugs.
Time is running out. There has been criticism about the handling of this by NHS England. NHS England has provided an assurance that all the proposals considered as part of its prioritisation process will be subject to the same robust assessment of clinical and cost effectiveness and relative prioritisation within the resources available, as well as the impact on people from vulnerable and protected groups.
I felt that the leader in the Times got the balance about right when it said:
“There are reasons, however, to resist the conclusion that HIV prevention should be left to the HIV-positive. Few would be comfortable if the state stepped back from HIV treatment altogether, just as it would be thought indecent of a society to let smokers die of lung cancer or allow the obese to succumb to heart disease on the basis that such illnesses are behaviourally induced”.
There is no intention at all on the part of NHS England or the Government to discriminate in any way against the use of PrEP because of people’s lifestyle choices. I can give that absolute assurance to noble Lords. The appeal is taking place on 15 September and I cannot comment further on the court case, but I can assure noble Lords that the decision on whether or not to use PrEP will be assessed in an absolutely normal way.
I will make just one last comment, which I do not expect some Members of this House to agree with. The decisions about which drugs to prioritise and how to prioritise drugs should surely be made by clinicians and NHS England, not politicians. The noble Lord is shaking his head but that is the whole thrust of the way that the NHS has been set up, and the involvement of politicians in picking one drug against another is surely not the right way forward. I have to leave it as it stands.
House adjourned at 8.43 pm.