§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Jamieson.]
1.24 am§ Dr. Gavin Strang (Edinburgh, East and Musselburgh)I am grateful for the opportunity to initiate this short debate on HIV and AIDS in the United Kingdom. HIV is the most important communicable disease in the UK. That is not my judgment, but that of the Public Health Laboratory Service Board. Since AIDS was first identified in the UK in 1981, a total of 32,200 HIV infections have been diagnosed. There have been 12,800 AIDS and HIV-related deaths, and more than 16,000 people are currently living with diagnosed HIV.
Thirteen years ago, I introduced the Bill that became the AIDS (Control) Act 1987. That Act requires health authorities to report annually about the disease—how many cases there are, and what the authorities are doing to help people with HIV-AIDS and to prevent the spread of HIV.
In introducing the Bill, I had three main objectives: first, to give us an understanding of the epidemic in each area of the United Kingdom; secondly, to tell us what health authorities and local authorities were doing on the ground, as a monitoring tool and in order that we could learn from best practice; and finally, to help ensure that there was a focus at national and local level on this terrible disease.
Much has changed since the Act went through Parliament. The profile of the disease is ever-changing. Sex between men remains the major route of transmission in the UK, but sex between men and women was the transmission route for more than a third of all newly diagnosed cases last year. The majority of those cases were acquired abroad, usually in sub-Saharan Africa.
One of the biggest successes has been in slowing the spread of HIV through intravenous drug use. Although that was once the major route of transmission in Scotland, the number of new cases of HIV transmitted by intravenous drug use has declined from 241 new diagnoses in 1986 to 25 last year. Such improvements can, however, be swiftly reversed, and indeed have been in other European countries.
There has also been tremendous progress in treatment for people with HIV and AIDS. For many years, AZT was the only drug licensed for use by people with HIV and AIDS. Now, there are several different classes of drugs that can be used in combination to prevent the onset of AIDS and to help prevent illness for people with AIDS.
These new treatments have brought their own challenges—challenges for individuals on tough drug regimes; challenges for our health services, which must cover the costs; and challenges for the significant proportion of those living with HIV who are unable to benefit from the new therapies. In addition, the success of the new treatments in prolonging life will result in significant rises in HIV prevalence, and increasing numbers of people undergoing long-term treatment.
Just as the profile of HIV-AIDs has changed, there is now a strong view among those working in the field that 12 years on, we would benefit from updating the workings 795 of the AIDS (Control) Act 1987. The all-party parliamentary group on AIDS concluded in its recent inquiry that the Act should be
reformed into a more meaningful tool of accountability and audit, related to progress in implementing local strategies".I hope that if my hon. Friend the Member for Walthamstow (Mr. Gerrard), who chairs the group, catches your eye, Mr. Deputy Speaker, and the Minister is willing, he will have a chance to take part in the debate.I propose four changes to make the workings of the 1987 Act as relevant as possible to HIV-AIDs in the UK today. First, when the 1987 Act was going through Parliament, there were fears that people in low-prevalence areas might be identified by the press, and it was decided that where the number of cases was fewer than 10, an asterisk would be used instead.
However, the climate has changed, and it is felt that as long as confidentiality can be guaranteed, it would be useful to amend the 1987 Act to enable reports to publish the number of cases under 10, for epidemiological purposes, for the purpose of studying the allocation of resources between districts, and for the purpose of studying HIV-AIDS strategies among districts.
Secondly, the reports should include data for those resident in a health authority area, as well as those merely diagnosed or appearing for services in the area. I understand that a London local authority believed that it had just six people with HIV living in its area, but it commissioned research which revealed that 179 cases of HIV were readily identifiable as living within that authority's boundaries. The authority had been unaware of those additional people, as they had been travelling elsewhere for treatment.
Making available data by district of residence would help in compiling a more comprehensive picture of the changing nature of the disease in different areas. It would provide a more accurate basis for planning and monitoring prevention work and social service work, preventing health authorities and local authorities from having a false sense of security about the amount and type of work that they should have under way. Also, it would allow more meaningful scrutiny by interested parties of the work of local authorities and health authorities. Again, however, we must be able to guarantee confidentiality.
Thirdly, it is vital that the Government money provided to prevent the spread of HIV is spent effectively, but there are fears that HIV-AIDS funds are not being spent effectively on the people most at risk of getting HIV. It is the job of the AIDS (Control) Act reports to tell us what is being done, but there is concern that the Act and the Department of Health guidance do not do enough to ensure that health authorities account properly for their use of their HIV-AIDS funding, and that there is perhaps too much flexibility for health authorities to apply their own rules. The National AIDS Trust has said:
The returns made under the AIDS (Control) Act are not an effective tool to promote accountability at a local or national level.It is important that health authorities show how their prevention spending reflects the local profile of the disease. I suggest that the Act should be amended to require the reports to show total expenditure on recognised epidemiological target groups. Those groups should be identified in the Department's guidance and should be mutually exclusive. I also propose that health 796 authorities should be required to give some evidence that what they are doing is based on good practice, setting out the evidence base on which they are acting.Regional AIDS (Control) Act reports have not been compiled since the regional health authorities were dissolved. The Department of Health receives 100 reports from the English health authorities, which is hardly a manageable number. That does not make it easy for the Department to make optimal use of the important information in them and the bigger picture does not emerge as a result.
I propose that regional AIDS (Control) Act reports should be prepared and collated annually by the national health service regional offices. We would also benefit greatly from an annual national report from the Department of Health. Such a report, perhaps from the Secretary of State, would give us an extremely valuable national overview of HIV-AIDS prevention, treatment and care work. I should add that that is a devolved matter, although surely the four nations of the United Kingdom should learn from one another.
The Government's decision to initiate a national HIV-AIDS strategy has been welcomed in every quarter, and I welcome the announcement of the steering group to take it forward. In her reply to my letter to my right hon. Friend the Secretary of State for Health setting out these proposals for changes to the AIDS (Control) Act, my right hon. Friend the Minister for Public Health suggested that they should be considered by the steering group. I am happy for it to do so and should be grateful if, in the meantime, my hon. Friend the Minister of State would share his preliminary views with us.
The apocalyptic predictions of the mid-1980s have not come true. When I introduced the AIDS (Control) Act, there was talk of the AIDS time bomb, Edinburgh was dubbed the AIDS capital of Europe and Government reports warned that Britain could have more than 30,000 AIDS cases by 1992. Compared with other European countries, the United Kingdom has done relatively well in dealing with the disease, but complacency about HIV would be a terrible mistake.
There is a danger that people think that HIV is not a threat any more, or that it does not matter if they get it because drugs can help, but HIV is as great a risk as it ever was. There are still 2,500 new diagnoses of infection every year. Given the information we now have about how the disease is transmitted, I hope that my hon. Friend agrees that that figure is still too high. In addition, the new treatments can be tough to take and some people cannot take the drugs at all.
It is vital that the Government money provided to prevent the spread of HIV is spent effectively and, 12 years on, it is time to bring the AIDS (Control) Act up to date. I have proposed changes to give us better accountability, better information and better vision. I look forward to hearing what my hon. Friend the Minister has to say.
§ Mr. Neil Gerrard (Walthamstow)I am grateful to my right hon. Friend the Member for Edinburgh, East and Musselburgh (Dr. Strang) and to my hon. Friend the Minister for allowing me to make a brief contribution to the debate.
797 As my right hon. Friend said, the all-party group on AIDS did a significant piece of work last year when it looked at what the UK's strategy ought to be. I want to say a few words about some of the report's conclusions and where we are a year on. I welcome the work that the Department of Health is doing and the setting up of a steering group within the Department. Its composition is important, and it is not made up simply of civil servants. Its members include people who are living with HIV, workers in the field, academics and medical experts. We need a range of expertise to be introduced. In particular, we need people who have daily experience of living with HIV.
A national strategy can make a difference, as it has in Australia, where a strategy was developed a few years ago. Some complacency has crept in, not among health professionals or the Department, but among the public and in the media, as if we are somehow immune from what is happening in the rest of the world. One need merely consider the enormous changes in eastern Europe to see that that is not so, or the fact that of the 33 million infections across the world, 60 per cent. are in Commonwealth countries. We cannot regard ourselves as immune.
HIV is a public health issue, and my right hon. Friend noted what the Public Health Laboratory Service Board has said. However, wider issues, to do with discrimination and prejudice, remain very much alive. They may not be the primary responsibility of the Department of Health—legally, they fall to other Departments—but a strategy that reaches across the board must take those issues into account.
I shall end by naming four areas that a strategy should cover. First, it should deal with treatment and care, and with the setting of minimum standards across the country. Whether a person lives in an area of high or low prevalence, he or she should be able to expect minimum standards. Services must also be culturally appropriate. In London, problems arise particularly in the African communities, and it is sometimes difficult to get in touch with people in those communities, and to make them understand and participate in available services.
The second major issue is funding. We are moving towards district-of-residence funding, as the stock-taking group at the Department of Health recommended last year, and most people agree that we should. However, we should consider how we allocate funds. This year's allocations were announced late, causing problems for health authorities and for organisations with which they contract, including service providers that are voluntary organisations. We need to ensure longer-term funding, tying together funds provided by the Department of Health, and those provided separately through local authorities and the AIDS support grant.
The third issue is prevention. Whatever we do in care and treatment, we must first consider what we can do to prevent the spread of HIV. My right hon. Friend said that we should target to ensure that money is spent on the right people—those most at risk. I hope that allocations will continue to be ring-fenced as the National AIDS Trust report suggested that some money given to health authorities for prevention work was not necessarily being used in the areas of highest need.
798 Finally, we need to involve people who have the virus and who live with AIDS in the development of the strategy, both locally and nationally. Through that involvement, we are more likely to get a strategy that works, and that will be able to tackle discrimination and prejudice, which affect work on prevention. Prejudice and discrimination discourage people from coming forward for testing.
I welcome the work that is being done. I hope that later this year, we shall have the first results of the working group and that the Department will embark on consultation, so that we get a strategy that addresses the problems that still need to be addressed.
§ The Minister of State, Department of Health (Mr. John Denham)I congratulate my right hon. Friend the Member for Edinburgh, East and Musselburgh (Dr. Strang) on his success in proposing this important topic for debate. I also acknowledge the contribution of my hon. Friend the Member for Walthamstow (Mr. Gerrard). They have both made an important personal contribution to this topic over the years.
The United Kingdom has fared much better than many other countries in limiting the spread of HIV infection. Over the last three years, important developments in drug therapies have led to a dramatic reduction in the number of deaths from AIDS. HIV-AIDS is now often referred to as a chronic disease rather than a disease with a rapidly fatal outcome.
As my right hon. Friend said, HIV and AIDS have not gone away. The people affected are living longer, but coupled with that is a continuing rate of new infections of between 2,500 and 3,000 each year. HIV and AIDS affect mostly young, economically active age groups. It remains an important public health issue that poses some particularly difficult challenges. For that reason, the Government have decided to develop a specific strategy for HIV-AIDS. Our plans to develop an HIV-AIDS strategy for England were contained in the Green Paper, "Our Healthier Nation." To pick up on the point made by my hon. Friend the Member for Walthamstow, we are determined that people who use or work in HIV-AIDS services will have every opportunity to make their contribution to the development of that strategy.
Early and sustained action to control the spread of HIV, such as screening of the blood supply, national health promotion campaigns, and the availability of free, open-access genito-urinary medicine clinics and needle exchanges, has contributed to the relatively low prevalence of HIV in the United Kingdom compared with some of our European neighbours. We have a good record on prevention, and we want that to continue. This year, we provided more than £53 million as a ring-fenced sum to health authorities to fund local HIV prevention activities, and centrally we provided some £5 million to carry out national HIV health promotion activities.
With regard to health service delivery of treatment and care for people with HIV and AIDS, the concentration of specialist treatment centres matches the geographical distribution of the disease. Delivery remains skewed towards London and other major cities. In the current year, we have provided £234 million to health authorities for the treatment and care of people with HIV and AIDS, and £15.5 million to local authorities for care in the community.
799 As I said, we continue to have 2,500 to 3,000 new infections each year. We have a high number of babies born with HIV. We need to ensure that we respond to the demand for new drugs and for common standards, that we maintain our efforts on prevention and that we ensure that we keep prevalence low. Those are some of the issues that the new strategy will tackle.
The process of developing the strategy was launched by my right hon. Friend the Minister for Public Health at a conference last October. The conference made an excellent start on the process that is now being taken forward by the steering group, which met for the first time last week. I am grateful to my right hon. and hon. Friends for their positive comments on that process. We hope that a draft document will be ready for consultation by spring next year. It will cover issues related to treatment and care and HIV testing and prevention, and it will draw on available evidence and relevant work already under way.
As for strategies for the United Kingdom, my right hon. Friend the Secretary of State for Scotland is tackling the issue, and an expert group, due to report later this year, is currently reviewing the HIV health promotion strategy in Scotland. In 1994, the Department of Health and Social Services in Northern Ireland issued a strategy for HIV and AIDS, which recognised the need for increased efforts in public education, alongside education programmes in schools and youth settings, and the need for support for those involved in this work. Such efforts are continuing.
In October 1998, the Welsh Office published the "Better Health, Better Wales" strategic framework, and work to implement the various strands of the framework is being done by expert groups. The sexual health working group has held its first meeting, and the group to develop the communicable diseases strategy is to hold its first meeting at the end of this month.
The policy context that will shape the strategy in England will include the White Papers, "The New NHS" and "Modernising Social Services", and the forthcoming White Paper, "Our Healthier Nation". We shall also wish to provide the necessary frameworks to monitor the implementation and progress of the strategy.
I want to say something about the role of the AIDS (Control) Act 1987 in the context of the HIV-AIDS strategy. My right hon. Friend was instrumental in the enactment of the legislation through his private Member's Bill some 12 years ago. I think there is no doubt that that legislation laid the foundations for one of the best surveillance systems in Europe for HIV and AIDS, and successive Governments have been able to build on it over the past decade. The Act has, uniquely, allowed the Department of Health and the NHS to build up information on service development and HIV prevention programmes undertaken by local health authorities over time throughout the country.
I am grateful for my right hon. Friend's continued interest in the matter, and for his suggestion that a review of the legislation would be timely and, perhaps, should be incorporated in HIV-AIDS strategy work. His suggestion was supported by a recommendation from the all-party parliamentary group on AIDS in its recent and very welcome parliamentary hearings report on national HIV-AIDS strategies.
I am pleased to report that the HIV-AIDS strategy steering group was satisfied that such a review would fit sensibly into its work plan. Any proposed changes in the 800 wording of the Act and its provisions will, of course, need careful consideration, but the development of a national HIV-AIDS strategy provides an excellent opportunity to update the Act in line with changes that have taken place in the epidemic, and in the provision of services. The Act provides for the submission of annual reports by health authorities on epidemiology, and on the use of resources for HIV-AIDS treatment and care and HIV prevention. Any changes in monitoring that are considered necessary will be indicated in the HIV-AIDS strategy document.
I recognise, and share, my right hon. Friend's wish for rapid progress. The strategy work provides the opportunity to get any review of the Act right, and I am keen that we should use it in full for that purpose.
The strategy development will also take into account developments on a number of different fronts that are of direct relevance to the formulation of the new strategy. Earlier this year, the Government announced their intention of drawing up an integrated strategy for the whole of sexual and reproductive health, with the aim of joining services and health promotion messages when that is relevant. We have known for some time that the presence of other sexually transmitted diseases can influence the spread of HIV, and it makes sense to link some health promotion messages.
A key component of the overarching sexual health strategy will be the separate and complementary strategy for HIV-AIDS. The separate strategy will provide a clear focus in a difficult area where there are major cost implications for the NHS. Our priorities remain to communicate clear messages about safer sex, to focus on groups at high risk of infection, and to continue to enlist the help of community organisations in delivering our messages.
The overall framework of the sexual health strategy will include key messages from other related programmes, including those involving HIV-AIDS, which will link with the communicable diseases strategy. We will thus be "joining up" health promotion messages when it makes sense to do so, but there will be no let-up in the important targeting of messages to the groups that are most vulnerable to HIV infection. Those are gay and bisexual men, people from countries with a high prevalence of HIV, currently sub-Saharan African countries, and injecting drug users.
This country's excellent surveillance systems keep us alert to the changing epidemiology of HIV and AIDS and allow us to assess the impact on the UK population of the HIV epidemic elsewhere in the world. They also allow us to keep a close watch on groups such as injecting drug users, among whom HIV prevalence has been at a steady level for years.
The NHS budget for drug misuse has been bolstered with funding from the NHS modernisation fund. This year, £12 million has been provided to health authorities. That will rise to £20 million over the next three years to achieve the key objective of increasing participation of problem drug misusers, including prisoners, in drug treatment programmes that have a positive impact on health and crime. The Government's anti-drug strategy is expected to strengthen prevention activities for vulnerable young people, particularly with regard to injecting behaviour.
The surveillance data show that mortality due to HIV and AIDS in 1998 was a quarter of that in 1995–96. That is a direct result of the success of combination drug 801 treatments that are delaying progress of the disease and decreasing the mortality rate. As a result, we have an increasing prevalence of HIV, which makes our HIV prevention activities even more vital.
Meanwhile, national work for African communities has produced new information resources on HIV issues for African men and women. A mass media and poster campaign and a weekly radio project are all under way. Health promotion directed at the general population to keep them alert to the seriousness of HIV, AIDS and other sexually transmitted infections has included a website and targeted work for young holiday makers. Health promotion work with gay men included a new media campaign that focused on awareness of undiagnosed HIV infection. A second conference on the community HIV and AIDS prevention strategy has taken place, which focused on HIV prevention, understanding risk and gay men with diagnosed HIV infection.
Recently, there have been activities with a direct bearing on future services for people with HIV and AIDS—for example, the published work on standards for HIV services and developing networks for HIV care in London, which we hope will be extended to the rest of the country. We believe that developing networks of services throughout the country, using published clinical guidelines and agreed standards, will be key elements in the success of our overall strategy.
Under the new arrangements, commissioning of services for HIV-AIDS and genito-urinary medicine will be commissioned at least at health authority level. The most complex level of HIV services involving the 802 administration and monitoring of combination therapies will probably be commissioned regionally. That should ensure that a coherent package of services that is based on previous experience and expertise is developed.
As part of commissioning in the new NHS, alongside work on partnerships between health and local authorities, development of guidance on long-term service agreements is under way. The guidance will build on good joint working and the introduction of three-year contracts, where possible. Many authorities, especially in London and other cities, have long worked in consortia with their constituent boroughs to place three-year contracts with their voluntary sector partners.
The strategy will clearly have an important role in setting the framework for future services for people with HIV and AIDS. The stocktake group was asked to make recommendations for the distribution formula, taking into account current use of the budget, financial pressures generated by combination therapies and the need to preserve open access GUM services. Some of the group's work has been used in distributing part of the treatment and care allocation to health authorities this year, in line with them taking responsibility for their residents. However, the redistribution of such large amounts of money must be considered carefully and in great detail. We need to move forward at a measured pace to ensure that specialist services are not destabilised while—
§ The motion having been made after Ten o'clock, and the debate having continued for half an hour, MR. DEPUTY SPEAKER adjourned the House without Question put, pursuant to the Standing Order.
§ Adjourned at six minutes to Two o'clock.