Children and HIV/AIDS

HL Deb 14 December 1999 vol 608 cc185-208

6.45 p.m.

Baroness Massey of Darwen

rose to ask Her Majesty's Government what steps they are taking to help children living with HIV/AIDS.

The noble Baroness said: My Lords, just before National AIDS Day this year I chaired a conference at the National Children's Bureau on Children Living with HIV and AIDS. This Question arises as a result of that conference and some of the problems presented there. I am grateful that many Members of your Lordships' House, present and absent, have shown interest in this issue. The problems relate to young people who are themselves, or who have a family member or friend, infected by HIV or AIDS. My Question is concerned with the UK. I am aware that similar and worse problems exist in other parts of the world, particularly poorer countries. Some of your Lordships know a great deal about these issues.

I shall begin with a brief statement on HIV and AIDS statistics in the UK. I shall then discuss some areas of concern with reference to research and the experiences of young people themselves. In the UK 774 children under the age of 15 are known to be infected with HIV. This includes:317 with AIDS. Infection is transmitted largely from mother to child before or during birth or through breast feeding. There has been a marked increase in HIV in children of parents from sub-Saharan Africa. There is no accurate prediction of the life expectancy of these children. Barnardo's estimates that there are more than 4,000 children in the UK whose mothers are HIV positive and that about 500 children have lost their mothers through AIDS.

Several organisations have expressed concern about the multiple problems of children who are infected with, or affected by, HIV and AIDS. For example, the charity Children with AIDS has spelt out concerns such as: children may be ill from taking medication; education is likely to suffer; they may care for a sick relative or visit someone in hospital; the home environment of children may be stressful; children may face fostering or adoption; they may be faced with family bereavement; they may be living in low income families either because of their immigrant status or because the adults have become too ill to work; children may feel that they are not included in information or decision-making about the crisis. Children may also have to keep their own or the family member's HIV status secret at school.

Families who live with HIV and AIDS may have the following problems: prejudice and stigma; fear of confidentiality being breached; economic hardship; uncertainty about the future; fragmented services; cultural and language vulnerability; and limited knowledge of medical treatment and care issues.

The Council for Disabled Children, in its submission to the All-Party Parliamentary Group on AIDS, suggested that a national strategy to address the problem of children living with HIV and AIDS should include certain elements. First, there should be health education and promotion to raise awareness and the appropriate information should be provided. Secondly, there should be prevention strategies related to antenatal testing and new combined therapy treatments and decisions about breast feeding, for example. Thirdly, there should be family support policies using multi-disciplinary teams. Fourthly, there is concern about young carers—young people with or without HIV status—who may support and care for one or more family member who is ill. This may impinge on their educational and leisure needs.

In its review last year of support services for HIV-affected families and carers the National AIDS Trust identified three issues: the concerns and needs of those affected by HIV and AIDS in the UK; the existing services for those thereby affected; and the barriers to providing those services. Needs and concerns included the issues of tackling social stigma, isolation, lack of information about HIV/AIDS, emotional trauma such as bereavement, problems of travelling to places of support, particularly in rural areas, pressures on carers, and employment issues. Disclosing HIV status to family and friends appeared to be a source of immense distress.

The survey of service provision was carried out regionally and covered statutory and voluntary provision. The extent of provision varied across the UK with particular problems outside cities. Fewer than 30 per cent of those organisations responding said that they provided specific support services for children affected by HIV and AIDS.

Barriers to service provision were said to be a reluctance by those affected to use services, lack of resources, lack of identification of needs of those affected by HIV/AIDS and poor working links between organisations providing help and support.

The National AIDS Trust summarised the way forward as the need to form a national network with a contact directory for those affected, to provide information perhaps through a publication, and to address the unmet needs, such as isolation, of those affected.

The All-Party Parliamentary Group on AIDS made recommendations following a series of parliamentary hearings held in July last year. These recommendations included one on social care which stated: The specific needs of children living with, or affected by, HIV need to be addressed in a co-ordinated way to deliver appropriate care with a high level of continuity. Social work with families must ensure that work with children and adults with HIV in the same family is well co-ordinated". Again, there is an emphasis on co-ordination and an intersectoral approach.

Finally, on education and health promotion, last year Brook Advisory Centres carried out some focus group research with 14 to 18 year-olds to gain awareness of their perceptions of HIV and AIDS; what the terms mean; whom they affect; preventive behaviour and sources of information. The major concern of those young people was with pregnancy rather than HIV, and we must be vigilant that HIV/AIDS does not slip off the agenda for young people.

I was particularly touched to read in the Why Me? booklet the stories of those young people who are, together with the demands of school and other aspects of life, responsible for a relative with HIV or AIDS. I conclude with an extract from a contribution to the booklet by one of the young people. I have copies of the booklet if noble Lords are interested in it. She says: Writing this story brings me bad memories … My mother was very, very ill—this was in 1994—and nobody knew what she was suffering from. She stayed at home for about two weeks, then went to see her GP—all she got were painkillers. I think this was because she couldn't actually explain what was wrong with her and how she was feeling. Then she was put into hospital and she was there for a long time. As I was the oldest in my family my job was to cook for her. I'd go to school every day, come home, start cooking. Then do the same thing again for a few months. At the time I couldn't write or speak English, so I had to keep everything to myself for a very long time. I was never late for school or missed a day, but I never did my homework because there was no time. My school started at 8.45am and finished at 3.45pm. I would then get home at 4.30pm and start cooking … I had two other younger people [to cook for as well] … This had to be done every day … My school work was bad, I couldn't concentrate in class. I'd cry on the way home and when I was going to school. Then we … got used to seeing her ill … She was at the hospital almost every two to three months, then she'd be out. After a few months she'd be back in there—she called it prison. What was worrying her most was that if the social services took us, she wouldn't see much of us … At the time I was only 13, I felt confused, lost … Then she died … I miss her a lot. I only found out that mum was HIV positive five months before her death. She also knew that I knew, but we never talked about it. I had to keep all this to mysel'. We should be aware that children and families affected by HIV and AIDS are faced with complex and distressing situations. Further help may not cost a lot of money. It seems that if support were more co-ordinated at national and local level and concern put clearly on the agenda, then lives may be improved. I look forward to the discussion and the Minister's response.

6.54 p.m.

Baroness Masham of Ilton

My Lords, I am pleased that the noble Baroness, Lady Massey of Darwen, is asking this Question today. Christmas is a time when many people like to be with their families. It is a time of giving and sharing. I am pleased that, by taking part in this short debate, this small band of noble Lords is sharing some thoughts on the needs of children living with HIV/AIDS.

There are many difficult medical conditions with which parents and children have to contend, but HIV/AIDS is much the most difficult to live with outside a special unit, as it is shrouded by confidentiality. Grieving and coming to terms with the condition has often to be done in private. Hidden grief is so much more difficult to live with. For children it must be even worse.

Many people shun an infection. With HIV/AIDS people's attitudes differ greatly. The very best can come out; and the worst. For people living with HIV that unpredictability among members of the family, schools or the public, can mean insecurity, loneliness and living with a secret.

Last week on the radio programme "You and Yours", I heard a young girl say that there was no education on HIV in her school. Another person said that HIV education was not included as part of the core curriculum. As we live in a period of reform and change, what is the present position about education on HIV in schools? At one conference I attended I heard two head teachers saying that they preferred outside experts to come into the school. If that is not possible in some areas, it is important that teachers are equipped with the correct teaching packs so that they can attempt to cover this sensitive and difficult subject.

For your Lordships' information, I should like to go back in history for a few moments. On 14th July 1983, Lady Dudley asked the first Question in your Lordships' House on the incidence and control of AIDS. The noble Lord, Lord Glenarthur, answered for the Government. The noble Baroness, Lady Gardner of Parkes, and myself asked supplementary questions. The Minister said that there was no conclusive evidence that AIDS was transmitted by blood or blood products. In 1983 there had been 14 confirmed cases of AIDS.

On 18th March 1985 the noble Baroness, Lady Cox, introduced a debate on prevention and control of AIDS. With other noble Lords, some of whom have now died, I, too, took part. Afterwards, several of us were accused of scaremongering. If noble Lords read the report of that debate—it is available in the Library—they will note that some of the questions we asked then are still being asked today. I refer to the need for counselling, the importing of blood products and the need for adequate education.

Only today a doctor told me that he thought the infection rate of HIV had gone down. Unless the impetus on health education is kept up, society will become complacent and more children and their parents will become infected.

Most HIV/AIDS initiatives and funding tend to concentrate on adults. Responses for children have lagged a long way behind those for adults and tend to be fragmented, ad hoc and inconsistent. However, one place which has kept up with the times is the Mildmay Mission Hospital in Hackney. Mildmay was not only the first hospice in Europe for people with AIDS; it was the first and only residential family care centre in the world available to care for the whole family. On many occasions, I have heard the noble Lord, Lord Morris of Manchester, say that a disabled child can mean a disabled family. Mildmay has recognised that.

The unit, like all the others on the Hackney Road site, is full to overflowing and has a waiting list. It recently opened a further six rooms, thus caring for 12 families. The nursery is oversubscribed. It is registered to cater for 30 children, but the social services will fund only 20. It is open seven days a week, collecting the children in the morning and returning them in the evening. It has to prioritise, depending either on the needs of the children or the severity of the illness of the mother or father.

The children are taken in from the age of 28 days to eight years. They have access to all the services that are provided for adults. However, the bereavement counsellor is especially trained to deal with children. Once a week, a consultant paediatrician from Great Ormond Street visits the centre. It has been found that if the mother has HIV and is given the anti-viral drug AZT in late pregnancy and during labour, and if it is given to the baby for one month, transmission is reduced by 68 per cent. It also reduces trauma to the baby during delivery, which is done by caesarean birth before the 38th week of pregnancy and before the onset of labour. Furthermore, the avoidance of breast feeding reduces transmission.

If the mother's viral load is high, she receives full combination therapy and other measures. If her viral load is low, she receives AZT alone and other measures are taken. It is important that mothers who are HIV positive know that they are. Therefore testing and counselling should be available to all expectant mothers if they believe that they could be at risk.

Another supportive, warm and friendly organisation which helps HIV-positive children and teenagers as well as heterosexual adults is Body and Soul. It has adapted two old wards in the Homeopathic Hospital in Great Ormond Street. I was pleased that the noble Baroness, Lady Amos, visited the organisation with me. She was impressed. Young children have their own play area, giving mothers a break. Teenagers receive support and go on interesting holiday breaks.

Psychological support is much needed. Young children and teenagers having the extra discipline of taking combination drugs sometimes early in the morning and throughout the day need some relief and a lot of support. Sometimes they are supporting their ill parents, too. Such good organisations need support to keep going. Perhaps the Minister will also visit them.

It was a complex tragedy for the haemophiliacs who became infected with HIV and hepatitis B and C. The biggest new problem for those suffering with HIV and hepatitis C is that they have to take two sets of combination drugs which can react against each other, damaging the liver. The drugs can also become less effective. Historically, the problem has been complex with the infected Factor 8 coming from America, Britain then making its own, and last year Britain deciding to import again because of the new variant of CJD. Is that still a concern?

I want to ask the Minister about the six-week window of testing. How up to date are we in identifying HIV in potential blood donors? Testing will identify HIV only after about six weeks. However, it seems that in the USA infection can be identified much sooner because it has an advanced testing procedure. Are we lagging behind? Is there more we can do to improve our Blood Transfusion Service?

All the families in the Macfarlane Trust have been affected in some way. There are 148 widows with dependent children. Fourteen of the widows are infected with HIV. Just think of explaining to sensitive children what has happened to their fathers. Twelve haemophiliac children with HIV are still living; 39 under the age of 17 died. Of the adults, 785 have died and 454 are still living. I had the privilege to be invited to a private meeting of women affected by haemophilia and HIV. I can assure your Lordships that there is grief, anger, hardship and many family complications. They need everyone's support.

There is much to be done to prevent more children being born with HIV. There is much to be done to support those living with HIV. I hope that the Government will not submerge the real needs of HIV in an overall sexual strategy. HIV needs its own identification and strategy. I know that the noble Lord, Lord Hunt, as a former member of the All-Party Group on HIV and AIDS knows this. I hope that today he will give us hope that the Government will not let HIV slip down the health ladder.

7.6 p.m.

Lord Winston

My Lords, I am grateful to my noble friend Lady Massey for introducing this short debate on an important issue and I want briefly to address two areas. I had intended to address only one during the nine minutes allotted to me and should have taken perhaps only four minutes. Unfortunately, my noble friend—perhaps I may call him that even though he is a Cross-Bencher—Lord Patel, who is a most distinguished obstetrician, had to leave to attend a meeting and is therefore unable to participate in the debate. I promised that I would try to raise some of the points he intended to make as a leading obstetrician and former president of the Royal College of Obstetricians and Gynaecologists and someone much more experienced and weighty than myself.

The first issue concerns children affected with HIV in this country. Each year, about 300 babies are born with HIV and it is clear that we could do more to prevent that. The noble Baroness, Lady Masham, spoke of limiting the infection in pregnant women. The fact is that we are detecting only about one third of the population at risk in pregnancy. In London, about one in 500 births are from infected women. That is true also in Edinburgh. In other parts of the country, the figure is about one in 5,000. It is clear that the high risk groups can be identified during pregnancy and much more could be done by the Government to offer voluntary screening. Too few trusts have clear information about the risks of HIV. Such information is important for two reasons. First, it is clear that one can reduce the chance of infecting the baby substantially by the use of drugs, by the use of caesarean section and by the limitation of breast feeding. Indeed, if such actions are taken, current estimates put the risk at about 7 or 8 per cent, which is low. Without such actions, the risk of infecting the baby is higher.

Secondly, major progress is being made in the area of certain viruses. Surely, it is in the interests of the pregnant woman to know that she may be infected. Research in my own institution at the Hammersmith Hospital, London, shows that we shall acquire better methods of tracking the disease and treating it in due course.

Therefore, I hope that the Government recognise the fact that we should be more active in offering screening services, which are relatively cheap, auditing what is happening as regards their take-up and ensuring that money is spent in counselling and support. We are lagging behind the EU in that respect and we need to do much more. It is rather sad that we are not as good in that respect as other countries.

I must say to the Minister that almost every Royal College—I believe with the exception of the Royal College of Surgeons, although perhaps I am wrong and it is also included—has agreed on the need for better screening during pregnancy. Without that being promulgated in trusts there is a major problem.

The other concern that I want to raise briefly is that this is not only a British issue. Three weekends ago I was face-painting children in an orphanage about 40 miles outside Nairobi. It is difficult to describe to your Lordships what that meant. Each of the children that I face-painted was an orphan because its parents had died from that infection. All the children in that orphanage were infected with the virus. I had on my knees a child aged three-and-a-half, who was the size of my own son when he was about nine months old. The child was constantly coughing; he had open tuberculosis. He was blind, but able to sign what he wanted to us remarkably and he was in amazing control of his environment.

There are 350,000 such children in sub-Saharan Africa. I doubt that that child is actually alive three weeks later, because his tuberculosis was too far gone and untreated. The truth is that it is not only an African problem; we cannot just say that that is Africa. They are real people. Those children are remarkable; when I walked around that orphanage I observed that when they fell over, they wanted to be cuddled. When they wanted to play, they wanted to play with an adult. They were much more open than any British children with whom I have ever come into contact, because they did not have any fear of adults—which is a curious thing—and they were bereft of their parents.

The truth is that we can no longer regard this as a problem of the third world, because, with the exception of poverty, all the other consequences also affect us because those diseases spread to other countries; the bacteria such as tuberculosis, which cannot be treated with modern antibiotics, will spread with air travel. The consequences of poverty in those villages has a knock-on effect in terms of national unrest, strife and war. It is quite shocking—I direct these comments at those noble Lords who have not been to that part of Africa—to see whole villages where no one is working and where no one can care for people who are growing old. It is quite a revelation and one that must drive us to tears.

In one of those areas in sub-Saharan Africa I met a Catholic priest named Michael Meegan—a most remarkable man and a deeply religious Catholic, who demonstrated clearly that by getting into the mindset of the Africans and getting inside the prevalent culture, he could really influence the effect of the transmission of HIV. That is in a country where, for 30p, one can buy a prostitute in Nairobi. Yet he was able to demonstrate, as a Catholic priest, that by giving appropriate condom protection to villagers he could actually reduce the infection.

What is remarkable is that he was doing that with hardly any support and he was carrying out scientific surveys of the results of his work among the African population and publishing it in scientific journals. I found it sad that he told me that he was unable to get in touch with any British Government Minister and that indeed he had not received an answer from the Prime Minister when he wrote to him. It seems to me that we should be listening to such people on the ground much more and offering them as much support as we can, because, as I said, this is a problem for which we all have some responsibility.

7.14 p.m.

Earl Baldwin of Bewdley

My Lords, we are all grateful to the noble Baroness for asking the Question. I am spurred to contribute to the debate by some unfinished business surrounding a series of Starred and Unstarred Questions which I tabled in 1997, and on which I later corresponded and traded scientific evidence with the noble Baroness the Leader of the House when she was at the Department of Health. The Minister will not be surprised that I take a rather different line from other speakers.

What I was asking two years ago was not specifically directed at children, but it has such general relevance to the problems of HIV and AIDS that it will be helpful to summarise it before looking at children and how they can best be helped. My focus was on long-term survivors. There are a good many of those around, some of whom have lived with a full-blown AIDS diagnosis for years. The curious thing, to a layman, is that no one knows how they have survived, because no one has done the research to find out. Medical scientists, odd though it may seem, do not look at success stories. One reason is the methodological difficulty of retrospective studies. At the time the noble Baroness told me that it was thought that their survival was due to the medical drugs they were taking, but she could provide no evidence. My own impression was different.

Quite apart from the fact that drugs such as AZT are so acutely toxic that it is unlikely that already depleted patients could take them for as long as five years and survive the treatment, there are any number of references in the medical literature to the fact that long-term survivors have shunned antiviral medication. In the nearest thing to a systematic survey, the AIDS activist Michael Callen, no friend of unorthodox methods, reported that of the many survivors he interviewed, only four had ever taken AZT, while all of them had, dabbled with what are generally referred to as holistic approaches to healing". That may not be as surprising as it sounds, given that we are talking about an immune deficiency syndrome and that improving immune status is what holistic medicine claims lo be good at.

Professor Root-Bernstein, also in the US, in Rethinking AIDS, drew attention to studies that achieved remark able results without anti-retroviral therapy, especially using nutrition. Amazingly", he wrote, no formal study of long-term survivors … has ever been done". It seems that a combination of methodology and belief systems has so far deprived us of a crucial area of knowledge which might help to prevent as well as treat AIDS effectively. That is as relevant to mothers and children as it is to those diagnosed in later life.

A presentation by the Parliamentary Group for Alternative and Complementary Medicine, which I chair, also in 1997, underscored those points. Three long-term survivors of HIV or AIDS told how they had turned their back on conventional treatment and remained healthy on regimes which included herbs, meditation, psychotherapy, optimum nutrition and other non-standard approaches. They mentioned two other factors of interest. The first was the unreliable nature of the HIV test, which is amply documented. One speaker said lie had been told he was positive, then negative, then positive, within a short space of time, which was not unusual.

The second factor was the appalling pressure from the medical profession to go down the conventional drugs route. Not only those speakers, but others also with HIV or AIDS, have told of being harassed and intimidated by their doctors. That has added greatly to the stress of living with a serious diagnosis. Almost worse, it has driven many such people right out of the system. Most of those who think differently about treatment now will not go near doctors or hospitals if they can possibly avoid it. That pressure is not only counter-productive in conventional medical terms, but also puts a whole cohort of sufferers beyond follow-up and the research on the holistic methods which alone can determine just how effective they are.

Adults can, I suppose, with difficulty, withstand such pressure. Children, it seems, cannot. I read with astonishment and disbelief this September about the four month-old daughter of an HIV-positive mother who was ordered by a court of law, against the parents' wishes, to undergo a test for the virus, with the strong implication that, if positive, she might be forced to take medication. I find that wholly objectionable in principle, even if it were not for the obvious care and intelligence of the parents; the non-specific nature of the test itself; the evidence of cases of young children who have sero-reverted to negative without any treatment; and the indications that I have already given that a non-drugs approach may have merit.

It is not difficult to find anecdotal evidence, from HIV agencies and in the press, of children born to HIV-diagnosed mothers who remain quite healthy in the absence of anti-HIV therapy. The judge in this case is reported as saying that the family went against "every piece of medical advice". Well, that is their right—I do it myself—even if the advice in question had been certain, unchanging, and demonstrably successful in outcome. Are all those who want to take away the mother's choice to breast-feed unaware that studies are divided on this issue, that adequate vitamin status probably enhances the protective effects of breast milk, and that a recent report in the Lancet suggests that exclusive breast-feeding is in fact the safer course?

I believe one of the principal steps the Government can take to help these children is to defend their and their parents' freedom of choice of treatment. After all, it is not as though 45 billion dollars of drugs-based research has yielded spectacular results. The Government, I think, should use their influence in the fields of health and social services to put a stop to the bullying of parents, and of older patients, who decide to take a different line of treatment. Doctors who say "If you don't take my treatment I have finished with you"—and, my Lords, this still happens—have no place in a civilised healthcare system.

The Government can do more. They can follow up the questions I raised two years ago and look seriously at the results of using non-conventional approaches, not just as palliative medicine, which is how they are chiefly regarded, but as a means not simply of "living with" HIV or AIDS, in the words of today's Question, but possibly of overcoming them as well. This might involve, by way of a start, allocating resources to establish a voluntary data-base of children born to HIV-diagnosed mothers who are thriving with no antiviral therapy, or with alternative therapies.

They could talk to those in the AIDS field who use these approaches and, perhaps more important, do not subscribe to the deadly equation HIV = AIDS = Death, so that they can give balanced advice to all parents that the avoidance of toxic medication is a viable option. I quote a mother from Alberta, Canada: I've been HIV-positive, and healthy, for 15 years. The only time I felt sick was when at my doctor's insistence I took anti-HIV drugs for a month". More specifically, they could urge their medical advisers to get on top of the nutritional literature in this field, so that parents can be advised of the merits of a healthy diet and of vitamin supplementation, which may be one of the few potential treatments inexpensive enough to be made widely available to HIV-infected mothers and children.

In summary, I would suggest—and the Minister may like to consider this and not necessarily reply tonight—that government have a research and information role which could serve to counterbalance the aggressive one-sidedness of current advice about HIV and AIDS. They might be surprised by what this could do for children "living with" these conditions.

7.22 p.m.

Baroness Rendell of Babergh

My Lords, I begin by thanking my noble friend Lady Massey for asking this Question and for speaking with such clarity on a difficult and distressing subject. The issue she has raised is one which concerns us all but which many people, unlikely to be personally affected by it, increasingly choose to ignore.

Once erroneously supposed to be a virus peculiar to homosexuals or transmitted through the use of infected hypodermic needles, HIV/AIDS is now spreading most rapidly through the heterosexual population. Where there are heterosexual couples, there will be children. According to BBC Radio 4's "You and Yours" programme last Wednesday, infected people are having children without telling a partner that they are HIV positive. In other words, they are risking giving birth to a child infected with HIV.

It may not have fallen to the lot of many of your Lordships who are not health professionals to have been closely associated with an AIDS sufferer. It has to mine. A very close friend of mine was infected with the virus in San Francisco 15 years ago. He was HIV positive for a while. Full-blown AIDS developed, and he died in 1989.

The AIDS sufferer exhibits the symptoms of a number of distressing diseases; indeed, he or she seems to ape them. They include respiratory and digestive problems, skin trouble, thrush and mouth ulcers, rheumatism and arthritis, weakness and emaciation, among others. There is nothing sinister about that. It is due, of course, to the damaged and ultimately destroyed immune system. Then there is the disfiguring Kaposi's sarcoma, where the sufferer's skin is stained with naevus-like patches.

He or she will also be emotionally and psychologically affected. Anger is a normal ongoing reaction to HIV/AIDS. "Why me?" is a question that cannot be answered but is persistently asked by the sufferer, whose whole personality may seem to be altered by it. My friend, a man of cheerful, sunny character with an enormous capacity for enjoying life, gradually became bitter, morose, savage and often cruel to those around him. The noble Earl, Lord Baldwin of Bewdley, mentioned holistic, nutritional and multi-vitamin treatments. I must say that my friend tried almost every available approach of that kind and every type of unorthodox medicine, but in vain.

We must ask ourselves how we would behave towards friends and loved ones if we knew that we had an incurable disease which would most likely end in pneumonia. I do not refer to the pneumonia that would have been the death of our grandparents but which these days we have come to accept will respond to treatment, but the AIDS-related pneumonia which recurs and which, finally, because drugs can no longer help, kills without hope. Children witness this and some know that a similar fate very likely awaits them.

The situation for children with a parent who is an HIV/AIDS sufferer or even two parents with the condition is particularly painful. That is so not only because of the home situation and the demands on the child to perform tasks for which he or she is unfitted, such as nursing, cooking, cleaning and possibly the care of younger siblings, but also because of the fear of HIV/AIDS generally in the population and the superstitions, myths and horror stories which surround it.

The belief is still prevalent that one has only to touch or be in the same room as a victim with HIV/AIDS to risk infection. AIDS is still looked upon by some as divine punishment for being homosexual. Many are convinced that AIDS is a homosexual disease. In this area, the media—particularly television—are unhelpful. Hospital sitcoms regularly show some member of the public or medical staff splashed with an AIDS sufferer's blood. Subsequent scenes of horror and fear are all featured with the maximum sensation. That is the climate in which the children of the HIV/AIDS victim grow up and have to handle their lives.

AIDS is transmitted by sharing injection equipment, by a woman passing the virus on to her baby before or during birth and, as we have heard from several noble Lords, by breast-feeding, and through unprotected sex. Much as they were in the 19th century, sexually transmitted diseases are looked upon by many as disgraceful. Of course, that means that sufferers and those close to them feel unable to talk to anyone about the condition.

Cancer used to be the unmentionable affliction—something one did not talk about. Now it is common (it happened in the case of my friend) after death for the relatives to say that the AIDS victim died of cancer. Children often tell their contemporaries that their parent has cancer rather than the virus. They fear being shunned or cruelly insulted unless they lie. Cancer has become the life-threatening disease which it is fashionable to discuss freely. People declare openly if they are suffering from it. have received treatment or are still under threat from the disease. HIV and AIDS have taken over from it as the illness that must be kept secret.

Perhaps I may ask the Minister what steps Her Majesty's Government are taking to lessen the stigma still attached to the virus. What help is given to children obliged to care for HIV/AIDS patients? Do children know that they can consult the National AIDS Helpline and that help is available in Punjabi, Bengali, Hindi, Urdu, Gujerati, Cantonese and Arabic, as well English; and that there is also a service for those with hearing difficulties? When such children miss school, is that known to the authorities as a cause for concern? Do they routinely receive suitable and sympathetic counselling? Are they educated in the true significance of HIV/AIDS free from the superstitions which surround it? Are children infected with HIV told of their chances of developing AIDS or not, as the case may be? Is their reaction carefully monitored? Are schools encouraged to discuss that subject with students? How do schools deal with the problem of children's ignorance or knowledge of HIV and AIDS.

According to the programme I mentioned earlier, most counselling organisations are geared to the gay community and few have a scheme designed for heterosexual people. The provision of support is haphazard and HIV/AIDS charity support funds are directed away from research and the direct combating of the virus.

The United Kingdom is a low prevalence country for HIV compared with other countries. In general, Europe is a low prevalence area. Nevertheless, the World Health Organisation estimates that 30,000 adults and children in western Europe were newly infected with HIV in the month of December 1999; 9,600 adults and children in the same area died from HIV/AIDS during the year.

It seems that there has been no national campaign to alert people to the risks and dangers of HIV/AIDS since the so-called iceberg advertisements of the late 1980s. Will the Minister tell the House whether Her Majesty's Government have any plans to institute a new campaign with heterosexuals and their children in mind? As my noble friend Lord Winston mentioned, is there not a case for a more general routine screening programme for HIV?

7.31 p.m.

Lord Clement-Jones

My Lords, I join with other noble Lords in thanking the noble Baroness, Lady Massey, for raising this important issue today and for her very moving speech in opening the debate. I am very pleased to see the Minister here today as I know that he has had an extremely busy fortnight dealing with other Bills. Therefore, it is a particular pleasure see that he is taking part in this debate today.

As a member of the all-party group on AIDS and a former council member of London Lighthouse, I believe that I understand the difficulties of adults living with HIV/AIDS. But children are a dimension even larger than that, as the noble Baroness, Lady Massey, made graphically clear in her speech. Indeed, many other noble Lords made moving speeches in the same tenor.

Today has provided us with an opportunity to highlight just how widespread is the problem and, indeed, what needs to be done. The international figures are quite horrific. I know that today's debate is essentially domestic but, as the noble Baroness, Lady Massey, made clear, they are of major importance. The noble Lord, Lord Winston, demonstrated that in a very telling speech. We should put matters in an international context. This year in the order of 570,000 children under the age of 15 have been newly infected with HIV. There are 1.2 million such children now living with HIV/AIDS and this year there have been around 470,000 deaths of such children from AIDS.

If we can develop ways of coping in this country, perhaps we can use that experience in order to help developing countries with their problems, which are of an even greater dimension. But even though our problems are not quite so large, one in 500 births in London now is to HIV-infected women. Every single one of those children with HIV/AIDS is an innocent victim who must be treated, cherished and helped to live as full a life as possible.

Some of the individual stories of the lives of families with children who are HIV positive are quite harrowing. Many, indeed it may be most, families must keep their plight secret for fear of stigmatisation. Many children with HIV themselves see their parents and siblings die of AIDS as they grow up. In the meantime, they act as carers for other infected members of their family. Those children are at risk, as has been illustrated during the debate, of suffering from a great deal of stress and isolation.

There was a very moving article in the Independent in August this year which talks of two 15 year-old girls, Bella and Lizzie, who were born HIV positive. Lizzie was told only recently at the age of 14. Bella was told at the age of 9. Both young women have to keep their condition secret from their friends. For both, despite new treatments, the future is cloudy. They wonder whether they will ever be married and have children. Bella takes 105 different pills every single week. Previously, she had been in and out of hospital with various complications, but until she was told, she had no idea why.

An article in the Observer at the same time talked of Elizabeth who, like Lizzie, was told when she was 14 years old. No one previously thought that those children would survive. Now we must make sure that they have a future. Those are just individual case histories, but that was confirmed by extremely well-done research carried out by the National AIDS Trust last year, which has been referred to by several noble Lords.

In terms of prevention, we welcome the Government's adoption of targets for voluntary screening of 80 per cent by 2003 for HIV/AIDS during pregnancy, which was adopted in August this year. But will there be adequate counselling for those tested HIV positive? We have a long way to go from the current 30 per cent, as the noble Lord, Lord Winston, said. Perhaps the Minister will tell the House what funding has been allocated to that screening process.

I also welcome the recently announced campaign to encourage more mothers to take the test to be carried out in conjunction with the Royal College of Midwives. But a substantial proportion of those mothers come from developing countries; have English as a second language; or are asylum seekers. As the noble Baroness, Lady Rendell, made clear, communication needs to be available in the appropriate language.

In terms of ensuring that children born of mothers who are HIV positive are not themselves infected, I wonder whether we should not take a leaf out of Eire's book. It is almost four years since an HIV-positive child was born in Eire. Should we not study the experience there?

As regards treatments, there is much food for thought in what the noble Earl, Lord Baldwin, has said. But the case, as for conventional medicine, needs to be demonstrated scientifically. In the meantime, I believe that families need to have access to the best possible information on effective treatments. I do not believe that anyone is talking of compulsory treatment. But there are difficulties when children simply do not understand what condition they have.

On conventional treatments for young people, a recent report in the Observer said that health authorities are having to fund combination therapies by, making desperate cut backs in spending on AIDS prevention, health education and needle sharing programmes for drug users". Dr George Kinghorn, the clinical director for communicable diseases at the Royal Hallamshire Hospital, Sheffield, said, "It's crazy, absolutely crazy, but we have no choice". That is deplorable enough relative to adults, but even more so with children and young people. Those new combination treatments offer real hope to young people growing up with HIV/AIDS. Will their hopes be dashed because of postcode prescribing?

As to support services for families, the National AIDS Trust report last year made very clear what was needed and, as the noble Baroness, Lady Massey, made clear, better understanding and co-ordination will go an extremely long way towards improving those services. The beacons of treatment mentioned by the noble Baroness, Lady Masham, such as Mildmay hospital, are what we should all like to see for those children.

I want to end today by paying tribute to those voluntary organisations working in this field. They are a great source of help and comfort to those children and they need our strong support and commitment.

The noble Lord, Lord Winston, made it clear that we lag behind Europe. In addition, as the noble Baroness, Lady Rendell, made clear, this issue is not simply related to the health service, but crosses government departments. The education services need to understand what is expected of them if these children are to come out of the closet. I look forward to hearing what the Minister has to say.

7.49 p.m.

Lord McColl of Dulwich

My Lords, I thank the noble Baroness, Lady Massey of Darwen, for drawing our attention to this terrible problem. At the outset I declare my interest in the subject. I am Chairman of the Board of Governors of the Mildmay Hospital in Hackney, to which the noble Baroness, Lady Masham, has kindly made reference.

In the mid-1980s we opened as the first hospice for people dying of AIDS in Europe. At the outset we decided to try our best to avoid the mistake of failing to care for the carers. We remembered the situation of one hospital which had the excellent idea of providing a hostel for people undergoing outpatient radiotherapy. They also wisely provided a warden to look after the radiotherapy patients. Of course, he found himself involved with the patients, discussing their fears, their worries and their bad experiences. Unfortunately, the authorities failed to appreciate that it was necessary to look after the warden. Within a few months the strain took its toll and he had a nervous breakdown. At the Mildmay we have taken particular care to care for the carers with trained counsellors and ministers from various local churches. Even so, it proved an uphill task.

So far, I have confined my remarks to talking about caring for the professional carers. Nurses, doctors, cleaners and administrators are all involved. However, the debate is about caring not for the professional carers but for the children who do the caring. As most speakers have emphasised, one of the most important aspects that has not been addressed is the issue of children whose parents have AIDS, but the children are not infected. Those children may not be infected, but they are very much affected. At the Mildmay Hospital our experience is that when the mother becomes sick often the other partner disappears which results in some affected children being the young carers to their mother and to their siblings.

Such children are presenting to us with serious emotional problems. In most cases nothing is done for them because they are not acknowledged as children with special needs. Clearly, they have tremendous unmet needs. The noble Baroness, Lady Masham, mentioned the charity called Body and Soul which was founded three years ago. It does a great job trying to help some of the children.

The majority of children who live with HIV and AIDS are the children of parents who have existing problems. In the case of maternal transmission the mother may be an immigrant or a drug user or an ex-drug user. On reaching puberty the children need to be advised about the transmission of the infection. That marks these children as different. The parents and teenagers fear that people will find out about their HIV status. The fear of breaches of confidentiality is overwhelming for parents and children because such a stigma and so much prejudice exist in this country to which the noble Baroness, Lady Rendell, has already drawn our attention. We have experienced that stigma in Hackney where families have shared their information with so-called friends and have been identified and targeted and persecuted.

On the treatment of the children, there are problems concerning compliance, as the noble Lord, Lord Clement-Jones, has mentioned. Often they have to take a great number of drugs of different varieties, some before meals and some after meals and it all becomes rather complicated. The mother herself may be HIV positive and may have been traumatised through feelings of guilt at having infected her child.

At Mildmay we have a purpose-built nursery for children under the age of eight who have HIV positive parents and for children who are infected. The nursery takes about 30 children every day and there is a large waiting list. Currently, it is 50 per cent funded by voluntary donations and the rest of the funding is from the health authority, but that funding is considered to be at risk as the health authority says that social services should look after those children who are not actually infected. However, they are certainly affected and sometimes they are the only carers of their sick mother and the other children.

Children in the United Kingdom have access to prophylaxis and treatment as required, but we need to recognise that those children are born not only with a physical condition which affects their lives even if they receive treatment, but with a condition that is also socially disabling because of the continuing prejudice related to HIV. Although such children may take antiretroviral combination therapies, their lives are still affected because they tire easily, cannot keep up with their peers and succumb to all kinds of intermittent infections. Noble Lords will appreciate the enormous problems that such children face and the great strain under which the staff at the Mildmay work, ably led by Dr Jeanette Mead way.

As we were treating a large number of Ugandan women and children, the centre at Mildmay attracted the attention of President Museveni of Uganda. On seeing the place he asked us if we would build a similar centre in Uganda. Of course, we readily agreed, not considering from where the money would come. Under the leadership of the noble Baroness, Lady Chalker, the ODA Minister in the previous government, we were able to build a splendid, purpose-built outpatient and teaching centre. That was completed last year at a cost of £3 million. The present Minister of DfID, Clare Short, has continued to give magnificent and robust support to that Ugandan project. It is run by a former matron—a good old-fashioned matron—Ruth Sims, and medical directors, Dr Veronica Moss and Dr Catherine Sozi of Uganda. That splendid team battles away all hours of the night and day. We have to take great care of the carers themselves because of the emotional strain.

In September I visited the children's clinic in Uganda and my experiences were much the same as those of the noble Lord, Lord Winston. There were 30 children, all with AIDS, many of them dying and all were orphans. Seventy per cent of them had tuberculosis of the lungs; many had widespread scabies, shingles and there were several cases of malaria. They have no resistance to such infections. The good news is that the diagnosis of malaria is made in five minutes, which is a good deal better than most London teaching hospitals.

The new drugs which are partially effective against AIDS cannot, of course, be afforded, but at least most of the complications can be treated—tuberculosis, malaria, shingles and scabies. That greatly improves the quality of what little life is left. All the children are given a large meal every day and there is a special play centre for them. The doctors, nurses and administrators play with the children and read to them. I found it a most moving scene. All have lost their parents and they are cared for by relatives, who are often reluctant to look after them, or by other children.

Although the problems in Uganda are much greater than they are here, the stigma of AIDS there is much less than it is in London. As noble Lords know, some African countries may lose one third of their population through AIDS. So although our problem here is much less, it is totally unacceptable that there is so little provision for the child carers who are looking after brothers, sisters and parents.

Will the Government issue clear guidelines to health authorities and social services so that they can work together to help those children, both affected and infected? And perhaps I can reinforce the point made by the noble Baroness, Lady Rendell; that is, we need to repeat the successful public health campaign of a few years ago and alert the population to the fact that the AIDS problem still exists and the dangers are as great as ever.

7.50 p.m.

Lord Hunt of Kings Heath

My Lords, I begin by thanking my noble friend Lady Massey for raising this extremely important issue of children and HIV, and thank all speakers for their positive and moving contributions to the debate. I agree with the noble Baroness, Lady Masham, that this is a time of giving and sharing. It is also a timely debate because the Government are currently developing an HIV/AIDS strategy.

The Question asked tonight offers an opportunity to raise issues the House would like the proposed strategy to address and for me to attempt to give some answers. I thank my noble friend for drawing to my attention the booklet Why Me? that she launched on 29th November. I hope that we can arrange for all noble Lords who have spoken to be supplied with a copy. It sets out the testimony of children who are either infected or affected by HIV in order to raise awareness.

My noble friend talked of issues for young people in relation to fostering and adoption, some of the emotional stress with which they have to cope through not being provided with information that is useful to them, and also the stigma involved. I learnt more from reading the booklet, which is extremely moving, than any number of heavy tome guidance documents. It deserves the widest possible circulation.

As the noble Lord, Lord Clement-Jones, said, the number of children involved may be small but the burden they bear is great. The HIV/AIDS strategy thereby provides an opportunity for the Government to think holistically in relation to how we can help them. If I bat some of the questions asked tonight into the strategy, that is not because I am running away from giving an answer; it is simply that I shall make sure that this debate is drawn to the attention of officials working on the strategy and that the constructive points we heard tonight are considered with care.

It may be helpful if I read out some of the headings to be covered by the strategy. It will begin by looking at the national picture on HIV/AIDS; what data are available; the levels of reporting of information and public access to it. It is important to have an effective information base line on which to work in the future. We will be looking at tailoring prevention efforts to the different needs of people in different population groups. Also, we will be addressing issues of social exclusion—mentioned by a number of noble Lords tonight—which prevent people coming forward for testing and accessing services.

We will look at treatment and care in relation to the standards that are used and can be reasonably expected regardless of how the services are delivered. I shall pick up the issue of counselling in that respect raised by the noble Lord, Lord Clement-Jones. We will also look at health authorities' and local authorities' legal duties to co-operate and how the new joint finance arrangements can be used to deliver seamless prevention, treatment, care and social support services. In that regard, I shall examine the issues raised by the noble Lord, Lord McColl, in relation to the problems he identified in terms of health and local authority support arrangements for centres like the Mildmay. If he cares to send me information we shall certainly feed that in.

We shall look also at how we engage and empower the voluntary sector and at the performance management of the NHS to ensure that its services are effective, adequate and meet the wishes and needs of users. We shall be looking particularly at the role of users in service development. That is crucial if we are to obtain the right kind of service with the right kind of support and effective counselling. That is so important. We shall look also at the implications of the work of other government departments; for instance, the Home Office policy on HIV positive prisoners and the DfEE in relation to education—a point to which I shall turn in a moment.

Within all of that, as my noble friend Lady Rendell suggested, we will have to focus on the needs of children as a group. I can assure noble Lords that the messages that have been shouted loud and clear tonight will be taken on board. One of the most important points—touched on by the noble Baroness, Lady Masham, and my noble friend Lady Rendell— concerns the health promotion work the Government need to do in this area. It is important that it be research-based; that it reflects the latest epidemiology; and that it is rigorously evaluated. Of course, as part of the NHS's general health promotion work, we expect health authorities and other bodies to take a vigorous approach. But we also provide funding of almost £3 million for the Health Education Authority and others to undertake health promotion campaigns and supporting work.

Work done by the HEA targets young people from 16 to 25 years. It includes information resources on safer sex, including the benefits of condoms, advice that should be sought if a young person thinks they might have been at risk of having unsafe sex and overcoming peer pressure to have sex. Campaigns have also involved work with young people's magazines, national radio and the National Union of Students. Earlier this year the HEA launched its safer sex website and a new safer sex resource aimed at holidaymakers. However, I take the point raised by a number of noble Lords regarding whether or not the overall effect is sufficient in terms of current public perception of the risks. That is something I expect the strategy to look at.

Baroness Masham of Ilton

My Lords, before the Minister leaves education, can he say whether the core curriculum is part of the strategy?

Lord Hunt of Kings Heath

My Lords, that is an important point. It leads me on to the issue of stigma to which the noble Baroness, Lady Masham, and my noble friend Lady Rendell particularly referred. There is no doubt that children, families and individuals are often faced with the considerable extra burden of stigma, discrimination and social isolation. That can occur not only within the communities where they live, but also in the wider social context. Clearly, our nationally-funded health promotion work aims to overcome that by providing clear information on how HIV is and is not transmitted. Some of the public mass media campaigns have helped to contribute to a more tolerant social climate. But I accept that there is room for improvement. As I said earlier, the health promotion issues will be an important component part of the strategy.

That leads me on to the issue of education. The noble Baroness will know that sex education is a compulsory component of the core curriculum in secondary schools. But the specific content of that sex education by a school is the responsibility of the school governors in association with teachers and parents. It may involve issues surrounding HIV/AIDS, but also it may not. I said earlier that one of the important components of the strategy has to be the contribution other government departments can make. I hope that as a result of the strategy we will be enabled to have discussions with the Department for Education and Employment. But, of course, what can be done has to rest in the law and the regulations applying to sex education. I very much share the noble Baroness's concern in this area.

My noble friend Lord Winston and, indeed, the noble Lord, Lord McColl, graphically described some of the challenges faced by other countries. I was very struck by what both noble Lords had to say. If my noble friend wishes to provide me with information regarding the letter that has not received a reply, I shall certainly do my best to ensure that it does receive a response.

In responding to this particular point, I think it would be helpful i f I described the communiqué issued by the Commonwealth Heads of Government meeting on the area of HIV/AIDS. This was an important communiqué, which viewed HIV/AIDS as a global emergency with heads of government personally pledged to lead the fight against it. The communiqué emphasised measures, especially preventive measures, and urged that greater priority be given to vaccine prevention. In addition, and in line with that, we have confirmed our grant of £14 million over five years to the International Aids Vaccine Initiative.

Moreover, DfID is giving priority to sexually transmitted infection prevention for all through essential information services, care and commodities. I was glad to hear the remarks made by the noble Lord, Lord McColl, about the support that. DfID has been able to give to Mildmay. I am very encouraged by that. Clearly, if there are other ways in which we can support international efforts, we would very much want to do so.

The noble Baroness, Lady Masham, asked about blood testing and the differences between the United Kingdom and the United States. Perhaps I may tell her that the National Flood Authority is actively assessing several methods of advanced testing to continue to ensure a safe blood supply. However, I shall be happy to write to the not le Baroness with further details on that matter.

The noble Earl, Lord Baldwin, raised the issue of whether more effort should he placed on looking for less toxic complementary medicine alternatives and stressed the fact that many long-term survivors of HIV/AIDS are using this approach. I am advised that there are two groups of HIV/AIDS patients who are often described as "long-term survivors". First, about 5 per cent to 8 per cent of HIV infected individuals are long-term, non-progressors who survive for at least 10 years after infection. They are either asymptomatic or have mild symptoms. I am advised that there is most likely a genetic factor at play here, such as not carrying the genes which code for HIV cell receptors.

Secondly, patients who survive two years or more after an AIDS diagnosis are referred to as "long-term AIDS survivors". With the widespread use of combination theories, as other noble Lords have suggested, the survival time increases. I accept that many HIV/AIDS patients have found complementary therapies helpful. I give way to the noble Earl.

Earl Baldwin of Bewdley

My Lords, I am grateful to the noble Lord. I should just like to point out that some survivors of frank AIDS diagnosis have been around for five years or more, which is some time longer than the combination therapies have actually been in existence.

Lord Hunt of Kings Heath

My Lords, I do not seek to say that the answer I am giving is a definitive and complete response to the points raised by the noble Earl. I am merely suggesting that certain factors need to be taken into account. The noble Earl and I have debated previously the issue of the Department of Health's research programme. The noble Earl will know that there is a procedure under which applications for research are considered and that the R&D programme does fund a number of research projects in relation to the use of complementary medicine.

In relation to the High Court ruling mentioned by the noble Earl, I must tell him that we do not comment on individual cases. We were not party to the case brought by Camden Council social services. In such circumstances, local agencies decide how to respond to individual cases, taking all the facts of the case into account.

As far as concerns the article in the Lancet mentioned by the noble Earl on infant feeding and mother-to-child transmission, I know that that has caused much comment. I should point out that the article was a South African study, which suggested that exclusive breast-feeding carried a significantly lower risk of vertical transmission of HIV than a mixture of bottle/breast and bottle-only feeding. Previous results from South Africa indicated that the highest rate of HIV transmission was an exclusively breast-fed instance. My advice is that recent results certainly need careful assessment.

I listened with great interest to the comments of the noble Lord, Lord McColl, and the noble Baroness, Lady Masham, on the contribution of Mildmay. The noble Baroness is constantly inviting me to visit centres. Therefore, if the noble Lord, Lord McColl, is agreeable, I would be very pleased to do so in this case because, clearly, there is much to learn. I was especially taken by the noble Lord's remarks about caring not just for young carers but also for professional carers. As regards the NHS, we sometimes forget the pressures that are placed upon so many of our staff when they deal with such stressful and tense situations.

A number of questions were raised about our approach to prevent transmission in the first place. As the noble Baroness, Lady Masham, and my noble friend Lord Winston suggested, anti-retroviral drugs, delivery by caesarean section and avoiding breast-feeding all reduce the risk of mother-to-baby transmission. Together, their effect is to reduce the risk of transmission from 25 per cent to less than 5 per cent.

My noble friend Lord Winston asked about our ante-natal screening policy. The previous policy was to offer an HIV test only to pregnant women at high risk. The policy was clearly not working, as 70 per cent of HIV infected pregnant women were not identified. This meant that those women could not be offered measures to reduce the risk of their babies becoming infected; nor could they be offered advice about treatment for their own infection. The advantage of the new policy to offer an HIV test to all pregnant women means that all women are treated equally. As the noble Lord, Lord Clement-Jones, mentioned, we have set a national objective to reduce the number of babies born with HIV by 80 per cent by the year 2002.

In relation to resources, I should tell the noble Lord, Lord Clement-Jones, that we have allocated £233 million for the treatment and care of people with HIV/AIDS in England. Those allocations take into account the associated costs of the new combination therapies. However, I should also point out that we are currently considering the recommendations of the Stock-Take Group on the funding of HIV/AIDS treatment and care. We hope to make an announcement shortly in that regard.

Before I conclude, perhaps I may turn to a crucial point of importance regarding the support for young people as carers. During the past two years we have discussed on a number of occasions in this House the crucial importance of supporting carers. How much more important is it to support young children? The National Strategy for Carers aims to ensure that children whose relatives have specific needs arising out of disability, or health conditions, enjoy the same life chances as all other children in their locality in terms of education, welfare and development. This requires local authorities to identify children with additional family burdens, to raise awareness among professionals of the many sensitive issues around this area and to provide services that are geared to ensure that those children's education, general development and their life chances do not suffer.

So we are developing—and have developed—a set of policies that we hope will tackle those issues. The Department for Education and Employment is working with the Carers National Association to identify good practice in existing young carers' projects in schools. We are also working to ensure that local authorities recognise the need to sustain and enhance the number of young carers' projects, and to ensure in particular that they have access to leisure and recreational activities. We also expect children's services plans to set out local support that ought to be available.

In addition, we are currently looking at ways in which we can improve awareness training about young carers for general practitioners. I very much take the point raised by one noble Lord earlier about the crucial importance of GPs, but how they cannot play that role if they do not have the right information. That applies not just to general practitioners but also to primary healthcare teams, social workers and teachers both at the time of their initial training and throughout their subsequent career development.

The clock ticks on. I am sure that I have spoken for far too long. If I have not replied to specific points—we shall read this debate carefully—I give an assurance to noble Lords that they will be fed into the strategy. The aim is to produce fairly soon some broad issues which will be followed by a more detailed consultation document.

I sum up. The Government fully recognise the issues and concerns which noble Lords have raised. I appreciate in particular the initiative of my noble friend Lady Massey in introducing this debate. She has done us a great service. We shall take on board the comments which have been made.

House adjourned at ten minutes past eight o'clock.