HIV/AIDS

HL Deb 20 February 2003 vol 644 cc1338-60

7.15 p.m.

Lord Fowler rose to ask Her Majesty's Government what action they are taking to combat HIV/AIDS.

The noble Lord said

My Lords, no one can doubt the importance of this Unstarred Question. The world is faced with one of the most profound health challenges that we have ever experienced. Globally, there have been 23 million deaths already. It is estimated that AIDS has created 13 million orphans. Around the world 40 million people live with HIV.

That is not all. All the forecasts indicate that we have not yet seen the worst. The worst is still to come as the epidemic spreads through India, China and Eastern Europe. Yet the tragedy is that the deaths and the sickness are not inevitable. HIV/AIDS is preventable. We can prevent its spread; we can prevent babies being born infected. People with AIDS do not have to die. Although there is no cure and no vaccine, retroviral drugs can extend life for many years.

Therefore, on one side are deaths which are counted literally in millions and on the other the ability to drastically reduce that toll and all the other suffering that HIV/AIDS brings. What has prevented such action from being taken? What I fear has been lacking is the will here in the West to do everything in our power to halt the spread of the disease. Even though the figures are so self-evidently terrible, there is still a lack of concern, a lack of outrage and a lack of anger at what is happening. We watch with something approaching indifference. It does not affect us in the West to anything like the same extent.

I pay tribute to the wonderful voluntary organisations working both in the United Kingdom and overseas. They carry out some truly heroic work. That should be recognised and the tribute to them should be underlined. But generally, I fear that public concern has not been remotely at that level. Would we get millions of people on the streets of London demanding more action on AIDS in Africa? I doubt it. Are there calls for emergency debates in Parliament on the position? Certainly that is not my experience. Yet, the human damage being inflicted by this epidemic dwarfs the results of terrorism.

This week, the Chancellor of the Exchequer gave interviews to both the Guardian and the BBC. Incidentally, the reports by those two organisations were excellent. I congratulate both. I particularly pay tribute to the BBC which receives much criticism from politicians. Thank goodness we have a media organisation with the courage to lead its 10 o'clock news with HIV/AIDS, as it did earlier this week. I am tempted to say that the media are doing rather better than the politicians in this particular area.

Responding to questions, the Chancellor of the Exchequer called on drug companies to provide much cheaper drugs. I agree with and endorse what he said. This is not remotely a matter of party politics and nor should it ever be so. However, I must add that initiatives like that do not absolve governments from their own responsibility. All the evidence suggests that the role of government is absolutely crucial in fighting HIV/AIDS. No one else has the power or the resources.

In Britain in 1986–87 the then government sought to lead with their public education campaign, comprising advertising on television and in newspapers; posters, and a letter sent to every household. As Secretary of State I received much advice on what we should put in the letter and what we should and should not do. What was fascinating was that the public response to the letter was very mature. There were few complaints. I think that most of the public reacted extraordinarily well to the careful medical advice being given. I admit that we made one mistake. We sent a letter in Welsh to a non-Welsh speaker. We learnt of the mistake when he turned up at a social security office believing the letter to be an application form for a heating allowance. In the main, however, I am glad to say that the impact was much more beneficial. I know too that in Africa, the lead given by the Ugandan Government in tackling AIDS has had an important and fundamental effect.

So I would suggest that today the question for the Chancellor of the Exchequer and for the Government is whether they are doing enough. For unless they are, it is difficult to say to others, "You must do more". I regret to say that I do not believe that the Government are doing enough.

As regards the United Kingdom, what most concerns me is the high degree of public complacency, as well as the degree of ignorance. Surveys show that today almost half the country feels it knows very little about HIV/AIDS. One survey showed that four out of 10 teenage boys had not even heard of the disease, a condition that is causing so much suffering around the world. I know of no one working in the area of young people who considers the present position in this country to be satisfactory. The truth of the matter is that public education is failing.

I have to say to the Minister that it took the Government four years—I repeat, four years—to produce their sexual health strategy paper. It was as if they were afraid of offending the public by raising such issues. Whether that is right or wrong, there is no doubt about what is happening. The pressure on clinics dealing with sexually transmitted diseases has become intense. Between 1991 and 2001 new cases being seen at the clinics has increased from 670,000 a year to over 1.3 million. The clinics are grossly overcrowded. One has only to go across the river to St. Thomas's Hospital to see that. People have to wait weeks to be seen. Indeed, the position is particularly bad in London.

Turning to HIV infection, it is estimated that last year there were 6,500 new diagnoses, the highest figure ever recorded. Furthermore, the number of homosexual men now being diagnosed is again increasing after levelling off in the early 1990s. That is bad news because it obviously means that the safer sex message is not getting through.

The one part of the picture which has remained good has been the low number of reports of HIV contracted from injecting drugs. Although at the time I was much criticised for introducing clean needle exchanges—it was not one of the easiest of discussions in government at the time—I would claim that the policy has worked.

Of course it is true that today the figures for HIV are much affected by heterosexual transmission. There were over 4,000 reports last year, and of those 80 per cent of the infections were acquired in sub-Saharan Africa. We have all seen the reports in The Times of 13th February stating that all immigrants are to be given compulsory HIV tests, as cases rise. I would be grateful if the Minister could comment on those reports. Certainly there is a strong case for such checks when someone is going to work in the National Health Service and will be involved in procedures such as surgery, gynaecology and dentistry, where the patient may be put at risk. But if you are to have general checks, the question becomes what action follows those checks, particularly with HIV, where the condition can be dormant for months.

We should always remember, and perhaps underline again, that HIV is not infectious in the sense that it can be easily spread. There is certainly a question about the cost of medical treatment, but not a massive new threat to public health. So we await the Minister's comments on the Government's policy in that area.

Let me take the argument further. At the same time as recognising that concern, we should also feel compassion for people from Africa who are seeking treatment. In this country, we are talking about 4,000 people, many of whom have come from Zimbabwe where their country is being laid waste.

Compare that with the figures for sub-Saharan Africa. Almost 30 million people have the AIDS virus, including 3 million children under the age of 15. More than 4 million require immediate drug treatment. Yet across that continent only 50,000 people are receiving the medicines they need. The others are condemned to die. That is the bleak and dreadful truth of the problem. Those are truly terrible figures.

I am in no doubt as to what is the most urgent task. It is for the prosperous western nations to come together to provide the resources so that we can save life. In that respect, the most hopeful development came in President Bush's State of the Union Address last month. In that he pledged 15 billion US dollars over the next five years for this cause.

What a contrast with what has gone before. I remember going to the United States in the late 1980s to see what the Americans were doing at government level, to be told that already we in Britain were doing more. The word "AIDS" had not crossed President Reagan's lips; the Governor of California, which had the biggest problem, ignored the issue. Voluntary organisations and Churches were doing a great deal; government were doing very little. So I unreservedly welcome the President's commitment.

Of course there are issues about how such money should be divided between bilateral aid and the Global Fund, but the issue, the challenge which we should face, is what we can do in Britain and Europe to match that commitment.

I acknowledge the Government's increased contribution through the Department for International Development and I welcome it. But I have to say—and I suspect that Clare Short would agree with me—that it is still not enough. The noble Baroness, Lady Amos, said last night that the Government had contributed 200 million US dollars over five years to the Global Fund. In reality, that is a small amount compared to the billions of dollars that the Global Fund needs each year—7 to 10 billion US dollars is the goal.

There needs to be a step change in the resources we are providing. That applies not only to Britain but also to the other developed and prosperous countries of the European Union. Europe is skilled at argument and debate—often with each other—but there is here the opportunity, the challenge, to come together and to devote resources and effort to a cause which we can surely all agree. Our aim should be to match the effort and commitment now coming from the United States.

Equally, we could follow the United States in having a European high level special co-ordinator. The President of the United States has said that his appointment will have the rank of ambassador. We could give a European appointment equal importance. The point would be to bring greater direction and greater purpose to all the different programmes that now exist and to encourage the new resources which are needed.

A terrible tragedy has already unfolded. On present policies, that tragedy will deepen and extend even wider. We have the knowledge and the ability to prevent millions of deaths from taking place. We should use all the resources at our disposal to fight this epidemic and be totally committed to this goal. Future generations will judge us on how we respond.

7.30 p.m.

Lord Rea

My Lords, I congratulate the noble Lord, Lord Fowler, on asking this Unstarred Question. I think it is admirable that the noble Lord, who was Secretary of State for Health at the time the epidemic first appeared in Britain, should demonstrate his continuing interest. His team then at the Department of Health, backed by the Cabinet Committee headed by Lord Whitelaw, really went into action. It was a scary time, but the response was appropriate. Very explicit health messages went out on billboards, in newspapers, on television and through letter-boxes. Sexual topics which till then had been taboo were frankly discussed. Some people were shocked. I was impressed by the ability of a Conservative government to be so open. And the campaign worked. The incidence of new cases of HIV slowed from 1985 to 1988. Some other countries at a similar state of development tried to follow suit, but few were so successful in containing the epidemic as the United Kingdom.

In looking at the situation today, I could quote many statistics which have been kindly given to me by the Public Health Laboratory Service, but I shall be selective. Like the noble Lord, I shall divide my time between the UK and the developing world. The two pictures are linked, as the noble Lord implied. New notifications of HIV in the UK increased gradually from 1989, but more rapidly from 1998. Deaths from HIV/AIDS are now much lower than in the early years of the epidemic because of the availability of combination anti-retroviral therapy, and are down from over 1,000 per annum to about 400.

The increased rate of HIV transmission that we are seeing now is largely due to sex between males and females. The rate among this group has increased relentlessly, from a very low level in 1985 to 2,441 according to the most recent (2001) figures. It now makes up 55 per cent of the total. Transmission resulting from sex between men is now only 32 per cent of the total—down from 72 per cent of the total in 1986. But the number of cases from men having sex with men has crept up, even though the percentage has gone down, in the past three years—in parallel, as the noble Lord suggested, with a rise in other sexually transmitted diseases, because the practice of safe sex is diminishing—possibly because of a mistaken belief that HIV, now that it can be treated, is no longer lethal.

The noble Lord also pointed out that the incidence of HIV spread by drug abusers is very low because of the success of the needle exchange programme. That is still operating. I very much hope that the Government will keep it going or strengthen it, because it has been effective.

The increase in heterosexually transmitted HIV is largely confined to communities in the UK consisting of people originally coming from countries with a high HIV prevalence—mostly from sub-Saharan Africa. Many of their infections have been acquired abroad, and the culture of denial, which is all too common in those countries, still prevails among some immigrant communities here—those affected are mainly in London.

The Government are fully aware of these trends, as is shown by the National Strategy for Sexual Health and HIV, and are working with black African people, especially in London, in an attempt to increase awareness through health promotion programmes and are encouraging HIV testing and counselling. The African HIV Policy Network co-ordinates these activities which are carried out, for example, through the National AIDS Trust and the Terrence Higgins Trust. The department funds projects by NGOs. One in particular is the African Services Development, which is under the aegis of the Terrence Higgins Trust. Core funding for the organisation is not, however, provided by the Department of Health, and I strongly recommend the Minister to look at ways in which the department can strengthen this work and put it on a more strategic and co-ordinated footing, with a long budget line, (if that is the way to describe money promised over three to five years instead of one year).

There are other initiatives which need encouragement. It is not easy, working with these communities. The African community in London comes from disparate cultures. It is different from working in a village in Africa, where there is usually an informal administrative structure headed by respected elders.

The noble Lord, Lord Fowler, spoke about the proposal to screen and test all immigrants, treating those found to be positive for HIV, TB or other diseases. There is a strong case for that on public health and individual health grounds, but there are many political and ethical arguments against it, and it might even be counter-productive. Like the noble Lord, I should very much like to hear the Minister's views on that.

The total prevalence of HIV infection in the UK, estimated to be 41,200 by the Public Health Laboratory Service, is only 0.08 per cent of the population. That, of course, is considerably greater than the figure for those infected by variant OD, caught by eating the wrong kind of beef, but it is tiny compared with the disastrous rate of 25 per cent or more in many sub-Saharan countries. DfID is well informed about the devastating nature of the pandemic—the noble Lord has given the figures. It is suggested that although sub-Saharan Africa bears the brunt at the moment, as the noble Lord suggested, there are indications that India, possibly China, Russia and the other former Soviet countries may also be about to see an onslaught of similar dimensions.

A large part of the reason for the African disaster is the refusal, until recently, of many, but not all, African heads of state to accept that intimate sexual behaviour, patterns or habits which have become part of the cultural norm will have to change and include the use of condoms—not very popular. They could take a leaf out of the noble Lord's book and look at what we did here. I am sure it was not easy for the noble Lord or his colleagues to reveal and publicise the seamy side of life, but they took the plunge and it worked. In Africa, President Museveni has done the same but, sadly, President Mbeki of South Africa still seems to be in denial. But former President Mandela has given encouragement to many in South Africa to stand up and he counted. There are many courageous people there, giving the true message.

It is in South Africa that the most vigorous campaign has taken place to purchase an ti-retroviral drugs at low cost. The South African Government have finally agreed, in principle at least, to offer all HIV-positive pregnant women the option of receiving the drug Nevirapine at the time of delivery to reduce the transmission of HIV to their babies. The campaign to persuade the pharmaceutical giants to provide low-cost anti-retroviral drugs to the world's poorest and most afflicted nations continues.

At present, South Africa and some others are buying generic drugs from India and Brazil, but even these are well beyond the reach of most developing countries if they were to give them to their entire HIV-positive population—were that ever possible through a very basic and sometimes absent health infrastructure.

However, there is a strong possibility that the marginal cost of increasing the production of antiretroviral drugs by the major pharmaceutical companies would be less than that charged by the generics industry. By marginal cost, I mean the cost of production. They would not lose, but they would not make a profit. The production could be vastly increased, but we do not know the full figures for the marginal costs. That is the route through which a huge increase in the production of the drugs could be achieved. However, deadlock appears to have been reached at the World Trade Organisation. Let us hope that an agreement can be reached between now and next September, at the next ministerial WTO meeting in Cancun, Mexico. I very much hope that my right honourable friend Patricia Hewitt—if it is to be she who represents us—will speak strongly in favour of such an agreement before and at the summit.

Equally crucial is the need to build up Kofi Annan's global fund for AIDS, TB and malaria. It is still woefully below its target level of 10 billion dollars per annum. If all countries in relation to their wealth had contributed as generously as the UK, the kitty would contain more than the 2.2 billion dollars that it now has, but it would still be grossly underfunded. That is a sad story in comparison with the huge sums of money now being spent on the build-up to the possible war in Iraq. If the war starts, the cost will be vastly higher—maybe 100 billion dollars, which would be enough to finance the global fund for 10 years, with inestimable benefits to the poorest people in the world and the saving of millions of lives. On the contrary, a war would cost many thousands of lives and cause destruction that would take many billions of dollars to rebuild.

However, we have to deal with the situation as we find it. Many low-cost projects can be carried out to soften the impact of this worldwide disaster. Many are in action already. DfID is helping some of these bilaterally through the EU, the multilateral agencies and, particularly, through non-governmental organisations. These measures include support for governments and NGOs to carry out preventive programmes, especially with young people—I am sorry that there is not time to go into this—and to help those with HIV and AIDS to live better lives. Much can be done to improve their quality of life in their own homes as they become weaker.

Just after Christmas, I spent a week with ICROSS—a small, Kenya-based non-governmental organisation headed by a dedicated Anglo-Irishman called Mike Meegan. It trains local village or slum people to look after their fellow villagers who are sick with HIV, give them simple remedies when they suffer opportunistic infections, refer them to hospital if necessary, but be ready to receive them back to continue treatment at home, thus saving many hospital beds. I thought that the visit would be harrowing. It was not. The patients clearly had a feeling of inner contentment, because in their suffering they were being cared for and their children, who were to be orphans, were already bonding with other villagers who would take over the parents' role. There are many similar caring organisations, some receiving help from donor countries, some from individual donations. It is good that they are there, but it is a sad reflection on the fact that at present we cannot do more.

7.44 p.m.

Lord Alderdice

My Lords, I join the noble Lord, Lord Rea, in thanking the noble Lord, Lord Fowler, for obtaining this opportunity for us to address the most significant plague to have appeared in our globe in my lifetime and a deeply serious and worrying matter.

The small number of noble Lords taking part in the debate tends to suggest that colleagues may be taking comfort from the fact that much progress has been made in pharmacological treatment, public health and preventive measures in this country. In much of the developed world, the early fears of galloping epidemic have, fortunately, not been realised. However, the picture in developing countries is very different. This debate allows the House and those outside it with an interest in these matters to be updated in the approach being taken by Her Majesty's Government, but it also provides your Lordships with an opportunity to proffer some thoughts and advice on the matter to the Government.

I address myself largely to the situation in the developing world, rather than to that in this country. I shall refer especially to sub-Saharan Africa, where the impact of the disease has been, and will be for the foreseeable future, absolutely catastrophic. It is not possible or appropriate in a debate of this kind to try to address all aspects of the problem, so I shall restrict myself to two or three.

There is a dilemma involved in reaching people with educative and warning messages to inform them how and why they must modify their behaviour to protect themselves and their families from the disease. One difficulty is in reaching them in a way that works. In this country, as the noble Lord, Lord Fowler, said, we have radio, television, advertising hoardings, newspapers, the Internet, leaflets delivered to every home and many other methods of health education. Those methods are all possible and have been undertaken with significant success.

The limited research evidence available on this matter, which includes an interesting report that was published in the past 12 months by the United Nations, and the common-sense appreciation of the realities of life in sub-Saharan Africa, make it clear that there is only one significant way in which to get across a message to the population at large. That is the use of radio. In many parts of Africa, it is simply impossible to reach people in any other way, because of rurality, illiteracy and the other manifold social and educative problems. Radio is not only a way in which to reach people individually; in many developing countries, listening to radio is a group activity that stimulates thought and discussion.

Despite that knowledge, there has been relatively little concentration on ensuring that journalists, especially radio journalists in developing counties, are adequately encouraged and trained to use radio to get the message across. In this country, the United States and a few other countries, there have been laudable attempts at limited schemes to train health journalists. However, that tends to involve a privileged few journalists travelling to attend worthwhile courses in the developed world. Reaching really significant numbers of journalists would mean conducting training exercises in developing countries, although that might involve taking some of our skills and experienced people to assist. It would also involve a follow-up. Training journalists to appreciate the value of this is of little consequence unless there is a continued provision of stories that can be introduced into the programming and the news to ensure that the message continues to get across.

The BBC World Service Trust has done some work in the area of HIV/AIDS health journalism. Money invested in that area gives the prospect of a significant multiplier effect. Will the Government consider encouraging not only the subtle mention of HIV/AIDS in soap operas, although that is valuable in its own way, but also other definitive and clear information through radio? That would require some significant, though not colossal, public funds. The Government could encourage other foundations and funders to assist organisations such as the BBC World Service Trust and other bodies to develop such work. I believe that such training and support of journalists to use radio is an extremely important way of getting the message across.

That leads us to the question of what precisely we should be saying about our understanding of the illness. That question has come to the fore even today with the publicity about three articles published by the Royal Society of Medicine in the International Journal of Sexually Transmitted Diseases and AIDS. I have been provided with the articles by the editor of the journal, Professor Wallace Dinsmore, and I have read them. It seems to me that there may be reason to revisit some of our assumptions about the spread of HIV/AIDS in sub-Saharan Africa.

As some noble Lords will know, the received wisdom has been that in excess of 90 per cent—some people give even larger numbers—of transmission is by heterosexual intercourse, a very different situation from that which is understood to be pertaining in this country, for example. What those articles raise is the possibility that a significant element of the transmission may be by other means, including possibly the use of infected needles. The reasons given for those findings are that the spread of AIDS in Africa has not followed the pattern of other sexually transmitted diseases. For example, in Zimbabwe in the 1990s, HIV increased by 12 per cent annually while other STDs diminished by 25 per cent and condom use actually increased in the high-risk groups. In one study, the mothers of more than 40 per cent of HIV-positive children tested HIV negative, and the children who tested HIV positive experienced twice as many injections as compared with HIV negative children.

Very worryingly, it is often countries with high levels of healthcare that have the highest rates of HIV transmission. I remember being particularly struck, a year or so ago, when visiting Botswana, a country with a relatively small population, a very good infrastructure, a good healthcare system, and rampant AIDS. I wondered why that was. It did not seem to me reasonable simply to assume that it was a matter of sexual behaviour. I therefore think that it is important to look at those articles. The authors quite properly insist that their findings are not definitive. However, they raise an important question. It is a little disappointing that the immediate reaction of a WHO representative was reported to be negative, although as politicians we know that it is a little dangerous to take reports at face value.

I can understand the deep anxiety that all the work done to persuade people to exercise greater care and less risk in their sexual behaviour could be damaged. However, I hope that the Government will not simply dismiss those articles but examine the issue properly. If further investigation sets them to the side, that will be well and good. Better that than that a warning bell be rung and ignored and that subsequent findings confirm the findings. Apart from the loss of life in the interim, the damage done to the standing of western medical science and its use would be absolutely profound. If there is a real issue, we need to know about it.

In any case, it raises another important question about how we apply medical treatments developed in western contexts in less developed situations. In this country, for example, we would not dream of not using sterile single-use needles, but in other parts of the world, finance makes it difficult to do otherwise. In this country, we would not contemplate embarking on anti-AIDS multi-drug treatment without proper tests and proper monitoring. But how possible is it to ensure that such tests and monitoring take place even if we are able to provide the multi-drug treatments that we desperately hope will soon be available for people in sub-Saharan Africa?

The implication is that not only do we need to ensure that those pharmaceutical products are made available at affordable costs in developing countries, whether by encouraging employing companies to provide them—such as in South Africa, where they have begun in enlightened self-interest to realise that AIDS rampant among their employees is not good for business—or by government-sponsored schemes, as elsewhere, we also need to ensure that all other aspects of the treatment and of the AIDS campaign are present, such as supporting healthcare professionals and providing them with single-use needles. The noble Lord, Lord Fowler, pointed out that in this country we took that step with intravenous drug abusers and it has been helpful. Why assume that it is irrelevant in sub-Saharan Africa? I do not believe that it is.

I mention again facilitation and encouragement in radio broadcasting as a feature of public education. By concentrating on sub-Saharan Africa I do not suggest that it is more important than other parts of the developing world or that the situation is satisfactory here. The powerful speech by the noble Lord, Lord Fowler, makes clear that there are problems here and problems elsewhere. I am convinced that in good conscience we cannot simply forget the utter disaster that is affecting not just many of our Commonwealth colleagues but all other countries in sub-Saharan Africa. I hope that Her Majesty's Government will have something encouraging to say in that regard.

7.56 p.m.

Earl Russell

My Lords, it is not enough to thank the noble Lord, Lord Fowler, for introducing the debate; we must also be thankful that it is through the noble Lord that this debate was initiated. He is a modest man; he has been the first to admit that his rate of success has been very partial. But the rate of success in dealing with major pandemics is almost nil. The noble Lord will stand comparison with any Minister in any century that I know of who has tried to tackle any epidemic. We are fortunate to have him here tonight.

As my professional skill is not medical, it naturally occurs to me to think of this issue in the context of other major pandemics, especially that of the Black Death. One of my interesting questions is whether the similarities or the differences are more relevant. The scale of death in the Black Death was at many stages greater. It is believed—I cannot put it more strongly than that—that in 1348–9 something like 30 per cent of the population of England died. Even in sub-Saharan Africa we have not yet seen figures of that kind.

Right down to the plague of 1665 there were at least four occasions in any normal century when 20 per cent of the population of London died. What strikes me about such occasions is the extraordinary resilience of human society. If one looks at the records of the Parliament of 1625, when they had to step over the dead and the dying in Palace Yard to get into the House, one can read through without knowing that that was taking place. If one looks at municipal records, where they continue, which is not always, one sees presented an unbroken surface. That resilience is crucial, both in the strength of the family bond—during the bubonic plague there is no recorded case of parent and child or husband and wife failing to nurse each other through it—and in the capacity of the population to recover.

After each of those epidemics there was an abrupt drop in the age of marriage that lasted for about three years which replenished the population and then it settled down to its previous age. My academic colleagues are correct in ascribing that to the economic opportunity for marriage, created by inheriting the house, the farm, the shop or whatever. In the words of the epitaph: Beneath this stone, in hopes of Zion, Doth lie the landlord of the Lion; His son keeps on the business still, Resigned unto the heavenly will". It is of course the intensity of the human urge for reproduction that carried us through, but that is where the difference lies. The danger of AIDS is that it attacks us at the point where we feel the reproductive urge most. It threatens the very mechanism that enabled us to survive much worse epidemics in times past. That makes me wonder whether one of the best places to try to tackle the whole problem is the mother-baby link of transmission.

I listened with great care to what the noble Lord, Lord Rea, had to say about the use of anti-retroviral drugs. I thought of the previous problem of rhesus negative babies. Obviously there is a point of parallel, although not a complete one. It is not so long ago that having a rhesus negative baby was a really life-threatening situation in a way in which it is not now. If we could break the link, the strength of the human urge for reproduction would again be protected.

However, we must think also of the feeding of the baby. Clearly, it cannot be done on the mother's milk. The practice of wet nurses, as used in Tudor and Stuart England, is of limited application, because there is a limited supply. That brings us back to the question of bottles, which brings us back to the question of the Johannesburg Summit—of clean water. I remember that stage of parenthood as an endless process of scrubbing out bottles with a substance known as Milton. Being brought up on Gray's Elegy, I always thought of it as mute inglorious Milton. It is no good having any amount of mute inglorious Milton if there is only polluted water to use. The question of clean water, as it came up in the Johannesburg Summit, may even be vital for our survival as a species.

If one looks at the subject, one realises the importance of blue-skies research. If we think of San Francisco, AIDS came literally and metaphorically out of the blue sky. I remember it being said during the education debates of the 1980s that it can take up to 20 years to build up a competently trained first-class research team in a particular field. Of course, microbiology was not the flavour of the month immediately before AIDS.

We do not know where the next danger will come from. If one begins to build up academic capacity only after the need is perceived, one comes into something like the curve of pursuit in calculus, which was the only bit of calculus that my father ever managed to make me understand. A dog runs diagonally across the corner of a field to pursue his master who is walking along the other side. He runs towards where his master is, but since his master continues to progress along the field, the dog is perpetually running behind him. That is what happens if one tries to commission research according to perceived need. It is always behind the need for which it is designed. There will be other such problems, so we must have blue-skies research.

I noted what the noble Lord, Lord Rea, had to say about healthcare. The key question for me is whether the motive is purely medical. In the 16th century, syphilis was known in this country as the Spanish disease. In the 17th century, it was known as the French disease. That change is not a matter of medical evidence, but of changing English foreign policy. If a test is imposed on everyone, regardless of nationality, coming from a particular country, one can make a scientific justification for that. However, if it were applied to people on the basis of nationality, not on the basis of where they have been.

I would find that a highly suspicious proceeding and not one particularly easy to justify in scientific terms. I also wonder, with some curiosity, whether one might do something to improve the situation by moving towards greater equality of the sexes. The reluctance to wear a condom is, of course, normally a male phenomenon. One understands perfectly well why, but understanding why does not make it any more helpful. In a situation of greater equality, it may be easier for the female partner to insist on its being worn. Therefore, that may be one area where progress might be possible.

I think also of the specific context of prostitution, which is clearly one in which the spread of AIDS must be possible. According to the Sunday papers—independent journalists in different papers repeat themselves so consistently that I believe they are probably on to something—prostitutes are regularly offered extra money for being prepared to have sex without a condom. Of course, I do not need to say that that is a dangerous practice, but it is also an exercise of crude economic power in an unequal relationship. I cannot help wondering whether it might strengthen the prostitute's bargaining position in this situation if it were a criminal offence to offer to pay a prostitute money for intercourse without a condom. Of course, the very last thing that any man wants in that situation is publicity. There are risks in the idea; I throw it out only as something that we might consider.

On the question of the drug companies, I understand that research has costs. I understand that those costs must be met somewhere. But it is also necessary for any commercial organisation to think in a wider context. Commercial organisations need customers, and I cannot think of any more extreme form of short-termism than killing one's customers. Therefore, it might be in the drug companies' economic interests to listen to some of the things that the Chancellor is saying to them.

I listened with great interest to what my noble friend Lord Alderdice said about needles. I had read about it in this morning's papers, but he developed the case in much greater detail and with much greater scientific precision than one ever expects from any newspaper which has been sub-edited in the middle of the night.

The one thing that is clear to me at present is that there is no academic consensus on the matter. Where there is not academic consensus, one usually needs more research with larger samples and a wider range of questions. But I must confess that, when we were talking about the supply of needles, unbidden came into my mind the voice of my noble friend Lady Northover last night. She spoke about the supply of condoms provided by one particular charity, which, she said, amounted to one condom per male per annum—not a particularly satisfying allowance.

I cannot help wondering whether that might be true of the supply of needles to some areas of sub-Saharan Africa, where there is a considerable shortage of such things. I also wonder whether, in the task of sterilising needles, the problem of clean water may, again, be rearing its ugly and polluted head. After all, what is the point of attempting to sterilise a needle in polluted water?

Therefore, again, we need to get across to those who are influential in the World Trade Organisation—I am glad that a number of people have attracted our attention to that organisation—the proposition that the short-term pursuit of profit is not always profitable, again, according to the principle that one does not want to make profits at the expense of killing one's customers.

The invisible hand has something to be said for it, but some hands are rather more invisible than others. The hand that says, "You shouldn't deal with problems of polluted water because it diminishes your short-term profits", is a hand that I find quite peculiarly invisible. Indeed, it is in more senses than one a hand of a ghostly quality.

So, in discussing World Trade Organisation problems with those who take some of the new economics which come from places across the Atlantic, I hope that we shall be able to get people to take a slightly wider view of the matter. It is in the World Trade Organisation that in the end the battle will be won or lost.

8.10 p.m.

Lord McColl of Dulwich

My Lords, I, too, congratulate my noble friend Lord Fowler on initiating this debate. I agree very much with what he said. I also endorse his remarks about President Bush's admirable contribution.

The recent increase in the incidence of AIDS in this country is very worrying and therefore the timing of the debate is particularly helpful.

At the outset I should declare an interest. I have been president and chairman of the Mildmay centre in Hackney, which we set up in 1986 as the first hospice for people dying of AIDS in Europe. As we found ourselves treating quite a number of Ugandan women and children, President Museveni of Uganda visited the centre and asked us to build a similar organisation near Kampala. Of course we readily agreed, not thinking how on earth we would find the money.

My noble friend Lady Chalker was very supportive. The Overseas Development Agency provided us with several million pounds to build a large outpatient and teaching centre, which continues to serve a large number of people, not only in Uganda but also in many other African countries.

I found attending a clinic in the centre to be a very harrowing experience. One would see about 90 children, all with AIDS, all orphans and all dying; 80 per cent of them had open TB; and many had scabies. It was not the usual type. Because they have no immunity it is a generalised rash and does not look like scabies, but is very distressing. Of course that can be cured quite easily. There was also shingles. I have never seen such terrible cases of shingles. Again that condition can be helped. One problem is looking after the staff of the centre. It is such a strain that we have to make sure they get regular holidays.

I want to look at how the incidence of AIDS can be reduced. There have been many attempts to that end, but none more successful than the Ugandan policy, which succeeded in reducing the number of new cases from 30 per cent to 11 per cent.

In order to be up to date, I obtained the latest figures by telephoning the two ladies in Uganda who have done such wonderful work there for many years. One is a real live matron—how we miss them in this country—Ruth Sims, and the other is the medical director, Dr Veronica Moss. They said that the incidence of AIDS in pregnancy has fallen even lower to 7 per cent.

The question arises: how has Uganda achieved this while other countries have not? I think that President Museveni is probably one of the most outstanding of Africa's leaders. When he realised what the problem was in the late 1980s, he decided that above all the country had to face the facts. Concealing the truth, he knew, was a recipe for disaster. So it has proved to be a disaster in several of the African states.

I was very interested by what the noble Earl, Lord Russell, said about the percentage of people that the plague carried off. I knew that the plague carried off about one-third of the people, but the same thing looks to be happening in some of the African states. Furthermore, a similar catastrophe appears to be in store for several Asian countries that pretend that AIDS is not their problem.

As the noble Lord, Lord Alderdice, mentioned, even today there was a dubious report about the spread of AIDS in Africa, stating that it had more to do with faulty medical treatment—including contaminated equipment and blood transfusion. I put more store by what Professor Michael Adler had to say about those papers. He is a distinguished doctor who has been involved in HIV/AIDS for many years. His view was that those propagating that view had produced no new data and that most of their analysis dated from the 1980s. Blood transfusions are now much safer; people are much more aware of the dangers; and people are more careful about medical interventions.

On the "Today" programme this morning, a senior doctor working in Kenya pointed out that 1.5 million Kenyan people have died of AIDS and 2 million currently have AIDS, but those people never see a hospital until they have developed the disease. He also emphasised that for the past 10 years in Kenya they have used only disposable needles and that all blood transfusion is doubly checked.

The World Health Organisation figures estimate that unsafe injections are responsible for only 5 per cent of HIV/AIDS infections. A United Nations unit called the Safe Injection Global Network has been established to promote safer practices, focusing mainly on hepatitis, which is much more easily transmitted in that way than HIV/AIDS. As a surgeon myself, I am very careful with the knife and needles not to incur any injury to myself or my assistants, but it is not AIDS that I am concerned about, it is hepatitis. It is actually quite difficult to pick up AIDS from a needle stick, but easy to pick up hepatitis. So the policy is, when operating on a person, to assume that everyone has hepatitis. That makes one very careful indeed.

Of course, it was not so long ago that surgeons did not need to wear gloves at all and, during the war, many of them did not. But we now tend to wear two pairs of gloves. Someone said that the only reason that surgeons wore gloves in the old days was so that they did not leave any fingerprints behind.

Experts have pointed out that if contaminated needles were responsible for the spread of AIDS, Hepatitis B would be spreading faster than HIV/AIDS in Africa and Asia. It is not. An Imperial College epidemiologist, Professor Roy Anderson, has said: Understanding the root of infections is very difficult unless you do cohort studies which compare groups of people who get the disease with similar groups who don't get the disease". When that was done for HIV/AIDS, two risk factors were identified. The first was sexual behaviour and the second was the presence of other sexually transmitted diseases, which may facilitate infection with HIV/AIDS. The number of injections that anyone has had does not appear to be important.

Another specialist has stressed that if the main spread of the disease was through needles, one would expect to find the disease in similar concentrations across all age groups. But that is not the case. It is overwhelmingly concentrated in the sexually active age groups.

President Museveni himself launched a sustained campaign based on preventing AIDS by encouraging faithfulness within marriage. He said that, if a person could not confine sex to within marriage, precautions should be taken on the clear understanding that they are not always successful in preventing AIDS. They are not all successful in preventing pregnancy either. Sperm are many hundreds of times bigger than the HIV virus. He emphasised that education was not enough; a change in behaviour was required. Recently, that was underlined when a young lady doctor who went to work in Africa had an affair and, tragically, returned home with AIDS. She was highly educated. I was struck by the suggestion of the noble Earl, Lord Russell, that perhaps attitudes to women should change. That comment is typical of the noble Earl. In his entry in Who's Who he lists one of his hobbies as uxoriousness.

Noble Lords have drawn attention to the tragedy that developing countries cannot afford the antiretroviral drugs, which would relieve a great deal of suffering. It has already been pointed out that a single dose to a mother with AIDS during childbirth can protect the baby from developing the disease. But, sadly, that has stimulated some very chilling ethical discussions. Many argue that it is unfair to save a child who will be left with no-one to look after him. Clearly, much more effort must be made to find money from the wealthier nations to supply those necessary drugs. But simply attacking the drug companies is no real answer. In my own experience of working in Africa, not only in the Kampala centre in Uganda but also on a hospital ship with Mercy Ships, travelling to developing countries and staying in port for several months, doing the operations that people there cannot do and showing them how to do them, I was struck by the generosity of the drug companies. When the companies found out that some charities were using out-of-date drugs to economise, they offered to replace them free.

Reference has already been made to the great concern that we all feel about the recent, unacceptable increase in the incidence of AIDS. It emphasises how essential it is never to let up in the campaign to try to persuade those at risk to take every care to avoid contracting this fatal disease.

We all look forward to hearing from the Minister what the Government plan to do to turn the tide of the epidemic. As I know the Minister is aware, there is an urgent need to provide more resources to deal with those awaiting treatment in genito-urinary medicine clinics. I am sure that she is aware that the waiting time is now unacceptably high. We also need more resources for an effective screening programme for chlamydia, especially among young women.

I would also like to know how government publications, advertisements, videos and so on are being distributed throughout the country, and whether they are the ideal format. I have been impressed in the past with the BBC and other broadcasting companies who have incorporated those essential messages into their programmes—"Coronation Street", "The Archers" and so on. It is great that they do so. We need constant vigilance if we are to succeed in containing this plague.

8.25 p.m.

Baroness Andrews

My Lords, it is a considerable privilege to wind up a debate that has not only been led by the noble Lord, Lord Fowler, but has attracted the contributions of noble Lords who speak with authority and expertise on the medical side not only in Africa but also at home. The noble Lord, Lord Fowler, has the gift of foresight. In 1986, when he was Minister of Health, he responded extremely well to what was then a completely unknown and unpredictable situation. He also found a time for our debate in a week in which, as he said, the BBC and the Guardian have done excellent work in drawing international attention to the challenge at home and abroad.

It has been a good debate, and we have ranged far and wide. To return to something that was said in the debate, I think that one of the reasons why we have, in some respects, a good record in containing the infection relative to those of our European partners was the foresight that was shown in introducing prevention intiatives such as needle exchange. I enjoyed all the contributions and have learnt a great deal from the debate. I hope that, in the time available, I can answer some of the questions and reflect on some of the issues and on the interesting suggestions as to some aspects of policy.

I will not repeat the details of the scale and implications of the global tragedy; that has been done better by other noble Lords. I am grateful to the noble Earl, Lord Russell, for making, as only he can, the chilling historical comparison with previous plagues, particularly the Black Death. On television the other night, someone describing the way in which teenage children follow their parents to the grave referred to the plague as an African Black Death. That is a more than sobering thought.

One of the problems is that one's vocabulary is exhausted when one tries to describe the current situation and its implications. The numbers defy imagination. As the noble Lord, Lord Fowler, said, the focus is on sub-Saharan Africa, where the phenomenally high figures are so daunting, but the fastest rate of growth is in eastern Europe and the central Asian republics. We have only begun to think what alternative strategies are needed to address the different cultural reasons for that expansion.

We have the excellent and inspiring story of Uganda. I pay tribute to the work done by the noble Lord, Lord McColl of Dulwich, in Uganda and on the Mercy Ships. It was interesting and not a little humbling to hear of the time that he gave to that work and the positive impact that it had. Comparing the situation in Uganda with that in Swaziland and Botswana helps focus our mind, so I will talk first about what we are doing to meet the global challenge. I hope that I can convince the noble Lord that, if there is a lack of will, it does not exist in this Government. We have a good record of responding quickly to the HIV/AIDS epidemic, focusing on priorities and maintaining vigilance, which is all the more important, as the epidemic spreads.

First, I shall speak about what the Government are doing to meet the global challenge. I hope that I can convince the noble Lord, Lord McColl of Dulwich, that if there is a lack of will, it is not in the Government. We have a good record of responding quickly to the HIV/AIDS epidemic, of focusing our priorities and maintaining a vigilance, which has been all the more important as the epidemic has spread.

I turn now to the reasons for the growth of AIDS and the issues raised concerning needles and cleaning. There is no academic consensus. I was interested in the comments made by the noble Lord, Lord McColl of Dulwich, about the alternative point of view. The Government have not yet had time to study the research. It is important that we do some triangulation on views and evidence. We know that UNAIDS disagrees with the results. We agree that more resources are needed to ensure sterile medical care in all countries. That is one reason why we have put such a huge effort—£1.5 billion since 1997—into health care systems as part of our contribution.

There is a wide range of measures that the Government are attempting. We are trying to build effective health care systems. We are focusing some of our work on high risk groups. I shall turn later to the transmission of the infection between mothers and babies. Essentially, we are helping countries to build up strategies. I, too, pay tribute to the heroic work of the voluntary organisations, both in this country and in sub-Saharan Africa.

Our record is something of which we can be proud. We played a key role in setting up the global fund to fight AIDS, TB and malaria, launched in July 2002. We pledged 200 million dollars. In response to the point raised by the noble Lord, we intend to monitor, evaluate performance and review our contributions. The Government believe that the global fund has made a good start. It is now inviting bids for the third round. It has moved fast. As a public/private partnership mobilising additional finances, it holds considerable hope of a more focused and complementary resource which will work alongside the nationally-driven bilateral effort.

In looking at such efforts, the Government have increased their contribution from £40 million in 1997 to £200 million last year. That is a significant increase. The type of measures that are happening on the ground are, for example, working with orphans in home-based care in Kenya. We are assisting the Russian Federation with a £16 million programme to assist with prevention focusing on harm reduction and needle exchange programmes. In Swaziland we are working on regional initiatives to raise awareness of HIV.

In response to the noble Lord, Lord Alderdice, I am sorry every day that Lord Young of Dartington is no longer with us, but he was a great believer in the power of radio in South Africa. Certainly, he would have championed the ideas put forward. However, there is good news. Among the programmes that DfID funds for African communities, we have funded the weekly South Africa radio programme for African communities around London. We support a number of successful and influential television-based soap dramas in Africa. That is being replicated in a number of other high-prevalence countries. Clearly, we are aware of the power of radio and television. In the light of points raised by the noble Lord, Lord Alderdice, we shall consider the training of health journalists because they hold the key to much of this.

In addition, our work involves committing £14 million to the international AIDS vaccine initiative. Vaccine is interesting because it is not entirely out of sight. We believe that in seven years there may be a vaccine. It is important to keep up the range of research and development on which we are spending approximately £21 million per year. I do not know how much of that is blue sky, but I could probably find out. The Government are also supporting the Medical Research Council's Microbicides Development Programme. That has a narrower focus—probably something available in about five years, based on the best evidence.

Turning to the extremely important issue of drugs, noble Lords will know that at the end of last year the Prime Minister launched the report of the High Level Working Group on Access to Medicines which brought together the UK Government, the pharmaceutical industry and international partners, and so forth, to enable poorer countries to buy cheaper drugs through differential pricing. In the Southern Africa debate yesterday, the Minister for the Foreign and Commonwealth Office said that we are now seeking support from RGAs and other colleagues to take recommendations forward on this work. It is a question of persuasion and of selling this model which holds out the prospect of some successful ways of getting cheaper drugs into these countries. The current World Trade Organisation negotiations have attracted a great deal of attention over the past week. The Government are disappointed that the WTO has not been able to resolve the issue of the manufacture of cheaper drug substitutes in any country with insufficient or no drug manufacturing capacity. We cannot disguise that. The Chancellor has made it perfectly clear that this is a problem around which the whole world needs to unite. We shall continue to work with energy and commitment with the EU and all other WTO members to find a workable solution to the problem.

However, as the noble Earl, Lord Russell, quite rightly insisted, we have to plan for the long term and in the context of sustainable development as a whole. The programmes of clean water and good nutrition will come into play when seeking to meet development goals. This weekend the Chancellor will meet with representatives of the G7 countries to discuss the proposal launched in January for an international finance facility which aims to double global aid flows to around £100 billion per year in the years leading up to 2015, thus helping to meet our millennium development goals.

Turning to the position in the United Kingdom, we cannot be immune to the global epidemic. Figures for the increase in HIV infection have been quoted by noble Lords and it is obvious that we have a major public health problem on our hands. Several noble Lords asked about our intentions as regards entry requirements for those coming into this country. What I can say is that the Cabinet Office is currently coordinating a comprehensive review of imported infections and immigration. That involves discussions between all the relevant departments, including the Department of Health. Work is being taken forward as a matter of urgency.

We know that early diagnosis and excellent surveillance is absolutely essential. We have increased our efforts to reduce undiagnosed HIV infection. Two particular programmes are extremely important in regard to that effort. First, we are beginning to reap the benefits of changes made in 1999 to our HIV testing policy for pregnant women. By routinely offering and recommending HIV testing to all pregnant women and ensuring that they are offered routine interventions, over the past year we have been able to save around 100 babies from transmission of infection. Secondly, an HIV test should now be offered to all genito-urinary medicine clinic attenders on first screening for sexually transmitted infections.

I agree that genito-urinary medicine clinics are under great pressure. That is why this year we have invested an additional £5 million in these services. We expect to continue that investment in future years. It is not an end in itself, but is intended to pump-prime services, open doors, release more resources and improve access. It is a way of expanding capacity.

Lord Fowler

My Lords, perhaps I may ask one question. The noble Baroness moved rather rapidly over the issue of the tests being looked at by the Cabinet Office. Is the Cabinet Office inquiry going to consider the whole issue of compulsory tests? Is that proposal under consideration? I should be glad to know the position.

Baroness Andrews

My Lords, the inquiry is looking at the whole range of public health issues associated with immigration. I hope that that answers the noble Lord's question.

Earl Russell

My Lords, I beg the pardon of the noble Baroness. She referred to issues "associated with immigration". Does that mean that she cannot give the assurance I seek; that is, that tests will be based on medical need or risk and not on nationality?

Baroness Andrews

My Lords, the Cabinet Office is conducting a factual inquiry and we shall have to wait for the outcome. It is a broad inquiry and in that context many issues will be discussed.

I shall take a few minutes to respond to some of the additional questions that have been raised in the debate. I want to talk briefly about the sexual health and HIV strategy. The noble Lord, Lord McColl, and my noble friend Lord Rea pointed out that there is a close link between sexually transmitted disease and HIV infection, which is why we are spending an additional £47.5 million over the next three years to implement the strategy.

This is the first sexual health strategy we have ever had in this country. It has been designed to address the problems in the round. I should add that the £47.5 million is only a small element of and additional to the £300 million we are spending on AIDS in terms of prevention and treatment. Within that strategy we have five aims relating to HIV, which include reducing transmission, reducing the prevalence of undiagnosed HIV, reducing stigma and so on.

I am delighted to inform noble Lords that we have made much progress in implementing the 27-point action plan agreed last July. Rather than reading out live pages of closely printed text, I shall circulate to noble Lords the information on what has been happening.

I particularly commend the commissioning toolkit, which has been issued very recently indeed, not only on the web but in hard copy. It provides guidance and good practice examples for the NHS on planning and delivering sexual health and HIV services.

The roll-out of the chlamydia screening programme is now in place, a point referred to by the noble Lord, Lord McColl, and relates to capacity building, training, investing in technicians, laboratory services and so on. We now have in place 286 sexual health strategy leads in primary care trusts.

Implementation is the key. By taking away the ring-fencing around budgets we can ensure that on the ground the money will match the need. HIV/AIDS is not evenly distributed throughout the country and, given the variations between them, we need to give local authorities the power to use the money wisely.

We have learnt from the AIDS (Control) Act reports that we need more systematic monitoring and more intelligent use of the information we receive, and we shall monitor more closely in that respect. We are also finalising new recommended standards for HIV treatment services.

We are extremely aware of the need to be not only vigilant in terms of health promotion but to get the message across. That is why the target groups for that message remain gay men and the African communities to which my noble friend Lord Rea referred. We are spending a fair amount of money on the community HIV/AIDS prevention strategy—CHAPS for short—which includes a mass media campaign aimed at the gay community. It has been sufficiently successful to have been picked up by the United States and Australia.

As regards the African communities, the focus is on culturally appropriate information. Obviously we are funding the African HIV policy network to ensure that we pick up people's concerns. It is operated in a language which will enable them to feel confident about going for diagnosis and so on.

The general population presents the other great challenge of appropriate messages. I am sure that noble Lords will have seen the sex lottery campaign, which will cost about £4 million and is aimed at 18 to 30 year-olds. The Minister in another place said that this has been tested to death, and we are confident that it is reaching the people who need to know about it. That goes alongside better guidance in schools following the Ofsted report, a matter about which the noble Lord is concerned.

I have run out of time. I am grateful to all noble Lords who have spoken with passion, compassion and tremendous expertise. The debate has been enormously valuable. I hope that it will set the record straight from 1604, or whenever it was when politicians stepped over the bodies of those who had died from the plague.

House adjourned at fifteen minutes before nine o'clock.