HL Deb 19 May 2004 vol 661 cc809-45

5.22 p.m.

Lord Fowler rose to call attention to the worldwide spread of HIV/AIDS; and to move for Papers.

The noble Lord said: My Lords, some people ask why we spend time debating HIV/AIDS when there are so many other medical conditions that demand our attention. I suggest that the answer is threefold. The first reason is the sheer scale of the human tragedy that HIV/AIDS has caused. So far, the total throughout the world is 25 million dead, which is four times the Holocaust and vastly more than the results of terrorism.

UNAIDS estimates that last year alone there were 3 million deaths, which is the highest-ever total. That figure includes 500,000 children under 15, many of whom had been born with HIV, although we now have the medical means to prevent such mother-to-baby transmission. The year 2003 saw new additions to the vast number of orphans living around the world who have lost both mother and father to this disease.

The second reason is that the epidemic—the pandemic—is predominantly wiping out young men and young women. They are the men and women nations rely on for their development and are the men and women who should become leaders in business, trade, education, medicine and politics. For example, the pandemic is killing Zambian schoolteachers at twice the rate at which they are being trained. This is not a disease striking at the old and infirm but is an epidemic wiping out the young and the economically active.

The third reason, and perhaps most ominous one, is that the position throughout the world is not improving but is all too often deteriorating. We may deplore what has happened in the past but, unless we take all the action open to us, there is worse to come. The tragedy is that we have the ability to prevent much of the spread of HIV/AIDS, and to offer hope to those who are already infected, but too often we do not have the will or the determination to act. The best estimate is that today there are 40 million people living with HIV throughout the world. Last year 5 million new men, women and children were infected and 700,000 of those infected were children under 15.

This is not an epidemic that has been halted; it is an epidemic that is spreading. It now threatens new countries and new generations of young people. The destruction continues. Today the epicentre remains sub-Saharan Africa where last year alone there were 2 million deaths. One prediction that we can make with absolute certainty is that this death toll will continue to rise. There are somewhere between 25 million and 30 million people living with HIV in that area and it is estimated that 3 million to 4 million of them urgently need treatment today. We know that the vast majority of them, about 98 per cent, will not receive such treatment. Anti-retroviral drugs may have reduced deaths in the West—although it should be emphasised that they have not provided a cure—but in Africa such treatment is for a tiny minority.

However, there is a profound danger in believing that Africa is alone in facing this crisis. No government anywhere in the world can say that it will never happen in their country. At this moment, HIV is taking hold in a range of countries where a few years ago ministers were assuring us that they had no problem. In India, although the official estimate is that today 4.5 million people are living with HIV, the real number is likely to be 6 million to 7 million. Experts in the field say that the Indian epidemic could be devastating unless massive efforts are launched now. In China we know that blood transfusion errors and the use of contaminated equipment by drug-users has helped to lead to a total of at least 1 million living with HIV. Nearer to home, an estimated 1 million people in the Russian Federation are living with HIV. At first, transmission was by the contaminated equipment of drug users but it is now by mainstream heterosexual sex. Drug use is also the entry point elsewhere, as in some countries of central Europe, where it is reported that heroin can sometimes be as cheap as alcohol.

Let us not believe that the West is in some way immune. There are around 1 million people living with HIV in the United States and some 600,000 in western Europe, including at least 50,000 in the United Kingdom. The latest figures for the United Kingdom were the worst on record. The number of new diagnoses has doubled since only 1998 and, in my view, the Government have done too little to counter this rise and far too little to combat the startling increase in sexual disease generally.

This takes me to an absolutely fundamental point about combating HIV/AIDS. What is so deeply frustrating and tragic about the figures of death and infection is that so often we know the action that needs to be taken, action which could prevent the disease and action to treat those who are infected. But we also know that first and foremost it is necessary for governments to take the lead. Where governments have done this, as in Uganda, Thailand and Senegal, the harm has been reduced. Where governments have failed to take a lead, their national position has deteriorated and the epidemic has spread. No government can evade its responsibility here.

We know that sexual behaviour can be influenced. I would claim that our campaign in the United Kingdom in 1986–87 succeeded in reducing HIV and also succeeded in reducing sexually transmitted disease generally. I pay tribute to the support that we received from television companies, radio and newspapers, most of which supported our campaign then and would do so again. I single out the BBC World Service for the extremely good work that it is currently doing in several overseas countries.

We certainly know from our experience in the UK that clean needles can dramatically improve the position as far as drug users are concerned. To those who say that free needle exchange is too radical, too liberal a step, I reply that it was introduced here not by some way out administration of the left but by the government of Margaret Thatcher. I concede that there were one or two constructive debates along the way.

Of course I accept that there are questions of what message of prevention should be given. I was in receipt of much advice on this point. Our message was concerned with being faithful to one partner and the use of condoms. In Uganda they added abstinence to this message—abstinence, being faithful and condom use. Some preach abstinence only.

I am strongly in favour of trying to persuade children scarcely into their teens to postpone their first sexual encounter but I rather doubt the impact of that message further up the age scale. It has not worked in the past—it was certainly tried and failed in the First World War to counter venereal disease—and I remain convinced that promotion of the use of condoms must be a central message.

I deplore the entirely false statements of some— including, I regret, one or two senior figures in the Roman Catholic Church—that cast doubt upon the safety of condoms.

I have concentrated on prevention, for that is crucial if we are to check the spread of HIV. But treatment is of course the other essential part of any global policy. There is no point in advocating more testing for HIV if there is no treatment to follow it up. People will ask what is the point.

Here we come to the question of increased resources. We have much of the mechanism to deploy such resources in place, like the excellent Global Fund, which I visited a few months ago in Geneva. What we so clearly need is a greater commitment from the West—from the high-income countries—to this fight.

And here, perhaps against the trend, I praise the United States. When I went to the United States when President Reagan was in power HIV was scarcely on the national agenda. There was an atmosphere of embarrassment about the whole position. Earlier this year when I returned, I found a President committed to spending overseas 15 billion dollars over the next five years and a new co-ordinating office based at the State Department to bring together that effort.

Indeed, I would say that we in Europe spend rather too much time asking what more the United States can do and too little time asking what more Europe can do. We spend too little time examining our own priorities—priorities that meant that last year the European Union spent £32.5 billion on the common agricultural policy while millions die unnecessarily in countries which do not share our standard of living. Just think what more we could achieve with just one tenth of that budget.

I believe we should follow the American example and have a European co-ordinator for HIV/AIDS who would not only bring the European effort together but also work to raise the resources so that at least we matched the American effort.

I see now that the Government here intend to re-develop their policy and take the lead in Europe. I certainly welcome that intention. But if the Government are to do that, then it must be more than another declaration of intent—another initiative which grabs the headlines today but is forgotten tomorrow. It must be action that makes a real difference.

And I also say this to the Government. They must have the authority to lead. They cannot lecture others abroad while doing all too little themselves at home. Their record on HIV/AIDS at home is not remotely impressive. Their record on sexual disease generally is lamentable.

The number of attendances at sexual disease clinics has more than doubled since the early 1990s to over 1.2 million a year. Since 1996 chlamydia is up by 140 per cent, gonorrhoea by 106 per cent and syphilis by 910 per cent.

Everyone in the field—apart from the Government— talks of a crisis, and a crisis there is. So yes, let the Government make a new effort abroad—and I support that entirely—but let them also show at home the kind of leadership that they urge governments overseas to take.

On the face of it, there is all too little for our comfort around the world. But there are also opportunities. There are countries like India which stand at a crossroads. We can reduce the harm and the deaths. We can provide hope. We can check some of the destruction that HIV/AIDS will otherwise cause. We will need determination and we will need resources. But history will not forgive us if we fail to take the action which is open to us. I beg to move for Papers.

5.36 p.m.

The Lord Bishop of Salisbury

My Lords, last week I visited the offices of Hope and Homes for Children, a charity based in Salisbury, which is a testament to the brave vision of its founders Mark and Caroline Cook. It works in 14 different countries across the world and, in the words of its mission statement it seeks, To give hope to children who have nowhere to live". Its most recent fundraising video is subtitled, When the cameras move on, we stay". It is a slogan that speaks to the changing and changeable nature of public concern, easily drawn to new and vivid calamity and perpetually on the move.

It is against that background that I congratulate the noble Lord, Lord Fowler, on securing this debate. The cameras do so often move on; many subjects clamour for public concern; yet the worldwide spread of HIV/AIDS demands our urgent and constant attention.

As the Archbishop of Cape Town has said: No one should care alone. No one should die alone. For we are all living with AIDS". The diocese of Salisbury is linked to the Episcopal Church in Sudan. The House will know that war has disfigured Sudan for more than 30 years, leaving the south of the country bereft of any organised economic activity or civic administration.

Ironically the near impossibility of travel and the isolation of many communities mean that the AIDS pandemic has had little impact yet. Because the bridges are down and most roads are impassable to lorries and trucks, that particular source of infection has been halted in its tracks. It is a war that has cut a swathe through Sudanese life and torn apart the fabric of society. But, none the less, in that society there is one small glimmer of hope. People are not able to move as easily in that southern part of the country as they would in other parts of sub-Saharan Africa. That has curiously given us an advantage.

The consequences of HIV/AIDS for other African communities are no less devastating than these decades of brutal war have been for Sudan. Individuals suffer, and their families with them, but the spread of infection is so great that the precious threads that bind societies together are stretched to breaking point and beyond. When breadwinners die, when parents die, when carers die, the impact is felt far beyond the walls of the family home. Each death is a blow to the commonweal— the whole human family—a fresh assault on the possibility of people living peacefully and creatively together, because AIDS erodes trust and breeds fear. As one 15 year-old says: Although my friends support me and I can talk to my grandparents I feel very sorry for myself. I have lost all the happiness in life and I won't be able to achieve my ambition to be a nurse. I don't want to get married because I'm afraid of getting HIV". Last week was Christian Aid Week and all over the country volunteers have taken part in the largest house-to-house collection of its kind in the annual programme. They have done so because of their commitment to Christian Aid's determined slogan, "We believe in life before death". It is because of that belief and that commitment to life, and to life lived together purposefully and creatively, that the Anglican Communion has pledged itself to, the promise that future generations will be born and live in a world free from AIDS", as the Primates of our Communion declared over two years ago.

It is not a wholly unrealistic aspiration. When the Secretary of State for International Development addressed the General Synod of the Church of England in February, he said: This is not a hopeless battle. We have the means to defeat HIV/AIDS". As a result of the Secretary of State's address to the Synod and the motion passed there, the Mission and Public Affairs Council has published a report telling the story, being positive about HIV/AIDS. Perhaps I may read the House two paragraphs from it, the story of a young man. It is as follows: Vitalis … is 29 and lives in Njombe in Tanzania. He is HIV-positive but doesn't know how he became infected. He thinks it may have been when he and his elder sister (who is also positive) visited a traditional healer. The doctor's 'cure' for his sister involved cutting both their hands with the same instrument he had used on other patients … Although Vitalis has a girlfriend he hasn't told her his status; he has simply said that he has decided he doesn't want children just yet so they must use a condom. He is trained in building construction and still works when he is well and there is work available, but that is not enough to support him". It is stories such as those that indicate the extraordinarily porous boundaries of the disease and the way in which the slightest accident or negligence can easily infect someone. A nurse from Salisbury who went out to work in a hospital in sub-Saharan Africa caught the infection, probably from a discarded needle on a surgery floor, and died a long and painful death in Salisbury some years ago now.

But this battle, as battle it is, needs resources. Her Majesty's Government have given generously to HIV work and are, I believe, the second largest donor in the world. It has been estimated that, by 2007, 15 billion dollars per year will be needed to secure a minimal global level of prevention, care and treatment. I believe that our Government must continue to show leadership by doing what many donors to Christian Aid will have done this last week, and giving again, giving recklessly and giving more than their share.

For their part, the Churches and their partners will continue their work of caring for those most directly affected by AIDS and fighting against the stigma that still shamefully attaches to it. But if these greater resources are to be found and the promises to be realised, then—at the risk of sounding a familiar note—above all else it needs attention, attention, attention. It cannot be allowed to slip from the public agenda and the Churches will do their best to ensure that it does not.

We are told that we are engaged in fighting a war against terrorism. We need also to be engaged in fighting a war against poverty and disease. Were we all to be convinced of that then slender budgets would cease to be a constraint.

What can we do? First, HIV is about people in relationships. The sick need to be cared for in their own homes and orphaned children need care in their own communities. Prevention is best done through the informal networks of community, peer group and family. That is why the Churches, which in Africa are frequently the most vibrant and far-reaching community networks, are so well placed to help. And the community focus is key if people with HIV/AIDS are not to be stigmatised and therefore shunned. When people are afraid to talk, afraid to declare what they fear may be happening to them, the hidden fears eat away at the bonds of community. Who trusts who? Who will support who? Support for the carers and treatment for the sufferers will not be forthcoming unless there can be an international climate of concern and openness which brings HIV/AIDS to the top of governmental agendas in sub-Saharan Africa.

The people of Sudan hope that peace will soon be theirs. Peace will mean the building of roads and the rebuilding of bridges and the advent of the huge trucks, the harbingers perhaps of economic reconstruction and inward investment. How tragic if that new communication brings with it the deadly threat of HIV/ AIDS. As Mark and Caroline Cook know, the children of Africa deserve homes and families. Above all, they deserve hope and a future.

5.45 p.m.

Lord Colwyn

My Lords, my noble friend Lord Fowler initiated a similar debate on 20 February 2003 and was congratulated on his commitment as Secretary of State when the AIDS epidemic first appeared and on his continued interest in the current situation. I should like to offer similar congratulations today, but warn him that my views do not and have not always conformed to popular opinion. I think that it is unlikely that any of your Lordships will agree with any of what I have to say.

I have always been concerned that there are many scientific facts that can show that the human immunodeficiency virus does not fulfil the epidemiological and biological requirements, nor the common sense requirements, to be the cause of the human immunodeficiency syndrome. We do not understand AIDS. Virtually all of the scientific community has taken a germ-theory view that HIV is capable of causing a syndrome of ever-advancing immune suppression that will eventually cause death.

The lack of understanding means insufficient knowledge to be able to intervene in or control the disease process. Epidemiologists must be able to predict accurately when outbreaks will occur and who is at highest risk. Microbiologists must be able to prove the underlying causes of the disease. Immunologists must be able to explain how the immune system fails and what may be done to protect it. Anthropologists and sociologists must be able to identify behavioural patterns and cultural environments that put people at risk. And public health officials and physicians must be able to implement effective preventative measures and cures. By these criteria, we do not understand AIDS.

It is imperative to rethink and research AIDS. There are a few lone heretics such as the University of California professor of molecular biology, Peter Duesberg, and Australian biophysicist Eleni Papadopulos Eleopulos, who have offered exhaustively referenced argument that HIV infection does not lead to AIDS and that the test is so inaccurate that it should not be used. Both have been vilified for their troubles, but even if they are only pointing to an alternative pathway, the implications are of great concern.

By rallying round the HIV theory we may be erroneously lumping together under the umbrella term AIDS some 25 disparate, previously identified diseases acquired by a number of non-contagious means. With the inaccuracy of the tests, this means that we could be misdiagnosing as HIV-positive many thousands of basically healthy people and subjecting them to highly toxic, potentially lethal drugs, the side effects of which are now indistinguishable from what we consider AIDS-related illness. Certainly that was true of AZT, which was originally marketed as an anti-cancer chemotherapeutic agent and found to be too toxic for use.

Having HIV does not mean having AIDS. My noble friend Lord Fowler and the right reverend Prelate referred to HIV/AIDS as a single entity. The presence of human immunodeficiency virus is not proven beyond doubt to be the sole cause of AIDS, nor does the presence of HIV lead inevitably to AIDS.

The HIV virus is not a particularly aggressive or fast-replicating virus. It affects different people in different ways, which is why some people can contract the virus and die rapidly and others are alive and healthy 15 to 20 years later. Investigators who defend HIV as the cause of the syndrome have proposed a vast variety of agents as helpers or cofactors of HIV in the genesis of AIDS. However, those cofactors are in themselves causal agents of immunodeficiency and may generate AIDS with or without the diagnosis of HIV. Dr Roberto Giraldo calls such cofactors "immunological stressor agents".

The real circumstances that surround all the groups of people who develop AIDS with the greatest frequency is the exaggerated exposure to a variety of stressor agents against the immune system that can have a chemical, physical, biological, mental or nutritional origin. AIDS has appeared at a time when the immune system of human beings is saturated and is deteriorating due to exposure, both involuntary and voluntary, to immunological stresses. The capabilities and functions of the immune system are neither infallible nor infinite.

The incremental stressors in our ecosystem are endangering the preservation of our species. AIDS is an alarm call. The distribution of those stressors varies within groups of people who develop the syndrome and explains the different clinical forms of AIDS that occur in different people. Progressive and continuous deterioration of the immune system causes a deficit of the defence, surveillance and homeostasis immunological functions with the subsequent development of infections, neoplasias and metabolic alterations.

Although I am not an expert, I am concerned that drug treatments for AIDS, the protease inhibitors and other antiretrovirals can add to the total of immune system stressors. That toxic hypothesis of AIDS provides a rational explanation that the infectious hypothesis has not solved, not to mention the millions of pounds invested in research, prevention and patient care within the infectious concept of the syndrome. The AIDS test is neither sensible nor specific for detecting past or present infection with HIV.

The medical and research communities are the greatest asset in the fight against AIDS and potentially also the greatest threat to its success. There can be no breakthroughs without research, but breakthrough research is not possible when conformity is rewarded and sceptical inquiry punished. AIDS may continue to plague modern society, just as other preventable infections plagued our forebears, because of the closed-mindedness of the very physicians whose job it is to diagnose, treat and prevent those diseases.

A century ago, they let patients die by denying that germs had anything to do with disease. Today they may be letting them die by insisting that the germ is everything. Without doubt the virus is detrimental to the immune system and speeds up the process of disease, but it is not solely responsible for the ill health associated with AIDS.

More relevant is long-term abuse of the body through poor nutrition, environmental toxins in the air and food chain, the chemicals produced by stress, drugs and frequent exposure to infections and the antibiotics with which they are treated. A happy medium must exist somewhere in between, but it will be reached only when informed scepticism and razor-sharp reasoning skills become as valuable assets to scientists and physicians as are advanced degrees, an infallible memory or respect for authority.

5.53 p.m.

The Earl of Sandwich

My Lords, I thank the noble Lord, Lord Fowler, for his energetic pursuit of the subject, which we all know to be one of the most urgent in the world, even though, as we have just heard, we may not altogether understand it.

I welcome the new government strategy set out in the consultation document and I salute DfID's leadership alongside UNAIDS. I join the debate as one who advocates a greater role for civil society in the AIDS campaign. That was a key point in the declaration of commitment adopted by the UN in June 2001, which called for the active participation of civil society, the private sector and faith-based organisations.

I have seen for myself the effectiveness of those organisations in tackling HIV/AIDS, especially in Uganda where a few years ago I visited projects supported by Christian Aid, of which I am a trustee, and by UWESO, the Ugandan charity for orphans, which I greatly admire and support.

I am glad to see the noble Lord, Lord McColl, in his place, because we were both present at the opening of the Mildmay Centre—a new international hostel for AIDS patients near Kampala—and at the AIDS conference opened by President Museveni. The poverty focus of the DfID approach is welcome, not least because of the millennium development goals, of which AIDS is an important part. They could easily be in jeopardy since such a pandemic cruelly eats into every aspect of development.

But there are risks that earmarked support or a short-term emergency response will bypass normal health services and create a parallel culture, as has happened with some vertical UN programmes in the past. It is a paradox of aid that sudden epidemics or new sources of funding produce new vehicles, clinics and personnel that may demonstrate visible action but do not necessarily serve the poorest communities.

Connected with that is the problem of centralised budgets. Will the Minister confirm that DfID policy within the poverty reduction strategy process is to provide direct budgetary support for health services? How will that policy conflict with the need to target AIDS programmes in the voluntary sector without going through national budgets? I know that many NGOs here are concerned about that issue and how even the "Three by Five" initiative and the "Three Ones" programme may work against them.

One way round the problem is for DfID to identify and directly support civil society organisations that are part of a network and known to be in close harmony with existing HIV/AIDS and other health services. That is particularly true in countries such as Uganda and Senegal where there is an active network. It is much more difficult in countries or regions where, perhaps because of internal conflict, there is much less national co-ordination.

Section three on page 12 of the strategy highlights effective national responses and endorses the need for a pluralist approach, which is important. On the one hand, it is essential to strengthen and improve access to general health services, because acute needs arising from poverty, ill health and other causes of child mortality are linked with vulnerability to HIV/AIDS. At the same time, responses to HIV/AIDS prevention must be highly targeted and inevitably selective, because of the differences of approach and capacity in different communities.

The consultation paper therefore says that a multi-sectoral approach is required, but I wonder whether the strategy places enough emphasis on the current effectiveness of civil society partners and the need to involve them more in decision making. One area of AIDS prevention where civil society may be paramount is in health education. Of course the use of radio and public advertising is helpful, but as the right reverend Prelate said it is through word of mouth through the churches, mosques and village-level organisations that the message is best channelled.

I have attended, as I am sure have many noble Lords, an evangelical church service that devoted large parts of the liturgy to teaching and story-telling about the risks of AIDS. In villages I have attended singing and drama sessions involving all sections of the community, ensuring that information is shared among young and old and that the basic needs of patients and families are being met.

Civil society, in the official language of development, is now a key partner in poverty reduction strategies. That sounds good. But integrating NGOs into a national strategy is not easy and it obviously raises much deeper questions about accountability and political representation. Yet more advocacy by prominent civil society groups could be especially crucial in bringing HIV up the political agenda in those newly affected countries—some of which the noble Lord, Lord Fowler, mentioned—at an early stage of an epidemic where the impact of HIV is not yet apparent. DfID should, and perhaps does, prioritise support for such work, which could bring about the high-level political commitment which we have seen to be so effective in Uganda.

Another area where such an approach is important is in the reduction of stigma. Christian Aid in its submission to DfID's consultation offers the example of a group of four NGOs in Karnataka, south India, known as the MILAN coalition. They are also supported by the Elton John Foundation.

According to this group, stigma is fuelled by six factors: ignorance of HIV/AIDS, fear, taboos concerning sex, too little sex education for young people, lack of sensitisation in the medical profession, and lack of anti-retroviral therapy. The project aims to address some of these factors through information provision and discussion at community level. The MILAN group identifies sex workers as particularly stigmatised and vulnerable—and in its first phase the project is focusing attention on them.

Then there is advocacy. Besides pooling their knowledge of training and counselling, the four organisations select what they call, "positive speakers"—we know of similar examples in South Africa—who can openly talk about their status in public as part of prevention as well as for the media. This is a very powerful means of reducing stigma and motivating people to undergo testing. It is difficult to find enough people willing to be so open about themselves, but combining four organisations is more likely to result in the critical mass needed for effective impact on the public.

The consultation paper says comparatively little about ARV, perhaps because research is moving so fast, but I hope that the Minister when he covers the question of ARV treatment will explain why that is so.

I have one further question for the Minister in respect of tuberculosis. One in three people worldwide living with HIV is co-infected with TB, and nine out of 10 die of TB within a few months of contracting HIV unless treatment is available for TB. But HIV causes TB to spread so fast that the health service cannot possibly catch up, even though it is expanding. What is DfID doing to help UNAIDS and WHO to combine AIDS and TB services as a matter of urgency? I am sure that the Minister recognises that AIDS programmes could learn much from the experience of other programmes of primary healthcare, for example, and reproductive health, including in the training of paramedics and local workers—programmes which already use this integrated approach could be applied to HIV/AIDS.

6.3 p.m.

Lord Brooke of Sutton Mandeville

My Lords, it is a privilege to follow the deeply impressive speech of the noble Earl, Lord Sandwich—he often makes such speeches in international debates in your Lordships' House—just as it is a rich pleasure to join others in your Lordships' House in congratulating my noble friend Lord Fowler on having secured this debate and on the comprehensively magisterial way in which he opened it.

A quarter of an hour is a smidgen in which to lay out a global problem: imagine what Mr Gladstone would have made of it. As the poet once said, the Ancient of Days is an hour or two old. My noble friend moreover played a distinguished part in orchestrating Her Majesty's Government's response to the AIDS challenge in this country two decades ago. No one can read the mind of another but it would not surprise me if my noble friend felt within himself that it was the finest thing he did in more than a decade at Cabinet level, and he has enhanced that record by the way that he has kept the faith of this issue in the near decade and a half since he left office.

As a parishioner in the diocese of Salisbury I express pride and pleasure that our eponymous bishop should have taken part in this debate. I admire the courageous heterodoxy of my noble friend Lord Colwyn—heterodoxy which is the touchstone of your Lordships' House—though I shall not follow him precisely in the line that he took. My own qualifications for speaking are much more modest but I passionately hope that the moment has come when global society has begun fully to gird its loins—if I may be allowed to use the phrase—to cope with this challenge, as my noble friend did 20 years ago.

Colin Powell said last month that HIV/AIDS is the greatest threat to mankind today—the greatest weapon of mass destruction on the Earth. It has been likened to the Black Death. I had never thought of the consequentials of that before today, but our hearts must go out down the centuries to the despair of those of our ancestors in the same positions of influence as ourselves then wrestling with that challenge armed with the knowledge and the instruments of 14th century experience. That comparison alone should put us on our mettle.

We come together, too, in this particular capital at an appropriate crux of timing. Last month the Economist published a thorough and well informed special report on AIDS in India. Yesterday, inspired perhaps by the Government's commission on Africa—and parenthetically Parliament's renewed interest in the Dark Continent is a profoundly encouraging development—the All-Party Parliamentary Group on Africa was due to publish its report on AIDS in Africa, developed after evidential hearings. That is now delayed until after the Recess, but the final coda in the draft version runs to nearly 150 footnotes, which itself is a potential index of thoroughness. Its original publication date prompted the colloquium which is due to take place at Marlborough House tomorrow— a location that underlies the salient role this country can relevantly play on the international stage in this regard.

Then we have, too, the Government's draft consultation document on the new strategy of HIV/AIDS in the developing world, to which a couple of references have been made. At the vortex of this pouring out of printers' ink, after 20 years in which disaster has been tempered by comparative and often unpredicted recovery in different continents—I add to my noble friend's listing of Thailand and Uganda, Brazil, which is in yet another continent still—one is driven back ineluctably to the ancient human truth that, if a human group is to change its behaviour, the critical essential is that the leader of the group has with genuine resolution to want that to happen.

To illustrate that in the unfolding story—I go away from Brazil, Thailand and Uganda—the leadership example of Chandrababu Naidu, the Chief Minister of Andhra Pradesh, where the HIV prevalence rate is over 1 per cent of the population, is a classic instance. April's Economist report is eloquent on what that commitment has involved. If his insistence that all his Ministers should include a reference to AIDS in every speech they make, whatever the topic, challenged their speech writers, it was a nobler cause than that similar instance in Belfast in the late 1980s when an editor insisted that every musical criticism in his paper should contain a disparaging reference to the Anglo-Irish Agreement.

In this context the prose of the Government's draft consultation document, perhaps inevitably, has, at least to my ear, all the charm of a "speak your weight" machine. I do not necessarily regard that as a disparagement for it may be responsive to the nature of the subject, though I suspect that Mr Gladstone would have been more Homeric or perhaps Aeschylean. What matters is that the policy strategy should optimise the deployment of our own resources. It is one of those cases where the Prime Minister's rhetoric could more usefully follow the plan than precede it. Most important of all will be the role of Mr Hilary Benn, whose pedigree as a communicator is matched by a most engaging matter of fact modesty. What matters is that he should recognise and then make clear the centrality of this issue in this decade to his department's raison d'être. I am obviously referring to DfID.

There is one sentence in the draft document which is an encouraging harbinger of this possibility, and I quote: The UK response at global level in providing support to these key agencies (e.g. UNHCR, WHO through its Health Action in Crises, UNICEF, UNDP and others) to enable them to tackle HIV in difficult environments is essential". That remark has a flavour of our centrality. As an American historian once wrote, Lincoln wanted to have God on his side, but he had to have Kentucky". In peacekeeping the UN has a perennial specification that British troops should if possible always be involved. HIV/AIDS may confer on us the same necessary ubiquity.

If local leadership is critical, and British leadership a potential catalyst, how do we play our role where denial is in operation and neo-imperialism classically counter-productive, and there seems to be a job for all of us?

The last time that I was in Pretoria, I had a long conversation at a High Commission party with an Afrikaner girl, who said she found HIV/AIDS hard to grapple with because she had, within her social milieu, absolutely no experience of it at all. The places where denial rules are, I suppose, the equivalent of the despair that policy makers felt towards the Black Death six and a half centuries ago. Wiser men than I will know how one should respond. At my simplistic level I feel relief that there is so much else to do on a worldwide scale that one can concentrate on the feasible, even if one reluctantly put the temporarily intractable on the back burner.

I want to deal with Africa before I conclude, hut, first, to say an ominous word about India—to which my noble friend Lord Fowler referred. When I was at school, my school number was 666, which the Bishops' Bench will recognise as the number of the beast in the Book of Revelation. In the Economist report on India I could not help noticing the awful symmetry that 4.58 million are infected with HIV—and my noble friend qualified that figure upwards—and that almost 450,000 Indians die of tuberculosis each year. There, I echo the noble Earl, Lord Sandwich. That figure is most commonly among HIV positive people, but 4.56 million dollars will be spent each year for the next three years by Star television on airtime for public service advertisements about AIDS.

Like my noble friend Lord Fowler I was at the beginning of the Government's response here, for it was the Medical Research Council which persuaded the late, great Sir Keith Joseph that a database of incidence was crucial to an effective strategy and I would be interested to hear in the Minister's reply how far our experience of that early step in the process is transmitted to countries such as India, if they genuinely want to learn, and whether it is part of the practical help that we offer.

In what is still the draft African report from the All-Party Group, what runs through chapter after chapter, haunting and spectral, yet golden in its examples of heroism, are the orphans. They are their countries' future, but they are also a cause to which all mankind can reach out. In the mean time, as Dr Alex de Waal said memorably at the Africa All-Party Group meeting that sparked off the report, Africa is in some ways like a university where the student union leaders have disproportionate authority because many of the dons who would have lent them balance and guidance are dead.

Finally, for those who ask us what difference the man on the Clapham omnibus can make, I report what your Lordships' House will already know—that the charity whose title is the entrancing injunction Send a Cow are now sending whole farmyards of different farm animals to east Africa in general and fruit trees to Ethiopia in particular. In the world's long history, this is not the occasion where, for individuals, passing by on the other side of the road is an option.

6.13 p.m.

Baroness Stern

My Lords, I would like to echo the remarks made by the noble Lord, Lord Brooke, about the noble Lord, Lord Fowler, and thank him for initiating this important debate.

The United Kingdom response in the mid-1980s to the HIV/AIDS problem is seen as a model in international circles. The noble Lord, Lord Fowler, was in the driving seat at that time and must take the credit for the enlightened and far-sighted approach that was taken. I remember receiving the leaflet he sent me and the rest of the population and thinking, "This is an unusually sensible document to come from the Government".

I wish to limit my contribution to one aspect only of this problem, but I hope to show a very central aspect—the prevalence, transmission and prevention of HIV in the prison systems of the world. In that context I declare an interest as a board member of Penal Reform International. Rates of HIV infection are very high in prisons in many parts of the world. Prisons have always been places where sickness is concentrated and from where epidemics have spread; and the HIV epidemic is no different.

According to the World Health Organisation, one can multiply the official HIV statistics of a country at a given moment by a factor of between five and 10 to get an actual estimate of the rate of infection in a country's prisons. HIV in prisons is particularly acute in eastern Europe and central Asia, where the rates of HIV infection are now increasing rapidly. In some of the new European Union states, HIV infections are also on a rapid rise in prisons. In Estonia, the first HIV-infected prisoner was diagnosed in 2000. Since then the number has increased by four or five every week. In Latvia, the number of HIV-positive prisoners increased by 58 per cent between 2000 and 2001.

There was a well publicised case of an increase at one prison in Lithuania. In 2002, 229 infected prisoners were being held there. Between May and July of that year 44 more infections were added because, it is said, they all used the same needles to inject drugs. Recorded cases of infections in prisons in Russia have risen from seven in 1995 to 30,000 in 2003. I strongly endorse the point made by my noble friend Lord Sandwich regarding the co-morbidity with TB. In some of the countries that I have mentioned, active TB affects 10 per cent of all prisoners.

The reasons for those high infection rates will be obvious to noble Lords. One reason is the nature of the population that prisons receive. People in prison come from the most disadvantaged sections of any society. They come to prison with ill health, with many untreated conditions and they engage in risky behaviour such as drug taking. Prisons are full of people who use illegal drugs. In Russia and Ukraine more than 90 per cent of HIV-infected prisoners are intravenous drug users. Secondly, the environment itself in prison is disease-producing, because of unprotected sex—consensual and forced—tattooing with unclean needles and injecting drugs with shared needles. It is not just those who enter prison as drug users who engage in that behaviour. Research shows that in west European prisons the percentage of prisoners who first start to inject drugs while in prison ranges from 7 per cent in some countries to 24 per cent in others. Research also shows that a quarter of Russian prisoners were tattooed in prison—two thirds with needles already used on someone else.

This is a crisis for many prisons and, as the noble Lord, Lord Fowler, said, we know exactly what to do about it. Therefore, it is vital that prisons are included in all national HIV prevention policies. It is also vital that harm reduction measures are accepted and that public health priorities are clearly asserted. But this is a real challenge that causes dilemmas and grave difficulties in prison systems all over the world.

Prisons need to take action to stop the spread of HIV. They need to stop prisoners taking such risks as unprotected sex or injecting with the same needle. However, we will all be aware of how easy it is to say that and how difficult it is to implement. To do those things, prison officials have to accept some harsh realities that they would often rather deny. However good their security measures are, however many sniffer dogs and body searches take place, drugs get into prison. In some countries with poorly paid prison guards corruption ensures a regular supply. Sex takes place in prisons the world over, so condoms should be available to prisoners easily and without embarrassment. I will not recite the long saga of getting prisoners access to condoms in the Prison Service of England and Wales. I understand that prisoners now have access, but that the method of giving them access is likely to be a deterrent to many.

Substitution, maybe a methadone maintenance programme, needs to be available so that those who inject drugs may move to a safer method. The provision of bleach and other disinfectants in prisons is basic and absolutely essential, so that shared needles may be cleaned.

Finally, there is the provision of needle exchange facilities. The Government are greatly to be congratulated on the move they took to bring prison health services in England and Wales into the Department of Health, and under the National Health Service. I know this has meant significant progress in taking forward measures that should have been in place since those early days when the noble Lord, Lord Fowler, was at the Department of Health.

I would like the Minister to reassure me that the rollout of the programme to provide disinfectants will continue energetically, the provision of condoms will be improved, and the possibility of needle exchange programmes, where the need can be proven, will at the very least be kept on the agenda. I would also like the Government to ensure that the question of HIV in prisons is part of their international development and human rights agendas.

Those noble Lords who visit prisons abroad may well have seen the compulsory testing of prisoners that leads to a diagnosis but no treatment. This results in the segregation of HIV-positive prisoners in the worst and darkest accommodation, where prison staff do not go, and medical staff give treatment through a grille in the cell door without touching the prisoner. Compulsory testing and segregation of HIV-infected prisoners are condemned both by the WHO and the Council of Europe. It is heartening to see that many countries new to this problem are taking action to improve their treatment of such prisoners. Kazakhstan has taken the lead in central Asia by eliminating compulsory testing and segregation. Noble Lords may be interested to hear that the noble Baroness, Lady Massey of Darwen, who cannot be here today, has played a key role in educating medical workers in Kazakhstan about HIV prevention and treatment. Kyrgystan has initiated needle exchange programmes in its prisons, as has Moldova. There is much to do, and much good work to encourage.

I draw the attention of the House to the Moscow declaration of the World Health Organisation in Europe, entitled Prison Health as Part of Public Health, which calls for prison and public health services to work together, to ensure that harm reduction becomes the guiding principle on the prevention of HIV/AIDS in prison systems.

Will the Minister ensure that this declaration will be wholeheartedly supported by the UK representatives at the next annual meeting of WHO Europe?

Finally, will the Minister ensure that all HIV prevention projects funded by his colleagues in the DfID include the prison system and prisoners in their scope, because hundreds of thousands of prisoners leave prison every year taking their infections with them?

6.23 p.m.

Baroness Masham of Ilton

My Lords, I thank my noble friend Lady Stern for what she said about prisons. I agree with all of it.

I congratulate the noble Lord. Lord Fowler, on his choice of debate, because the increasing spread of HIV/AIDS needs addressing. It is devastating communities and mutilating families, especially in some African countries. I thank the noble Lord, who understands the many problems relating to HIV/AIDS. He was Secretary of State for Health at the start of the AIDS catastrophe, and I am sure the campaign warning people of the dangers of HIV/AIDS had an effect on prevention.

I am also sure, with the current increase of HIV and other sexually transmitted diseases, that there should be continued campaigns on prevention. We have a very dangerous situation at the moment, where many young women and men just do not care and have unprotected sex with many different partners. As sexually transmitted infections facilitate the transmission of HIV, it is possible that the rise in these may have played a significant part in the increase in HIV among gay men. All sexually transmitted infections have increased in England, Wales and Northern Ireland. That is why I asked the Government a few months ago whether there should be a national service framework—for this growing problem.

Something has to be done. People across the world did not take the advice that one partner was the safest option. The recent case of the man from Middlesbrough who had come from Africa and knowingly infected three women, and has now been given a 10-year prison sentence, might make a few people think. Should there not be clear legal guidelines, stating that it is a criminal offence to knowingly infect people with the HIV virus?

There is concern that the removal of dedicated funding for treatment and prevention of HIV/AIDS in recent years will place the investment in services over the past 20 years at risk. There should be a commitment to ongoing funding, not one-offs, to ensure the availability of appropriate treatment and care for those eligible.

Many people and organisations from Britain are helping and giving support to developing countries, and that is good. But we must not neglect our own people, living in our own communities. HIV/AIDS is a horrible condition. It complicates lives. The difficulties over confidentiality can make communication difficult. There are many problems which can arise for people whose health deteriorates, such as housing needs, social care, arranging meals, visits to hospitals, and companionship if people live alone.

A very unfortunate situation has arisen at the Mildmay Hospital in Hackney. This is a dedicated hospital for people with HIV/AIDS, giving respite, rehabilitation and hospice care. It founded a family centre for children and parents living with HIV/AIDS who needed support. The children had good play facilities and lunch, while the mothers had rest and treatment. The family care centre ceased to operate in 2002. Health authorities are no longer prepared to fund family admissions, arguing that this is not something they do with other illnesses. Health authorities withdrew funding for children infected or affected by HIV, on the basis that this is not a health issue. The Mildmay is concerned about the withdrawal of HIV-specific funding. It is being increasingly financially squeezed, as PCTs no longer give HIV priority.

As the Mildmay Mission Hospital does missionary work, it has two thriving AIDS centres in Africa: one in Uganda and one in Zimbabwe. Should we not be looking after our own people at home, as well as helping others? When I think of the smiling little faces of these children enjoying their play facilities and lunch, it makes me sad to think that some of them will now be isolated at home while their mothers lie resting, without the support that was so needed, which the Mildmay was able to give them.

I hope the Minister will be able to tell the House what progress the Global Fund to fight AIDS, TB and malaria is achieving. This has been a priority for the UK and I wonder whether the Minister can say which countries have supported the Global Fund and which have not.

Last year, a parliamentary delegation from the HIV/AIDS group from India visited us in Parliament. It was good to meet them and to hear that, like us, they had a parliamentary group. With more than 4.6 million HIV-infected people, India has the second-highest rate of HIV infection in the world after South Africa.

HIV/AIDS is the biggest threat to global development and stability in our time—not only in Africa but also across the world. It is no longer simply a health issue; it is a human rights issue that cuts across all aspects of social, political and economic life.

Children orphaned and made vulnerable by HIV/AIDS experience a wide array of problems. In addition to the psycho-social distress of losing one or both parents, they may also lack food, shelter, clothing or healthcare. They may be forced to drop out of school or required to care for chronically ill adults or younger siblings. They may face discrimination, abuse or exploitation. Deprived of parental guidance and protection, they may themselves become vulnerable to HIV infection.

HIV is causing so many problems, it is encouraging when one hears that governments have accepted there is a problem with HIV in their country. Governments from all over the world must do all they can to prevent the spread of this deadly infection.

6.32 p.m.

Lord Chan

My Lords, I, too, thank the noble Lord, Lord Fowler, for giving us this opportunity to focus on HIV/AIDS, which is typically a sexually transmitted disease. It disproportionately affects the poorest people, with devastating results, in developing countries. I intend to focus on the integration of existing health services to help in particular children in developing countries—the 700,000 who were infected last year resulting in 500,000 deaths.

Globally, as the noble Lord, Lord Fowler, told us, between 40 million and 46 million individuals live with HIV, 95 per cent of them in developing countries. Africa is now the most affected continent, with 30 million in sub-Saharan countries where six in 10 sufferers are women.

Twenty-nine million people have died of AIDS so far, with 3 million dying last year. As most of the deaths occur in young adults, some 14 million children have lost at least one parent to HIV/AIDS. It is estimated that by 2010, 20 million children will have lost a parent from AIDS. That orphaning in highly affected countries may cause children to enter the labour market before they have completed school education and exacerbate problems of child labour. Financial help needs to be given to families where one or both parents have died of HIV/AIDS.

The low status of girls and women in many traditional societies in Africa and especially in Asia, has led to them being sold into prostitution, which in turn spreads HIV/AIDS faster and further in those countries. In India, where young women join the sex industry in metropolitan cities from poor rural communities, including from Nepal, HIV spreads to their home when they return with the disease. India now has between 4.58 million to 6 million living with HIV, a number that is second only to South Africa, as most of us are aware.

However, when I was working in India in the late 1980s and early 1990s, there was a denial that HIV and certainly AIDS were important. It was said that only a few thousand people were infected. Well, the figure has now grown to millions. Therefore, if all girls were educated in schools, they would be economically active without being exploited in the sex industry. Is that something in which we can encourage the international community to invest?

Some services which reduce the risk of HIV infection exist, but they are mainly for reproductive health and are not integrated with initiatives in HIV/ AIDS. Because poor developing countries cannot afford to establish a separate service for sexually transmitted infections, particularly because of the stigma, integration of reproductive health services with HIV would seem to be logical and economically sound. Services such as maternal and child health clinics that incorporate family planning information and supplies of condoms could also identify mothers with HIV and provide them and their babies with anti-retroviral drugs to prevent the new-born babies from becoming infected. Improving reproductive health services is essential to combating HIV/AIDS through HIV counselling, increased condom availability for use by men and also condoms for women through the management of sexually transmitted infections.

Teams that treat malaria in endemic areas are becoming another avenue of tackling HIV and associated infections such as tuberculosis. These teams give anti-malarial medicines after testing the patient's blood for malarial parasites. Blood can also be collected to screen for HIV and implement treatment. When providing advice on how to prevent children from being bitten by malaria-carrying mosquitoes, information on how to avoid sexually transmitted infections can also be given to the community. As chairman of a charity, the Malaria Consortium, I am encouraged by these positive developments to integrate the management of malaria and HIV in our African field areas in Uganda and in Ghana by local health teams. In addition, treatment for TB is given where required. We are monitoring the implementation of these programmes and collecting data.

The All-Party Parliamentary Group on AIDS, of which I am a member, is particularly concerned about the rapidly emerging epidemics in eastern Europe and central Asia that have been identified by other noble Lords. The enormous growth of HIV in these countries cannot possibly be due only to better detection and is clearly a result of the rapid spread of HIV infection. This rapid infection rate will reduce economic growth by 1 per cent as spending on health in these countries on HIV/AIDS increases from 1 to 3 per cent of gross domestic product.

When the HIV infection rate has increased beyond 1 per cent among adults, no country has been able to contain the epidemic. Russia is now approaching that 1 per cent threshold.

The Chinese Government estimate that there are 840,000 HIV-positive people in their country and that 80,000 have AIDS. The UN estimates that there are at least 1 million people with HIV in China and that this number could grow to 20 million by 2010. That is probably a more realistic estimate than that of the Chinese Government because only 10 per cent of individuals in China know that they are infected with HIV.

About 7.2 million people in Asia are HIV positive, with 5 million living in India and China. An estimated 500,000 people died of AIDS-related complications in Asia in 2002. The growing epidemic in Asia accounts for approximately 25 per cent of the world's new cases of HIV/AIDS.

I know that the Department for International Development is consulting on its future programme for HIV/AIDS in developing countries. DfID has done, and continues to do, effective work to combat HIV/AIDS —something of which we can all be proud. Perhaps the Minister would consider international plans to control the spread of HIV/AIDS in Asia through education, capacity building and support for the treatment and prevention of this serious disease.

In partnership with local mass media, information can be given to all communities about the dangers of HIV/AIDS and about how to avoid infection. In 2002, the BBC World Service assisted All India Radio and Doordarshan TV in disseminating information on HIV/AIDS. It was aimed at young people in northern India and information was given on how they could protect themselves and end discrimination against those living with AIDS. Is the Minister aware of any other partnerships along those lines in other parts of Asia?

Finally, some developing countries in Africa and south-east Asia have begun to assess the effect of their local and national programmes for reducing the spread of HIV/AIDS. Uganda and Thailand, which have already been mentioned, have made progress in combating HIV/AIDS. Will Her Majesty's Government encourage and assist developing countries in learning good practice from other countries in their region or continent? Such learning would be more appropriate than using models that work in industrialised countries.

6.41 p.m.

Lord St John of Bletso

My Lords, it is a pleasure to follow my noble friend Lord Chan with his distinguished international medical career. I join in thanking the noble Lord, Lord Fowler, for introducing this debate on the worldwide HIV/AIDS pandemic.

We are all acutely conscious of the gravity of the situation in many parts of the world but, among the cacophony of statistics and projections, I was particularly moved by a recent report by Stephen Lewis, the United Nations Secretary-General's special envoy on HIV/AIDS in Africa. He was visiting a paediatric ward in Lusaka last year where doctors told him that, in that hospital alone, a child dies of HIV/ AIDS-related causes every 15 minutes. I fear that such situations are duplicated in many other hospitals, particularly in southern Africa. This is not about sterile statistics; this crisis is about human suffering on an almost unimaginable scale. Therefore, I thank the noble Lord, Lord Fowler, for once again bringing this issue to your Lordships' attention.

Much is being done, and many new initiatives and projects are being launched month on month. The noble Baroness, Lady Jay, and the noble Lord, Lord Holme, will be co-chairing an important workshop on HIV/AIDS in southern Africa at Marlborough House tomorrow. As the noble Lord, Lord Fowler, mentioned in his powerful speech, this pandemic is a global problem. However, I should like to focus my remarks today on the serious situation in South Africa—a country in which I have spent most of my life.

In South Africa, where the Minister of Health has long been extolling the medicinal qualities of olive oil, lemon, garlic and the African potato, the Government last November eventually—I stress, eventually—agreed to start the distribution of anti-retroviral drugs to patients with a CD count below 200. Almost 15,000 patients are now receiving this form of treatment, which will save some lives and certainly extend many others. This is a welcome start.

I had lunch yesterday with the governor of the Reserve Bank of South Africa, Tito Mboweni, who confirmed that the South African Government have committed themselves to spending 12 billion rand on the struggle against HIV/AIDS over the next five years. This massively increased health budget, combined with the billions of dollars in aid from other countries—most notably, the United States and Britain—should maintain the delivery of anti-retroviral drugs nationwide.

Incidentally, while this debate focuses on HIV/ AIDS, we should be mindful that it is not the only killer disease in Africa. I was pleased that my noble friend Lord Chan mentioned the scourge of malaria. More than 350 million Africans—nearly half the population—contract malaria every year, and yet malaria medication is not proclaimed a basic human right. As my noble friend Lord Sandwich quoted, one in three people living with HIV worldwide are co-infected with tuberculosis, and nine out of 10 die of TB within a few months unless treatment is available. Spending on HIV/AIDS research currently exceeds spending on TB by a factor of 90 to one.

Aside from caring for the suffering of HIV/AIDS patients, it is also important to focus funds on the whole issue of prevention. In this regard, it is encouraging to see the South African Government and private enterprise there combining to warn and inform the population. That prevailing resolve was reflected by Mbhazima Shilowa, the Premier of Gauteng, the former Transvaal, when he said last month: Forty million South Africans are HIV-negative, and we want to keep them that way". The "Love Life" campaign has been spread across roadside billboards, candidly advocating safe sex and urging self-preservation. The Kaiser Foundation has put 500 million rand into a youth prevention campaign, and various British NGOs are making an invaluable contribution to this cause. Recent findings of the Reproductive Health Research Unit at the University of the Witwatersrand suggest that such measures are starting to produce positive results. The survey of 12,000 young people aged between 15 and 25 found that 32 per cent regularly use condoms—up from 8 per cent in 1998. It also suggests that the infection rate among 15 to 19 year-olds is slowing.

There are positive indicators in what otherwise remains an extremely bleak situation. HIV/AIDS awareness remains almost non-existent in urban squatter camps and rural areas, and the alarming rate of infection among South African youth remains the highest in the world. More campaigns and more programmes are required to address persistent behavioural trends, such as multiple sexual partners and alcohol and drug abuse. I entirely agree with the call of the right reverend Prelate the Bishop of Salisbury that the threat of the pandemic should be preached in churches, mosques and other religious forums.

Of course, there remains a great deal to be done but, 12 months ago, South Africa appeared to be sleepwalking to disaster. That is thankfully not the case today. At long last, the tide has started to turn. I would, however, like to sound a note of caution on the accuracy of the available statistics. Many of your Lordships will be aware of the recent report by UNAIDS, which estimated that 5.4 million South Africans have been infected by HIV—that is, one in every nine of the 45 million. It has also been reported that the HIV/AIDS virus is carried not only by 100,000 of the country's 1 million civil servants but also by a quarter of mineworkers employed by Anglo American.

I challenge how these noticeably round numbers are calculated. Like anything else, they should be subject to scrutiny. Estimates of infection and death rates are based not on the results of actual testing, which are costly and clearly impractical, but on sparse information fed into computer models. Such systems are patently imperfect.

The World Health Organisation initially used Epimodel to calculate that 250,000 South Africans had died of HIV/AIDS related causes in 1999. This system was subsequently upgraded to ASSA 600, which concluded that only 143,000 South Africans had died because of the virus in 1999. Towards the end of 2001, the agency then introduced another model, ASSA 2000, which further reduced the total to 92,000.

Of course, we must take the statistics seriously, but they are estimates, not facts. Last year, it was widely reported that the population of Botswana had fallen from 1.4 million to below 1 million because of HIV/AIDS related deaths. However, a recent census put the population at 1.7 million.

The HIV/AIDS pandemic remains an immense problem in southern Africa. However, the campaign to control the virus in South Africa and Botswana is, thankfully, starting to make headway. I hope that the focus remains as firmly on prevention as on cure.

The Earl of Sandwich

My Lords, before my noble friend sits down, perhaps he could answer one question. He has given us very encouraging news of the change of heart in South Africa. Does that imply that that is real political leadership from the top?

Lord St John of Bletso

My Lords, the situation is that for some time President Thabo Mbeke has swept the issue of HIV/AIDS under the carpet. Fortunately, through pressure from his colleagues in cabinet and from international organisations, the president has agreed that this is indeed a major problem for which he has to take responsibility. Therefore, I say that the tide has turned.

6.52 p.m.

Baroness Northover

My Lords, I am very glad that the noble Lord, Lord Fowler, has put down this Motion for debate. When he was Secretary of State for Health in the 1980s his efforts in this area were brave and widely admired. I remember that he was also much vilified. Such national leadership is now desperately needed around the world. As most noble Lords seem to feel, the AIDS epidemic is surely one of the greatest challenges of our time. Although the plague of the Middle Ages, to which the noble Lord, Lord Brooke, referred, wiped out whole communities and generated great social unrest, it was not on this scale. It should, however, serve as a warning of what such epidemics can do to the social fabric.

I listened to the noble Lord, Lord Colwyn, with some interest. When he extracts a tooth from an apparently HIV/AIDS patient, I wonder whether he feels it necessary to take special precautions. I am glad to say that my husband, if operating on an HIV/AIDS patient, does so. But diverse views encourage research which is badly needed, especially if a vaccine is to be developed.

In my view, AIDS threatens not only to devastate the lives of those infected, but also to destroy societies. As we have heard—I understand the question about the figures—there are perhaps some 40 million to 46 million people living with HIV globally, 30 million of whom live in sub-Saharan Africa. As we have heard, there are at least 14 million AIDS orphans. AIDS is spreading rapidly around the world. There are probably at least 1 million people living with HIV in China and the UN estimates that that may reach 20 million within six years. The fastest growing incidence of the disease is now in eastern Europe, right on our borders.

So why have we failed to recognise the significance of this catastrophe? Can we see evidence, as the noble Lord, Lord St John, said, of the huge tanker of international concern gradually turning around? We are deluged with news of conferences, communiqués and commitments, but to what extent is money following the pledges? Clearly this disaster is on such a catastrophic scale that even massive efforts do not yet meet what is required.

Profound changes in behaviour are also required. As the noble Lord, Lord Fowler, has said, prevention is clearly the key to containing the disease. But like him, I am glad that we are now also talking about treatment. Until recently, treatment had seemed an almost impossible dream in much of Africa at least. It was said that there was not the health infrastructure or the drugs required. That has now been recognised as a counsel of despair. Instead we see that prolonging lives is good in itself, but also helps to hold societies together. At the very least it postpones the time when children are abandoned to care for themselves.

The agreement to provide generic anti-retroviral drugs has been a huge step forward, and is a credit to international institutions. This weekend we heard the excellent news that the US Government will also apparently speed the approval there of cheap ARVs. That is desperately needed. Only 3 per cent of those who need ARV drugs in Africa have access to them. The "3 by 5" initiative of WHO and UNAIDS is ambitious, but not ambitious enough.

A blueprint for what can be done is surely the ACHAP scheme in Botswana to which the noble Lord, Lord St John, referred. The incidence of AIDS in Botswana is generally around 38 per cent, but as high as 65 per cent among certain groups. A partnership of Merck & Co and the Gates Foundation with the Government of Botswana has committed 100 million dollars to addressing almost every aspect of the AIDS epidemic in Botswana. Almost half of the population of 1.7 million live on only one dollar a day. ACHAP is investing in prevention, education, strengthening capacity and providing care so that all potentially have access to treatment.

As yet those who are well are not coming forward for testing or for treatment, although information about the disease is being disseminated. Fewer than 10 per cent yet know their status. So it is the very ill who are coming to the clinics. But here the scheme has already made a huge difference, reducing what might have been a 100 per cent death rate among this particular group to 8 per cent.

However, they are finding that they have enormous problems with capacity—too few doctors and nurses—and they are drawing them in from other countries around. That is clearly something that the international community will have to address. Can the Minister comment on whether there might be schemes for training doctors, nurses and teachers more rapidly, given that they are especially needed and yet they are particularly badly hit by the epidemic?

Sixty-four per cent of those who are being treated in Botswana are women. The impact of this epidemic is far greater on women than on men. Women and adolescent girls are socially, culturally, biologically and economically more vulnerable. Women are not only at greater risk of contracting the disease, but they also carry the greatest social burden, as caring falls to them, whether as elderly carers or as children.

Fundamental changes in attitudes towards women are necessary, but I cannot imagine that they will be anything but slow to come. If I can see any bright spot in this epidemic it will be if indeed it causes a shift in the position of women. There are short-term measures that can certainly be taken. Educating girls, supporting carers, developing microbicides with which women may help to protect themselves and changing legal systems so that women can inherit land and property on their husband's death can all be moved forward while pushing for more profound changes in attitudes towards women.

The worst and the saddest aspect of the AIDS story is surely the plight of the children. I cannot believe that we have taken so little action to help AIDS orphans up to now. As Save the Children has put it, Children are the most affected and the most marginalised in the fight against this epidemic". There are the children with HIV. In South Africa there is now a prevalence of over 6 per cent in children between the ages of two and 15. UNAIDS estimates that over half of new infections are occurring in young people between the ages of 15 and 24.

But in addition children are being orphaned every minute. Fourteen million children under the age of 15 have already been orphaned and this number is projected to double by the end of this decade. In the hardest hit countries in southern Africa, up to one quarter of all children, one in eight of the entire population, is an orphan.

We clearly have to do what we can to try to support extended families who have taken in orphan children. For a start, the care-giver should never need to have to worry about how to feed those in their care. Free schooling is needed so that children can continue their education and make it less likely that they themselves will fall victim to the disease. Clearly, trying to support children in large extended families or within communities is likely to be far preferable to establishing huge orphanages. But there is already evidence of extended families breaking down under the strain. Society itself is at breaking point. It is better therefore that they receive some care than end up as street children, prostitutes and child soldiers.

In the Government's last policy statement on AIDS, orphans were mentioned as an effect of AIDS without their needs being addressed. The Government surely must be at the forefront of developing comprehensive plans for these children and not see them simply as some by-product of the disease. I look forward to hearing what the Minister says on this matter.

Spending by the international community has dramatically increased, but the UN reckons that spending needs at least to double again. Can the Minister tell me how much the Government will be contributing to the Global Fund and when he anticipates the Government will reach 0.7 per cent of GNP donated to aid? I welcome the proposal put forward by the noble Lord, Lord Fowler, that there should be an EU co-ordinator for AIDS. That is a very positive and useful proposal.

We have to recognise that we are still only at the beginning of the AIDS epidemic and its impact. First, the incidence of HIV rises exponentially. Then the number of AIDS cases rises. Only after that do we see the exponential rise in the impact of the disease. In many areas we are still at the stage of seeing the rise in HIV infection. We therefore know that even if we keep in check the increase in the number of infections, we are still yet to see its huge impact. It is like watching a tidal wave roll in.

We therefore have to recognise that we are in this for the long term, and that we have to act with a far greater sense of urgency. There is surely no higher priority for DfID. AIDS is already reversing development, so that instead of moving towards the MDGs by 2015, we will simply move away from them. That is why I welcome this debate and all those communications I receive which tell me that there is an ever increasing number of people who realise quite how important this pandemic is for all our futures.

7.5 pm.

Lord McColl of Dulwich

My Lords, may I also thank the noble Lord, Lord Fowler, for initiating this extremely important debate. It was his characteristic modesty which precluded his mentioning that he was the Secretary of State responsible for this very successful campaign in the 1980s.

I should declare an interest. I have been president and chairman of the Mildmay centre in Hackney, which was set up in 1986 with the help and encouragement of Lord Shaw. He was of enormous help and encouragement to us. It was the first hospice for people dying of AIDS in Europe. Then at the invitation of president Museveni of Uganda we later set up a similar organisation in Kampala, with the invaluable support of my noble friend Lady Chalker, as mentioned by the noble Earl, Lord Sandwich.

When the World Health Organisation predicted in 1999 that there would be 27 million people with HIV/AIDS by now, it was thought by many to be scaremongering. The estimate was wrong. The figures today are 50 per cent higher than predicted. The numbers are set to grow even more as infection rates continue to rise especially in countries where poverty, poor health systems and limited resources for prevention and care accelerate the spread of the virus.

A young Zulu lady from Durban has been working in many districts in this country during the past six months and she has been alarmed by the attitude that she has encountered. Everywhere she goes people give her the impression that they think that AIDS is a problem of the sub-Sahara, but the danger in Europe is very grave indeed.

A WHO study released this month showed that HIV/AIDS is spreading throughout Europe faster than anywhere else in the world. Almost 2.5 million people on the Continent are affected. In developed countries HIV/AIDS claimed approximately 18,000 lives in the past year. There is increasing evidence that prevention strategies in several high income countries are not keeping pace with the changes occurring in the spread of the disease. These shortcomings are most evident among the marginalised group of populations such as immigrants and refugees.

The spread is fastest in Eastern Europe where one third of 1 million new cases were identified last year. That is up from 27,000 in 1995. In Eastern Europe and Central Asia the worst affected areas are the Russian Federation, Ukraine and the Baltic states, but the disease continues to spread in other eastern countries such as Belarus, Moldova and Kazakhstan, and more recently in Uzbekistan. It is estimated that 1 million people aged 15 to 49 are living with HIV/AIDS in the Russian Federation.

Over 1 million people in Asia and the Pacific acquired HIV/AIDS in 2003, bringing the total number to an estimated 7.4 million. This region saw 500,000 AIDS-related deaths in 2003 alone.

The prevalence of the disease is hard to estimate in these regions due to the vast size and population of the countries. That has the effect of focusing attention towards the prevalence in major urban areas, often obscuring the epidemics in smaller provinces.

There is also the notion that North Africa and the Middle East have side-stepped the global epidemic, but the latest figures prove that that is not so. It is estimated that 600,000 people now have HIV/AIDS in this region, which killed 45,000 people in 2003 alone. Over 2 million people are now living with HIV/AIDS in Latin America and the Caribbean including 200,000 who contracted the disease in 2003. At least 100,000 people died of AIDS in the same period, which is the highest regional death toll after the sub-Sahara and Asia. It is estimated that approximately 50,000 people are living with HIV/AIDS in the UK, of whom about one-third are thought to be undiagnosed.

Until 1998, infections acquired in homosexual men were the main exposure category for new infections in the UK. However, by 1999, heterosexually-acquired HIV/AIDS had become the main exposure category for new cases in the UK. That situation has continued. The proportion of infections acquired through injecting drugs has been much smaller in the UK than in many other European countries. That is largely due to the well implemented harm reduction methods—for example, needle replacement programmes.

The use of highly active anti-retroviral therapy (HAART) has proven effective in delaying associated deaths and the onset of AIDS. However, the decline in the number of cases and deaths in the surveillance data will not necessarily be maintained. Some of the progressions to AIDS or death, which continue to occur in the era of widely-available HAART, may be attributed to patient non-compliance, failure to tolerate a demanding drug regime or the emergence of drug-resistant viral strains.

In the past 15 years, there has been a great increase in the incidence of HIV/AIDS infection among heterosexuals in the UK. By 2003, the total number infected was nearly 20,000. Infection rates are particularly high in African communities in the UK where, often, one or both of the partners has contracted the infection in Africa before arrival.

I was very glad that the noble Baroness, Lady Masham, mentioned the withdrawal of support from the children services at the Mildmay centre in Hackney. PCTs will not fund them. I suspect that that is because there are no government targets for the management of those children. Naturally and understandably, PCTs feel obliged to try to concentrate on reaching the targets that have been set by the Government in other areas. Perhaps the Minister would look into that rather sad state of affairs.

This morning, I was speaking to Mrs Ruth Sims in Uganda, who is the director and founder of the Mildmay centre in Uganda. For many years, she has done wonderful work in Uganda and many other parts of Africa. She said that one of the problems in Uganda is that it has now become clear that many children were infected at birth unbeknown at the time. HIV/AIDS is now becoming manifest in teenagers as old as 18, who picked up the infection at birth. In retrospect, many of them have been ill off and on for most of their lives but they were not diagnosed.

As the noble Baroness, Lady Northover, mentioned, the number of orphans is putting an intolerable burden on the already extended families, especially in Uganda. For instance, a granny may look after 10 orphans. Then, one of the children becomes sick. That could be the last straw because the granny already goes out to work all day to earn enough money to support the orphans. She does not have time to look after the sick child.

Of course, making available ARVs (anti-retroviral drugs) is a great help. The problem now is that there are far too few people able to administer those drugs to the children. What is desperately needed is not only ARVs but also palliative care and people on the ground who can look after those unfortunate children and give support at grass-roots level for the elderly grandmothers on whom most of the burden of care falls.

Another problem that has arisen in Uganda is that the supply of drugs which are necessary to treat the complications of HIV/AIDS has been reduced. In a clinic in the Mildmay centre in Uganda, I saw about 80 HIV AIDS infected children being treated. Most of them had treatable complications, such as opportunistic infections, toxoplasmosis, PCT, pneumonia and fungal infections, which respond well to relatively cheap drugs. Incidentally, 80 per cent of those children had open TB. Noble Lords have mentioned an incidence of one in three, but in those unfortunate children 80 per cent had open TB.

One commercial firm is continuing to supply some of the drugs for free, but it is essential that we have enough drugs to treat all those infections. They improve the lives of children so that they then can be treated with ARVs. Will the Minister kindly consider making funds available for those drugs and for palliative care?

In some countries in Africa the stigma of AI DS is appalling. For instance, as has been mentioned, it is widespread in South Africa. When someone in a family is diagnosed with AIDS, instead of his or her family rallying around, they tend to isolate and ignore the person. In some of the general hospitals in South Africa, as many as 50 per cent of children under the age of 5 attending hospital are HIV positive.

It has been shown that rates of HIV transmission vary by social standing, especially in the southern United States. The WHO proposes that prevention activities need to be designed with the local epidemiology and the spread and management of the disease in mind. For example, in settings in which HIV/AIDS is largely sexually transmitted, information and education campaigns can save lives. A prime example is Thailand, which has already been mentioned.

In the fight against HIV/AIDS, the role of heads of state has been crucial. Those presidents who have denied the problem have presided over disasters, as has been mentioned in South Africa. Those who have been honest and have given real leadership are well worth studying.

From Africa, perhaps we have most to learn from President Museveni—mentioned by the noble Earl, Lord Sandwich—whose campaign has led to a really significant reduction in the incidence of HIV from 31 per cent to 7 per cent among pregnant women. We are not sure whether we can extrapolate that figure to the rest of the population, but, certainly, his leadership and close liaison with schools, Churches and non-government organisations has been inspiring. As has been mentioned already, at the centre of his campaign has been the well known ABC programme; that is abstinence, be faithful in marriage and condoms.

Some emphasis has been put on the need for education, but that is only part of the answer. A young British lady doctor went to Africa to work for six months. She had an affair and returned with AIDS in spite of being highly educated. The tragedy of the disease is that many people could avoid it by changing their behaviour. Sadly, even if behaviour in many developing countries changed overnight, those countries would still lose one-third of their populations.

7.19 p.m.

Lord Triesman

My Lords, I join everyone in congratulating the noble Lord, Lord Fowler, on securing the debate. His knowledge, compassion and commitment are well known and applauded on all sides of the House. There is no one with a better right to pose the critical questions—a point made by the noble Lord, Lord Brooke, and others, in which I join.

This is a subject of global importance with massive ramifications. We have had what must certainly be one of the most thought-provoking exchanges of views that I can recall. I shall try to reflect on those views here, but I promise noble Lords that I shall be reflecting on them long after today's debate is over. Some parts of the discussion have been harrowing. The right reverend Prelate the Bishop of Salisbury and the noble Lord, Lord St John of Bletso, also raised issues that have probably moved us all.

There have been a great many significant recent developments at home and overseas which have signalled an increased, almost unprecedented, focus on the epidemic. I am bound to say, not at great length, to the noble Lord, Lord, Lord Colwyn, that there are always outlying theories in any branch of medicine, but it is inconceivable that we could stand aside from the overwhelming weight of epidemiological research studies across the world and across cultures. There has been a diversity of research and yet a commonality of conclusions. People do not die of AIDS unless they have HIV. It is probably true that other factors such as poverty and malnutrition accelerate the onset of AIDS, but not without HIV. The AIDS pandemic is not just old illnesses. The rapid increase in sickness and death among populations principally made up of groups that are sexually active demonstrates that that is a new phenomenon. Noble Lords who have a great deal more medical experience than I made that point during the debate. As the noble Baroness, Lady Northover, said, there is of course a need for greater research, but we hope that as that research takes place, the AIDS dissidents—if I may describe them in that way—will be receptive to its outcomes.

World AIDS Day 2003 marked a stepping-up of the UK's political attention to HIV/AIDS, with the launch of our Call for Action. I shall return to the developments around the Government's new HIV/AIDS strategy. We have focused on a number of questions. Those questions relate to our domestic arrangements, but also to the international position; for example, how best can the UK work with its partners? What is the best balance between UK-led action and our support for international action? What is the best balance between multilateral and bilateral research activity? We shall have to discuss in the ways that have been raised in the debate the balance of work between governments, civil society and the private sector. What is the balance between prevention, treatment and care, and impact mitigation? Those are all vital questions. As the noble Baroness, Lady Northover, said, they are big questions and they need some pretty big answers.

The noble Lord, Lord Fowler—I hope that I am quoting his words accurately; I do not mean to distort them—described the issues as issues of sheer scale, as matters where the sheer scale of the question should be absolutely fundamental to us. The noble Lord, Lord McColl, also placed the right emphasis on these figures. They are truly staggering statistics: 60 million people have been infected with HIV since the late 1970s; 20 million deaths so far; 40 million people living with the virus; 5 million new infections in 2003. I shall try to break those figures down to smaller time capsules: 14,000 people die from AIDS every day; 570 people die an hour; nine people die every minute. One can almost do the sum while we have been holding this debate. Three million people died of AIDS in 2003; five people died every minute; 342 every hour and so on. As noble Lords have pointed out, more than half of new infections occur in young people between 15 and 24 years old. As the noble Baroness, Lady Northover, also said, women and girls are at much heightened risk. That is a fundamental issue in itself.

The noble Lord, Lord McColl, was quite right to draw our attention to the 2.5 million people with AIDS on the Continent. Eastern Europe is close enough to us and it has grave difficulties. We need to comment on that before we comment on people who are further afield.

Perhaps I may take up the point about Mildmay. I was not aware until this evening's discussion of all the issues, but I undertake to look into the matter.

I think that we would all accept that the greatest impact of AIDS so far has been in sub-Saharan Africa. Southern Africa has 30 per cent of infections and only 2 per cent of the world's population, even allowing for the risk of the statistics being not all that we would want them to be. As noble Lords have said, there are fast-growing epidemics in the Russian Federation. Potentially the highest increase is in China and India, in both cases, as has been pointed out, with people not knowing.

The noble Lord, Lord Brooke, made a very powerful point when he said that our own early experience needs to be conveyed to others, not in any patronising way, but in order to make sure that early lessons can be learnt. The noble Baroness, Lady Stern, said that our experience was and is a model and I agree with her.

The issues are important and are recognised as such. I shall underline that with a brief quotation from Khadija Moalla, the project manager who has been dealing with many of those issues in the Arab states. He said that it has to be accepted almost like a mathematical axiom that there has been a failure in dealing with HIV/AIDS so far, which implies that we need many new ways of working on those fundamental problems. That is the stark reality that we face.

Perhaps I may deal briefly with a couple of domestic issues. The noble Baroness, Lady Stern, asked about prisons and about the scope of the law here. I offer her a couple of assurances. A good deal of discussion has taken place about the problems of sharing needles in prison and the issues surrounding the provision of injecting equipment. That is prohibited in prisons at the moment and a fundamental change in policy would be needed.

As a proportionate response to the issue of sharing needles, the Prison Service is reintroducing disinfecting tablets to prisoners. The London School of Hygiene and Tropical Medicine has been contracted to design and implement a strategy for their introduction in all prison establishments in England and Wales. The programme should have rolled out from April 2004 and I believe that it is doing so. The reintroduction of disinfecting tablets on a trial basis just a couple of years ago has now been evaluated. That project has led to the conclusion that I have just announced to the House.

The Prison Service also recognises that sex in prisons is a reality and carries a public health dimension. Prison doctors have therefore been advised that they should prescribe condoms to individual prisoners on application if, in their clinical judgment, there is any kind of known risk of HIV infection. Policy probably varies across the prison estate, but it would obviously be better if it were raised to a much better standard in general. There are no plans to introduce needle exchange at present, but that matter is reviewed regularly.

I thank the noble Baroness, Lady Stern, for drawing the attention of the House to the declaration on prison health which I understand was adopted by the annual conference of the World Health Organisation in Moscow in October 2003. Officials working in the prison health team, which is a joint Home Office and Department of Health unit, are taking forward the reforms to improve prison health care. That unit is also acting as a collaborating centre for the WHO project. It will ensure that officials representing the UK at the next conference in October 2004 are fully briefed on the details of the declaration and will be in a position to look at progress.

On the legal status of people wilfully or knowingly transmitting HIV, it is not possible at present to confirm that there will be new legislation. My understanding is that prosecution is achieved under existing categories of law, particularly GBH. We would be concerned about the excessive use of legal instruments to protect public health, because the burden of proof in intimate relations is not always an easy matter in tests of law. The carrot-and-stick approach is usually most effective in health promotion HIV projects.

More broadly, the impact of AIDS, as we have all agreed, is devastating. It is killing development in the developing world. Life expectancy in many African countries is falling to around 30 years of age. Botswana is the worst affected. An upper-middle income country, it faces a decline in life expectancy from 65 in 1990–95 to 40 today and it is projected that it may be 27 by 2010. The country may drop to low income status. Death among young people is undermining the workforce and potential carers. It has also been pointed out in debate that to cope with the crisis, households may be forced to sell off assets, children to go out to work, and there may be a switch to growing lower-value crops.

There are acute problems in public services. Africa is having to deal with significantly depleted resource capacity. Education and health services are the hardest hit. Teacher absenteeism, let alone the rate of death among young teachers, is dramatically cutting the number of teaching hours across southern Africa. The noble Lord, Lord Fowler, made the dramatic point that the number of teachers dying is outstripping those who are entering the profession.

Other problems include depleted work forces, lower productivity, economic growth rates decimated, with the private sector equally hard hit. There is a sharp decline in productivity, less resource and what has been described in the course of our debate, if I can put it in slightly different words, as the 1 per cent tipping point, where this becomes catastrophic.

The social impact is enormous. The fabric of our societies, as the right reverend Prelate said—and he must be right—is an intricate network that binds us together in very subtle ways, and fear finally begins to usurp the binding.

The noble Earl, Lord Sandwich, and the noble Baroness, Lady Masham, both made points about this. I do not think I can respond in a reasonable amount of time to all those points, but I shall write to noble Lords who have raised the point about the difference between budget support for local initiatives and the way in which we might get a more co-ordinated support where we are trying to assist in single government settings. In some countries, such as Uganda, one model is more appropriate than it would be in Tanzania, where it would not necessarily work as well. There is a degree of subtlety which needs considerable thought, and I shall write to noble Lords on that. I will say in that response why there is relatively little reference to ARVs in the HMG consultation document, although it is covered in other consultation documents. I draw noble Lords' attention to those. HIV and TB are strongly linked, and treatment with ARVs is one of the most fundamental issues.

Noble Lords raised the question of orphans. There are 14 million AIDS orphans in the world; the figure will rise to 25 million by 2010. Families are being dislocated as children are sent off to live with elderly relatives. Orphans are less likely to attend school. They are more likely to suffer from poor health and malnutrition and are more vulnerable to physical and sexual abuse. The impact is felt long before their parents die, when children, especially girls, have to drop out of school to become carers and take responsibility for farms, household chores and income-generation. We must pay great attention to the rights of orphans—that is one of the central parts of the Government's programme.

The social consequences could be enormous, with children who have suffered profound distress, with little adult guidance or support, facing very uncertain futures, often in the face of widespread stigma and discrimination. Social breakdown can itself fuel conflict.

Women shoulder the burden of caring and are less likely to be cared for. They suffer the greater discrimination; they face the greater poverty—unequal inheritance and land rights laws fuel poverty and HIV risk. Women and girls are biologically, socially and economically at the greatest risk of HIV infection. The sexual education of girls is at the heart of DfID's approach. That approach is not always easy because it sometimes has to be taken in countries where there is a great deal of conflict. Getting any kind of help through is not easy, creating a lack of access to information and a breakdown of services. We must address those questions.

The noble Lord, Lord Chan, talked about some of the information which is available in some of the areas where malaria is important. The Malaria Consortium plays a vital role; the data that it is generating is important for much broader epidemiological and clinical research as well. The noble Lord, Lord St John of Bletso, provided valuable insights into what is happening in South Africa in relation to antiretroviral drugs.

DfID is giving the highest priority to tackling the HIV/AIDS issue. We have increased our funding to developing countries; we are working with non-governmental, private and multilateral partners to improve prevention, treatment and care programmes. UNAIDS describes DfID as the world's second biggest bilateral donor of HIV/AIDS finance. Bilateral funding on HIV/AIDS and sexual and reproductive health has increased sevenfold over the past six years from £38 million to more than £270 million in 2002–03.

We were the first bilateral donor government to contribute to the World Health Organisation/UNAIDS 3x5 initiative—to get 3 million people on life-saving anti-retroviral treatment by 2005. Our contribution of £3 million has led to others and we welcome the significant contribution from Canada, announced only last week.

We are guided by the 3 Ones programme to which I believe a fourth One is about to be added. In each nation, we need a single strategy, so that everyone knows where they are going. We need one national AIDS authority, although I understand that we do not want to kill off' initiative and the things done by many of the voluntary bodies. But there needs to be some co-ordination. We want to see one monitoring framework, not least to get the better statistics to which the noble Lord, Lord St John, referred. The fourth One, if it comes along, will be that we want to see donors working through a financial mechanism which will reduce transactional costs.

We support wide-ranging HIV/AIDS work in 40 countries. Bilateral funding largely supports the national HIV/AIDS strategies of our developing country partners, including Malawi, South Africa and Zambia. We are major donors to the Ugandan Government's poverty eradication programme.

We work extensively through the multilateral organisations, including UNAIDS, the World Health Organisation and the World Bank. We also support worldwide research initiatives on HIV and sexually transmitted infections. As the noble Lord, Lord Chan, said, capacity-building is vital in all those areas, and it is most vital that what is learned and what is practised in similar countries is among the information that is shared.

We were a prime mover in setting up the Global Fund to Fight AIDS Tuberculosis and Malaria, and we have committed 280 million dollars over seven years to contribute to long-term stability of funding. I am pleased to announce that there are 58 other nations now making contributions, and contributions are being made through the EC. We are heading towards the 0.7 per cent target. An answer was given to a Question in your Lordships' House only a couple of days ago, and I cannot improve on it. Together, the EU member states and the EC have provided more than 50 per cent of the total funding of the global fund. This is in line with the call from the Prime Minister and President Chirac for Europe to play a full part. A good deal of this money needs to be spent on drugs and palliative care. I will ponder hard the proposal of the noble Lord, Lord McColl, that the amount should be increased.

Countering the devastating impact on developing countries requires improved access to affordable medicines, good healthcare services and knowledge. This has been a priority, and it is a priority in the partnerships we are striking with India—to respond to another question from the noble Lord, Lord Chan.

The United Kingdom is providing substantial support—£1.5 billion since 1997. We are doing more in our own health service, although I understand the arguments for doing still more. The GUM clinics have just been given a further £15 million for expenditure on sexual health, and a great deal of that will be going towards AIDS.

The UK Government have a progressive workplace policy, particularly for staff working overseas, in order to make sure that our approach is consistent, whether people are working here or overseas.

The Call for Action is the start of a process that will take us beyond our presidency of the EU in 2005. In all of this, working together will involve working with strong leadership—points made by the noble Lords, Lord Fowler, Lord Brooke and Lord McColl. President Museveni, quite rightly, deserves honourable mention. We will be supporting the New Partnership for Africa's Development. We need better funding, and we will be working hard for that. We need better donor co-ordination, and we will be working hard for that.

We will be working hard with those who have also made contributions which are not governmental—the Bill and Melinda Gates Foundation, Bill Clinton's charity, the Rockefeller Foundation, Merck, the Kaiser Family Foundation and a number of others, who are such important players.

We need better HIV/AIDS programmes. This is the purpose of the major areas with which we are concerned. We want to work to eliminate global poverty, which underpins our commitment to addressing HIV/AIDS. We want to work specifically on the problems of women and girls because of their particular susceptibility, which has been mentioned. We want to work on marginalised groups, defined by poverty, gender, ethnicity, age, sexuality and disability. We want to make sure that research in our own country moves ahead because this is a great centre of research—and research is one of the most helpful elements that can be contributed to this debate. I thank all noble Lords who have taken part.

7.41 p.m.

Lord Fowler

My Lords, this has been an outstanding debate. Dare I say that I think it is a debate that could only have taken place in the House of Lords because of the experience that has been shown during it? I would like to thank all noble Lords for their contributions. I agreed with almost all those who spoke. I very much agreed with the right reverend Prelate the Bishop of Salisbury when, in his very important speech, he said that HIV/AIDS cannot be allowed to slip from the public agenda and that it must go to the top of governments' agendas. I think he is entirely right to say that.

My noble friend Lord Colwyn said, in the most genial way, that he did not think that I would agree with much of what he would say. He was right on that. He said that there is so much that we do not understand about HIV/AIDS. It is true that we still have no cure and no vaccine. But we know what can be done to prevent it and we know what can be done to treat it. My noble friend Lord McColl and the noble Earl, Lord Sandwich, both pointed to the experience in Uganda where the incidence of HIV has been brought down. My noble friend Lord Brooke, in his elegant speech, also pointed to Brazil.

It would be wrong of me to try to summarise what all noble Lords have said. There were important contributions from each of them; for example, from the noble Baroness, Lady Stern, with her vast experience on the position in prisons; from the noble Baroness, Lady Masham, on the need to have a more outward going campaign in the UK; and from the noble Baroness, Lady Northover, on orphans. I was fascinated by the speeches of the noble Lords, Lord St John of Bletso and Lord Chan, about South Africa.

Lastly, I would like to thank the Minister for his thoughtful reply. I agreed with much of the diagnosis. If I may gently say so, I was a little less convinced on the new action that the Government intend to take. We will have to study the figures that came out in a shower at the end of the speech. I am always suspicious about figures that talk about spending over seven years and what that means year by year. However, I thank him. We still have a long way to go—I think that we agree on that—both in policy at home and overseas. We will support all the Government's genuine efforts but we will also not hesitate to point out when the Government are not doing enough. That is my position. In other words, I think we will debate this matter again. I beg leave to withdraw the Motion for Papers.

Motion for Papers, by leave, withdrawn.