§ Dr. Gavin Strang (Edinburgh, East and Musselburgh)It is now more than 20 years since AIDS first appeared in this country. In those early days we had a particular problem in Edinburgh, mainly associated with intravenous drug users. It was because of that problem that I first acquired an interest in the subject, and went on to introduce successfully a private Member's Bill in 1986, which became the AIDS (Control) Act 1987.
Much has happened since then, and in the last few years there have been some key developments in policy. In July 2001, after some considerable delay, the Department of Health published the first ever national strategy for sexual health and HIV, which was followed up by tool kits and new recommended standards for HIV services. Those developments have been scrutinised by my colleagues in the Select Committee on Health. In June, the Committee published its report on sexual health, and in September the Government published their response.
My hon. Friend the Minister does not have responsibility for this area of policy in Scotland, but it is worth pointing out that in December 1999 her counterpart in the Scottish Parliament, Susan Deacon, who was then Scottish Health Minister, announced that the Scottish Executive would introduce a sexual health strategy. Earlier today, the draft sexual health strategy for Scotland was published and the Scottish Health Minister, Malcolm Chisholm, has launched a wide-ranging consultation on its recommendations. The Welsh Assembly has published a strategic framework for promoting sexual health in Wales and a post-consultation action plan, while in Northern Ireland work on a comprehensive sexual health strategy was due to start this year.
So much for the history of policy. What has been happening in the real world? Perhaps the most important development of the past 10 years has been the introduction of a cocktail of antiretroviral drugs that has revolutionised the expectations of people with HIV. When HIV first appeared in my constituency, the norm was for people, usually young people, to die within a few years. Although resistance to drugs is an increasing problem, we learned last month that the vast majority of people on highly active antiretroviral therapy were alive more than 10 years after diagnosis.
The causes of the disease have changed greatly. Last year saw a record number of new HIV diagnoses in the UK—some 5,542 people were diagnosed with the virus, which, adjusted for reporting delays, is slightly more than 6,500 new diagnoses. The most common way of acquiring HIV in the UK is via sex between men. The number of such cases is not declining. Indeed, a small but noticeable contribution to the increase in the total number of new HIV cases in Scotland last year was made by an increase in the number of diagnoses among gay men.
The number of people newly diagnosed with HIV in the UK via heterosexual sex has increased dramatically in recent years, from 835 in 1996 to 3,152 last year. As has been the case over the years, the vast majority of those infections were acquired abroad, although the 127WH Public Health Laboratory Service, which is now the Health Protection Agency, expects that the number of people infected heterosexually in the UK will gradually increase in the years ahead. A huge increase in heterosexually transmitted cases last year resulted in Greater Glasgow overtaking Lothian as the Scottish region with the highest number of new diagnoses for the first time since testing began.
The number of cases transmitted through intravenous drug use has declined, and in Scotland the domestic epidemic has altered unrecognisably. In the years up to and including 1997, 73 per cent. of HIV diagnoses in Scotland were among intravenous drug misusers. Last year, the figure was 4 per cent. That is a real success story. Only 10 infections through drug use were diagnosed in Scotland last year—the lowest since records began. However, we must not let our guard down. The Scottish drug misuse database shows that in 2002–03, 36 per cent. of users asked had shared a needle or syringe in the previous month.
Although effective intervention can prevent babies from contracting HIV from their mothers, there were 99 cases of mother-to-baby transmissions in the UK last year. Routine antenatal testing has been in place in England for a few years now, and has been introduced in the whole of Scotland this year. We must hope that effective implementation of antenatal testing policies will help to prevent more transmission of HIV to infants.
It is not just the unborn and new born who benefit from HIV testing. As a result of huge advances in treatment, the sooner someone knows that they are HIV positive, the better. However, about a quarter of people in the UK who have acquired HIV through sex between men, and nearly half the people who have acquired the virus through heterosexual sex, are thought to remain undiagnosed.
I have spent a little time setting out the challenge. What now must be the response? I shall touch on three key areas. First, I believe that we must reprioritise HIV and sexual health. In the past, they were given key priority status, but in recent years they have lost that designation in England. Of course there has to be a limit to how many priorities the health service has, or the term becomes meaningless. However, HIV is increasing at a rate that outstrips the rate of all other priorities in the health service. HIV is designated by the Health Protection Agency as one of the most important communicable diseases in the UK. The number of cases of other sexually transmitted diseases is soaring. There was a 900 per cent. increase in syphilis diagnoses in England between 1996 and 2002, and about one in 10 sexually active young women have chlamydia. Despite that, the evidence is that, in many areas, genito-urinary medicine services are creaking at the seams. The Terrence Higgins Trust's latest study into the effects of the NHS changes on the sector found that the Government's wish that HIV and sexual health be considered a priority was not filtering through to strategic health authority and primary care trust level.
My hon. Friend the Minister will have studied the report of the Health Committee, and will have seen the consensus among those who gave evidence that HIV and sexual health must be urgently prioritised. Several means of doing that were proposed, including prioritisation through the strategic health authorities' 128WH planning and priorities framework and through local delivery plans, or through a dedicated national service framework, which the Committee recommends is the best way.
The Government ruled out a national service framework, and felt that it would be too disruptive to reopen local delivery plans or the planning and priorities framework this time around. However, they promised to consider what could be done to raise the priority of sexual health and HIV services.
Last month, the Medical Foundation for AIDS and Sexual Health published the new standards for HIV services in England, which have been widely welcomed. However, the standards do not have the force of a Department of Health guidance note and MEDFASH executive director Ruth Lowbury stated that service standards will require active monitoring to ensure that they are up to the mark. She also observed that no money has yet been allocated to audit the compliance of NHS trusts with the new standards. If the Government are to raise the priority of sexual health and HIV, those standards should be properly supervised. I should be grateful if my hon. Friend would outline how the Government intend to enable active monitoring of service standards. The Department of Health has been reviewing the operation of the AIDS (Control) Act 1987. Can the Minister give us any results from that review?
Secondly, we must ensure continued and increased funding to tackle HIV and sexual health matters. The written evidence of the National AIDS Trust to the Health Committee put matters starkly:
NAT welcomed the publication of the National Strategy but we are disappointed with delays in its implementation and the failure to accord adequate resources to support implementation.In its written evidence, MEDFASH said that
the allocated sum of £47.5 million over the first two years to implement the whole strategy is inadequate given the scale of the task in the short-term, and a commitment to continuing resources over the ten years of the strategy is also needed.There is also a worry that the mainstreaming of HIV services will reduce investment.The Health Committee estimated that an additional revenue commitment of £22 million to £30 million per annum was required and the Government, to their credit, responded with an extra £ 1 I million. However, Baroness Gould, the chair of the Government's independent advisory group on sexual health, must be right in saying that, while the funds were welcome,
investment in these services needs to be increased and consistent in future years if it is to improve facilities and services.My third point of focus is HIV prevention. It is mainly agreed that we in the UK started off well in the 1980s, but in the past few years it seems that our attention has been distracted from the necessity of prevention work, perhaps by the laudable work that is being done to make HIV treatment available to those who need it. We should be driving down to rock bottom the number of infections caught in the UK. We know how HIV is transmitted and we know how to prevent it. It is a tragedy that so many hundreds of people still become infected with HIV in the UK each year. Two years ago, in the debate on sexual health that I initiated in Westminster Hall, I and other hon. Members urged the Government not to abolish the earmarked HIV 129WH prevention money for England. To the disappointment of many, on that occasion, Ministers did not take advantage of that advice.However, hon. Members may be aware that the Scottish Executive still have ring-fenced money for the prevention of HIV and other blood-borne viruses. I am pleased that the draft sexual health strategy for Scotland that was launched today recommends that the Scottish Executive keep the ring-fencing of HIV money to health boards and assess the sufficiency of the funding against the need to respond to the increasing HIV trends in Scotland.
In England, the ring fence has been abolished and, given the changes in the NHS, much HIV prevention work is now localised. My hon. Friend the Minister will be aware of the great concern that that will threaten the existence of specialist health promotion that often operates across primary care trust boundaries, and will exacerbate the historic under-investment in HIV prevention. I welcome the Government's reassuring words in their response to the Health Committee on the need to reprioritise sexual health and HIV. Will my hon. Friend say how the Government plan to follow up their words with concrete action?
In the context of prevention, as well as caring for people with HIV, we want to encourage the maximum number of people to come forward for testing. However, like the Health Committee and the all-party groups on AIDS and refugees, I am not persuaded that mandatory testing for HIV of asylum seekers and other visitors to the UK is the way to do that. It is vital to destigmatise HIV, to encourage people in the UK to come forward for testing and to encourage other countries throughout the globe to adopt humane policies towards people with HIV.
It is clear that much more work has to be facilitated in the African communities in the UK. People from those communities are often diagnosed very late in the course of the disease. Sigma Research found that about a third of people were diagnosed when they were an in-patient in hospital after emergency admission. Nick Partridge from the Terrence Higgins Trust outlined in his evidence to the Health Committee the contrast between the consistent and resourced targeted prevention work for gay men and the insufficient work being done for our African communities. Dr. Barry Evans, of the then Public Health Laboratory Service, said to the Health Committee that
we have grossly under-estimated the investment required in African community-based organisations to bring them up to speed and to give them the capacity to deal effectively with HIV. They face all of the same challenges that existing HIV community organisations face but they are doubly disadvantaged by the fact that they are often completely underfunded.I have concentrated my remarks on the prevalence of HIV in the UK, but of course a tragic global epidemic concerns us all. In sub-Saharan Africa, more than 30 million people are living with HIV/AIDS. In little more than 10 years, life expectancy has plummeted in some countries in the region from 62 to only 47 years. Fifty years of progress in raising life expectancy has been wiped out.
130WH We need to build on the momentum generated by the Prime Minister and President Chirac's joint call for the EU to pledge up to $1 billion from EU countries annually for the global fund for AIDS, TB and malaraia. My hon. Friend the Minister will be aware that non-governmental organisations estimate that a fair contribution from the UK to the fund according to our wealth would be £107 million in 2004.
HIV/AIDS can be tackled here and overseas. I urge my hon. Friend to do all in his power to encourage the Government to rise to the challenge.
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§ The Parliamentary Under-Secretary of State for Health (Dr. Stephen Ladyman)It is a convention to congratulate the hon. Member who has won the Adjournment debate on his great interest in the subject, even if that interest only started when his name came up in the ballot the previous week. In this case, it really is a pleasure to congratulate my right hon. Friend the Member for Edinburgh, East and Musselburgh (Dr. Strang) on securing this debate and on his continued interest in a subject for which he has been a leading campaigner for more than 20 years. He and his constituents can be justly proud of that record.
As my right hon. Friend stressed, HIV and AIDS present a massive tragedy on a global scale. An estimated 42 million people were living with HIV at the end of 2002. During 2002, an estimated 5 million people were newly infected with HIV, of whom 800,000 were children. In the same year, 3.1 million deaths were attributed to HIV. Sub-Saharan Africa continues to bear the brunt of the global pandemic, but eastern Europe and central Asian republics are experiencing the world's fastest growing epidemics.
The UK is not immune from the global epidemic. Recent rises in new diagnoses among heterosexuals are linked to the tragedy that has been unfolding in sub-Saharan Africa. In 2002, almost 2,500 new diagnoses of HIV were attributed to heterosexual exposure in Africa in people probably infected before coming to live in the UK, and there were over 5,700 new HIV diagnoses, which was more than in any year since the start of the epidemic. That is a cause for concern. However, it also reflects our increased efforts to reduce undiagnosed HIV, as early diagnosis and access to treatment can prolong the lifespan of many.
Two national initiatives in support of prevention efforts will have added to the number of new diagnoses in recent years. First, we are now reaping the benefits of changes made in 1999 to our HIV testing policy for pregnant women. Routinely offering and recommending HIV testing to all pregnant women prevented around 100 babies from becoming infected in 2001. Secondly, offering an HIV test to all genitourinary medicine attendees on first screening for sexually transmitted infections should accrue benefits for the future by reducing onward transmission.
The impact of immigration on the UK HIV epidemic is evident from the statistics. I am aware that there is great concern about this issue. There is concern that the NHS is struggling to deal with the increasing cost of treating and caring for those living with HIV, but there is also concern, expressed by my right hon. Friend, that the Government should not respond to the problem with draconian measures that contravene our international human rights commitments.
131WH That is one of the reasons why the Cabinet Office is currently co-ordinating work between the relevant Government Departments, including the Department of Health, to review immigration and infectious diseases. The review aims to establish the facts about the impact of immigration on public health and NHS expenditure, and to propose solutions should action be required. The review is ongoing and no decisions have yet been reached.
The driving factor behind the Government's work to tackle HIV is the first ever national strategy for sexual health and HIV. Backed by an initial investment of £47.5 million, with a further commitment of £51.4 million over the next two years, four of the strategy's five aims relate to HIV. They include reducing the transmission of HIV and the prevalence of undiagnosed HIV; improving health and social care for people living with HIV and reducing the stigma associated with HIV. Those are all issues identified by my right hon. Friend.
Earlier this year, we announced the membership of the sexual health independent advisory group. Under the able chairmanship of Baroness Gould, the group will advise the Government on the implementation of the strategy and monitor progress. Members include representatives of the key HIV organisations and HIV service users, who will contribute their wealth of experience and detailed knowledge of the real concerns and problems that face those living with HIV and AIDS. Their valuable contribution will help to steer the strategy implementation that will best achieve our objectives.
The implementation of the strategy is taking place against the background of major change in the NHS. Shifting the balance of power has resulted in the creation of new structures, and primary care trusts are now in the forefront of the fight against HIV and AIDS. PCTs now have the flexibility to allocate money to sexual health in order to meet local needs, just as they now do for other health areas such as cancer. HIV funding is now rightly part of the main NHS allocations. However, those are weighted to take account of variations in the distribution of HIV locally. I shall return later to some of my right hon. Friend's concerns about the potential impact of those changes.
The Department of Health no longer dictates how local services should be provided, but supports the local work by providing guidance and by disseminating best practice. As part of that, the Department supports and endorses the new recommended standards for NHS services for HIV and AIDS launched last month. They were produced by the Medical Foundation for AIDS and Sexual Health, in partnership with HIV clinicians, service users and key stakeholders. We believe that those standards will help to drive up the quality of treatment and care throughout the country. The Department of Health has also issued tool kits of practical guidance and good practice for those commissioning local HIV services, and also for those undertaking HIV prevention and health promotion.
That decentralisation of decision making will not mean that action on HIV will go unmonitored. The AIDS (Control) Act 1987 provides a valuable reporting tool for gathering data. I pay tribute to my right hon. Friend, who steered the legislation through in the form of a private Member's Bill. It is just as relevant today as it was then. As part of our implementation of the sexual 132WH health strategy, the Department of Health, with other stakeholders, has reviewed the information collected under schedule 1 of the 1987 Act. That will be implemented shortly and will take account of the strategy, the new NHS and the Department's commitment to streamlining central returns. Combined with our world-class HIV surveillance system operated by the Health Protection Agency, that will give us a complete picture of the epidemic.
Strategic health authorities are now well placed to monitor HIV prevention and treatment within their areas, and will be able to address problems and facilitate networking and consortium arrangements between primary care trusts. The chief medical officer is now actively engaging with strategic health authorities to ensure that sexual health and HIV are sufficiently prioritised at local level within the current planning and priorities framework.
A sample survey of high and low HIV prevalence areas undertaken in May 2002 showed that PCTs were maintaining their funding levels for HIV prevention, treatment and care, and we will consider repeating that survey if necessary. Despite an increasing rate of HIV diagnosis, a survey in April 2003 under the British HIV Association treatment guidelines showed little evidence that costs were affecting the prescription of optimum antiviral treatments for those with clinical need. I hope that my right hon. Friend is reassured by that.
Inevitably, increasing rates of HIV and sexually transmitted infections are putting pressure on services, particularly genito-urinary medicine clinics. That fact was highlighted in the Health Committee's recent report on sexual health, mentioned by my right hon. Friend. The Government agree that additional resources are needed to tackle the long waiting times and backlogs in some areas of the country. Of the original £47.5 million invested in the strategy, £15 million has been used to improve GUM services. That includes £2 million to fund pilots in certain areas to evaluate new improved models of working. We have prioritised spending on GUM services from the sexual health strategy budget and, in response to the Health Committee's recommendations, have invested an additional £5 million to pump-prime service improvements. An additional £0.4 million will be used to expand national HIV prevention initiatives.
We recognise and share the deep concerns expressed by the Health Committee and others about the poor state of sexual health, and we are committed to improving sexual health through the sexual health and HIV strategy. We have provided an additional £11.4 million this year to access services and tackle sexually transmitted infections. Again, I hope that my right hon. Friend is at least partly reassured by those steps.
There is no cure for HIV, and we are still some years away from an effective vaccine. New drug treatments have improved the quality of life and life expectancy of many, but antiretroviral treatments do not suit everyone. The drugs can have unpleasant side effects, and their effectiveness depends on rigid adherence to often complex treatment regimens. Poor adherence can lead to the development of resistance to the drugs. We are developing surveillance to track the emergence of that important problem. For all those reasons, prevention is still the cornerstone in our fight against HIV.
133WH The challenge for HIV health promotion is to develop and deliver sophisticated interventions that engage target audiences, whatever their experience of HIV. Interventions must be relevant and based on research into people's behaviour that accurately reflects how they live their lives in relation to HIV.
Rates of HIV diagnoses among gay men have remained relatively stable for a number of years, but we are concerned by the recent increase in HIV diagnoses in gay men. However, that is in the context of a growing pool of infection, due in part to new transmissions but also to the success of treatments in keeping people alive longer.
We are continuing to fund the Terrence Higgins Trust to lead a partnership of organisations throughout England to deliver a community HIV/AIDS prevention strategy. It is an evidence-based programme that provides information in a style that is credible with the gay community. It is gaining an international reputation for its health promotion literature, and its strategic framework has been adopted in parts of the United States and Australia. We are currently considering the most effective way to use the additional £400,000 announced this year for national HIV prevention.
For African communities, the focus is on culturally appropriate information as well as capacity building for the voluntary and community-based sector, which is best placed to undertake HIV health promotion. For 2003—04, the Department is funding the African HIV policy network to manage and develop a programme of national work aimed at increasing awareness of preventing HIV.
For the wider population, our sex lottery campaign—launched last year—is aimed at increasing awareness of sexually transmitted infections, including HIV. The campaign was extensively pre-tested with its target 18 to 30-year-old audience, and reflects research findings of what works best with that group. It uses radio, adverts in magazines, washroom posters, beer mats, scratch cards and a website to get the message across. It is an ongoing campaign, which will be thoroughly evaluated. We are also developing a specific HIV information resource under the sex lottery brand, to raise awareness among the general population.
134WH HIV is all too often accompanied by a unique type of stigmatisation, which is rooted in ignorance and often compounded by other forms of discrimination such as homophobia or racism. That can increase the risk of HIV transmission, cause or aggravate health problems and create a barrier to treatment, care and services. There are, therefore, very real reasons for tackling stigma. That is why the sexual health and HIV strategy includes a reduction in stigma as one of its main aims. We are working with stakeholders and people living with HIV to develop a detailed action plan to address stigma and discrimination.
Since the start of the epidemic, the voluntary sector has played a key role in providing patient-focused services. The Government believe that the role of the voluntary sector and community organisations is an important element of service delivery. Such organisations are often the first point of contact for many affected by HIV. The voluntary sector is under pressure from the growing epidemic, and its contribution is changing, but still remains invaluable. We shall continue to support it and work in partnership to achieve our strategy's aims.
With regard to the global fight against HIV, the UK recognises that the global fund to fight AIDS, tuberculosis and malaria needs predictable, long-term funding to be effective. Since the fund was set up in 2001, the UK has committed $280 million through to 2008. Additional funding will be subject to the fund reflecting a clear poverty focus, and achieving a better financing system. In addition, its activities must be more effectively integrated into national programmes and it must meet agreed benchmarks for monitoring its effectiveness.
Improving HIV services and changing sexual behaviour are long-term challenges, but I am confident that the strategy will make a difference to all those affected by HIV. However, the Government will not achieve that alone, but will rely on the essential contribution of the voluntary sector, health professionals and service users themselves.
I hope that I have dealt, broadly at least, with my right hon. Friend's points. I repeat my congratulations on his long-term interest in the subject, and promise to ensure that we will study the official record after the debate, and if we have not covered any of the points that he raised, I will make sure that we write to him.