§ Motion made, and Question proposed, That the sitting be now adjourned.—[Angela Smith.]9.30 am
§ Dr. Gavin Strang (Edinburgh, East and Musselburgh)
I start by welcoming the publication of the national strategy for sexual health and HIV. It is the first such strategy, and the Government are to be commended on their work. The document is not the end of the story: it is out for consultation, and the policy development work continues.
Hon. Members might be aware that my interest is in HIV-AIDS, on which I shall focus in the main. I am sure that other hon. Members will talk about other sexual health matters. My interest in HIV was triggered in the 1980s as a result of my being an Edinburgh Member of Parliament. Hon. Members will be aware that Edinburgh had a huge problem with HIV transmission caused by injecting drugs. In 1985 and earlier, 81 per cent. of HIV diagnoses in Scotland were for infections caught in that way. That has all changed. Injecting drug use accounted for 11 per cent. of diagnoses in the first half of this year, while sex between men is now the largest exposure category.
Many people have been tempted to see HIV as a threat of the past, but that is far from true. It would be helpful to take a quick overview of the HIV epidemic in the UK. There were 3,550 new HIV diagnoses last year—the highest number on record. The majority of cases stem from heterosexual sex, mostly in high-prevalence countries—the number has been rising steeply for several years. However, the majority of transmissions in the UK still arise from sex between men, and there is little evidence that the number of new infections is declining.
The UK's performance in limiting HIV transmission from mother to baby has been poorer than that of several other European countries, but there is evidence that rates have begun to improve. The number of cases that result from intravenous drug usage remains low, but the rate of works sharing is thought to be worsening.
The Government have said that the rise in the total number of HIV diagnoses could be accounted for partly by increased antenatal testing, and I would be grateful if my hon. Friend the Under-Secretary of State for Health, the Member for Salford (Ms Blears), could elaborate a bit further and tell us what proportion of new diagnoses results from antenatal screening.
The final point that I want to make in this overview was mentioned in the Government's strategy document. HIV is not distributed equally through the population. The Terrence Higgins Trust recently published a report showing the association between HIV infection and social exclusion.
The life expectancy of people with HIV has been transformed by combination therapy, and as a result many people with HIV are alive today who would 184WH otherwise not be. However, it is equally vital to prevent the spread of HIV. Against the background of the progress made in previous years, it is a matter of great concern and disappointment that high numbers of new infections occur in this country every year. In this day and age, every new HIV infection represents a failure of prevention.
I do not want to exaggerate—it is not all bad news. The HIV epidemic here is not as bad as that in many comparable developed countries, and there has not been the explosion in numbers that many people feared in the 1980s. Prevention work in the early years of the epidemic achieved successes—for instance, needle exchanges, which were controversial at the time, and the high-profile public information campaigns. I am concerned that such prevention work has been allowed to go off the boil in the latter years of the epidemic. In 1998, Peter Piot, the executive director of the joint United Nations programme on HIV-AIDS—UNAIDS—said that, at the very moment when we knew most about preventing HIV infection, there had been a weakening of the global effort to do something about it.
My hon. Friend will be well aware of the National AIDS Trust paper "HIV at the Crossroads" by Professor Peter Aggleton. Professor Aggleton said:Almost without exception, governments in the developed world no longer see HIV prevention as a top priority, and there has been a progressive weakening of support for the provision of public information and other prevention initiatives … In Britain, prevention initiatives for the population as a whole are presently conspicuous by their absence, and because there has not been a significant heterosexual HIV epidemic, many health authorities across Britain have sought to 'mainstream' their HIV and AIDS work into other programmes and activities.Hon. Members may be aware that the Department of Health funding for prevention has not kept up with inflation since the mid-1990s. Funding in Scotland was frozen for several consecutive years, until this year. Good people are doing good work in HIV prevention, but there is a real sense in which prevention work has not kept up with the changing nature of the epidemic.
I draw attention to the words of "John", a gay London man in his 30s, who was diagnosed HIV positive on 10 July. When interviewed by BBC News Online, he said:Clearly the message about safe sex is missing the target, if it is being delivered at all. In one internet chatroom used by many gay men in London you can find an area where up to 50 men a night are looking for unsafe 'bareback' sex. I think the reasons behind the rise in unsafe sex are complex. The fear of HIV and AIDS has undoubtedly subsided, making many people complacent. The appeal of taking a risk alongside sexual excitement is another factor. So is the belief among many gay men that sex without a condom is 'better'. Drink and drugs are also part of this potent mix. Lack of self-esteem among many gay men plays its part as well. Two years ago I rarely met people who wanted unsafe sex. In the last six months the numbers grew significantly. If we are really to challenge the spread of HIV and do it in an intelligent and effective way, we need to get to the heart of those issues.John managed to capture many of the key points. The epidemic—or epidemics—among gay men are complex and changing, and the safe sex message is simply not getting through.
I am aware that these matters are now largely devolved, but I should point out that Scotland might suffer a second wave of HIV infection. This summer, 185WH Dr. Jamie Inglis, director of public health at the Health Education Board for Scotland, called for prevention campaigns to be stepped up and warned that if there were a delay in taking new steps to raise awareness about the dangers of unprotected sex, it could be too late to stop a dramatic increase in the spread of HIV.
Derek Bodell, chief executive of the National Aids Trust, said that people becoming sexually active now will not have been influenced by the campaigns of the 1980s. He said:I think people are starting to think we don't need to think about this anymore. There is a danger that people don't remember the safer sex messages about wearing a condom which are so important.Meanwhile, as Professor Roy Anderson of Imperial college London said,you get a growing body of evidence that suggests that young people believe the threat of HIV is much less than it was because there's effective treatment. Well that's very far from the truth. This organism, this disease, is in my view the biggest threat human society has seen.HIV prevention work aims to prevent the suffering and hardship associated with HIV infection. Even with combination therapy, life with HIV is often hard. Resistance to the drugs is growing: around 20 per cent. of newly infected individuals are infected with a resistant virus. HIV is a young person's disease, and while other diseases that rightly attract funding priority tend to affect people in later life, those most vulnerable to HIV have their whole lives ahead of them. It is also fair to make the point, as the Government do in their strategy document, that the monetary value of preventing a single onward transition is estimated at somewhere between £500,000 and £1 million in individual health benefits and treatment costs.
I welcome the Government strategy and the additional money that they have announced. The Minister may be aware that there is some concern, which I share, that very little of the new money attached to the strategy is intended to increase HIV prevention efforts on the ground. I would be grateful to receive assurances on that point.
"Mainstreaming" has been a buzzword in the HIV field for a few years now, and it has several aspects. The mainstreaming of HIV policy is nowhere better illustrated than in the subsuming of the proposed HIV strategy into the current strategy for sexual health and HIV.
I understand the motivation behind the integration of HIV policy with other sexual health policy. Benefits may be secured from an integrated approach. However, there are dangers. We must ensure that the policy framework is not so tightly integrated that the specificity of HIV-related concerns is mainstreamed away, and that the growing skills and knowledge base acquired around HIV is lost.
Funding is also mainstreamed. From 1 April 2002, the HIV-AIDS budget ring fence in England will be scrapped, so the only central mechanism that has required health authorities to spend in this area will be abolished. The worry is that while good work will continue to be done in some areas, HIV work will disappear in others. The most vulnerable spending areas 186WH will be the unpopular ones, such as health promotion among gay men and African communities, and voluntary sector grants for social care.
Although the Government's strategy document contains helpful proposals, there are no mechanisms to ensure that they are implemented. I hope that the Government will consider delaying the removal of the ring fence, because it is the main weapon that ensures that the money set aside for the purpose is spent on tackling HIV. There is enough concern about it to justify further consideration and consultation.
As well as the removal of the HIV budget ring fence, the existing health authorities will be scrapped on 1 April 2002 and commissioning responsibility will pass to primary care trusts. That will give rise to two dangers. The first is the risk that we will lose the expertise in HIV-AIDS that some health authorities have developed. A great effort must be made to equip the primary care trusts with the knowledge and resources that they will need. The second is that, in the upheaval of the changes, we may lose sight of the areas for action on HIV that are set out in the strategy.
We can all agree that what is important for HIV prevention is what works, but that is where agreement ends. I read with interest in the strategy document that the Government's view is that the evidence base for HIV prevention is still dispersed and unsystematic. It is regrettable that that is still the case, but it is good that the Government have recognised it and that the Health Development Agency has been commissioned to address the problem.
The Minister knows that I piloted the AIDS (Control) Act 1987 through the House of Commons as a private Member's Bill. I hope that she is also aware that I have set out proposals to bring the Act into the 21st century, so that its provisions for accountability and information are improved, and it allows a better vision of what should happen regionally and nationally. The all-party group on AIDS has also recommended that the Act be updated to include a requirement to report more widely than within the health sector, to provide for greater consultation and to require health authorities to account for discrepancies between spending and local epidemiology. Accountability and communication are as necessary now as they were in 1987. The reports have a valuable role to play in that regard. The strategy promises that the Act will be reviewed, and I look forward to hearing what the Minister has in mind.
The Government announced in December 1997 that they would draw up a strategy on HIV. The membership of the strategy steering group was announced in April 1999. The strategy was published in July 2001 and the Government are now embarking on further consultation to refine it, as is right and proper. However, the situation is urgent, and I hope that the publication of the strategy and its implementation, combined with the work of the Health Development Agency, will prove to be a landmark in the efforts in the UK to reduce the spread of HIV.
Some countries have worse epidemics than we do. However, that is largely thanks to the work that was done in the earlier years of our epidemic. The commendable effort of those years has not been sustained. That complacency might be because combination therapy has allowed many people who 187WH would not otherwise be able to do so to lead relatively normal lives. Whatever the reason, complacency is a mistake. Every new HIV infection is a failure. We should take the opportunity that the strategy offers significantly to step up our efforts, especially in higher-risk groups, and to reduce the number of people who become infected with HIV in future.
§ Mr. Michael Weir (Angus)
I congratulate the right hon. Member for Edinburgh, East and Musselburgh (Dr. Strang) on securing this debate. As he rightly said, the health service in Scotland is a devolved matter, so my comments will be relatively brief. Although the matter is devolved, there is the possibility of a second AIDS problem arising in Scotland very quickly. AIDS is a worldwide problem and the virus does not respect borders. Given that we are all travelling more, we should consider the problem more on a pan-European and worldwide basis, not just in terms of the UK or Scotland.
The right hon. Gentleman stated that the highest rate of HIV infection in Scotland was originally among intravenous drug users. However, that has changed over the years. Last year saw the highest levels of HIV infection on record in Scotland, and the number of new cases of HIV diagnosed among heterosexuals was almost the same as among gay men—60 compared with 61. That shows that AIDS has moved out of the groups that were originally hit, and is hitting people throughout the population.
It has been suggested that Scotland's young heterosexual middle classes are becoming the new victims of AIDS. Why is that happening? The right hon. Gentleman hit on it when he said that the message of safe sex has been lost to some extent. Those of us who are now in our 40s remember the almost apocalyptic advertising about the dangers of AIDS that appeared in the 1980s, which had a great effect on young people at that time. That effect has largely disappeared, and many young people have become complacent about the dangers of AIDS. That is shown by the rising number of infections in Scotland and throughout the UK.
There may be other reasons for that increase. I draw the Minister's attention to an investigation carried out by the Sandyford initiative in Glasgow, which found that the recent rise in HIV cases in Scotland may be set to accelerate dramatically. The institute specialises in sexual health matters. It carried out tests on 59 people who were receiving the highly active anti-retroviral therapy HIV treatment. Its study, which was published in The Lancet, showed that 11 of the 43 men and 16 women had become infected with sexually transmitted diseases while they were receiving the treatment, so there is evidence that people infected with HIV are not practising safe sex. The right hon. Gentleman hinted at that.
The Government Minister and Ministers in the Scottish Executive must consider how to retarget the message at young people who are becoming sexually active. Young people are travelling much more than they would have done many years ago, so if there is a problem in other countries, it can be imported into the United Kingdom. Moreover, the message about the importance of practising safe sex should be reinforced 188WH for those who are already infected with HIV. The right hon. Gentleman quoted John, a young man in London. That was a frightening intimation of what might happen if the safe sex message were not reinforced. I urge the Minister to meet health officials in England and Wales, members of the Scottish Executive and our European counterparts to consider a strategy to cover the whole area, because the virus knows no borders.
AIDS is not the only sexually transmitted disease with a rising rate of infection: there has been a dramatic rise in instances of chlamydia over the past few years. The figures from my own area of Tayside show that infections have more than doubled during the past three years. The reasons for that worrying trend may be complex, but I suspect that the safe sex message is at the root of it. If the message has been lost in one area, it has probably been lost throughout the population, and that has led to the rises.
Although sexual health is a devolved matter, it concerns everyone in the United Kingdom and Europe. I welcome the Government's strategy. More funds must be made available. Ultimately, the message of safe sex must be put across to our young people. We must be on guard for changes in how the disease appears in Scotland and in the UK as a whole.
§ Mr. Neil Gerrard (Walthamstow)
I am glad that my right hon. Friend the Member for Edinburgh, East and Musselburgh (Dr. Strang) has secured the debate, as it is important that we consider the strategy on sexual health and HIV. As he said, the strategy is long overdue. It was announced in 1997, and progress appeared to have been made in 1999. I want to concentrate on HIV, for which we initially had a separate strategy that struggled to make any progress until it was merged with the sexual health strategy. That led to the publication of this strategy document earlier this year.
I recognise that the strategy covers many issues other than HIV. There are obviously relationships between actions on the prevention of HIV and those on the prevention of other sexually transmitted infections, such as hepatitis B. Some subjects not mentioned in the strategy may not be directly relevant, such as hepatitis C, which is not sexually transmitted but which remains an important issue and one that the Department of Health needs to tackle.
Anyone who read the strategy would accept that its scope was comprehensive and that it covered a wide range of issues. Someone described it to me as ticking all the right boxes, and it picks up on all the questions that need to be answered. Few would disagree with the key aims in the section on objectives and targets, which are to reduce the number of newly acquired infections, to discourage the practice of unsafe sex, and to raise awareness of services. Nor would many disagree with the methods that it proposes to achieve those aims, such as work in collaboration with health authorities and the voluntary sector, improvements in outreach services, and enhancing the role that HIV treatment and care services play in prevention. We have tended to regard treatment and care as a separate service from prevention, but it can affect prevention so we should ensure that it plays a role.
189WH My right hon. Friend mentioned the building of an evidence base. It makes sense to find out precisely what has worked. When we develop new programmes, especially to prevent HIV and other diseases, we often do not consider what has been effective in the past.
The strategy document for the first time sets specific targets. Paragraph 3.12 sets a targetto reduce by 25 per cent. the number of newly acquired HIV infections and gonorrhoea infections by the end of 2007".I am not clear exactly how that target will be achieved, and I shall return to the problem of implementation. How was the figure of 25 per cent. determined? Why was not 20 or 33 per cent. chosen? I suspect that the figure has been plucked out of the air, especially in the light of what has been said about the evidence base, and the uncertainty about what works. We clearly need to monitor progress towards the target.
Few people would fundamentally disagree with much in the strategy. However, the Department of Health will not be directly responsible for implementing most of it. That will be carried out by health authorities, primary care trusts and the voluntary sector, which has a significant contribution to make. It is unclear to me how some of the proposals will be put into practice and what mechanisms will be used to ensure that that happens.
Much of the strategy is about encouraging health planners to do the right things, but it is unclear how some of their actions will be monitored. We know from experience that monitoring is necessary. For example, it became clear from a survey by the National AIDS Trust in 1999 that money from the prevention budget, which has existed for some years, was not necessarily being targeted at the groups most at risk.
My right hon. Friend mentioned the AIDS (Control) Act 1987, and I am far from clear how that will operate within the new NHS structures. At present it requires reports from health authorities. I do not understand how the new structures will relate to the Act—as it is now or as it might be if reformed—if there are changes as to where commissioning takes place, and in responsibility for commissioning.
I am concerned about mainstreaming, which my right hon. Friend mentioned in opening the debate. We know that as from April there will be mainstreaming of all HIV budgets, at least within the health service. Various budgets exist, including the care and treatment allocation, the prevention budget, section 64 grants to voluntary organisations and the AIDS support grant to local authorities. The different allocations are not always planned together terribly well. However, we are told that the money will be mainstreamed. As my right hon. Friend said, that will remove the central mechanism that requires spending by health authorities on particular areas of work.
I understand the argument that ring-fencing does not apply to many other medical conditions, and I know that people ask why HIV should be considered unique. However, one of the achievements of the ring fence was to ensure that the money was spent on HIV. Without that pressure, some health authorities may not have spent it on that. The approach has led to the development of services that may not otherwise have 190WH existed. It has been a factor in developing the work of non-governmental organisations, including service delivery, and in developing the interest and involvement of many people in NGOs in what is happening with respect to HIV. Money can be tracked to see where it is being spent.
It is particularly worrying that the change to mainstreaming is happening while health service structures are in a state of flux. Primary care trusts and the new strategic health authorities are moving from the present system towards much more commissioning. Although I have read the strategy, I am still very unclear about how HIV commissioning will fit into the new structure. Most commissioning is expected to go to PCT level, but HIV services such as care and treatment have been regarded as specialisms. Will the new strategic health authorities have a role in commissioning? Will commissioning responsibilities be split in any way? I am not at all clear about the new structure of the health service.
As my right hon. Friend said, if mainstreaming and changes to the structure take place at the same time, there is a danger that we may lose some expertise. Such expertise usually involves a fairly small number of people providing specialist HIV services for a health authority. Some of those people are not clear where their jobs will be in a few months time, or whether they will even exist. Some GPs are well aware of what HIV means, and what type of services and prevention should be provided. However, many are not. If a lot more commissioning is to take place at PCT level, how will we ensure that services are developed and that GPs and PCT boards are aware of what is happening?
My right hon. Friend mentioned the worries that do indeed exist throughout much of the sector. Mainstreaming is an issue that we must think about very carefully. I realise that we cannot argue for ever that HIV should be funded in a unique way, but perhaps we should at least delay removing the ring fence for a year or two, until the new structure has settled down and we are clear about where the money will go and where the responsibilities will lie.
The strategy recognises that HIV is not simply a medical issue. It refers to social care and support for those living with, and affected, by HIV, and to how access to education, employment, leisure, housing and advocacy could be provided. It also refers to the Department's efforts to help deliver social care and support, but it makes little reference to other Government Departments. It discusses developing standards in consultation with the social services inspectorate, local authority commissioners, service users and voluntary organisations, but it says little about the involvement of other Departments.
Earlier this year, the all-party group on AIDS published a report on the United Kingdom, HIV and human rights, which made recommendations about what we should be doing. The report, and all of us involved in its production who talked to those working in the field, made it clear that HIV is much more than a medical issue. We made recommendations about the way in which other Departments should be involved. The Department of Health must clearly take the lead in certain areas, but the Home Office and Departments responsible for employment and for education have a 191WH role to play. As we develop the strategy, I would like clear indications of how links between Departments will be built up.
There must also be links with international policy. In his opening remarks, my right hon. Friend mentioned that many people diagnosed in the UK acquired their infections overseas. At the United Nations Special Assembly in June, at which the Department for International Development played an important role, it became clear from the discussions that domestic and international policy must be related, even though strategies may differ. We must make sure that those policies are linked.
Given yesterday's announcement on changes in the asylum system and the setting up of reception centres, perhaps the Home Office could re-examine what health checks could be carried out in those centres to help to deal with the problems affecting asylum seekers with HIV infection, who do not always find it easy to disclose that fact.
Those are the areas that concern me. There is a great deal in the strategy document to be welcomed, and I am glad that it has been published. I think that there is very little in it that people would fundamentally disagree with, but we need to consider how it will be implemented, how to ensure that its targets are met and how we can drive its policies forward within the new structures in the health service.
§ 10.7 am
§ Dr. Evan Harris (Oxford, West and Abingdon)
I should like to thank the right hon. Member for Edinburgh, East and Musselburgh (Dr. Strang) for securing this debate. His long-standing interest in HIV and AIDS is known by all hon. Members. The Edinburgh clinical community has played a leading role, and its paediatric work on identifying the epidemiology of maternal transmission from the intravenous drug-using community was staple education for those of us in medical school at the time. I remember the papers authored by Dr. Jacqueline Mok, who was active in the Edinburgh clinical community.
We have heard useful contributions from the hon. Member for Angus (Mr. Weir), and the chair of the all-party parliamentary group on AIDS, the hon. Member for Walthamstow (Mr. Gerrard). He has been tenacious in' advocating the need to address the issue of HIV-AIDS, as he has been over the issue of refugees, which he mentioned in the last part of his speech. The two issues come together, especially over heterosexually acquired infections that are acquired abroad.
The right hon. Member for Edinburgh, East and Musselburgh made the point that new infections represent a failure of prevention. I want to concentrate my first remarks on why there has been such a failure, as the number of infections increases, and why the Government delayed introducing the strategy. Information was available from an early stage that made clear the extent and the shape of the epidemic. While we have been waiting for the strategy, all the key indicators have shown that the sexual health of the nation has worsened.
Figures covering 1995 and 1996, which showed the worsening situation, were known to Ministers by 1998. Since then, the number of new cases of sexually 192WH transmitted diseases has increased dramatically while the Government were delaying the publication and release of their report. Figures from the Public Health Laboratory Service show that between 1998 and 1999 diagnoses of syphilis rose by 58 per cent. in males. It more than doubled in males between the ages of 20 and 44, and rose by 27 per cent. in females. The number of new cases of gonorrhoea in England rose from 12,462 in 1997 to 15,572 in 1999, with the sharpest increases in males aged 20 to 24 and females aged 16 to 19. Genital chlamydial infection has increased by 76 per cent. from 38,997 in 1997 to 51,083 in 1999, with significant increases in both the female and male populations. Asymptomatic HIV infection has risen from just under 1,500 in 1997 to well over 1,600 in 1999, and the position with regard to newly diagnosed HIV infections is worsening and is of serious concern.
Projections made by the PHLS clinical diseases unit suggest that cases of HIV infection are set to increase by 50 per cent. between 1999 and 2003. According to what they describe as conservative forecasts, the total number of people diagnosed with HIV or AIDS may increase from 20,800 in 1999 to 29,000 in 2003. Within that, the figures for heterosexually acquired HIV infection are projected to increase from 6,579 to 11,215. Those figures show a worsening situation. The commentary by the PHLS points out:Perhaps the most consistent trend throughout all countries and regions in the UK has been the gradual and sustained increase in STI diagnoses since 1995. Prior to the rising numbers of diagnoses of many STIs in the UK throughout the late 1980s and early 1990s, figures had been declining or were stable, possibly reflecting the changes in sexual behaviour brought about in response to the HIV epidemic. The subsequent rises suggest that recently these behavioural modifications have not been sustained.The highest rates and increases in STI diagnoses are focussed in those aged 16 to 24, peaking earlier in females than males. Young people are behaviourally vulnerable to STI acquisition as they are more likely to have higher numbers of sexual partners and a higher frequency of partner change than older age groups. Young women may be at particular risk through lack of skills and confidence to negotiate safer sex resulting in inconsistent use of barrier contraception.Even the Government noticed the urgency of the problem. In July 1999, the public health White Paper, "Saving Lives: Our Healthier Nation", stated:Sexually transmitted infections are increasing, particularly chlamydia and gonorrhea".It then set out the figures, and continues:HIV and AIDS remain serious threats to health … we cannot afford to be complacent.However, there has been significant delay in bringing forward a strategy: not in starting the work—that has been announced and is under way—but in making progress. The public health Green Paper of February 1998 contained only two paragraphs on sexual health and no mention of STDs generally, only of teenage pregnancy and HIV and AIDS. The absence of that information was explained away by the sentence:The Government is preparing a separate strategy to combat the spread of HIV infection and to meet the challenge to services which HIV and AIDS present.193WH Plans for a new strategy—the first promise—were set out in a keynote speech by the then Minister for Public Health, the right hon. Member for Dulwich and West Norwood (Tessa Jowell), at an HIV and AIDS strategy meeting in October 1998. She said:The policy development process started today will be overseen by a Steering Group whose membership I will announce shortly. But I hope that it will be possible to issue a draft strategy for wide consultation early next year.However, no draft strategy was issued during 1998, 1999 or 2000, and the membership of the steering group was not announced until April 1999.
The second promise was also made by the then Minister for Public Health at a conference of the Family Planning Association in March 1999. She said:The Social Exclusion Unit's work on teenage pregnancy and parenthood … has highlighted what we already knew—how much we need an integrated health strategy … Over the next 12 months, the Government will be developing a framework that takes the radical approach that provides for the first time, a strategy that covers the whole of sexual and reproductive health … We will publish it next year"—that was to be 2000—but I want to get cracking on it now.Of course, there was no sign of it. The public health White Paper described the strategy on HIV-AIDS as "forthcoming".
The third major promise, which was announced in a Department of Health press release on 24 April 2000, was of an integrated strategy. The Minister for Public Health, the hon. Member for Pontefract and Castleford (Yvette Cooper), announced the integration of the HIV-AIDS and sexual health strategies into a single programme. She said:We need to make rapid progress … This is important public health work and I want to see it progress as rapidly as possible. I take a keen personal interest in this work, and look forward to working closely with Mike Adler and Sheila Adam to ensure an agreed strategy is in place by next spring.She was referring to spring 2001, which came and went without the strategy being published.
The fourth promise was made in June 2000 by the Minister for Public Health in a written answer. She stated:A draft strategy will be issued for consultation in the autumn."—[Official Report, 19 June 2000; Vol. 352, c. 59W.]Autumn became winter, and still no strategy was issued. On 6 February 2001, in another written answer, she announced:We plan to issue the strategy for consultation shortly."—[Official Report, 6 February 2001; Vol. 362, c. 508W.]Finally, at the end of July, we got the strategy.
I understand from members of the steering group that during the time they were appointed they never saw the draft strategy. One member publicly criticised it after it was produced, which was presumably the first time that he had seen it. Derek Bodell, the chief executive of the National AIDS Trust, is quoted in The Guardian on 27 July 2001 as saying:For such an important public health issue this strategy is far too limited in its scope, and fails to look at the broader social impact of HIV such as employment, education in schools and housing. We are disappointed that this strategy is not as far-reaching as we would have wanted.194WH Although the Government, in their holistic approach, talk about "education, education, education", we appear to have had procrastination, prevarication and yet more procrastination. The signals were not good, because the Health Education Authority was abolished and its replacement, the Health Development Agency, has had a lower profile than its predecessor. Perhaps that was the Government's aim because they were embarrassed by the messages being sent out by the Health Education Authority, but it was a pity that that professional unit was abolished when there was such a challenge in this area, and in many others.
As the hon. Member for Walthamstow said, there is much in the strategy that is unarguable, and can be welcomed and agreed with. It is important to state that—but I want to stress that we have been waiting an awfully long time to make the point—many of the Government's ideas can be welcomed. The Government point out that little clear evidence on prevention has been gathered. It is sad that the Health Development Agency has only now been asked to gather evidence to find out what works. One would have hoped that that had been done from 1997 to 2000.
Despite recognising that little evidence is available, in paragraph 3.5 of the strategy the Government state that various initiatives, includingthe Department for Education and Skills' revised Sex and Relationship Education Guidance are all helping to expand young people's knowledge of and understanding of sexual health and relationships.I am sure that that was the intention, but I do not believe that there is any evidence that it has worked. Indeed, people working in the field, who were disappointed by the guidance, suggest that it may not be working. We need to ensure that we do not limit ourselves in our examination of what might work. In that respect, the Government have been timid when considering European models that have worked. In paragraph 3.15, the Government state:An evaluation of safer sex campaigns in Holland shows attitudes and intentions towards safer sex were affected positively but that the effect was lost when the intervention ended.We do not have much in the way of a co-ordinated Government health promotion campaign related to safer sex. It is not a question of worrying about behaviour changing when intervention ends; we want intervention actually to start. As the document makes clear, the Government have not set out a health promotion strategy with an advertising campaign or a sustained, co-ordinated programme through schools and youth activities.
Is the Minister convinced that helplines, such as the national AIDS helpline and Sexwise, are coping with demand? Is too much or, as I suspect, too little money being spent on those helplines? As the right hon. Member for Edinburgh, East and Musselburgh said, the Government cut funding in real terms for prevention work in earlier years, and that has made it very difficult for professionals in the field.
Reference has been made to targets, and I want to question the Government further. I have always wondered whether setting targets is sensible because they are targets also for Opposition parties who are more interested in making attacks than examining policy—I do not include myself in that. They are also a 195WH distraction to delivery. I have never pressed for rigid targets in this area because they may confound policy. More HIV testing would produce more positive HIV test results, and that would not help to meet a target to reduce the number of detectable newly acquired HIV infections. It is difficult to explain the context of increased HIV infections against a background of decreasing prevalence in anonymous testing, and it will be difficult to get the message across. Setting a target is unhelpful and I would not criticise the Minister for downplaying the target, so long as we agree what the policy should be. The danger is that, ultimately, the target may become the symbol. If professionals believe that their performance will be measured on the outcome, they may decrease their outreach work in the hope of escaping censure.
A fascinating meeting took place last week to examine the national strategy on HIV and sexual health. A number of matters were raised, and I should be grateful if the Government would respond to them. There is potential tension between the PCT's commissioning of sexual health services and specialised HIV treatment and care that is planned at the appropriate strategic level, which may not be PCT level. Split level commissioning following abolition of the health authorities and the need to involve the strategic health authorities will not lead to integration. There is also tension between open access and local funding, because people may congregate on one service and funding may not follow that flow.
The hon. Member for Walthamstow hinted at a significant worry about funding. Money has been announced, but it is only for two years, and if we are to develop new services in this area a commitment to long-term funding and a 10-year funding strategy would be most welcome. The fear is that money is available only for projects and not for the necessary major systemic change. Indeed, primary care organisations have been asking when the money will arrive and when they will know exactly how much they can do. There is also a significant worry that the organisations that currently deliver the service are about to be abolished. The Minister must accept that the effect of continuous change is causing major difficulties.
A spokesman for the Association for Genito-Urinary Medicine has said that general practitioners do not want, or are unable to, become more involved in genitourinary medicine. Diverting funds to GPs who are not motivated to deliver the service would diminish the service in the short term. Education and training of GPs is needed, but genito-urinary specialists are already overloaded, so who will provide the training?
There are many other issues but not enough time to raise them. I shall finish by asking the Minister some specific questions. It is well recognised that the presence of section 28 on the statute book impedes the ability, whether legally or not, of teachers and other professionals in schools to deliver effective sexual health education. During the previous Parliament, the Government were committed to its repeal, so it is reasonable to ask the Minister whether that will happen sooner rather than later and, if sooner, how. When will the health promotion strategy start, and will it take the shape of a national advertising strategy as well as local initiatives that are properly funded? Will she say whether she thinks the prison service is winning or losing 196WH the battle on HIV infection, whether it be sexually transmitted through men having sex with men, or through intravenous drug use?
I want to finish on the same point as the hon. Member for Walthamstow. I am no great believer in ring fencing and bids for funds; I would be inconsistent if I were. There should be more flexibility locally to deliver services. It is wrong to worship on the altar of eternal ring fencing. However, there will be significant structural changes when ring-fencing ends, so will the Minister consider retaining ring-fencing for one year so that we can track whether funding is being retained in the services?
§ Mr. Simon Burns (West Chelmsford)
I congratulate the right hon. Member for Edinburgh, East and Musselburgh (Dr. Strang) on securing an extremely important debate. Given that it has been 20 years or so since the emergence of HIV-AIDS, it is depressing that in the area of sexual health, which is dominated by HIV-AIDS and other important issues, many of the problems of 20 years ago remain. In that time there has been a move forward, although sadly not far enough, in research, in the development of drugs to alleviate medical problems and in the work done by the voluntary sector, charities, the health service and the Health Department to improve public health.
Unfortunately, three critical areas remain that I think are unacceptable: stigma and prejudice; ignorance and complacency; and delay and procrastination, to which many hon. Members have referred. The first is a matter not only for government; we need to deal with attitudes throughout the country. Any hon. Member who receives constituency mail on the subject is left in no doubt about the prejudice and stigma attached to those suffering from sexual ill-health, particularly, but not solely, from HIV. We all have an important role to play in that area. We must provide a lead to break down the barriers caused by prejudice and to help to educate public opinion. The media also have an important role to play.
While listening to the right hon. Member for Edinburgh, East and Musselburgh, I was reminded that 10 years ago, when the House of Commons was sitting, I was living in London not 20 yd away from where Freddie Mercury died. I was appalled that the paparazzi and tabloid photographers turned up before his death and patrolled the area for six weeks until he died. To be able to remove his body after his sad death, the coffin had to remain in his home for 12 hours until the Sunday evening. The police then emerged to clear the street of the press so that his body could be removed with dignity and without the glare of press photographers. Photographers and the press would not intrude on other people's private grief if it involved any other illness that has resulted in death. That is all part of the picture of prejudice.
§ Mr. David Borrow (South Ribble)
I am sure that the hon. Gentleman has seen submissions to the Government on these issues, particularly on prejudice. Most submissions call for the abolition of section 28, and point out that however symbolic it is, it makes it more difficult for those working in this area to deal with 197WH prejudice and the prevention of HIV and AIDS. Has the hon. Gentleman taken account of that, and has he given serious consideration to the sexual health consequences of his party maintaining its position on section 28?
§ Mr. Burns
I confess that I had expected a question on section 28 if certain hon. Members were in the Chamber. I sincerely believe that a genuine difference of opinion on an issue does not necessarily mean that there is prejudice. That there is ignorance may seem staggering to many of us, given what has happened in the past 20 years, such as the campaign to explain the problems and to show the preventive measures that people can take in their active sexual lives.
The Government's strategy document for sexual health and HIV shows that the extent of the problem is depressingly formidable, even now. The number of visits to departments of genito-urinary medicine has doubled in the past 10 years. According to Public Health Laboratory Service statistics, since 1995 syphilis has increased by 143 per cent.—by 225 per cent. among gay men—chlamydia by more than 106 per cent. and gonorrhoea by 99 per cent. The number of new diagnoses of HIV last year was the highest for more than a decade. The 3,616 people diagnosed last year represented a 20 per cent. increase on the previous year.
Although the United Kingdom can be reassured by the fact that it has one of the lowest rates of HIV in Europe, it is estimated that more than 30,000 people in this country are HIV positive. Every year, about 400 of them die, although, as has been said, it is reassuring that developments in medical science and drug treatments are helping people to live longer and to sustain a better quality of life than was possible a decade ago. That is a step in the right direction, but until a vaccination is possible or a cure is discovered more must be done to try to reduce the death rate.
Sadly, it is estimated that by 2003 HIV prevalence in the UK will be 40 per cent. higher than in 1999. More worrying in some respects is that, as predicted many years ago, the problem has increased in the heterosexual community to a greater degree than in the gay community. In 75 per cent. of cases recently diagnosed the disease had been picked up abroad. Far more must be done to bring it home to people that they are playing Russian roulette with their lives if they do not heed the message of safe sex, or are ignorant of it, and do not know how to minimise the risk of contracting sexually transmitted infections.
The extent of ignorance and complacency is staggering. Recent studies show that between 33 and 50 per cent. of teenagers do not use contraception when having intercourse for the first time. A 1999 survey of gay men showed that 58 per cent. under the age of 20 did not always use a condom, and that of the 44 per cent. who were HIV positive who had sex with a new partner, 40 per cent. reported that they inconsistently, if ever, used a condom. That is partly due to a lack of advertising, particularly on television. In the mid to late 1980s, advertising on television and in newspapers, magazines and specialist communications was considered highly controversial and, as I understand it from reading political biographies and autobiographies, it presented a squeamish problem for some of my former 198WH colleagues. However, the fact is that the advertising was effective: it was hard hitting and got the message across. People began to understand that they should consistently practise safe sex.
Sadly, time and the lack of constant reminders has dulled the message, and we have slipped back considerably. It is a dangerous position and the Government must act quickly, so that they do not undermine work being done in other sectors. For example, a survey showed that 90 per cent. of teenagers thought that the pill would protect them from sexually transmitted diseases. That is equally staggering and shows the depth of their ignorance. I urge the Minister to do more to back up other work and her Department's strategies by ensuring that the message is brought home to people across the board that they cannot afford not to indulge in safe sex.
§ Dr. Evan Harris
Some people have said that there is too much sex education in our schools. On the basis of what the hon. Gentleman has just said, does he identify himself with those of us who believe that there is too little or the quality is too poor? Does he believe that what we require is not a return to Victorian ignorance, but more information for young people?
§ Mr. Burns
As the hon. Gentleman will know, I accept that the question of sex education in our schools is controversial. I believe that it is up to individual parents to decide whether they wish their children to attend sex education lessons in schools. As a parent, I would want my children, at a suitable age, to gain the benefit of impartial sex education from both their parents and schools.
The final strand of my speech concerns delay and procrastination. I have great sympathy with what hon. Members have said about that. The Government announced the idea of a strategy in 1997. Four years later, in August this year, the strategy document was published. It is now out for consultation and has not yet been implemented. We must await the end of the consultation process and the Government's final decisions. On an issue so crucial to the country, that was an unusually long delay and a wasted opportunity.
Steve Jamieson, a key sexual health adviser to the Government, told delegates to a conference earlier this summer:The Government sat on the strategy for a long time before finally launching it at the end of July. That was a political decision because Tony Blair and his government were so embarrassed by the level of STIs in this country.He went on to say:While they were sitting on the strategy, there were still people out there who could not access services and who were contracting STIs. I also believe the lack of a government advertising campaign has been a factor in the rising levels of STIs.He also suggested that the strategy was launched on a Friday in mid-summer in an attempt to ensure minimum media interest. I am quoting not an Opposition spokesman, but one of the Government's key advisers on sexual health. I emphasise that we cannot tolerate such a delay any longer. It is time for the Government to act quickly and put the strategy in place, and to make sure that it is backed up by a proper advertising campaign to start to reverse the trend.
199WH It is crucial that we have a strategy to deal with such a problem. However, given the four-year delay, it is slightly surprising—it shows an odd sense of priorities—that the Government spend time telling people to eat more vegetables rather than producing a coherent strategy to minimise sexually transmitted infections. I accept that the sum of £47.5 million has been described in the strategy as an initial investment, but I echo the comments of other hon. Members that it could be seen—if the Government are not careful—as too little money overall to develop the programme. I urge them to keep an eye on the position, particularly as that investment was described in their in-house NHS magazine as comparatively modest. I am sure that few hon. Members here today would dispute that description.
The hon. Member for Oxford, West and Abingdon (Dr. Harris) referred to targets. The Government seem to need a target for everything. Their target for the waiting list initiative led to gross clinical distortions. It would be a disservice to this area of health care if targets were imposed that caused clinical distortions. I therefore warn the Minister against having targets. Has an assessment been made of the extra work that the strategy will place on GPs? We already know of the pressures that are placed on them, so if the strategy is to be delivered successfully, what consideration has the Department of Health given to their extra work load? How will the Government ensure that GPs are not so burdened and overworked that the whole strategy falls flat on its face because of their inability to deliver?
The Minister will know of the worries that have been expressed by GPs in the past few months. For example, how confident is she that they will be able to provide the sophistication that is required for them to undertake HIV counselling? It is a crucial area, and I hope that the Government have given some thought to it.
Given the publication of the strategy three months ago, it is extremely fortunate that the right hon. Member for Edinburgh, East and Musselburgh has enabled us yet again to discuss this subject and to explain our genuine worries to the Minister. We are united in wanting the problem to be tackled successfully. We want help to be provided to bring down the figures and to relieve the suffering that STIs have caused to far too many members of our population.
§ The Parliamentary Under-Secretary of State for Health (Ms Hazel Blears)
I, too, thank my right hon. Friend the Member for Edinburgh, East and Musselburgh (Dr. Strang) for having given us the opportunity to debate this subject. I also thank all hon. Members for supporting and welcoming the strategy in spite of the issues that they have raised today.
My right hon. Friend the Member for Edinburgh, East and Musselburgh has a tremendous record on the issue. Indeed, it was he who brought the AIDS (Control) Act 1987 on to the statute book through his private Member's Bill some 14 years ago; and he has continued to take an active interest in the development of policy on the issue. He wrote to the Department when the strategy was first announced, suggesting that a review of that Act would be timely. We entirely agree. Experts have already started reviewing the Act, and the review will be 200WH undertaken as part of the process to implement the strategy. In particular, we need to consider appropriate reporting mechanisms. Tremendous progress has been made in collecting data and analysing the treatment that is available, but changes to the national health service have shifted the balance of power and commissioning has been devolved to primary care trusts, so the reporting elements of the Act will need to be reviewed.
I thank the all-party parliamentary group on AIDS for its comprehensive report, to which reference has been made this morning. It is entitled "The UK, HIV and Human Rights: recommendations for the next five years" and was published almost simultaneously with the strategy, at the end of July. Work on several of its recommendations is being pursued as part of the strategy implementation. The report is extremely helpful and contains several practical recommendations that we shall be extremely keen to pursue.
As hon. Members said, the strategy is the first ever national strategy for England. It recognises the need to take a holistic approach to sexual health. It covers HIV and AIDS as well as the broader issues of contraception and sexually transmitted infections.
Several hon. Members mentioned delay and procrastination and the fact that the strategy has taken some time to emerge. Some delay was perhaps inevitable with the merger of the sexual health strategy and the HIV issue. We also wanted to make absolutely sure that we consulted extensively with voluntary groups, NHS organisations and service users to try to ensure that the strategy was in touch with the experience of people in the field. In spite of the delay, I am pleased that they gave the strategy a broad welcome. The Terrence Higgins Trust welcomed the proposals, and although the National AIDS Trust expressed reservations about the need to join up the proposals throughout government, it has given the strategy broad approval.
Many hon. Members asked what is being done to promote the safer sex message to the groups that are most at risk. A fundamental part of the strategy is to improve health promotion work with those most at risk and those who already have HIV, and to try to reinforce safe sex messages for both those groups. Several contracts are already in place that are designed specifically to target those at risk from HIV and sexually transmitted infections. Health Promotion England undertakes sexual health promotion work aimed specifically at young people aged 16 to 24. The Terrence Higgins Trust undertakes work with community-based groups directed towards those most at risk of HIV and AIDS, including gay and bisexual men in England. The Department of Health has funded health promotion work for African communities, including a pilot African AIDS helpline, a Health Africa radio show, a website and printed information resources. We have used the mass media and funded the National AIDS Trust's work to support World AIDS day. We are funding a National AIDS Trust project to tackle the stigma suffered by people with AIDS, which the hon. Member for West Chelmsford (Mr. Burns) mentioned. It is important for that work to continue.
A great deal of health promotion work is already being done. A key aim of the strategy is to build up an evidence base on effective promotion work, but little is done in the field. It will be important to draw together the evidence on what succeeds, otherwise there is a 201WH danger that we will not get maximum value from the proposed new investment. We also lack evidence on which information campaigns work, other than those that concern sexual health. For instance, the same issues apply to drugs. We must discover where messages are best targeted, what media to use and how messages are most likely to be conveyed to those at greatest risk. We are determined to do that.
My right hon. Friend the Member for Edinburgh, East and Musselburgh asked about the effect of antenatal testing on the number of diagnoses. He is correct to say that diagnoses are increasing as a result of the introduction of the test. However, it is right to offer a test to mothers. If it is part of normal health care—not special or singled out but treated as part of general good health—it will reduce stigma, and we should continue it.
Many hon. Members, including my hon. Friend the Member for Walthamstow (Mr. Gerrard), raised worries about the effect on funding of removing the ring-fenced budget and putting the money into mainstream health authority budgets. I assure hon. Members that the Government are determined that when the funding goes into mainstream allocations, it will continue to be monitored through the service assessment frameworks that performance manage all NHS funding. We will closely monitor where and how money is targeted. In the future, health authorities will receive a fair share of the funds. The distribution of HIV infection is uniquely skewed and we want to ensure that allocations take account of that. Money should go to the areas in which there is greatest need and the most people who need treatment. We will ensure that we follow the money through the mainstream budgets.
All hon. Members asked how HIV services will be commissioned, following shifts in the balance of power and the creation of strategic health authorities. Services will be commissioned at primary care trust level, and we will ensure that a number of primary care trusts come together to share their expertise and knowledge. Perhaps one primary care trust in each area could take the lead and develop the expertise that is the key to specialist commissioning. Such an arrangement will apply not only to services for people with HIV and AIDS, but to other specialist services, such as those for burns and haemophilia. The development of specialist commissioning expertise in primary care trusts is crucial if people are to rely on the quality of those services. That will require support, and that is already provided in the system. We must ensure that the experience gained at specialist commissioning level is available to primary care trusts, so that their commissioning process is of a high quality and provides correct services to local people.
The hon. Member for Angus (Mr. Weir) asked whether there is a strategy for Scotland. I am delighted to tell him that the Minister for Health and Community Care has committed the Scottish Executive to producing a strategy for Scotland, and preliminary work on that is under way. Obviously, we keep close contact with colleagues in the devolved Administrations to ensure that expertise and knowledge is available for developing strategies. The hon. Gentleman also asked about chlamydia screening, and the extent of that disease in the community. A phased roll-out of targeted screening will 202WH start next year. A couple of pilot projects are under way, and we will learn from those experiences to try to deal with the disease.
My hon. Friend the Member for Walthamstow asked, as did other hon. Members, why we have a target. Clearly, that is a matter of controversy, but it is difficult to persuade an organisation to focus its work without having a target. Targets were drawn up following extensive consultation with voluntary groups and service users, not just plucked out of thin air by the Department of Health. Targets were developed that were intended to be realistic but challenging, so as to have a major impact on public health. We want to maintain focus on those targets, but accept that that must not distort our other policy objectives. We have to get the balance right. Having done that extensive consultation—we did not simply decide on a figure ourselves—we hope that the targets will have broad support within the community.
My hon. Friend the hon. Member for Walthamstow raised the issue of commissioning. I hope that he will be reassured that we intend to make the role of primary care trusts as robust as possible. He also referred to cross-governmental work on education, housing and social care to support people in the community with HIV and AIDS. The strategy has a health focus—we did not want to dilute the health focus message—and mechanisms at official and ministerial level will ensure that we implement the strategy across the board. We are learning from the teenage pregnancy strategy, in which those mechanisms are already in place and which, two years on, is beginning to show some real results.
I can tell the hon. Member for West Chelmsford that our strategy on teenage pregnancy has resulted in a downturn in under-18 conception rates. Under the Conservative Government, teenage pregnancies went up by 25 per cent., but I am delighted to say that our strategy is beginning to work.
§ Ms Blears
The achievements of the teenage pregnancy strategy are a matter of record.
Training for professionals will be a key part of the Government's HIV strategy not only for GPs but for people involved in supplying the full range of services for people with HIV and AIDS. However, we want to mainstream not just the finance but the general approach to HIV and AIDS. It is a serious health problem but it should be treated like many other health conditions. We should not single it out, but should provide support and training for a whole range of professionals, which they can integrate into their practice. That commitment is part of our strategy.
The hon. Member for Oxford, West and Abingdon (Dr. Harris) raised the issue of repealing section 28. The Government remain committed to that, although we will clearly need to find appropriate parliamentary time for it. He also referred to the Prison Service. It is fair to say that the message we are receiving on the Prison Service's practice of supplying condoms in prisons is 203WH that it is pretty variable, and a great deal of work remains to be done to ensure consistency. That will be an important part of our work.
The hon. Gentleman also asked us to delay the ring-fencing issue for a year in order to track the funds. I hope that he will be reassured that our commitment to track the funds through the single assessment process will ensure that funds are targeted where they are needed for best effect.
The strategy is the first ever to cover such matters. It has been improved by the length of time taken to involve all the interest groups, and there will be a further period of consultation until 21 December. Comments from people in the services and the voluntary sector, and from users themselves, will be welcomed as they will inform the development of the implementation plan. We have been encouraged by the work that has been done on our campaigns to target teenage pregnancy, and we want to learn from them. The evidence base for information campaigns is poor, but we are beginning to build that base and we hope that we can continue to make similar progress with this strategy. The consultation period will enable us to learn even more about building evidence of what is effective.
People with HIV who live in the community clearly need the best services that we can provide. I want to make sure that the strategy helps us to make a real difference to essential services in the community, such as care, treatment, support, counselling and screening. We have a real opportunity to make significant step changes in the way in which services are provided. I look forward to working with all hon. Members to implement the strategy and to ensure that we improve services for people with HIV.