Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 380-399)



Julia Drown

  380. On the one hand you are talking about lapses where people do not use condoms but, on the other hand, you are talking about people making more sophisticated judgments. Is it more sophisticated not to use a condom?
  (Mr Imrie) No. When I say that, I think to be clear what I am saying is that people are developing their own strategies, so the rigid adherence to the early condom messages of "a condom every time" or "one hundred per cent condom use", are falling more by the wayside. One of the important things, and I believe it is figure 4 in the submission, shows that although we are seeing a trend of an increase in the proportion of men who report having had any unprotected anal sex, we also see a significant increase in the proportion of men who report only having sero-concordant, and by that I mean having established or believing their partner is of the same sero status as they are, either positive/positive or negative/negative. We should emphasise that in public health terms this carries no risk of transmission so it can be an effective prevention strategy. Perhaps one of the areas for concern about this is that, in one of the studies that has been using anonymous saliva specimens to test for HIV that are linked to questionnaires, we found there is a fairly important proportion—it is a large proportion relatively but fairly small numbers—of men where their perception of their HIV status does not tally with what the saliva specimen said, and if these men are choosing to engage in the different approaches or perhaps not using condoms consistently there are perhaps important prevention and possible onward transmission issues. I should add that those who incorrectly perceived their HIV status, men in both groups, so men who perceive themselves to be positive, or believe they are, who are in fact negative and the reverse It is not an even split but there are men who fall into both groups.
  (Dr Weatherburn) I would just reiterate that we are using the language of unprotected sex as though it was a strategy to some extent. Unprotected sex is only risky if it occurs between men of different HIV status—something we often overlook, especially in the Health Service. Most gay men do not have HIV, and anal intercourse between two men who do not have HIV is of no consequence to HIV transmission.

  381. You do not know, do you? Even if you have just had your test and been cleared, you do not know your antibodies about to build up, and is there not also an issue for people who are both positive about resistance?
  (Dr Weatherburn) There is but that is a different issue because most men are not positive. My sense is it is a very absolute position and I can see why you take it. I am fairly confident that I do not have rabies but I have never been tested for it. I just have not been bitten by a dog in 20 years. Many men apply that kind of criteria. They have been safe and have only taken very specific risk; they have been tested negative; and in that context it is a risk worth taking. You have to bear in mind that using a condom every time for the rest of your life is a very difficult thing to do. The other thing to bear in mind is that HIV risk occurs in a social and cultural context. Few men engage in HIV risk without thinking of the consequences and most men apply some form of risk or harm reduction strategy. It is not that they do not care or that they do not know what might happen as a consequence of the act they are about to engage in; it is about the risk worth taking. It is important in that context and it is worthwhile. They are very sophisticated strategies and they are not epidemiologically perfect. Errors will occur and that is the nature of risk. There is no such thing as safe sex and there never was.

John Austin

  382. And that risk will be compounded by drug influence or alcohol influence?
  (Dr Weatherburn) I would agree absolutely with John's point about lack of self esteem, lack of self efficacy, depression, anxiety, alcohol or drug use. Also, social and cultural factors have a fairly large part to play. If you are poor and badly housed and black and young and unhappy with your life, the chance of getting HIV and dying at some point in the next two or three decades might not seem that relevant to your everyday life, so there are interpersonal psychosocial issues that are important but that is not everything.

  John Austin: I am a little bit cross with Nick Partridge for having blown the storyline in EastEnders. As someone who does not read the tabloids or the media and relies on a video of the omnibus edition on a Sunday, it has all been blown! But I think the Mark Fowler point may be of interest. You were saying you have been very much involved in consultancy on the Mark Fowler character and that it has been very positive, but I wonder if any of our witnesses think that the availability of the effective anti HIV drugs has in any way contributed to more risk-taking behaviour. At one stage AIDS and HIV was an instantaneous sentence to death, and now the Mark Fowlers of this world have shown us that he is still alive and has been for quite some time.


  383. The Chairman still has not got a clue who Mark Fowler is!
  (Mr Partridge) I ought to be clear he is not dying in the series; he is just going to leave it to live somewhere else, just to clear that point up. He is a character in a soap opera and he has been living with HIV since about 1987, and we have been consultants on that story line since then.

  384. Thank you.
  (Dr Weatherburn) Unfortunately Mark Fowler's means of transmission has never been very clear, and when it has been it has not been one of the ones that was most common, but I do approve of his presence in the programme. John will probably talk about this more productively than me but treatments optimism, which is what we have dubbed the notion that the awareness that HIV is possibly a long-term treatable condition, has in my view had less than no impact on the risk behaviours undertaken by gay men or any other target group. The research is not conclusive but I have seen reviews that cite 200 papers with conflicting evidence. John has been involved in some very robust work looking at the beliefs of positive gay men and the contribution that treatments make to their risk behaviour and I am sure he will tell you about that in a second. I would be really plain though and say that it is impossible to estimate, but my sense is the notion of treatment optimism has absorbed a third to a half of all research funding for the last 2-3 years, and it has been impossible, as it always is in research terms, to prove something is not the case but the frustration I feel to even talk about it is a consequence of its ability as a sponge to soak up everything that might occur. I should not go any further or I will get really bitter!
  (Mr Imrie) I would support much of what Peter says. Something that was drawn to my attention today is that this idea of treatment optimism was developed by a psychiatrist and is effectively a highly medicalised concept, and I think that is important to take on board. I think the bottom line answer to your question in terms of what impact and to what extent has the availability of antiretroviral therapy influenced sexual behaviour is not terribly satisfying. It is not entirely clear, and if we look at the main most affected groups in the United Kingdom, the African communities and homosexually active men, the first thing to say is there is only very limited data to look at the impact of antiretrovirals in African communities. However, if we draw inferences from the one large behavioural surveillance study done in African communities, this suggested that 70 per cent of the respondents who came from five mainly affected African communities in central London believed that they were not at risk of acquiring HIV but this certainly did not tally with their previous history of STI diagnoses or their condom use at the last intercourse. I think the important thing here is that it may emphasise an underlying lack of awareness of HIV and of treatments. Internationally when we look at studies of gay men, the results are very conflicting—even opposing. For example, one very large study in the United States showed that, among positive men who were treatment optimistic and prevention fatigued, these men were more likely to engage in high risk behaviours. Perhaps most alarmingly it was the men with the highest viral load, the most likely to transmit, who were likely to engage in this behaviour. In contrast, in a study in Amsterdam, they found it was the men who had achieved the greatest level of viral suppression that were most likely to report having engaged in high risk sexual behaviours. A third possibility was that, in our findings here in the United Kingdom, a large study of HIV positive gay men attending a central London clinic, what we found was that on the whole being on antiretroviral therapy meant men were less likely to report engaging in high risk behaviours for onward transmission and, even when we controlled for things like age, disease stage and other potential founding factors, this continued. So I think the picture within the positive men is still a bit murky. When we look at negative and untested men I think it is not a dissimilar picture. We have studies from the US that show that young men who believe in some of the treatment optimism ideas are more likely to engage in unsafe sex, but I think it is important that we consider the other factors and what other factors have come out of these studies as being involved . I think particularly with HIV positive gay men they tell us a lot about where we should be going with prevention. Specifically we identified other factors as being more important than the availability of treatments—issues around disclosure, and assumptions about sexual partners HIV status, previous negative life experiences and negative sexual experiences—so ever having been raped or having had non consensual sex—ever having been involved in commercial sex, and, quite controversially, experience of sexual dysfunction or erectile dysfunction were also predictive of more high risk sexual behaviours. We found there were strong associations with all of these and having engaged in high risk behaviours, but also important for transmission is recent STI diagnosis. So treatment optimism I think we should probably put to bed and start looking at other factors.

John Austin

  385. Can I go back to one of the points made earlier about safe sex and risk behaviour? You referred to two men who may be HIV negative or positive, and therefore in a public health sense there is no risk in transmission. That only relates to HIV, of course, and people are at risk of other sexually transmitted infections so there is still a risk or an increased risk by non use of a condom, even with seroconcordant partners.
  (Mr Imrie) Absolutely, but I think when we are thinking of the social implications it is more the long term care of HIV that is a much more critical issue than dealing with gonorrhoea or what ever other STIs may be acquired, but this is also a factor that has to be included. I think that particularly within partnerships the kinds of negotiated arrangements that individuals will have is key to making sure that those strategies remain safe for reducing the likelihood of STI acquisition as well as HIV.

Julia Drown

  386. Could any of you help us with issues on HIV mums and babies? Recent figures show a high awareness of HIV amongst mothers before they give birth yet the number of HIV babies has gone up. Why?
  (Dr Evans) There is somewhat of a gap between the interventions that one can put in place and those having an effective outcome. We have seen increasing new diagnoses: we are achieving the targets in inner London but we are not achieving those targets in outer London nor in the rest of England and Wales, and that is an issue in terms both of monitoring and encouraging lower prevalence areas to get on with the job of more routine testing, and a recommendation of testing during pregnancy. So we have a way to go there before we can achieve those targets. We do have those specific targets and we need to monitor in terms of offering the tests as well as the outcome of those tests, and I do not think there is any doubt we will begin to see a decrease in the number of children newly diagnosed.

  387. So is it that the testing is not taking place outside London?
  (Dr Evans) We have not achieved the targets outside inner London.

  388. Why?
  (Dr Evans) I think there is a whole variety of reasons. I do not think HIV has been normalised in terms of ante natal testing in lower prevalence areas when people say, "We have such a low prevalence it is not worth our while doing it", and there may be currently a fairly low prevalence but unless we normalise HIV testing with the other tests in pregnancy people can say "No" to the test if they do not want it but if it is a recommended test with the other tests in pregnancy, then we are not going to achieve those targets outside inner London.

  389. So is it that some areas are seeing this as an opt-in test, whereas others see it as an opt-out test?
  (Dr Evans) That has been traditionally the issue that has prevented us from historically achieving the kind of targets we are now seeing we can achieve in London. It needs to be normalised so that it is not an opt-in; it is a normal test in pregnancy that the woman is given brief counselling and saying, "This is part of our testing", and if they want to opt out they can be counselled and opted out but the norm is that the testing is done.

  390. There were some nods across the panel. Would there be general agreement on that?
  (Mr Partridge) Yes. I think it is quite clear that one area of public health failure in this country has been the unconscionably long time it has taken us to gain proper benefit from the dramatic reduction we have seen in mother-to-child transmission, and the quicker we are able to roll out the ante natal programme that has worked well in inner London to the rest of the country is clearly vitally important. What that should mean is we get virtually close to no newly born, infected infants in this country but I would like to comment on some of the additional factors away from delivery and into care. Firstly, there is an issue that is raised with us very regularly which is the supply of free baby milk formula, and I would like to re-emphasise what that means for some of the most vulnerable mothers in this country, those seeking asylum or of uncertain immigration status. It is vitally important that is changed as quickly as possible. Also, given that the strategy covers a 10-year period, we should look at what changes in services are going to be required which manage both those of a declining number of children living with HIV as they grow older but also manages to care for the HIV negative children of positive parents and what implications they have for the provision of creche services and children services in what will become an increasingly invisible infection, if you like, but which will still have all of those really dramatic impacts on family life where parents are dealing with their own severe ill health. So I think there needs to be a focus on how we ensure that those children's issues, which will change thankfully over time, are met and that both health services and social services and voluntary sector services do not lose sight of the uninfected children of infected mothers and continue to care for infected young people.

John Austin

  391. Can I refer to the rates of acquired HIV acquired heterosexually? The evidence we have received suggests a number of areas where rates are going down, those who have a heterosexual partner who is an intravenous drug user or a partner who is biosexual, but we are told that the number acquiring HIV heterosexually from a partner who acquired their infection heterosexually is increasing, albeit these are small numbers and a slow increase. Do you have any views on the reason for this?
  (Dr Evans) We have had a small IDU epidemic which in countries in southern Europe, for instance, have driven a heterosexual epidemic so within the European context and within a North American context the IDU epidemic has determined a lot of the on-going heterosexual transmission. There have been transmissions from bisexual men but it has not driven a large increase, an on-going increase, so it has been the IDU epidemic, which in this country has been pretty small. Can I just say that we must not ignore the potential for spread of HIV through shared needle use. We are seeing significant amounts of hepatitis C and some hepatitis B transmission as well, and we must not let go of our goal in terms of continuance of needle exchange programmes, and let our eye go off the ball in terms of IDU. Canada has shown us when there are fluctuations in drug supply and new injecting habits and so on that you can get rapid transmission of HIV, even in situations where historically you have had very little HIV, so do not forget IDU transmission.

  392. That is obviously clearly important, but the figures of people acquiring HIV from a partner who is IDU have gone down, so that is good news.
  (Dr Evans) It is.

  393. And yet the rate of heterosexual HIV is rising slowly.
  (Dr Evans) It is. What I was saying previously was in terms of this slow but gradual rise in people acquiring HIV heterosexually within the United Kingdom from partners who had themselves acquired it heterosexually, so it is not primarily from injecting drug users and bisexual men, but now from people who do not realise themselves to have been at risk and therefore do not get tested until late, therefore have high viral loads, and therefore their transmissibility in terms of their sexual partners is increased.

  Chairman: Dr Miners, one of the more sensitive members of the Committee has passed me a note saying she is feeling sorry for you because we have not come on your to area, but we will!

Sandra Gidley

  394. The strategy contains some proposals to deal with stigma and discrimination around HIV and AIDS. To what extent do you think the strategy has it right and that what is proposed will work, and is there anything else that should be done?
  (Mr O'Reilly) Thank you for the question. The strategy I was going to say is light on detail in respect of how we approach HIV related stigma and discrimination. I might go as far to say it is almost completely absent, and I point out that I think this is a deficiency in respect of the development of the strategy which is not just manifest in respect of the absence of a strategy to tackle HIV discrimination. That deficiency exists because the strategy was led by and exclusively the domain of the Department of Health, and the Department of Health does not have responsibility, for instance, for antidiscrimination legislation, or for the plethora of other law frames required to create the enabling environment in which HIV is best tackled that I alluded to earlier in our session today. So before going on to point out that the stigma issue has been inadequately dealt with in the strategy, we need to recognise that in developing the next HIV and sexual health strategy that has to be about a cross-government and joined-up approach, and it has to include departments and government officers who would otherwise have something to say on this issue but who would be excluded purely by health driven strategy such as the Home Office in respect of asylum and antidiscrimination legislation and all of the other areas—prisons and corrective services more generally. So I think that is a real priority area and an absence in the strategy across a variety of domains. I think, however, that we have acknowledged in the form of the strategy that HIV discrimination is an issue and one of our recommendations is that Parliament has to address the deficiency in the Disability Discrimination Act that HIV to all intents and purposes is not covered; that AIDS, once one becomes symptomatic, is but that the vast majority of people who remain well with HIV could legally in some cases be discriminated against on the basis of their HIV status, and that has to be addressed and that uncertainty with respect to our antidiscrimination law has to be tackled. More broadly, though, discrimination occurs in a variety of other ways and settings and that is why we need a cross-departmental working group on this issue at a very high level operating with a view to developing a strategy to tackle discrimination in its manifest forms and in the variety of settings I am alluding to. So I think the strategy says that it is an issue and we have been talking to the Department of Health about that, but I think it would be very helpful if this Committee acknowledged that HIV discrimination exists and it is a priority, but it has to be dealt with by a variety of parties across government and not just the Department of Health. Also, in respect of HIV discrimination, it is directly linked to people's prejudicial attitudes about sexuality and race and this is the confluence of discriminatory factors which I think come together most compellingly in respect of HIV. One of the gravest deficiencies in tackling HIV discrimination is the absence of sexuality discrimination legislation. Not only does it remain lawful for people to discriminate against people on their HIV status, but one of the groups that is most adversely affected and shares the greatest burden in respect of HIV—gay men—can be discriminated against too. And so in a sense at a leadership level, a legislative level, a political level, the community at large does not see you, our legislators, our Parliamentarians and our political leaders, sending a clear message that discrimination on the basis of sexuality and HIV status and those things alone is acceptable. I think we all have work to do in making the Race Discrimination Act work better too and protecting people from it, but people with HIV and the two at-risk communities from which they come, the gay community and the black Afro Caribbean community, are incredibly adversely affected by the inadequacy of our antidiscrimination legislation and our antidiscrimination effort.
  (Mr Partridge) Adding something slightly more specific to this, I think the main thrust of the strategy for sexual health and for HIV is a greater involvement at primary care level and the creation of primary care teams able to deal much better with sexual health and HIV issues, and clearly we know from research I alluded too earlier of the discrimination that can be felt and perceived as coming from within the NHS itself, so the way in which resourcing is made available for the training and support of staff to deal with issues which are difficult, and are personal and complex often to deal with, is part of the human resources strategy that needs to work alongside and is part of the HIV and sexual health strategy as a whole. I fear there is a lack of clarity about the scale of that task if we are really going to make primary care part of the leading force for improvements in sexual health and HIV in the future.

  395. Is that more of a problem in areas with a lower prevalence?
  (Mr Partridge) I do not think it is as clear cut as that and I do not have the evidence to be able to answer that. I certainly think there is a distinction between the experience of the major hospitals dealing with HIV, but I would not necessarily guarantee that a GP practice or a primary care trust just yards from a major teaching hospital would necessarily be any better than one located in Exeter, for example.

John Austin

  396. There has been a shift in policy with regard to where HIV fits into NHS planning, and I think at one stage even the Terrence Higgins Trust was arguing for HIV to be not seen as part of a sexual health agenda, whereas it very clearly now is being integrated and instead of having ring-fenced and identified funding it is fed through in the budgets. That may be good in mainstreaming but it may have its disadvantages in ensuring the money gets spent, and I think we touched on this in the BCC Commission, etc. What do you think needs to be done to ensure that that implementation happens?
  (Mr Partridge) This is a crucial question but you are absolutely right: when the HIV strategy began to be developed four years ago, we were keen as an organisation to ensure that there was a coherent, cross-government, appropriate HIV strategy. We are, above anything else, realists and recognise that is not the world we currently inhabit and that we need to take advantages of the synergies that do exist between HIV work and broader sexual health work. However, how we ensure that resources are made available and properly used in the new environment of PCTs or arguments I rehearsed earlier this afternoon so will not go into in detail again, but I do believe there really is a need for either an NSF or for reprioritisation of HIV and sexual health to hit the top 20 SAF issues if PCTs are going to be encouraged, particularly in the next couple of years, adequately to fund GUM services, primary care services and voluntary sector services in sexual health and HIV. If we do not do that we need to remember how fast the clock is ticking. Even though this is a ten year strategy, we are already into year one of implementation, and when you begin to look at how soon some of the targets need to be met there really is very little time for this to be on the back burner of primary care trusts or of strategic health authorities. At the moment we are not convinced that the mechanisms are in place to ensure that much of the good work that we have done is sustained and much of the very important targets that are articulated within the strategy will be hit, be that from the voluntary sector side or from colleagues working in over-stretched GUM services and elsewhere in sexual health.

  397. You mentioned the voluntary sector there as well. What do you think the Department of Health should be doing in relation to the voluntary sector to get the strategy working? What is the key role that the voluntary sector can play?
  (Mr Partridge) We have produced a report which reflects on the impact of shifting the balance of power. It is a very constructive engagement for the voluntary sector with the new environment in the NHS, but it is going to be difficult and there are really substantial challenges. The key one for me is that we need better, more robust guidance and direction from the Department of Health in terms of the importance of consortia between PCTs and the importance in the short term of rolling contracts over. If in doubt, do not retrench at the moment because if we lose the activity that we currently have, it is going to be 50 or 100 times more difficult to re-create it in the future. Once it has gone, it has gone. So failing an immediate availability of a National Service Framework or of an ability to reprioritise HIV and sexual health within "must dos" for PCTs, at the very least we need clear guidance to ensure the continuation of funding to see us through this period of great upheaval, not just for the voluntary second but for other parts of the NHS as well.
  (Dr Weatherburn) My sense is I have less faith in the commissioning practice, whether it be in PCTs or historically where it has been in the health authorities. My sense is that the Department of Health can do something very profound with the health promotion tool kit and also the commissioning tool kit that they promised in the Implementation Plan. Both of these need to give substantial guidance to PCTs and probably refine the targets of the Strategy. My sense is that the Strategy is hugely problematic because the Implementation Plan conflates the causes of morbidity, sexual infections and unwanted conceptions in one section, and then conflates the groups experiencing them in another, and then put these needs in competition with each other for very finite resources amongst the PCTs. Our experience would say that because of a lack of expertise, and ignorance and prejudice amongst elected commissioners at a local level, young people will come to mean women who might get pregnant rather than young men who might get HIV and black communities will come to mean whoever is not white that we might reach instead of black Africans who might get HIV. The fundamental problem and the very real danger is that historically mis-allocated HIV funds will be further siphoned away from where the real risk of HIV infection occurs. The chances of a 25 per cent reduction in incidence seem very slim. The Strategy or its Implementation Plan does not provide any of the detail necessary for us to see a reduction in incidence of anything like 25 per cent. It barely defines what HIV prevention is, it does not prioritise it on a local level, and it does not give any clear indication of why it should be a priority. The sense is a reduction in incidence is unlikely on the basis of the documentation that the Strategy has come forth with to the present day.
  (Dr Evans) The voluntary sector to which you refer is also at various stages of development and preparedness with respect to dealing with HIV. For instance, 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 complete unfunded. Their governance, management and other structures are very nascent and we have to make a priority of engaging with them in a very constructive way centrally as well as locally so that they are equipped to deal with HIV.

Sandra Gidley

  398. At the recent Symposium in Barcelona there were various announcements including an HIV vaccine available in five years—but we have probably been hearing that for the last five years—and also big news about microbicides. Do you think this will make any difference over the next five years?
  (Mr 0`Reilly) The National AIDS Trust is a partner on the international AIDS vaccine initiative and the international microbicides initiative, so we are actively involved in trying to make sure that both of those prevention technology developments do have an effect. The announcement by VaxGen in Barcelona was a little optimistic and we cannot over-estimate the need to retain our focus on existing effort despite the fact that we need to invest in preparedness for both of those possible prevention technology investments. In the event that we had either of those developments ready in the next five years—and I think that is probably much more likely with respect to microbicides than it is vaccines—the question of getting them out to populations, to making them available, and to ensuring that they are affordable, and resolving the ethical and other dimensions that will arise in respect to all of those issues, are vast and we are nowhere near making either of those technologies readily available. So I think there is some hope but I do not think that we should engage in the sort of false hope announcements that might have come out of Barcelona. I acknowledge there is an imperative for the companies developing those products and for the researchers involved to retain interest in them and to generate political and community will to ensure that they are funded, but we also have to do that responsibly and at the moment we are not there yet. The National AIDS Trust here has some things to say to government about making sure that we are prepared when those technologies are available to make them available and to make sure that the issues associated with making them available are dealt with, but we are a long way from that at the moment.

John Austin

  399. Dr Miners—saving the best to last—could you give us some indication of the cost-effectiveness of the long-term use of antiretrovirals in HIV-positive patients? When you have answered that, if there is anything else you want to say please do.
  (Dr Miners) I am grateful for that but economics is very much my field. Quite surprisingly, when we started looking into this question a couple of years ago there were very few studies that were out there looking at the cost-effectiveness of antiretroviral therapy. Most of the studies that were there were from the US, but a paper published last year in HIV Medicine would suggest that highly active antiretroviral therapy is extremely cost-effective and, in fact, the figures that were produced were in the region of 15,000 per life-year saved to 18,000 per QALY saved. To put that into some kind of perspective, because when you talk about cost-effectiveness it is always relative to something else, if you think about second-line mono-therapy taxanes for advanced breast cancer, they are certainly in that bracket in terms of being comparable in terms of cost-effectiveness and I would even suggest probably a bit better.

previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries index

© Parliamentary copyright 2002
Prepared 2 September 2002