No vaccine, no cure: HIV and AIDS in the United Kingdom - Select Committee on HIV and AIDs in the United Kingdom Contents


CHAPTER 4: Prevention: Getting the Message Across

56.  The previous sections established that prevention should be a focus whilst there is no realistic prospect of either a vaccine or a cure for HIV. This is especially important given that the cumulative effect of year-on-year increases in the number of people living with HIV is that treatment costs will continue to rise, presenting an increasing burden for the NHS.

57.  This chapter examines existing prevention activity, reflecting upon the effectiveness and resource base of such work, before setting out how prevention initiatives should be developed and improved.

Prevention campaigns—the current situation

NATIONAL HIV PROGRAMMES

58.  Currently, nationally funded HIV prevention work is 'targeted' at the two groups most at risk of infection. Since 1996, the Department of Health has funded the Terrence Higgins Trust for a national prevention programme focused upon MSM; and since 2000, the Department has funded the African Health Policy Network (AHPN)[116] for work with African communities living in England. For 2011/12, the Terrence Higgins Trust will receive £1.9 million, whilst the AHPN will receive £1 million.[117]

59.  Terrence Higgins Trust and the AHPN work through partnerships which bring together a wide range of community and third sector groups to deliver locally specific HIV prevention activity. For MSM, this work is delivered through the Community HIV and AIDS Prevention Strategy (CHAPS), whilst for black African communities, activities and funding are delivered through the National African HIV Prevention Programme (NAHIP).

60.  In both cases, prevention activities undertaken typically comprise HIV awareness-raising through media campaigns (often using community-specific media), leafleting, advertisements and posters. This work is complemented by direct contact work including workshops, counselling and group activities, in addition to the use of the internet and social marketing tools. In some areas, open-access testing facilities are also available.

61.  NAHIP stated that: "The amount currently spent by the Department of Health on HIV prevention is not sufficient." Its funding of £1 million per annum equates to between £1 and £2 for each African living in England.[118] It noted that the £1 million currently spent on prevention for Africans is 0.25% of the £400 million annual cost of treatment and care for the African population. NAHIP concluded by stating that: "Greater spend on prevention is an investment to lower the HIV treatment and care costs to the NHS in the future. Reducing this future burden is one reason why UNAIDS recommends that spending on prevention should be close to 45% of the total spend on treatment and care."[119]

62.  We have highlighted the costs of treating HIV, and the long-term savings which could be made through investment in HIV prevention. The current levels of investment in national HIV prevention programmes are insufficient to provide the level of intervention required.

LOCAL HIV PROGRAMMES

63.  In addition to the national campaigns funded by the Department of Health, a range of local provision also exists. Prevention campaigns at the local level are usually funded by Primary Care Trusts, local authorities and charitable donations; typically, providers will draw funding from all of these sources. Some providers, such as Yorkshire MESMAC[120], match local funding with money received from the national CHAPS programme.

64.  Voluntary bodies play a strong role in these local programmes, building on campaigns delivered nationally through more direct work with at-risk groups. 'Outreach'—a diverse term which can include visits to churches, publicising HIV testing in gay nightclubs and promoting condom use in gay saunas—is a particularly important facet of the work of many of these providers.

65.  Of these local campaigns, the largest is the Pan-London HIV Prevention Programme (PLHIPP), with a budget of around £3m in 2009/10.[121] For the current financial year, the PLHIPP has experienced a reduction of 20% in the funding received from London PCTs.[122] This is illustrative of a trend towards disinvestment in local HIV prevention. Sir Nick Partridge, Chief Executive of the Terrence Higgins Trust, suggested that: "Over the past 10 years we have seen a consistent reduction in the investment and funding in local HIV prevention services ... That leaves a gap. It has meant that the responsibility and the expectation on the national programmes are far greater than they can deliver and are currently funded to deliver."[123]

66.  The Minister for Public Health acknowledged the important role of local campaigns and the voluntary sector, stating that: "voluntary sector organisations can be extraordinarily good value for money."[124] She acknowledged that it was a difficult period for voluntary organisations, but said that "the challenge for funding bodies such as councils, PCTs and others is to look at the provision of services imaginatively"[125], going on to state that "cuts can be counterproductive because of the costs further down the line. Invest to save."[126]

67.  At this point, we pay tribute to the voluntary organisations, without whose efforts the effectiveness of the early response to HIV and AIDS would have been vastly reduced. The Minister praised the "very, very responsible attitude" and "leadership" of the gay community in the early years of the epidemic.[127] Throughout the inquiry, we have been impressed by the continuing strength of the voluntary sector. At a national level, the AHPN, the National AIDS Trust (NAT)[128] and the Terrence Higgins Trust have coordinated policy and prevention work, whilst groups such as Positively UK[129], Body and Soul[130] and National AIDS Manual (NAM)[131] have been firm advocates for patients. Locally, groups such as Yorkshire MESMAC, Leeds Skyline[132], Summit House[133] and the Sussex Beacon[134] have been integral to local prevention, testing and support strategies. This work must continue to be supported.

68.  Local prevention programmes, and the voluntary sector bodies that deliver them, have played an important role in tackling HIV. Local authorities, health services and other funders should avoid undermining local HIV prevention work when taking budget decisions. The ongoing trend of pressure on local prevention services also underlines the importance of enhanced Government funding for national HIV prevention programmes.

WIDER SEXUAL HEALTH CAMPAIGNS

69.  Whilst the Department of Health spends £2.9 million on national HIV prevention work, this is only part of the £10.6 million that the Department spends on sexual health promotion more generally. A range of other campaigns have been supported including, for example, the Sex: Worth Talking About campaign, which ran from November 2009 to March 2010. This £6.7 million campaign, which sought to raise awareness of sexual health and promote dialogue around safe sex, ran across various media, including television, radio and newspapers. It did not mention HIV or AIDS.

70.  The omission of HIV from general sexual health campaigns is a cause for concern. NAT noted that HIV did not feature in the 2006 Condom: Essential Wear campaign either. It suggested that HIV awareness should be incorporated into wider sexual health campaigns.[135] This view was shared by AHPN, which stressed that: "the NHS' general sexual health campaigns, which are aimed more widely, still need to include information about HIV and increase support to targeted HIV campaigns."[136] Positively UK suggested that the lack of general national campaigning on HIV contributed to the stigmatisation of 'at-risk' communities.[137]

71.  Dr Rowena Merritt, Research Manager at the National Social Marketing Centre[138], said that campaign financing within the Department of Health took place within "silos", with HIV sitting separately from wider sexual health, even though different teams of staff were often working to target the same audiences. This, she felt, was "complete madness".[139]

72.  HIV awareness should be incorporated into wider national sexual health campaigns, both to promote public health and to prevent stigmatisation of groups at highest risk of infection. We recommend that there should be a presumption in favour of including HIV prevention in all sexual health campaigns commissioned by the Department of Health.

Do current campaigns work?

73.  In the course of visits to HIV clinics in London and Brighton, we received anecdotal evidence which suggested that levels of risky sexual behaviour are on the increase. To an extent, this is borne out by the findings of the 2009 University College London Gay Men's Sexual Health Survey. This community-based study found that, of those respondents who were HIV-negative, 46.4% had had unprotected anal sex in the past year; for those who were HIV-positive, this figure rose to 57.7%. In addition, 40.4% of those who were HIV-positive had had unprotected anal sex with a casual (once-only) partner in the preceding year.[140]

74.  These figures have increased since the mid-1990s as, indeed, has the level of HIV prevalence identified by the study—from 11% of respondents in 1996 to 15.2% in 2008.[141] These numbers are alarming, particularly given the high prevalence of HIV amongst the London MSM community.

75.  The Department of Health, however, suggested that HIV prevention programmes have been effective according to a number of outcomes for MSM, amongst them:

  • Awareness of the availability of post-exposure prophylaxis (PEP) following potential sexual exposure to HIV increased from 22% before the CHAPS campaign to 56% after the campaign[142]; and
  • Preliminary analysis of data suggested that between 2001 and 2008 there was a fall in numbers of sexual partners among MSM.[143]

76.  Likewise, the Terrence Higgins Trust argued that national programmes have demonstrated their effectiveness, suggesting that without them levels of new HIV infection would be much higher. It cited typical target audience recognition rates of 30 to 40% for CHAPS campaigns, as well as a reduction in the number of infections diagnosed amongst MSM between 2007 and 2009.[144]

77.  Others have suggested that current programmes are failing to either effect behaviour change or stem the tide of new HIV diagnoses. NAM felt that initiatives have been delivered with insufficient energy and pace, with expenditure declining over the past decade.[145] The London Specialised Commissioning Group suggested that national programmes have tended to be output, rather than outcome focused[146], whilst Status argued that a culture of complacency and 'provider knows best' meant that initiatives were failing gay men.[147] The Tuke Institute suggested that campaigns are not sufficiently informed by behavioural science, with data on the dynamics of transmission not informing the size or delivery of programmes.[148]

78.  We accept that levels of new HIV infection would have been higher without the national prevention programmes, and we support those delivering this work. We feel, however, that more needs to be done to reduce dangerous and risky behaviour that is leading to HIV infection. In part, more funding is needed but, in addition, a broader range of evidence-based approaches are required. We give further detail on this approach in paras 116 to 118.

DELIVERING THE RIGHT PREVENTION CAMPAIGNS

79.  We have described above the existing practice of 'targeting' national campaigns at those groups at greatest risk of HIV infection. The balance between targeting and more general campaigns is important. NAM[149], the African Health Forum[150] and AHPN[151] argued that targeting is an efficient use of limited resources, given that the epidemic within the UK is largely focused in two particular groups.

80.  NAT[152] and the Faculty of Public Health[153] argued that targeting is sensible, but suggested that high prevalence areas, as well as high prevalence groups, should be targeted. They suggested that broader, more general campaigns should be run alongside community specific activities in areas of high HIV prevalence.

81.  FPA[154], HIV Scotland[155] and the Medical Foundation for AIDS and Sexual Health (MedFASH)[156] believed that funding should be given to both universal prevention campaigns and targeted interventions for those most at risk. Awareness of responsibility and risk must extend to the population as a whole; general campaigns may be necessary to educate the wider population. Shield South Yorkshire noted that targeted campaigns at the national level produced materials featuring particular sections of the population, and that these groups were not always present amongst the local population.[157] This made materials difficult to use and prevention messages more difficult to convey.

82.  A general HIV prevention campaign, it is felt, would address this. NHS commissioners noted that some people at risk do not identify with campaigns targeted at particular groups.[158] MSM who portrayed themselves as heterosexual to friends and family were one example; young MSM who might not identify as gay were another. These sub-sections of the target groups are therefore missed by targeted campaigns.

83.  The 1986 Don't Die of Ignorance prevention campaign had a general, national focus. Post-campaign polling showed that 98% of the public understood the transmission routes for HIV.[159] This illustrates what can potentially be achieved through public health campaigns in this area. In contrast, a 2010 survey undertaken by NAT found that 20% of people did not know that HIV was transmitted by sex without a condom between a man and a woman.[160] A recent survey of young people, undertaken by the Sex Education Forum[161], found that 27% of respondents had not learnt about transmission routes for HIV.[162]

84.  Both targeted and national HIV prevention campaigns have an important role to play. Given the concentration of HIV infection in two specific groups, we recommend continued targeted HIV prevention campaigning focused on these communities. This should be coordinated at the national level.

85.  We also recommend that the Department of Health undertake a new national HIV prevention campaign aimed at the general public. This will ensure that HIV prevention messages are accessible to all of the population.

86.  Contributors also considered the technologies used to deliver prevention information. Professor Jonathan Elford, of the Department of Public Health at City University, and Peter Weatherburn both highlighted the increasing role that internet and mobile phone-based applications could play in delivering safe-sex messages.[163] This is of particular relevance given the increasing role of the internet in generating and forming sexual relationships.

87.  Shield South Yorkshire highlighted the reliance upon written and printed materials in current prevention activity.[164] It argued that over-reliance on these forms of delivery failed to take account of the limited literacy and English language skills of some members of the target audience. Television and radio campaigns would lend greater effectiveness—especially when complemented with the group and individual work that we have advocated above.

88.  For some audiences, however, printed media remain important. Felton Communications[165] highlighted that the gay press was still the most adept form of targeted media in reaching that audience, but that different messages and different audiences would require different approaches.[166] It was therefore important that campaigns combined all media options.

89.  We recommend that those delivering HIV prevention campaigns, whether nationally or locally, should utilise the full range of available media, including internet, social networking and mobile phone applications. We note that national sexual health campaigns, such as Sex: Worth Talking About, have been sufficiently resourced to purchase advertising time with national broadcasters. We recommend that messages around HIV are included in these campaigns in future, ensuring the greatest possible exposure for HIV prevention messages.

EVALUATING THE EFFECTIVENESS OF CAMPAIGNS

90.  At present, the national HIV prevention programmes commission their own evaluation from within their programme budgets. This is undertaken by Sigma Research, based within the London School of Hygiene and Tropical Medicine. Some contributors, such as Status, questioned the rigour and transparency of these evaluation arrangements, believing that evaluation should be commissioned independently by the Department of Health.[167] In their own submission, Sigma Research also suggested that the evaluation of campaigns would be stronger if commissioned directly by the Department of Health.[168]

91.  On this point, the Minister for Public Health stated that: "... I am always worried if there is a perception that evaluation is in any way biased, because what really matters is that evaluation is robust and people trust it. Otherwise, 50% of the job of evaluation has failed. So there is obviously, irrespective of the facts, a perception issue that we have to address ..."[169] Whilst we do not question the independence of current evaluation programmes, we agree with the Minister that the perception of independence is of equal importance.

92.  At the same time, a large number of witnesses suggested that more resources should be dedicated towards researching the effectiveness of different HIV prevention interventions. These included submissions from the British HIV Association (BHIVA)[170], HIV Scotland[171] and Professor Sir Andrew McMichael.[172] Professor Graham Hart, Director of the Division of Population Health at University College London, proposed the establishment of a HIV research strategy committee, to be led by the Department of Health.[173] He suggested that: "The major health funders in the UK could work together to look at the available evidence of success with regard to prevention, identify the gaps, look at the relationship between biomedical interventions and social and behavioural interventions ... and really determine the direction of travel ... to provide us with a clear strategy for HIV prevention."[174]

93.  Whilst we do not doubt the integrity of current evaluation processes, we recommend that the practice of HIV prevention providers commissioning their own evaluation of campaigns be ended. The Department of Health should commission evaluation, ensuring separation from delivery of prevention activity. We also recommend that, once instituted, such independent evaluation activities are used to inform, refine and reinforce subsequent prevention campaigns, providing an evidence-led approach to influencing behaviour.

94.  Given the significant cost savings that can be accrued from successful HIV prevention work, the Department of Health should prioritise HIV prevention research. We recommend that the Department establish an advisory committee, to give leadership and coordination to biomedical, social and behavioural prevention research.

Intensive prevention

95.  A large majority of our witnesses stressed that there were one set of interventions which had repeatedly proven to be effective. These were intensive group, workshop and one-to-one sessions that supported MSM in modifying sexual risk behaviours. Professor Graham Hart said that: "We have some very good evidence, mainly from the US, that behavioural interventions at the community, group and individual level are highly successful in impacting risk behaviour."[175] Professor Jonathan Elford went on to say: "Systematic reviews of different behavioural interventions have demonstrated that behavioural interventions can be effective at an individual and community level, but the most successful interventions were intensive. If they were provided at a one-to-one level they would involve, say, 10 one-to-one sessions."[176]

96.  Peter Weatherburn highlighted the financial difficulties of delivering this particular type of intervention, reflecting upon the work of the Terrence Higgins Trust: "Unfortunately, it invests in group work that 600 men can attend. Given that there are probably 500,000 to 600,000 homosexually active men in England, that is one in 1,000."[177] He went on to advocate " ... continuing to do the kinds of campaigns that we have done for gay men, for Africans and maybe even for the general population—such as Condom: Essential Wear—and following through with a far more robust programme of interventions for those at highest risk."[178]

97.  A range of intensive interventions—including group and individual counselling work—should be delivered for those who are most at risk of either contracting or passing on HIV. This should be set against a backdrop of national campaigns and awareness raising which is properly evaluated and refined for effectiveness.

Stigma—an obstacle to prevention

WHAT IS STIGMA?

98.  During the course of our work, we have heard numerous examples of stigma and discrimination. These include:

  • People not wishing to share cups or cutlery with people living with HIV[179];
  • People living with HIV finding themselves homeless and ostracised by their communities[180];
  • Graffiti being sprayed on the homes of people living with HIV[181];
  • Bullying of the children of people living with HIV[182];
  • People losing their jobs following disclosure of their HIV status[183]; and
  • Most worryingly, we have heard evidence of stigma being encountered from healthcare professionals, including patients being refused treatment by doctors and dentists.[184]

99.  HIV stigma is complex, and can take many forms. People living with HIV may experience discrimination, prejudice and stigma from others; they may also begin to internalise these messages and stigmatise themselves. Persistent stigma has effects upon both people living with HIV and upon public health more generally.

100.  Discrimination against those affected by HIV is based, at best, on ignorance and, at worst, on prejudice, and we unreservedly condemn it. This underlines the need for a general public awareness campaign on HIV.

THE CAUSES OF STIGMA

101.  There are many deep-seated causes of HIV stigma. Witnesses have suggested that there is a historic association of stigma with diseases or conditions where the person suffering is perceived to be responsible, in some way, for contracting it.[185] There is also, of course, a historic stigma around STIs, reflected in the long-established confidentiality arrangements for GUM services. Progressive and incurable conditions have also historically attracted stigma, as have conditions which are not well understood by the general public.[186]

102.  Positively UK suggested that people living with HIV may not wish to disclose their status due to a fear that they will be associated with particular behaviour. They fear that they will be judged to have had many sexual encounters, or to have been injecting drug users at some point in the past.[187] Witnesses from religious groups felt that stigma around HIV could be traced back to the 1980s, when it was perceived as a 'homosexual' disease and that "for many faiths it was seen as a judgement".[188]

EFFECTS UPON PUBLIC HEALTH AND PREVENTION

103.  Stigma and lack of understanding can undermine HIV prevention efforts. Misinformation circulated about HIV, suggesting that it is a 'judgment' or that it can be cured through non-medical methods, poses a threat to public health messaging. This is especially the case when such statements are made in faith-based settings, given the significant influence of faith leaders in some communities.

104.  The potential negative effects of a positive diagnosis (as outlined in para 98) can also have an impact upon prevention. Those at risk from HIV may be deterred from testing and, as a consequence, remain infectious and go on to infect other partners. Difficulties around disclosure of a HIV-positive status can also impact upon adherence to treatment, with negative impacts for the individual and a heightened risk of onward transmission through increased viral load. Stigma, therefore, impacts upon the prevention of HIV.

LEGAL PROTECTIONS

105.  The Equality Act 2010, and the Disability Discrimination Act 2005 before it, have provided a measure of legal protection to people living with HIV. In particular, the Equality Act, in prohibiting the use of pre-employment healthcare questionnaires, removed a significant barrier faced by people living with HIV when accessing employment.[189] It also introduced protection from discrimination for those perceived to be HIV-positive, as well as for people associated with someone who is perceived to have HIV.

WHAT MORE CAN BE DONE?

106.  In addition to action initiated nationally by Government, we acknowledge the work of others, principally in the voluntary sector, in combating stigma. Commitment to this work needs to be reaffirmed, and such work needs to be supported in a constrained funding environment.

WORKING WITH FAITH LEADERS

107.  Faith and religion play a strong role in the lives of many people. It is essential that faith leaders engage with HIV as an issue and provide effective and truthful support and communication around the subject. We are not convinced that this is happening universally at the moment, although evidence received from faith leaders suggested that opinions and approaches have progressed—to varying extents—over the past 30 years.

108.  Much can be learnt from recent work undertaken in the black African community. NAHIP runs a series of initiatives which seek to build and develop the knowledge of faith leaders on HIV. The partnership has produced a toolkit, Life and Knowledge, which seeks to support targeted work with faith leaders in this area. The importance of this work has been highlighted by the Department of Health[190], the African Health Forum[191] and Dr Sheena McCormack, Clinical Epidemiologist at the MRC Clinical Trials Unit.[192]

109.  Reverend Ijeoma Ajibade, of St Philips Earls Court, when reflecting on work with the AHPN, suggested that: "There are myths and taboos around HIV, and what our faith leaders can do in the churches is speak the truth about HIV," going on to state: "Stigma is very real and one of the things we do in the African Health Policy Network, which is a secular organisation, is give people the tools to speak about HIV, and we then have people who are HIV-positive speaking in churches about HIV, which I personally find very powerful."[193] In Leeds, we heard about the complexity of working to raise HIV awareness in a religious community that is often disparate, with many different churches, denominations, languages and cultures.[194]

110.  Work within African communities has been important in developing approaches to religion and HIV. It is not, however, only African churches who need to take on this focus and workload. HIV prevention messages are necessary across all communities and all faiths.

111.  Given the significant influence of faith leaders in some communities, we recommend that the Government, local authorities and health commissioners build upon work already taking place with all faith groups to enlist their support for the effective and truthful communication of HIV prevention messages.

112.  We recommend that the Department of Health ensures continued funding and support for work, building upon that currently delivered by the African Health Policy Network, which aims to develop the knowledge of faith leaders about HIV. Such work is vital in supporting a wider range of interventions which aim to address, prevent and treat HIV within all communities.

PEER SUPPORT GROUPS AND THE ROLE OF PEOPLE LIVING WITH HIV

113.  HIV-positive people, as advocates and confident service users, can play an important role in addressing stigma through publicising the condition and encouraging dialogue. Francis Kaikumba, Chief Executive of the African Health Policy Network, highlighted the work of its Ffena programme, which has trained over 100 people living with HIV to become advocates for understanding of the condition.[195] Silvia Petretti, Community Development Manager at Positively UK, highlighted her work in training 40 women from across Britain to become HIV advocates, undertaking radio interviews and responding to policy issues.[196]

114.  MedFASH believed that overcoming stigma will require openness, visibility and leadership on the part of people living with HIV.[197] The British Association for Sexual Health and HIV (BASHH)[198] and the Royal College of Physicians suggested that HIV-positive people should be empowered to build their self-confidence in medical settings.[199] Silvia Petretti stated that peer support networks, such as that provided by Positively UK, were vital in equipping people living with HIV to undertake this work.[200]

115.  People living with HIV need to be empowered to become advocates for understanding of the condition, in order to help to address stigma. We understand the importance of peer support networks and voluntary organisations in supporting this work, and recommend that local authorities and other public sector funders acknowledge the importance of this work in their future funding decisions.

Combination prevention

116.  Over the last 25 years, our knowledge of HIV has increased considerably. Whilst in the 1980s public education was one of the few tools available to prevent transmission, there are now a range of options, encompassing behavioural, social and biomedical interventions, which can limit the spread of the virus. The potential role of treatment as a preventive measure is becoming increasingly prominent. The prevention of mother-to-child vertical transmission, through HIV screening and treatment, has been an important success.

117.  These advances mean that public education measures, such as those described above, can now be combined with a range of interventions that either decrease HIV infectivity or limit susceptibility to infection. These measures, integrated with public awareness and engagement of those at high risk, can be brought together to provide 'combination prevention'. We discuss some of the measures that can be incorporated into this combined approach in the following chapters.

118.  Progress achieved over recent decades mean that there are now many facets to HIV prevention. We recommend that the full range of available interventions be used to prevent new HIV infections. We call this approach combination prevention.


116   See Appendix 8 Back

117   HAUK 19 (Department of Health). Back

118   HAUK 102. Back

119   ibid. Back

120   A sexual health organisation, based in Yorkshire, that focuses on HIV prevention amongst MSM. Back

121   Q 740 (Simon Williams), HAUK 17 (Sima Chaudhury) and personal correspondence with Mark Creelman, Inner North West London PCTs. Back

122   BBC Online, London HIV services cut as infections rise, http://www.bbc.co.uk/news/uk-england-london-13578283, accessed 15th June 2011.  Back

123   Q 106. Back

124   Q 1125. Back

125   Q 1125. Back

126   Q 1129. Back

127   Q 1089. Back

128   See Appendix 8 Back

129   A policy and advocacy organisation for people living with HIV. Back

130   A charity supporting children, young people and families who are living with or affected by HIV. Back

131   See Appendix 8. Back

132   A group providing HIV support services in Leeds. Back

133   A support service working with people affected by HIV in Dudley and Sandwell. Back

134   A clinical care centre for men and women living with HIV and AIDS. Back

135   HAUK 47. Back

136   HAUK 57. Back

137   HAUK 37. Back

138   A strategic partnership between the Department of Health and Consumer Focus, focusing on social marketing and behaviour change. Back

139   Q 960. Back

140   University College London, Gay Men's Sexual Health Survey 2009, London 2011. Back

141   ibid. Back

142   HAUK 19 (Department of Health). Back

143   ibid. Back

144   HAUK 64. Back

145   HAUK 24. Back

146   HAUK 51. The London Specialised Commissioning Group is a coordinated commissioning body for specialised services in London. Back

147   HAUK 33. Status is a HIV prevention campaign group. Back

148   HAUK 45. The Tuke Institute is a health think tank and policy organisation. Back

149   HAUK 24. Back

150   HAUK 81. Back

151   HAUK 57. Back

152   HAUK 47. Back

153   HAUK 38. Back

154   HAUK 5 and 83. FPA is a sexual health charity. Back

155   HAUK 61. HIV Scotland is the national HIV policy charity for Scotland Back

156   HAUK 63 and 66. See also Appendix 8 Back

157   HAUK 26. Shield is a South Yorkshire-based charity offering support to people living with HIV and/or hepatitis C. Back

158   HAUK 9 (LSL Alliance). Back

159   COI/Gallup poll, March 1987. Back

160   HAUK 47. Back

161   A sex education policy and advocacy group. Back

162   Sex Education Forum, Young people's experiences of HIV and AIDS education, May 2011. Back

163   Q 910. Back

164   HAUK 26. Back

165   An advertising agency used by the Terrence Higgins Trust for its media campaigns. Back

166   HAUK 84. Back

167   HAUK 33. Back

168   HAUK 27. Back

169   Q 1103. Back

170   HAUK 53.See Appendix 8. Back

171   HAUK 61. Back

172   HAUK 14. Back

173   HAUK 8. Back

174   Q 897. Back

175   Q 882. Back

176   Q 884. Back

177   Q 883. Back

178   Q 903. Back

179   Q 541 (Annemarie Byrne, Body and Soul). Back

180   HAUK 59 (NAHIP). Back

181   Q 549 (Annemarie Byrne, Body and Soul). Back

182   ibidBack

183   Q 130 (Deborah Jack , NAT). Back

184   ibidBack

185   Q 550 (Jim Jewers). Back

186   ibidBack

187   HAUK 37. Back

188   Q 647 (Revd Ijeoma Ajibade and Revd Dr Brendan McCarthy). Back

189   Including HAUK 37 (Positively UK) and HAUK 64 (Terrence Higgins Trust). Back

190   HAUK 19. Back

191   HAUK 81. The African Health Forum is an information platform for health promotion and social care initiatives relevant to African communities in London. Back

192   HAUK 56. Back

193   Q 651. Back

194   See Appendix 6: Visit to Leeds, 9 May 2011. Back

195   Q 113. Back

196   Q 551. Back

197   HAUK 63 and 66. Back

198   See Appendix 8. Back

199   HAUK 55 and 73. Back

200   Q 586. Back


 
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