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


CHAPTER 5: Taking Prevention Further

119.  The previous section discussed the importance of HIV publicity and prevention campaigns, supported by more targeted group and individual education for those at highest risk of HIV transmission. We concluded by explaining that these initiatives could be supported by a wider range of measures which, when combined, could provide an effective approach to HIV prevention. Some are already in place, and some need further support. We consider them all here.

Needle exchange

120.  HIV is mostly transmitted by sexual contact in the United Kingdom, but that is not the sole method of transmission. As a blood-borne virus, the sharing of injecting drug equipment is a major risk factor for HIV transmission. One way of combating this is to provide needle exchange facilities. Such facilities replace used needles with clean ones, to avoid the need for sharing equipment amongst injecting drug users (IDUs).

121.  The Government instituted needle exchange programmes very soon after HIV and AIDS emerged in the United Kingdom. This is widely considered to have been a success.[201] Professor Mike Kelly, Director of the Centre for Public Health Excellence at the National Institute for Health and Clinical Excellence (NICE), stressed that, "the provision of needles and syringes have been fantastically effective at keeping the HIV epidemic in check in that population".[202] Of the 112,000 HIV diagnoses since the start of the epidemic, only 5% have been as a result of injecting drug use.[203] Just 2.4% of those newly diagnosed with HIV in 2010 acquired their infection through injecting drug use[204], and only 2% of those accessing HIV services in 2009 (the latest point for which data is available) were infected through injecting drug use.[205] Amongst IDUs as a whole, HIV prevalence was only 1.5% in 2009—though this has risen from a rate of 0.7% in 2000.[206]

122.  These rates compare very favourably to rates in other countries that did not take the same proactive approach to needle exchange programmes. In the United States in 2009, for example, 12% of annual new HIV diagnoses and 19% of those living with HIV overall were infected through injecting drug use.[207] Indeed, the HIV epidemic is primarily driven by injecting drug users in many countries in Eastern Europe: in Russia, more than one third of the country's IDUs are living with HIV; whilst in the Ukraine, prevalence amongst IDUs is between 39% and 50%.[208]

123.  However, in light of the rise in prevalence in this country over the past decade, and the geographical variation in prevalence—which ranges from 0.6% in Scotland to 4.1% in London[209]—we must not be complacent.[210] One potential threat in this respect is the perception that needle exchange facilities could lead to an increase in criminality. This argument was emphatically refuted by Dr Ewen Stewart, Chair of the Royal College of General Practitioners' (RCGP) Sex, Drugs and HIV Group, who said that, "the evidence is actually to the opposite: that by bringing people into treatment, you reduce criminality; you reduce their need to fund a drug habit through criminal activity and therefore it has a wider social benefit than just a benefit to the individual."[211] Professor Graham Hart added that there was "no evidence" of increased drug use resulting from needle exchange".[212]

124.  Needle exchange programmes are a crucial component of a successful response to a blood-borne virus such as HIV. Statistics show continuing low levels of HIV incidence amongst injecting drug users. We are therefore pleased to see that the Minister for Public Health made clear that, "At the moment there are certainly no plans to get rid of needle exchanges."[213] We would go further. Given the problems elsewhere, we call on the Government to encourage other countries to heed the lessons learned in the United Kingdom, in order to combat HIV amongst injecting drug users worldwide.

125.  We support the continued provision of needle exchange programmes. The Government should use their influence, both through partnerships such as UNAIDS and their bilateral relationships, to make clear the benefits of needle exchange facilities, and encourage countries whose epidemics are driven by injecting drug use to institute or expand such programmes.

Education in schools

126.  Education is a critical part of HIV and AIDS prevention work. One of the most important targets for such education must be children and young people. HIV case reports show that one in ten new HIV diagnoses in the UK are amongst people aged between 15 and 24 years old, and incidence estimates suggest that one in six of those newly infected with HIV are young people.[214] Communicating the importance of safe sexual behaviour and the need to take care of oneself in relationships, therefore, is vital. Within schools, this is traditionally done in the subject of sex and relationships education (SRE). The Government has committed to a review of Personal, Social, Health and Economic education (PSHE), of which SRE forms part, although the remit has not yet been decided.[215]

127.  SRE is a broad term, which applies to learning about the "emotional, social and physical aspects of growing up, relationships, sex, human sexuality and sexual health".[216] Its main aim is not to teach children about sex; it is about ensuring their safety and security in intimate relationships. These are key skills to have throughout life, and issues that Nick Gibb MP, Minister of State for Schools, stressed were "very, very important to this Government".[217]

128.  Teaching requirements in relation to SRE, HIV and AIDS are complicated. The Sex Education Forum has detailed the position, which is outlined in Box 1. In summary, learning about HIV, AIDS and other STIs are the only aspects of sex education that are compulsory for all maintained secondary schools.[218] Present teaching looks at HIV and AIDS within the science curriculum. However, the separate subject of SRE, with its focus on broader social issues (which can increase levels of safe sexual behaviour[219]), should also be considered as part of HIV and AIDS prevention efforts.

BOX 1

Existing requirements around sex and relationships education[220]
(1) It is compulsory for all maintained schools to teach some parts of sex education, that is the biological aspects of puberty, reproduction and the spread of viruses. These topics are statutory parts of the National Curriculum Science which must be taught to all pupils of primary and secondary age.

(2) There is also a requirement for secondary schools to teach about HIV, AIDS and sexually transmitted infections as part of the National Curriculum Science.

(3) The broader topic of SRE is currently not compulsory but is contained within non-statutory PSHE within the National Curriculum and is strongly recommended within Government SRE Guidance (2000). School governors are in law expected to give 'due regard' to this guidance.

(4) Both primary and secondary schools are legally obliged to have an up-to-date SRE policy that describes the content and organisation of SRE taught outside the Science Curriculum. In primary schools a decision not to teach SRE outside the Science Curriculum should also be documented in the policy.

(5) It is the responsibility of the school's governing body to ensure that the policy is developed and is made available to parents. Parents have a right to withdraw their children (until the age of 19) from any school SRE taught outside the Science Curriculum.

(6) To qualify for Healthy School status, there must be a planned programme of PSHE which includes SRE in place.[221]

(7) Schools have a legal duty to ensure the wellbeing of their pupils and SRE contributes to this duty.

STANDARDS OF TEACHING

129.  Even though teaching about HIV and AIDS is part of the National Curriculum, it is inadequate at present. A survey of 821 young people conducted by the Sex Education Forum this year found that a quarter of young people had not learnt about HIV and AIDS in school; a problem that was more pronounced amongst older children.[222] This echoed the findings of a 2007 Ofsted report, which stated that HIV and AIDS received insufficient emphasis within schools.[223]

130.  The content of HIV and AIDS teaching is also a problem. The Sex Education Forum survey found that children were most likely to have learnt about the transmission of HIV (73%), but that learning about stigma and attitudes was less common (41%).[224] Body and Soul felt that the balance of information failed to properly communicate the risks of acquiring HIV.[225]

131.  Many of the concerns about HIV and AIDS teaching were expressed about SRE more broadly. A 2008 Sex Education Forum survey found that 92% of young people learned about biological aspects of sex, but only 21% were taught about relationship skills.[226] The need for a broader curriculum was widely supported.[227] Dissatisfaction was shared by teachers and school leaders.[228]

IMPROVING THE SYSTEM

132.  One area for possible development relates to mandatory teaching of SRE in schools. Lucy Emmerson, Principal Officer of the Sex Education Forum, argued that mandatory teaching would be a "huge lever" to help ensure that everyone had an entitlement to learning about SRE.[229] This call was supported elsewhere.[230] However, the Minister for Schools outlined that statutory provision was "not the approach we are taking to education policy"[231], and that it was "imperative that parents will maintain a right to withdraw their children from SRE lessons".[232]

133.  The age at which teaching begins is important too. Currently, teaching about HIV and AIDS begins in secondary school, whilst very basic biological information is first delivered to children aged between four and seven years old (at Key Stage 1). Existing guidance calls for teaching on SRE around healthy lifestyles and relationships to begin at the same age.[233] This had support from teachers, parents and governors[234] and from sexual health organisations.[235] Those calling for such provision stressed, though, that material had to be age-appropriate. This means that, at the earliest stage, teaching is about supporting children to be safe, and providing what Lucy Emmerson called "the building blocks and the language to build on".[236]

134.  Teachers must be properly trained for this teaching. A survey of parents, teachers and governors indicated that more training was the number one priority for teachers in improving SRE, with 80% of school leaders feeling insufficiently trained and confident about the topic.[237] The Minister for Schools stressed that the PSHE review would consider training requirements for teachers.[238]

CONCLUSION

135.  Broad teaching about sex, relationships and HIV can deliver key HIV prevention messages. It is an area acknowledged by the Government to be important, and one where the need to improve has also been taken on board.[239] This commitment to bring influence to bear will work to improve standards.

136.  Although the Minister for Schools stressed that he did not wish to pre-empt the findings of the PSHE review, it is clear that mandatory teaching of SRE is an unlikely development. The Minister's position was that change could be encouraged in other ways, such as through regard for SRE guidance in academy funding agreements.[240] We are of the view, however, that a statutory basis for SRE is essential. This would ensure that SRE is given appropriate priority in school timetables, driving the development of consistent standards. It would also support the integration of HIV and AIDS teaching into SRE, avoiding reliance on the science curriculum to provide all teaching on what is a wide and complex subject.

137.  Teaching should begin as early as possible. There is no question at all of this being explicit, or encouraging of sexual behaviour. At the earliest stages, teachers would simply deliver messages about the importance of being protected against abuse and pressure. In 2009, nearly 5% of children aged between 11 and 17 years old reported being sexually abused by an adult or another young person[241]; and one in four 18 to 24 year olds reported being physically attacked, sexually abused or severely neglected during their childhood.[242] Early, effective teaching could help to keep children safe from an early age. This could then be built on in order to develop the knowledge and skills required to prevent the acquisition and spread of HIV and AIDS.

138.  Although external providers can be "memorable"[243], this teaching should be delivered by trained and confident teachers, to ensure as many young people as possible gain the skills they need.[244] Existing training requirements, which only expect familiarity with National Curriculum guidance[245], are simply insufficient.[246]

139.  Ensuring that as many young people as possible can access good quality SRE is crucial. We recommend that the Government's internal review of PSHE considers the issue of access to SRE as a central theme. Teaching on the biological and social aspects of HIV and AIDS should be integrated into SRE.

140.  Whilst acknowledging that the review is yet to complete its work, we recommend that the provision of SRE should be a mandatory requirement within the National Curriculum, to enable access for all. Such education should begin within all schools from Key Stage 1, though this teaching must be age-appropriate.

141.  There is an important role to be played by external providers, but we recommend that SRE should be primarily delivered by teachers, who must be trained to deliver this teaching. This training must focus on all aspects of HIV and AIDS, to ensure that teachers are confident on the subject.

Preventing mother-to-child transmission

142.  During the course of our Committee visits, we received evidence of the effectiveness of current practice in limiting the transmission of HIV from mothers who are infected to their children. Measures taken, including HIV screening, reduction of viral load in pregnant women (through antiretroviral therapy), the provision of free formula milk[247] and sperm washing[248], have proven highly successful in limiting transmission to children.[249]

143.  Evidence suggests that, without intervention, around 30% of children born to HIV-positive mothers would be infected with the virus.[250] At the Chelsea and Westminster Hospital, with appropriate interventions, the rate of transmission was under 1%, with only two cases in seven years, from over 250 deliveries.[251] The national rate stands at around 3%; between 2002 and 2008, just over 210 HIV-positive children were born from a total of more than 7,500 deliveries by HIV-positive mothers.[252] The multidisciplinary work of the HIV family clinic at Chelsea and Westminster, including psychological support, was likely to have been a significant factor in securing a better than average rate there.

144.  Written evidence from the Children's HIV Association (CHIVA) suggested that free infant formula milk, vital in preventing infection via breast-feeding, is not always provided to mothers who have no recourse to public funds.[253] In the main, this problem affects individuals with an irregular immigration status. Provision—coordinated through local authorities—is variable across the country, producing a 'postcode lottery'. CHIVA argued that there is both an individual and a public health benefit in ensuring that local authorities provide free infant formula milk to HIV-positive mothers who have no recourse to public funds. We support this view. The costs of providing this service are minute compared with the costs, both financial and emotional, of a lifetime of treatment for HIV infection.

145.  The provision of universal opt-out testing in antenatal clinics has been a very important achievement. Introduced in 2000, this measure has seen testing acceptance rates of 95% amongst pregnant women attending clinics, ensuring that almost all pregnant women are screened for HIV.[254] A diagnosis can then be followed by the measures outlined above to prevent mother-to-child transmission, as well as partner notification and other follow-up work. This makes the diagnosis itself an important measure in preventing onward transmission. Antenatal testing has been hailed as "the most successful HIV testing achievement."[255] This success illustrates the potential of wider availability of testing, and supports arguments made in our later discussion of testing arrangements (see para 179).

146.  Procedures developed to limit the transmission of HIV from mother-to-child have been an outstanding success. We recommend that the Department of Health and commissioners ensure that such services continue to be provided as required. For the same reason, we also recommend that local authorities provide free infant formula milk to HIV-positive mothers who have no recourse to public funds.

Treatment as prevention

147.  A number of submissions have referred to the value of earlier diagnosis and treatment in HIV prevention efforts (see paras 174 to 175). Such claims are made on the basis of evidence which suggests that the behaviour of those infected changes following a HIV diagnosis; and on research which indicates that infectivity is reduced when on antiretroviral treatment, through the reduction of viral load. In addition, there is growing evidence that early commencement of treatment has benefits for those infected with HIV, preventing damage to the immune system which might otherwise take place. There is, therefore, a growing body of evidence which suggests that there are both individual and public health benefits to be gained from early treatment.

148.  Results of a 'treatment as prevention' trial were published by the US National Institutes of Health in May this year. This research (which took place at 13 international sites, although none were in the UK) suggested that, if an HIV-positive person adheres to an effective antiretroviral treatment regimen, the risk of transmitting the virus to an uninfected sexual partner can be reduced by 96%.[256] This work may begin to make the case for commencing antiretroviral therapy at an earlier stage than currently recommended. Indeed, written evidence from Professor Jonathan Weber called for scrutiny of existing treatment guidelines to explore whether treatment should be provided earlier for preventive effect.[257]

149.  Behavioural change as a result of HIV treatment and associated interventions has a broader link to early testing and diagnosis, which is discussed in detail in the next chapter. Ruth Lowbury, Chief Executive of MedFASH, cited US research which showed that the likelihood of unprotected sex was 68% lower when people were aware of their own HIV-positive status.[258] Links between diagnosis, treatment and positive behaviour change were also acknowledged by Professor Mike Kelly of NICE.[259]

150.  Treatment has an increasingly important role to play in preventing HIV infection. We note research demonstrating the potential for earlier antiretroviral treatment as a preventive measure. We recommend that the Department of Health, National Institute for Health Research[260], Medical Research Council and other research funders provide support in order to examine the utility of such approaches in the United Kingdom. In addition, the Department of Health should keep policy in this area under review as further research continues to emerge.

151.  In addition to the earlier commencement of treatment, recent research has highlighted the potential role of antiretroviral pre-exposure prophylaxis (PrEP) measures—such as microbicidal gel and oral tablets for those at high risk of infection—in reducing transmission.[261] This was referenced in a number of evidence submissions.[262] However, most asserted that more United Kingdom-based evidence is required before wider roll-out. In oral evidence, though, Dr Sheena McCormack detailed difficulties in obtaining funding for research into developing the effectiveness of microbicidal measures.[263] BHIVA and BASHH, together with other stakeholders, are currently drawing up a position statement with regard to the use of PrEP in the United Kingdom.

152.  Another prevention measure, post-exposure prophylaxis (PEP), is already available in the UK through GUM clinics. With PEP, individuals who have had a potential exposure to HIV can take a course of antiretrovirals for one month afterwards to limit the chances of infection. This measure has also been used to protect healthcare workers who have had a possible workplace exposure to HIV.

153.  Several contributors to the inquiry, including the African Health Forum[264], stressed the need for easier access to PEP to ensure take-up. NAHIP highlighted that commissioning routes for 'treatment as prevention' could become complicated under the proposed NHS reforms, given that those two aspects of HIV services will be divided under the new system.[265]

154.  There are, however, concerns that too flexible an approach to the distribution of PEP may encourage the development of viral resistance; there is also a feeling that supply should continue to be managed by GUM clinics, allowing supportive counselling and behaviour change work to be delivered at the same time.[266] Furthermore, an approach that is too flexible may encourage PEP to be seen as an easy 'solution' to HIV, and dilute messages encouraging use of prevention measures such as condoms.

155.  We recommend that the Department of Health, National Institute for Health Research, Medical Research Council and other research funders support programmes of work which examine the utility of pre-exposure prophylaxis. This research should take place both in the United Kingdom and in international settings. We recommend that the availability of post-exposure prophylaxis should continue to be determined by clinicians within GUM clinics.

Dealing with HIV in prisons

156.  The prison system is an environment of real risk for acquiring HIV. Nearly 200,000 prisoners pass through the system every year, and those with alcohol and drug dependencies, such as injecting drug users, are disproportionately represented.[267] If we are serious about giving HIV prevention the priority it deserves, tackling HIV in prison cannot be ignored.

157.  However, data in this area is seriously inadequate. Surveillance systems were only able to separate out diagnoses made in prisons for the first time in January 2011.[268] Figures that are available are likely to underestimate seriously the number of people living with HIV in prison.[269]

158.  Whilst there is no official figure for prevalence, HPA figures for England[270] would suggest that diagnosed HIV prevalence was at nearly 2.2 people per 1,000 of prison population at the end of 2009.[271] Even with the likely underestimation, this would still be more than 50% higher than the estimated prevalence (of people both diagnosed and undiagnosed) of 1.4 people per 1,000 across the United Kingdom as a whole in that year.[272]

159.  Within prisons, services are the responsibility of Offender Health, a joint Department of Health and National Offender Management Service unit, and are commissioned by Primary Care Trusts.[273] Under proposals for reform, integrated prison health services are to be commissioned at a national level by the NHS Commissioning Board.[274]

TESTING IN PRISONS

160.  The need to increase the uptake of testing is of particular importance in prisons given the relatively high prevalence of HIV.[275] Offender Health stressed that it had worked with commissioners and providers to allow more opportunities for HIV testing. Levels of service provision have not, though, been mapped across the country. A review against prison quality indicators, which include access to sexual health services such as testing, is being conducted by NHS South West and may tell us more.[276]

161.  We do know, however, that testing is not offered and recommended on a routine basis for those entering prison. Staff we heard from at HMP Brixton were not opposed to such a development on an opt-out basis (this is where a test is offered and then carried out, unless the person specifically objects).[277] However, staff mentioned the need to bear in mind the stresses upon those entering prison for the first time.[278]

TREATMENT FOR PRISONERS WITH HIV

162.  Treatment for those with HIV is important both in terms of their individual health, and in terms of reducing their infectivity (see paras 174 to 175). Standards of care for all health services in prisons are supposed to be equivalent to those provided in the community.[279] HPA figures indicated that, in 2008, the proportion of prisoners treated with antiretroviral drugs is similar to those diagnosed outside prison in England.[280] However, standards vary across the country.[281] Silvia Petretti of Positively UK asserted that she had seen "a number of women who have been delayed or denied treatment in our prisons in the UK, and this is jeopardising their lives."[282]

163.  There is no doubt, though, that providing continuing care for those with HIV in a fast-changing prison system is a challenge. Dr T Moss and A Woodland,noted the potential for interruption of antiretroviral therapy.[283] Offender Health stressed that it had worked with the British HIV Association to better understand the challenges in relation to HIV-positive prisoners, and developed an integrated computer system to share information nationally.[284]

PREVENTION IN PRISONS

164.  Prevention covers a number of areas. One is education. Offender Health made reference to a number of health promotion initiatives, including DVDs, posters and leaflets, but we did not receive any evidence as to how widely these were available. Providing condoms, lubricant and dental dams is another element of preventive work. Although the application process—where condoms are requested from a healthcare worker—is "as per all other requests for healthcare in prisons"[285], Silvia Petretti felt that it disincentivised their use, as "that is like outing yourself as having gay sex in prison, which people will not do."[286]

CONCLUSION

165.  The present approach to HIV and AIDS in prisons is not good enough. Data needs to be more robust, and the availability of sexual health services across the country should be mapped. The performance review underway through NHS South West is welcome, but a specific review relating to HIV and AIDS is also required.

166.  Establishing the scale of the challenge must then be the basis for action. Ensuring effective care, equivalent to that in the community, must be the goal. Professor Mike Kelly of NICE indicated that offender health, "might be an area that NICE could conceivably take forward in the future".[287] Given the persuasive and high-quality nature of such guidelines elsewhere (see paras 241 to 248), this would be constructive.

167.  Prisoners should be offered opt-out HIV tests on a routine basis upon entering the prison system. They should also have confidential access to condoms, lubricant and dental dams. We have proposed that routine opt-out testing be put in place for those registering with a new GP (see para 192); this should be no different for prisoners. This is especially so when prevalence within prison is likely to be greater than 2 per 1,000, the threshold at which such testing is recommended elsewhere.

168.  The shift to central commissioning of offender health services provides a real opportunity across all of these areas; commissioning for the whole prison estate can ensure consistency and equity for the good of the prison population as a whole.[288] In the meantime, the Government needs to make clear to prison governors what is required of them, to best serve individual and public health needs across the prison estate.

169.  We recommend that the Government pursue its plans to commission offender health services centrally, which would lead to better equity and continuity of care for prisoners.

170.  Data on HIV in prisons must be improved. The Health Protection Agency should utilise surveillance data newly available to provide a robust estimate of the prevalence and profile of HIV within the prison population. At the same time, a review exercise into offender health services in public prisons is underway. The Government should supplement this with a review of the extent and nature of HIV prevention, testing and treatment services within public prisons, to determine the levels of provision across the country.

171.  We recommend that best practice for managing HIV in prisons is made clearer. The Government should commission NICE to produce guidance for the management of offender health, which should include specific protocols for HIV prevention, testing and treatment.

172.  In the meantime, the Government should draw up a guidance note to prison governors to outline best practice for managing HIV in prisons. This must stress the need for high-quality, continuous treatment and care; robust testing policies, including routine opt-out testing on entry into prison; and the provision of condoms in a confidential manner. Governors should implement these policies within their prisons as soon as possible.


201   See, for example, HAUK 54 (Royal College of GPs), HAUK 63 (MedFASH), HAUK 59 (NAHIP), Q 873 (Professor Noel Gill). Back

202   Q 337. Back

203   HAUK 59 (NAHIP). Back

204   Health Protection Agency, United Kingdom: New HIV diagnoses data to end of December 2010, op. cit. (Calculation based on 160 diagnoses out of an estimated 6,750 cases = 2.37%). Back

205   Health Protection Agency, HIV in the United Kingdom (2010 Report), op. cit.  Back

206   Health Protection Agency, Shooting Up: Infections among injecting drug users in the UK 2009, November 2010. Back

207   Centers for Disease Control and Prevention, HIV in the United States, July 2010. Back

208   UNAIDS, UNAIDS Report on the Global AIDS Epidemic 2010, p73: http://www.unaids.org/globalreport/global_report.htm Back

209   Health Protection Agency, Shooting Up: Infections among injecting drug users in the UK 2009, op. cit. Back

210   HAUK 63 (MedFASH). Back

211   Q 675. Back

212   Q 888. Back

213   Q 1121. Back

214   HAUK 68 (Health Protection Agency). Back

215   Q 1013 (Nick Gibb MP). Back

216   FPA, Sex and relationships education factsheet, January 2011. Back

217   Q 1056. Back

218   Education (Non-Maintained Special Schools) (England) Regulations 1999. (SI no 2257). Back

219   HAUK 49 (Sex Education Forum). Back

220   Sex Education Forum, Current status of Sex and Relationships Education, March 2011. Back

221   Healthy Schools Status is a Department for Education and Department of Health accreditation scheme. Back

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

223   Ofsted Time for Change? Personal, social and health education, London 2007. Back

224   Sex Education Forum, Young people's experiences of HIV and AIDS education, op. citBack

225   HAUK 22. Back

226   HAUK 49 (Sex Education Forum). Back

227   See, for example, Q 593 (Sarah Smart, PSHE Association), Q 664 (Professor David Albert Jones, Anscombe Bioethics Centre, Catholic Church), HAUK 46 (Brook). Back

228   Durex, Survey of parents, teachers and governors on Sex and Relationships Education in England (Executive Summary), London 2011. Back

229   Q 616. Back

230   Q 617 (Simon Blake, Brook), Q 116 (Sir Nick Partridge), HAUK 22 (Body and Soul). Back

231   Q 1052. Back

232   Q 1057. Back

233   Sex Education Forum, Current status of Sex and Relationships Education, op. citBack

234   Durex, Survey of parents, teachers and governors on Sex and Relationships Education in England (Executive Summary) op citBack

235   HAUK 5 (FPA), Q 627 (Sarah Smart). Back

236   Q 631. Back

237   Durex, Survey of parents, teachers and governors on Sex and Relationships Education in England (Executive Summary), op. citBack

238   Q 1035. Back

239   Q 1132 (Anne Milton MP). Back

240   Q 1057. Back

241   NSPCC, Child cruelty in the UK 2011: An NSPCC study into childhood abuse and neglect over the past 30 years, February 2011. Back

242   ibidBack

243   Q 602 (Simon Blake). Back

244   Q 603 (Sarah Smart), Q 598 (Simon Blake). Back

245   Q 597 (Sarah Smart). This requirement is QTS 15:
http://www.tda.gov.uk/trainee-teacher/qts-standards/knowledge-and-understanding/subjects-curriculum/Q15.aspx 
Back

246   HAUK 64 (Terrence Higgins Trust). Back

247   This is because HIV can be transmitted through breast-feeding; the provision of free infant formula milk ensures that HIV positive mothers can avoid passing on the virus in this way. Back

248   This is a procedure to remove the HIV virus from semen prior to artificial insemination, for the avoidance of transmission to both mother and child. Back

249   See Appendix 5: Visit to London Clinics, 31 March 2011. Back

250   HAUK 10 (Children's HIV Association).. Back

251   See Appendix 5, op citBack

252   Health Protection Agency, New HIV diagnoses data to end of December 2010, op. cit.Back

253   HAUK 10. Back

254   HPA, HIV in the United Kingdom (2010 Report), op. citBack

255   Q 244 (Dr Keith Radcliffe). Back

256   Cohen MD et al., Prevention of HIV-1 Infection with Early Antiretroviral Therapy, New England Jounal of Medicine, July 2011. Back

257   HAUK 71. Back

258   Q 237. Back

259   Q 331. Back

260   An NHS-led research institute, which commissions and funds research. Back

261   Including, for example, Partners PrEP Study, University of Washington International Clinical Research Centre, July 2011. See http://depts.washington.edu/uwicrc/research/studies/files/PrEP_FAQ.pdf Back

262   Including HAUK 56 (Dr Sheena McCormack). Back

263   QQ 458-461. Back

264   HAUK 81. Back

265   HAUK 59. Back

266   Q 515 (Dr Simon Barton). Back

267   Health Protection Agency and Department of Health, Health protection in prisons, 2009-2010 report, March 2011. Back

268   HAUK 92 (Offender Health). Back

269   Health Protection Agency and Department of Health, Health Protection in prisons, 2009-10 Report, op. cit.Back

270   182 people living with HIV in prison in England in 2009. See HAUK 89 (International Centre for Prison Studies). Back

271   Calculation based on the 2009 HPA estimate of 182 people living with HIV in prison in England, and December 2009 prison population data for England and Wales (84,231 total inmates). Calculation was therefore: (182/84231)x 1000) = 2.161 per 1,000. Prison population figures taken from HM Prison Service population data:
http://www.hmprisonservice.gov.uk/assets/documents/100049D8population_bulletin_monthly_december_2009.pdf 
Back

272   Health Protection Agency, HIV in the United Kingdom (2010 Report), op. cit. Back

273   HAUK 92 (Offender Health). Back

274   Department of Health, Healthy Lives, Healthy People: consultation on the funding and commissioning routes for public health, November 2010, para 3.30. See also Q 225 (Dr Gabriel Scally). Back

275   HAUK 89 (International Centre for Prison Studies), HAUK 22 (Body and Soul), Q 258 (Ruth Lowbury). Back

276   HAUK 92 (Offender Health). Back

277   See Appendix 8. Back

278   Appendix 7: Visit to HMP Brixton, 17 June 2011. Back

279   HAUK 92 (Offender Health). Back

280   Health Protection Agency Health protection in prisons, 2009-2010 report, op. cit. Back

281   See, for example, Q 102 (Deborah Jack). Back

282   Q 554. Back

283   HAUK 25. Both were former healthcare workers. Back

284   HAUK 92. Back

285   ibidBack

286   Q 558. Back

287   Q 334. Back

288   Q 102 (Deborah Jack), Q 307 (Ruth Lowbury). Back


 
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