Examination of Witnesses (Questions 341-359)|
TUESDAY 23 JULY 2002
341. Could I firstly apologise both to our witnesses
and to members of the public for the delay in commencement of
the proceedings and also for the absence of the Chair, David Hinchliffe.
Most of you are aware that the Secretary of State has been making
a statement in the House on services for older people which is
extremely relevant to a report which the Health Committee is publishing
tomorrow on delayed discharges and hence it was felt appropriate
that as many members as possible should be in the chamber for
that statement. Mr Hinchliffe is trying to speak this very minute.
Could I ask the witnesses to briefly introduce themselves by stating
their name and their position and relevant expertise?
(Dr Weatherburn) I am Peter Weatherburn,
director of SIGMA Research, a specialist sexual health and HIV
health promotion research unit affiliated to the University of
Portsmouth. I am based in London.
(Mr Partridge) I am Nick Partridge. I
am chief executive of the Terence Higgins Trust and Lighthouse,
the largest AIDS service provider covering prevention, social
care, advice and support.
(Mr O'Reilly) My name is Joseph O'Reilly. I am the
deputy chief executive of the National AIDS Trust which works
both across the UK and internationally on HIV policy and advocacy.
(Dr Evans) My name is Barry Evans. I am a consultant
epidemiologist at the Public Health Laboratory's Communicable
Disease Surveillance Centre based at Colindale.
(Dr Miners) I am Alec Miners. I am a health economist.
I am a visiting research fellow from Brunel University but also
a health technology analyst at the National Institute for Clinical
(Mr Imrie) My name is John Imrie. I am a senior research
fellow in the Department of STDs at the Royal Free and University
College Medical School.
342. Dr Evans, could I ask you what the main
countries are, outside of the African continent, whose epidemics
may be affecting the UK?
(Dr Evans) At this point in time, there is no country
other than the African countries making a big impact on the UK
new diagnoses, but there are small numbers from countries such
as the Caribbean, small but slightly increasing numbers from India
and about between 50 and 100 cases a year where people have acquired
their infection in Thailand and south east Asia. There are small
numbers from those three parts of the world, but parts of the
world which historically the UK has had links with. We need to
maintain a watchful brief in terms of their impact in the UK.
We also need to maintain a watchful briefhistorically,
we have not had big links but the situation in eastern Europe
is fairly dire at the moment with regard to HIV transmission,
especially amongst injecting drug users, their sexual partners
and it is further spread heterosexually. That has had minimal,
if any, impact on the UK as yet, but potentially it is another
area where we need to maintain a watchful eye on its potential
impact for the UK. Africa has had a major impact. The Caribbean,
India, south east Asia and eastern Europe, in terms of the potential,
but this is a global epidemic. We must maintain a watching brief
in terms of the worldwide pandemic, rather than just viewing ourselves
as isolated in some way from the rest of the world.
343. Some of the specialist service providers
who have given evidence to us argue that to cope with the rise
in infections from abroad which manifest themselves in the UK
we need to provide acceptable, appropriate and culturally competent
services. Are there specific difficulties in monitoring HIV from
(Dr Evans) Sometimes our main sources of data come
from laboratories undertaking HIV testing or from clinicians undertaking
appropriate HIV care of patients. The facts that we would like
to collect from a public health viewpoint are sometimes not the
facts which are necessarily obtained in terms of the history from
the patient. Sometimes we do not have all the information which
we would like and need to generalise from perhaps having partial
data available, data such as when the person arrived in the UK
if they were born abroad. It may not be available to the clinician
reporting to us.
344. Can I first of all apologise to the Committee
and to the witnesses because I have a constituency engagement
at six o'clock. Can I look at the information about the communicable
nature of the infection? What do we know about the proportion
of those with HIV and AIDS who are infected within the UK and
those infected abroad, either with partners normally resident
in the UK but infected abroad or those infected by partners not
normally resident in the UK?
(Dr Evans) Our best estimate of thisand it
is based on partial data to a certain extentis that of
the new diagnoses made in 2001 about 60 per cent were acquired
outside the UK and about 40 per cent within the UK. If you look
at people born within the UK and infected abroad, we think about
seven per cent of the total are in that category.
345. Do we know what proportion of those are
(The Chairman took to the Chair)
(Dr Evans) There would be potentially
a higher figure. These are the new diagnoses occurring in 2001.
Of people born abroad, infected abroad, it is about 53 per cent.
Those constitute the 60 per cent acquired abroad and, of people
born in the UK and infected in the UK, about 30 per cent; born
abroad and infected in the UK, about ten per cent. Historically,
it has not been like that. If you look at the cumulative number
of people living with HIV that has been diagnosed currently, it
is more a 60/40 breakdown the other way round, so 60 per cent
of those currently living with HIV diagnosed in the UK at the
moment have acquired it in the UK and 40 per cent outside the
UK. The figures are different for recent diagnosis because of
the increasing impact of the African epidemic but cumulatively
the people living with HIV currently that have been diagnosed,
about 60 per cent acquired in the UK and 40 per cent abroad.
346. Is that comparable with the historic trend,
going back to the early 1980s?
(Dr Evans) If you look way back to the very early
1980s, many of the infections acquired in men who have sex with
men were acquired in America or had links with America. This is
one of the problems with looking at the pandemic and blaming other
countries. It was fairly soon that an epidemic took place in gay
men in the UK. The very first cases we had reported to us at CDSC
had links with the US. The US epidemic was two to three years
in advance of our epidemic so some of the transmission patterns
were of people who had acquired it in the US. Then it became endemic.
People acquired it in the UK but that pattern is changing now,
since the mid-1990s, where we have seen an increasing impact of
the worldwide epidemic.
347. When you say the pattern is changing, do
you mean in terms of the origins of the infection or that the
problem is generated from within the UK rather than abroad?
(Dr Evans) Two things. There is an ongoing epidemic
within the UK in men who have sex with men. There is a limited
amount but small in terms of heterosexual transmission within
the UK and the main heterosexual component are people who have
acquired their infection within an African context and have migrated
to the UK.
(Mr Partridge) Over the past 15 years, we have been
in a position to be able to make considerable public health interventions,
particularly for men who have sex with men, for gay men, so there
has been a consistency of targeted HIV prevention work for gay
men. That is not evident and has been much more difficult to create
in the recent past for African communities living in the UK, partly
because we have been well aware that most of those infections
have happened outside of the UK. Secondly, because it is new and
difficult work for us and for other African community organisations
that we need to build up experiencing HIV prevention work for
African people living here. Thirdly, because there has been a
lack of resourcing and a nervousness about doing that work. In
a way it should not be surprising that we have seen an ability
to contain new infections amongst gay men in a way which was unexpected
for many of us in 1985. It is still not good enough for many to
say that there is a continuing level of new infections amongst
gay men, but at least there are targeted, resourced programmes
for gay men. What we need to be able to do is to build up work
for and with African communities as the epidemic is changing.
Finally, an aspect that ought to be highlighted is that we do
see a difference in terms of a time of presentation for testing.
If you look at late diagnoses in this country, if you look at
people being diagnosed both with AIDS and HIV through accident
and emergency or in a hospital setting, well over half of those
are people from African communities presenting very late with
a very poor clinical outcome. That is another part of the picture
that I think we need to paint.
348. Do you mean recent arrivals in the UK from
African communities or from established African communities in
(Mr Partridge) It is quite mixed. It can be from people
who have been living here for 10 years or more. Otherwise, it
is people who have arrived over the past two to five years. The
data is not complete because it is difficult to collect that data
but all of these people have arrived in the UK for good, practical
349. Would it be too simplistic to say that
the attitude, the approaches, the policies we have taken towards
HIV and AIDS within the UK are robust but that we are part of
a wider world?
(Mr Partridge) That is very fair. We have had a very
robust, strong response. Certainly talking to colleagues in the
United States of America or Australia much of the work done in
this country for and by gay men is seen as a world leader. It
is seen as something which has continued to contain the epidemic
and it is also seen as being vitally important to sustain. What
is much more complex is how we deal with the global impact being
seen in this country. What we can do in this country is limited.
Once people are infected, you are looking at service provision,
support and creation of good networks of care. How we interact
and work with DIFD to ensure that we play our role in stemming
new infections in sub-Saharan African countries is a key question.
The record that is beginning to grow of the UK's investment in
those prevention exercises is something that we need to build
up. Secondly, how we forewarn ourselves and forearm ourselves
to deal with any changes that we know will happen in the years
to come, particularly with the expansion of the European Union,
is something that we are very conscious of at the Terence Higgins
Trust and I know that other prevention agencies are also conscious
350. That was an oblique reference to eastern
(Mr Partridge) Yes.
Chairman: Could I apologise for the inconvenience
of the meeting being called late and for my own late arrival?
351. I apologise as well. I have to leave in
a few minutes to chair a meeting in another room. I wanted to
follow up what it means for sex education and public health and
a number of things that have been said in answer to the opening
round of questions. What things do we have to take into account
to take account of the prevalence of HIV infections and the nationality
of those infected? What does that mean for health education and
sex education and public health in terms of policies to be adopted?
(Mr Partridge) Firstly, we need to remind ourselves
where we can be effective and we can be most effective in containing
and preventing as many new infections within the United Kingdom.
That needs to be our key task, so ensuring that we maintain good
harm reduction policies in needle exchange schemes and injecting
drug use; to ensure that the targeted work for gay men is properly
linked to any proposed, more general public safe sex campaigns,
so that those messages do nto cut across. Thirdly, that we continue
to build on sex education in schools so that we have a well educated
group of young people as they start their emotional and sexual
lives. Then we need to look at how we ensure that the materials
for people coming to this country potentially with HIV are appropriate
both linguistically and culturally. That is new, ground breaking
work, the kind of work that we need to be doing, particularly
with African communities at the moment. There are no clear, immediate
answers to that, but there is a lot of good work being done by
the African HIV policy network in order to be able to address
352. Will that involve targeting particular
(Mr Partridge) Absolutely. What we have learned amongst
gay men is transferable in terms of how we work with what are
quite small community groups and often they are fragmented and
under resourced, so using different venues, be that where people
meet in faith communities, in barbers, clubs and so on. That is
work that we are learning about all the time. If you think about
what we can do on a general public level, that is particularly
based on how we improve, enhance and use the evidence we now have
around sex education in schools and colleges, how we then take
that forward in the communities most at risk, and sustain that
work and make sure it is linked in to a general public understanding
so that those not directly affected by HIV and AIDS can support
their children, their brothers, their sisters, others in the community
to be able to keep themselves safe from infection both from HIV
and other STIs, right through to unwanted pregnancy.
353. How do you feel that current sex education
in schools could be better related to men who have sex with men?
(Mr Partridge) I believe that we have the tools available
to us. We know what we can do and in the best schools that is
well done and well delivered. We know that there is a correlation
between homophobia in schools, homophobic bullying in schools,
self-esteem and the risk of HIV infection. The difficulty which
covers sex educationI am sure that you have been through
this in previous sessionsis how we lift the whole of the
school system up to what the best schools are doing. It is now
quite clear to me that we have a good evidence base of what works
in sex education in schools. It is how we apply that and fund
that across the system as a whole.
(Dr Weatherburn) I would agree entirely. My sense
from my research among gay men is that very many of them are in
early adulthood and are hopelessly ill equipped to deal with the
hazards that they face. It is no coincidence that most of the
public health laboratory services' surveillance shows that young
gay men are most affected by new infections and this is as a direct
consequence of them entering a culture where hazards and risks
that are beyond their understanding are encountered in a very
immediate way. Sex education in schools does not serve boys very
well generally. Boys who enter into a gay culture or heterosexual
career are terribly served by it since they have in many cases
no reference made to the feelings that they have. In other more
shocking cases, they have had the feelings they have directly
undermined by the homophobia and prejudice of their teachers or
354. What do you feel our Committee might recommend
on that issue? We have had many debates in this place about section
28 and the impact that it still continues to have. Is it a factor
that teachers are very fearful of entering this whole area for
the reasons that we all understand? What are your views on the
kind of areas where we might make recommendations that could be
of direct relevance?
(Dr Weatherburn) The review undertaken by the Institute
of Education in London last year suggested that section 28 had
a huge inhibiting effect on teachers because it was so poorly
understood. Very many teachers in private schools understood well
that it did not disallow them doing anything and managed to provide
adequate sex education for boys, but most do not and are too fearful
of going there. A clear reading of the Act does not impede you
from doing anything, but that is not widely understood within
the teaching service.
(Mr O'Reilly) Section 28 is a big factor. The fact
that it is not understood means that it is read in a very conservative
way. If the Committee could see its way to recommending its repeal
once again, that would be a very positive move. What you need
to do is create an enabling environment in which HIV can be tackled
effectively. That will take a variety of forms, one of which is
a positive, constructive legislative environment and one of the
impediments to that sort of environment now is the existence of
section 28. Another key factor is leadership. I think Nick provided
a very eloquent list and a compelling testimony of the sorts of
things that are required in respect of sex education and the targeting
of educational efforts with a view to preventing HIV towards at
risk communities. Just like we have seen in respect of Peter's
point about the resistance in schools to dealing with sensitive
sexual matters, such as homosexuality and sexual practices and
behaviours of ethnic minority communities and the reasons why
they are more at risk than others, those same impediments and
sensitivities exist out in the wider community where decisions
in respect to investments in HIV prevention effort are being made.
In respect to an enabling environment under the new sexual health
strategy, one of the things we have to do is provide good guidance
and a good sense of what is required from primary care trusts
who by and large will be responsible for making the investment
and commissioning prevention effort at a local level. What we
do in not providing that leadership is run the very same risk
that we have seen occur in our schools and that is provide inadequate
leadership and inadequate guidance in respect to what primary
care trusts should be doing in resourcing and investing in the
very prevention efforts that Nick alluded to earlier.
355. In terms of those presenting with HIV or
being diagnosed, has there been any significant change in the
(Dr Evans) There has been very little change in the
age profile over the years. There has been a slight aging in injecting
drug users but the number of new diagnoses in IDUs is small and
there has been an aging cohort effect. The median age in gay men
has remained remarkably constant over the last 15 years and that
in heterosexuals has been, if anything, creeping up a little bit
but not very much, so very little change. We know from new diagnoses
in people under 25 and other sexually transmitted infections rates
that the amount of unsafe sex, especially at a younger age, is
increasing, but we do see new infections across the age spectrum.
356. On the issue of section 28, to my mind
a false impression is given of the real issues in the media, particularly
the Terence Higgins Trust and the National AIDS Trust. To what
extent have you tried to engage with the media to encourage a
more calm, sensible coverage? Clearly, that stalls progress on
this issue because people are fearful of the outcry that any progressive
move might receive. Have you actively tried to engage with them?
(Mr Partridge) For almost 20 years. It is a bruising
experience at times. I remember bringing together agony aunts
from all the newspapers and to her credit Deidre in The Sun
has done some excellent work. Lumping the media together as though
it is all awful does a disservice to the media. We should not
under-estimate the positive impacts of that. The long, ongoing
story line with Mark Fowler in Eastenders is something the Terrence
Higgins Trust have been consulted on and sadly that is going to
come to an end soon but that has had an educative impact reaching
an audience that we at the Terrence Higgins Trust would otherwise
find very difficult to do. Where it gets very difficult is in
knee jerk reactions to particularly sex education in school stories.
We do see very mixed, very confused messages being sent out by
the media. It is tragically easy journalism to be able to polarise
between the views of, say, the FPA and one of the family values
groups. It is very simple to get a rent a quote response. Developing
a better debate has been far more difficult but we will consistently
try to ensure that we get a good, honest airing of the issues
so that there is better public understanding of sex education,
sex and relationships and what people of any age can do to ensure
that their sex lives are rewarding and healthy.
(Mr O'Reilly) From a health promotion and HIV prevention
point of view, the media provides one of those characteristics
of a good environment if it is treating the issue properly. It
creates a popular culture in which people are aware of HIV and
in which we can respond to it very well, but the point that Nick
makes underscores the fact that we cannot rely on the media for
the HIV prevention message. What we have to do is invest in efforts
to make sure that communities most at risk from HIV get an accurate
message that is not distorted by the media's interest in portraying
the issue in a particular way. Whilst we need to look at the media
for open and honest reportage and encourage it to lift its standards
in respect of its reportage of HIV, in respect of health promotion
and HIV prevention, the message has to be targeted and that targeted
message has to be supported by investment which is underscored
by real engagement with the communities most at risk, because
they are not going to get the message or the honesty that is required
from the media.
357. There has been a lot of work outlined with
gay men. Recently, we have had the increase in the Afro-Caribbean
population. Could that have been predicted in any way or are we
always going to be having to react to an emerging group?
(Mr Partridge) There has been an awareness in the
Terrence Higgins Trust in south London, given the population in
south London and what we knew of increasing rates of STIs and
of unwanted teenage pregnancies, that there was a clear area of
work for us to address. In that sense, yes, it could be predicted.
Being able to fund and create interventions we are still not as
good at doing in a timely fashion as we should be, because there
are always going to be very real sensitivities. These affect the
most vulnerable groups in a very vulnerable part of London and
it is terribly difficult to ensure that your interventions are
not going to be misunderstood, misused and seen as a potential
for raising issues of racism, similar kinds of issues that we
had right at the beginning of this epidemic, of how it may well
raise homophobia which thankfully we have been by and large able
to overcome. We have regularly been reigned in by our own timidity
matched with a lack of imaginative funding and forward thinking.
There are ways forward as we get better working relationships,
particularly in south east and east London, and a recognition
that we can make interventions. As we get a better tie in between
statutory health services and voluntary services we should be
able to take those risks. The difficulty is if we get it wrong
and some of the more malicious media find out about that and choose
to target it. Then it can damage that work for a number of years.
(Mr O'Reilly) What we know now provides us with an
opportunity to look back and see how in the future we might be
able to better predict where emerging infections might occur.
It also provides us with an opportunity to do more now because
what we know at the moment in respect to the emerging epidemic
in the African community and the Afro-Caribbean community is that
we do not know enough about it. One of the real challenges is
to invest in research to better understand the nature of the epidemic
in those communities. One of the things that we have in respect
to the epidemic amongst gay men in this country is a large amount
of social research whereby we understand sexual practices of gay
men, how they live their lives, how HIV impacts upon them. As
a result, we are better able to understand all of those factors
with a view to creating new prevention efforts. There are deficits
in respect to what we know about them and we need to make investments
to ensure that that information is kept up to date and we know
the plethora of concerns. We have much more information in respect
to gay men than we do African communities. One of the things that
we desperately need in order to make sure that our future interventions,
HIV prevention efforts, treatment and care efforts in respect
of the African communities, are effective is more information
about HIV in those communities and how it is affecting them. That
is a very significant challenge because without that information
our efforts will not be effective and useful.
(Dr Evans) In terms of research, in terms of sexual
behaviour, that is very necessary, but also we need to maintain
sensitive, confidential surveillance systems so that, at the very
first signs of an increase, we are able to flag that up as a warning
with people doing HIV prevention with communities. I have no doubt
that other parts of the globe will impact on the UK. We will see
certain communities within the UK more affected by HIV than they
have been previously. We need to maintain sensitive surveillance
within the UK to flag that up as an issue.
(Dr Weatherburn) My sense is that research funding
and funding to do with HIV prevention follows quite slowly after
emerging epidemics. It is still quite a substantial challenge
to fund research into gay men's sexual health. It is still almost
impossible to fund research into the needs of African communities
with HIV or affected with HIV. To try and trace what might happen
as a priority for research or for interventions seems somewhat
naive in the current climate of funding, both the prevention activity
and the research to support it.
358. What would make it easier?
(Dr Weatherburn) We need a far more responsive system
that allows the expertise around the table to say what might happen
and to invest and risk being wrong in looking at how we might
stop it happening or at least intervene early enough to minimise
the harmful effects. It is still very much the case that HIV follows
the fault lines of society. Marginalised groups are affected by
HIV. We mainstream the way we provide services around HIV and
HIV prevention but it is still an infection that fundamentally
occurs amongst groups that are marginalised from society or otherwise
socially excluded. We could conjecture now about who else might
be infected in the long term but that conjecture would be unlikely
to bring you money in the current funding climate.
359. Dr Evans, you have given us pretty much
a broad overview of the origins of the affected groups. What about
geographical distribution in the UK?
(Dr Evans) London has been more affected than other
parts of the UK. About two-thirds of the people with HIV are resident
in London in terms of having been diagnosed. We have seen over
the last couple of years a bigger increase in certain regions
outside London, especially in the ring around London, the eastern
region, the south east region, Trent in particular, and the north
west has been one of the more affected regions in terms of Manchester
in particular with its MSM epidemic. We are seeing changing patterns
and part of that is as people migrate from London or one can speculate
it might be to do with the dispersal of asylum seekers. We do
not know that for sure. We do not collect that information but
we have seen larger increases out of London in terms of African
people being diagnosed.