Examination of Witnesses (Questions 360-379)
DR BARRY
EVANS, MR
NICK PARTRIDGE,
MR JOSEPH
O'REILLY, DR
PETER WEATHERBURN,
DR ALEC
MINERS AND
MR JOHN
IMRIE
TUESDAY 23 JULY 2002
360. Is that something that more work needs
to be done on?
(Dr Evans) More liaison with policy colleagues in
terms of the major implications, in terms of if we do have dispersal
of asylum seekers the implications of that for local HIV services
are considerable, in terms of potentially a large increase in
a clinic that has only seen a small number of HIV infected individuals,
both in the quality of care, in the language or other ethnically
appropriate services for those individuals being diagnosed and
the appropriateness of antenatal care as well. We need to make
sure that we liaise with colleagues and not be surprised when,
if you have a policy of dispersal of asylum seekers from high
prevalence parts of the world, you then say that is going to have
a big effect on local HIV services.
(Mr Partridge) It seems to me this is not solely about
dispersal of asylum seekers but, in terms of the national strategy
and how that sees an enhanced role for primary care, as the number
of people living with HIV continues to grow in this country and
will naturally disperse out from the centres that we have seen
so far, that does create real challenges for the training of primary
care staff in issues as simple as confidentiality, access to treatment
and so on. There are issues that we know from surveys that we
have carried out about concerns that many people with HIV have
about discrimination that they face within the health service
and within GPs' surgeries, so how that is going to be dealt with.
There is something about how that more diffuse nature of the epidemic,
what that means in terms of the strategy for resourcing and for
minimum, poor standards for services and how those can be built
on the BMA foundation of evidence that you have already heard.
Finally, a key issue of how we encourage PCTs to form consortia
in order to be able to meet the demands that are going to be placed
on them and that is going to be really key. How do we encourage
what are new health bodies to work together in order to be able
to meet the prevention challenges which need to be done over a
larger population basis than the average primary care trust would
cover. It has to be done with a consortium arrangement. One of
the things that I would certainly urge the Committee to look at
very carefully is the encouragement of the Department of Health
that you could give to ensure that appropriate, robust funding
happens at an appropriate level, because this is not going to
be able to be done by individual PCTs, whether in developing clinical
networks for clinical care or consortium arrangements for social
care, advice, peer support and so on.
Andy Burnham
361. You mentioned dispersal of asylum seekers.
Is there any attempt made at the moment to screen people when
they arrive in the UK?
(Mr Partridge) No, there is not.
362. There is no attempt to find out if they
are HIV positive?
(Mr Partridge) There is no attempt made to find out
whether people have tuberculosis or a range of health conditions.
363. We are in very controversial territory.
Obviously it would make the lives of the public health laboratory
services easier but it is controversial in terms of human rights.
What would you say to this?
(Mr Partridge) Having any kind of testing process
at borders has not worked. If you look at, say, the experience
in the United States of America, which has an exclusion around
its borders of people living with HIV, it has failed in all senses
to prevent a far more substantial epidemic than we have in this
country. It would be damaging in human rights terms and damaging
to our own sense of ourselves as a nation. I do not think it has
any place. It is just not going to work, it would be hugely expensive
to implement and it would help no one.
(Mr O'Reilly) HIV testing is obviously a very topical
issue. Only yesterday there were front page articles in both of
the major dailies in respect of doctors and nurses joining the
NHS, but the principle still is that any testing for HIV cannot
ever be mandatory. Wherever coercive attempts to test people for
HIV have been instituted, they have failed for a variety of reasons
and they have caused huge other problems in respect to getting
people to be open about their status. They have worsened stigma
and discrimination associated with HIV and they have undermined
the prevention effort and surveillance effort. Whether at the
border or in respect of someone seeking employment in the NHS
or anywhere else, mandatory HIV testing has to be dismissed at
the outset.
Sandra Gidley
364. As you have mentioned the subject that
was highlighted in yesterday's Times, Dr Evans, as far
as I am aware, no health worker has caused a transmission of infection,
but I wondered what your view of the Times article was
yesterday. Is there a risk? Can we say it is safe? Are you in
a position to say at all? Do you have any predictions as to the
future shape of the epidemic in the UK?
(Dr Evans) In terms of the worldwide literature around
transmission of HIV from a health care worker occupationally to
a patient, there have only been two cases, one in France and one
in the US, one a dentist and one an orthopaedic surgeon. The issue
of performing what are called exposure prone procedures, where
effectively you cannot see the tips of your fingers because they
are in the patient's body and you are sewing or whatever, they
are not giving injections. The picture in the Times yesterday
was very misleading because that is not an exposure prone procedure.
You do not jab yourself or if you do, you do not use it to inject
the patient. Theoretically, there is a risk in terms of an HIV
infected health care worker performing exposure prone procedures,
operative surgery and so on. That risk is extremely small, we
know from the world literature, but a person who is diagnosed
with HIV in this country is not allowed to perform exposure prone
procedures. Most nurses do very little in the way of exposure
prone procedures. They may act as a scrub theatre assistant and
may assist operatively and in intensive care units they may do
exposure prone procedures but most ordinary nurses on the wards
do not perform exposure prone procedures. It is only with exposure
prone procedures that any risk occurs at all. We know that risk
is extremely small because of only two instances in the world
literature. Anyway, nurses perform very few exposure prone procedures.
All of that makes us say that the risk is extremely small under
these circumstances. If someone has been diagnosed with HIV, they
are not allowed to perform exposure prone procedures whether they
are from Africa, whether they are a gay man, whatever their exposure
category. The same rules apply.
365. There would be plenty of useful jobs they
could do in the health service with no patient risk?
(Dr Evans) Yes.
(Mr Partridge) The other contextualisation is that
this should be seen as being blood borne viruses as a whole and
what applies to hepatitis C and HIV. There is no reason why people
who do test positive should not be able to retrain and use their
skills within the NHS or elsewhere very effectively.
366. Anything about future trainers?
(Dr Evans) It is very difficult to see, when we are
talking about the sensitivity of research and surveillance, in
terms of what other parts of the world are going to impact on
the UK and what the policy of migration in terms of the African
impact in the UK is. We have an ongoing epidemic and transmission
in men who have sex with men. I think it is still tragic that
1,500 new infections are diagnosed each year in men who have sex
with men. Our best guess is that roughly the same number of new
infections are occurring each year because we are not seeing any
aging of that epidemic. We are going to see an increasing but
gradually increasing number of heterosexuals infected within the
UK. I do not think we are going to see an exponential rise but
we are going to see more transmission within the UK heterosexually.
We have already mentioned the impact of other parts of the globe,
so an increasingly complex epidemic, increasing numbers as people
live longer, taking newer treatments, and increasing complexity
around their care as more develop resistance and therefore second
line therapies. There is a lot going on and that on top of a big
increase in other sexually transmitted infections. So our GUM
colleagues are faced with chlamydia screening, with a big increase
in other STIs, complexity of HIV and HIV numbers going up pretty
sharply. Our initial look at our annual prevalence survey suggests
a 16 per cent rise in 2001 compared with 2000. That is a lot of
extra people.
(Mr Partridge) We are also seeing people being diagnosed
who are poorer, less well educated and who have a greater number
of more complex needs, so not only are we facing an increase in
number year-on-year of the 16 per cent that Barry just alluded
to, but we are also seeing people, a sub-set of whom have multiple
and complex needs both in a clinical setting and in more social
care setting provided by social services in this country, and
we are seeing rapid increases in demand, and it is going to be
harder and harder for us to provide a broader range of services
to more diverse people than we have in the past.
Julia Drown
367. You said a bit about the social services
that government needs to be sure are there for people with HIV,
in particular the PCTs who work together to get a preventative
service together. Particularly given there is such a differing
incidence across the country of two-thirds of HIV diagnosis in
London, what is the priority in terms of getting government to
ensure that HIV services do meet the right quality and standards?
Can that be delivered in each and every area or does it lead to
concentration of services?
(Mr Partridge) Certainly money alone is not going
to be the answer of how we help. How we choose the structures
is a huge challenge for both colleagues in GUM services and how
we create networks of clinical care in which someone who is receiving
their clinical care in a very low prevalence area can also be
guaranteed that they will be receiving high quality, up-to-the-minute
care, because HIV medicine thankfully develops really very rapidly,
so the consistency with which new minimum standards of care and
best practice guidelines are updated needs to have a conduit,
from the centres of excellence held in the major metropolitan
cities through to the networks of clinicians.
368. How much of that is happening at the moment?
(Mr Partridge) I think it happens patchily. It is
not well-structured and I think it depends as much on past friendships
as on current robust training. It is not structured and that means,
for a person with HIV, it results on luck. No person with HIV
should be placed in that position, and it still does mean many
people with HIV travel considerable distances to access their
specialist HIV care. It creates other difficulties in the more
social environment, and I think there are substantial risks that
we need to be able to overcome for funding for, say, voluntary
sector organisations. We had an experience recently when Avon
County Council was disaggregated into three unitary councils,
and the impact on the Aled Richards Trust, which we merged with
and became Terrence Higgins Trust West, was in that disaggregation
one of the new unitary councils deciding it did not wish to fund.
That meant the Aled Richards Trust was faced with an immediate
25 per cent cut in its funding which destabilised the whole of
that unit. I fear there are potentials for that to happen as health
authorities, if you like, are being structured down into PCTs,
so it is how we ensure a consistency of funding that is appropriately
used, meets local needs and gains all of the benefits that primary
care trusts have for local populations, but does not mean that
organisations find parts of their funding being sheared off. This
recommendation that the Department of Health just monitors the
impact of this really is not enough for a voluntary sector in
this country which is mainly financially vulnerable, mainly working
on the margins, does not have substantial financial reserves,
and—one of the key issues for many organisations—is
managing cash flow. So I think how we see ourselves through this
period of rapid structural change within the NHS and how we constructively
engage with that, certainly the Terrence Higgins Trust and Lighthouse
is looking at new models of care so we can look at innovative,
integrated care services, for example. If you want to come and
visit our new integrated care service with King's College in Denmark
Hill, that is a really fascinating way of bringing together charitable
fund raising, local social services and the hospital in providing
an integrated service for people with HIV so they do not need
to be assessed two or three times. Those are the kinds of things
we need to be looking at.
369. You are saying that national monitoring
is not enough. Does the Avon experience suggest that you do not
think local politicians can be trusted for supporting local voluntary
groups in their way?
(Mr Partridge) I am not sure if it is local politicians.
It is down to PCTs and commissioning, and because HIV and sexual
health—this is not solely about HIV. Broadly there are issues
for Brook, FPA, for all of the voluntary services allied with
HIV and sexual development, focusing on HIV and sexual development—is
not a priority for PCTs, it is not on the 20 "must dos"
in the SAF round, it has not got a national service framework.
Now diabetes, for example, is not on that top 20 list either but
it does have a national service framework. What concerns me is
that at the moment HIV and sexual health has neither, so it has
very little to encourage chief executives of primary care trusts
to ensure that sexual health and HIV need is met and that good
competent people are placed to work collaboratively—and
we know that working consortia is difficult. It is often slow;
it only takes one person to say "No" and the whole thing
can collapse—
370. So it is about keeping it high enough on
the agenda.
(Mr Partridge) Yes, whether it is done through SAF,
through the NSF, but it needs to find greater clarity because
we also know that HIV and sexual health can get health authorities
into trouble. It can be at local media level—"Why is
this money being spent on African people or on gay men?"
It is very easy to knock and, if you have major deficits elsewhere
I fear that some may say, "Well, actually it is not on the
top 20, not in the NSFs, I think I can get away by drawing some
money out of this", and if that happens we risk unpicking
very rapidly the major advances in steps being made both in GUM
services, in social services and in voluntary services.
John Austin
371. I do not expect you to answer this now
necessarily but you point to the fact that there is no national
service framework in this area. Does your organisation have a
ready-made NSF which you would like to see the government adopt?
(Mr Partridge) Oddly enough we have got the framework
for it and I think it would not be difficult with colleagues in
the BMA Foundation—or MEDFASH as it now is—with colleagues
on the clinical side and from our perspective, I do not think
it would be difficult for us to pull together an NSF very quickly
indeed.
(Mr O'Reilly) Just to follow up, I would reiterate
everything Nick says in respect to the need for central government
to put in place some sort of method other than a monitoring mechanism
to ensure that, at a local level, with the devolution of responsibility
for prevention, treatment and care in respect of HIV to those
levels, it occurs. One thing Nick did not mention in terms of
those changes was also the removal of the HIV ring-fence which
had previously existed. We had a pot of money which was spent
at a local level but which was monitored and targeted to particular
communities who were most at risk from HIV. The reality is that
monitoring, targeting and provision of money which was linked
to particular things failed by and large because in many areas
it was not spent on those areas, but it provided at least a mechanism
by which guidance could be provided. So in the absence of nothing
at all, apart from retrospective monitoring, our concern is that
in low incidence areas—and even in high incidence areas—people
will not get adequate care for all of the reasons that Nick outlined:
that HIV is sensitive and a difficult issue, something that primary
care trusts in the main might not like to deal with. At the moment
the real risk with the HIV Strategy is there is nothing in place
to ensure they do that work, and there is a real risk that HIV
and people living with it and the communities most affected by
it and vulnerable to it will fall through the gap, and what will
then happen is we will have compounding problems and increasing
incidence, difficulties in respect of people presenting late for
treatment, and the costs will be greater than the costs in investing
in the provision of a mechanism which makes sure that HIV is a
priority at a local level.
Chairman
372. Have any of you got any experiences of
where the health action zone has addressed this area and looked
specifically at HIV, AIDS and sexual health strategies in a way
you would feel is commendable that we might look at and perhaps
learn from in the process of our inquiry? You may want to come
back to us on that.
(Mr Partridge) Can I come back to you on that?
(Mr O'Reilly) I do not have a health action zone as
an example but I might say that the teenage pregnancy strategy
provides another framework which we could look to in terms of
guidance and central government leadership. I think we are learning
from some of those lessons and in discussions with the Department
we are looking at the establishment of some sort of mechanisms
which parallel that, but I think it would be fair to say there
is a quantifiable difference in political prioritisation of the
teenage pregnancy strategy as against the sexual health and HIV
strategy.
(Mr Partridge) Adding to that, the teenage pregnancy
strategy was created and implemented pre the shifting of the balance
of power, and I am not convinced that the same strategy could
be implemented in the same way in the new environment in which
we now work. Finally, we need to remember that, within all of
this, we have seen a 70 per cent rise in the number of people
living with HIV and seeking care since 1995 but only a 30 per
cent rise in resources made available to meet that, so we are
also dealing with PCTs that start often with a funding gap, so
we have to be very careful about how we are going to see this
pan out in years to come.
Julia Drown
373. Moving to a slightly different issue, I
am interested in where people with HIV first present themselves?
What proportion go to GUM clinics and what proportion go to GP
surgeries and other centres? Is that different from other STIs?
(Dr Evans) We do not have good information on that.
The majority of people get diagnosed within the GU setting. There
are some diagnosed within primary care but currently not very
many. Often, even if they present to general practice, they will
be referred to GU in terms of the initial counselling and then
testing. Some are diagnosed within ante-natal context and some
within family planning but the bulk of new diagnoses occur within
GU. A distressingly high proportion still are diagnosed late,
especially from the African community ,and as we were saying earlier,
this often takes place within an inpatient setting, having gone
into hospital with PCP or tuberculosis.
374. So in terms of that, it is similar to STIs,
where the bulk would be GUM?
(Dr Evans) The majority of STIs do get diagnosed within
GU, but chlamydia in particular has an increasing diagnosis within
a primary care context, and other STIs may be treated within general
practice but not have the diagnostic specimens to make the diagnosis.
They may get a course of antibiotics for a vaginal infection or
what may be thought to be a urinary tract infection, but the diagnosis
for an STI is not necessarily made within the primary care context.
375. Would it get recorded or not?
(Dr Evans) No. That would not be recorded as such.
(Mr Partridge) What should be added is the number
of people with undiagnosed HIV infection and the questions that
still remain about how all of us and the GUM service and the NHS
as a whole are going to meet the targets laid out in the national
strategy for reducing undiagnosed HIV infection, and for speeding
up access to GUM services and to clinic services. What we have
seen sadly over the past three years is the delay, the wait, growing
rather than reducing. There are significant challenges for the
service as a whole in order to meet those targets.
(Dr Weatherburn) In the absence of any more robust
data, in our recent experience it is relatively rare to encounter
a gay man with diagnosed HIV who did not learn of his diagnosis
in the GUM or HIV outpatient sector, but we are moving towards
the end of a relatively large peer-led survey of people, African
people with HIV in London, and having conducted the first 350
interviews we found that less than half were diagnosed with HIV
in outpatients, with a full third being diagnosed as an inpatient
in hospital after emergency admission, and another 10-15 per cent
being diagnosed through ante-natal testing or standard GP tests
that they had been persuaded to have. So there seems to be a huge
disparity between the two main groups—the African people
and the gay men with HIV, who we barely ask where they are diagnosed
because the answer is so obvious.
Chairman
376. When will that conclude?
(Dr Weatherburn) The fieldwork is about to conclude
at the end of the month so it should be published in September
or October.
377. So it will be within the timescale of our
inquiry?
(Dr Weatherburn) Absolutely.
John Austin
378. Dr Evans has said there is clearly evidence
to show on-going HIV transmission in men who have sex with men
through the 1990s and on-going. We have also received in evidence
some of the information of the behavioural surveillance work that
has been carried out. I wonder if Mr Imrie could summarise that
work?
(Mr Imrie) I presume that you are speaking to the
behavioural surveillance with respect to gay men?
379. Yes.
(Mr Imrie) And I would just like to confirm that all
of the members of the Committee did receive the memorandum because
I think, rather than discussing in any detail the nature of the
various surveillance mechanisms that are in place, I would address
the headlines and then talk perhaps a little bit about the interpretation.
Among those with diagnosed HIV infection and also those with undiagnosed
HIV infection. Among men nationally, of the men who report having
engaged in anal intercourse more men are reporting using condoms.
I think this is a point that perhaps sometimes gets lost in a
lot of the surveillance data. However, at the same time, and it
may seem apparently contradictory, the proportion of men who report
having engaged in unprotected sex is also increasing.This may
appear at once contradictory but I think what it shows is that
we are moving away from a kind of dichotomised group, where people
are either non- condom users or 100 per cent condom users. I think
it also indicates that we are seeing that people are developing
over the years of the epidemic ,more sophisticated strategies
that may involve them making decisions in particular situations
about when they feel there is a greater risk or there may be less
risk, or they may be influenced by other factors—alcohol,
drug use, that sort of thing. I think it is important to understand
that in a sense what we are seeing is a breakdown of this dichotomisation,
and what we also see is that the proportion of men who report
never using condoms has remained very small.The proportion of
men who say they routinely use condoms continues to be high ,but
also those who have lapses or inconsistencies or do not use condoms
every time is the area where we are seeing the greatest increase.
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