Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 360-379)



  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.


  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.


  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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