Examination of Witnesses (Questions 626-639)
THURSDAY 12 DECEMBER 2002
DR SIMON
BARTON, MR
SIMON COLLINS,
MS RUTH
LOWBURY, DR
ADE FAKOYA,
MS CHRISSIE
GREEN AND
MS HEATHER
WILSON
Chairman
626. Good morning, may I welcome you to this
session of the Committee and particularly thank our witnesses
for their co-operation with our inquiry and for the written evidence
you have given us, which has been very helpful? It is traditional
for you each very briefly to introduce yourselves and say a bit
about yourselves before we start. May I begin with you, Mr Collins?
(Mr Collins) First of all, I am a patient.
I have been HIV positive since the late 1980s so have about 20
years' experience of HIV. I have been working in the voluntary
sector for the last five years in two voluntary projects which
provide publications to healthcare professionals, a bulletin for
doctors every month, and a range of patient guides to keep patients
informed. We provide a direct treatment support line for patients
and are also involved in some European treatment networks for
patient access.
627. Who funds your work? Is it a range of sources?
(Mr Collins) It is a very good question. It is very
hand to mouth. Although our organisation has been running for
several years, there is no money in the bank at the end of the
month and it is very difficult to identify a central fund which
links to the NHS given the services we provide. We get some funding
from independent charities and some funding from the pharmaceutical
industry.
628. That in itself is clearly an issue from
your point of view.
(Mr Collins) It is. In order to keep going it is an
ongoing issue. It is very difficult.
(Ms Green) I am Chrissie Green, I have worked in HIV
for about 11 years now both as a clinical nurse specialist in
the community and as a senior ward sister of a dedicated HIV unit[2]
(Dr Barton) I am Simon Barton. I have
been a consultant at the Chelsea and Westminster Hospital for
12 years. For the last six of those I have been Clinical Director
of the department of HIV and GU medicine which runs three sexual
health clinics on three sites and the largest outpatient and inpatient
community care unit for HIV patients in the UK.
(Ms Lowbury) I am Ruth Lowbury. I am
the Director of the Medical Foundation for AIDS and Sexual Health
which is a small charity supported by the British Medical Association.
We work to influence policy and improve the practice of health
professionals in relation to HIV and other sexually transmitted
infections. We have recently been producing new standards for
NHS HIV services and facilitating the further development of service
networks for HIV. That work is supported by the Department of
Health, London health authorities and the British HIV Association
and PACT which is the national association of NHS Providers of
AIDS Care and Treatment. Before I did this job, which I started
two and a half years ago, I used to manage the sexual health and
HIV programme at the then health education authority and I have
been working in different aspects of sexual health for over 20
years.
629. Your organisation was initiated by the
BMA, presumably because of concern by doctors about this area.
(Ms Lowbury) Yes; by the BMA and people close to the
BMA in the late 1980s when there was a lot of anxiety among the
medical profession about the implications of HIV.
(Ms Wilson) I am Heather Wilson and I am the Chair
of the National Society of Health Advisers on Sexually Transmitted
Diseases. I have been a health adviser working in sexual health
since 1989. For the first five years I worked at the Middlesex
Hospital, which is now the Mortimer Market Centre and since then
I have been the senior adviser at Barnet Hospital, North London.
630. Do you have a nursing background?
(Ms Wilson) No, I am actually a social worker. Originally
before becoming a health adviser I worked as a social worker in
a community health centre.
631. Would the majority of your membership have
a social work or nursing background?
(Ms Wilson) Yes. 77% of our members are from a nursing
background, mostly in sexual health. The minimum qualification
to be a health adviser is either to have a RGN or a qualification
in social work. On top of that we have had counselling training
or relevant experience.
(Dr Fakoya) I am Dr Ade Fakoya. I am a consultant
in HIV and GU medicine at Newham General Hospital which is in
East London. I have been the lead for HIV in the service for the
last five years. I have a particular interest in HIV in pregnancy—Newham
has one of the highest rates in Europe, between 1 in 150 and 1
in 250 pregnant women are HIV positive—and also in dealing
with HIV infected individuals from African communities. Newham
has quite a lot of co-infection with tuberculosis and Newham as
a borough has a rate five times the accepted WHO standard for
TB.
632. May I begin with a very general question?
This inquiry was motivated by a general recognition of concern
that there were serious problems in the area of sexual health
policy. In looking at some of the figures we have been given in
information for this specific session, the Kingston Hospital reports
the number of new HIV diagnoses increased by 77% last year. In
the years between 1996 and 2000, South-West London clinics experience
a 775% increase in the number of HIV patients. Why do we have
such a huge increasing problem? In what ways has the pattern of
HIV transmission changed?
(Dr Barton) The increase has been noticed not just
in London but across the country and those figures you give are
very well put in the PHLS report which regularly reports increases
and is projecting a further 50% increase across the next three
years. Where has that come from? If you look at new diagnoses,
albeit with the understanding that those individuals might have
been positive previously, but at newly diagnosed individuals,
the increase is coming from men and women who have had sex with
each other, heterosexual transmission, rather than a continuing
increase amongst men who have had sex with men. When you then
break that down, that increase is in the main coming from people
who were not infected in this country, who have come here, having,
we assume, been infected elsewhere by heterosexual transmission.
The biggest growth is in southern and south-eastern Africa. That
in itself is placing different stresses and strains on clinics
and different stresses and strains on those caring for patients
and supporting patients and on the support groups and the networks
and the information channels which have been used. Another factor
is that obviously we are seeing individuals faced with problems
because of the waiting times to access genitourinary medicine
(GUM) sexual health services, that there are now access issues
to get in for your HIV test, which may be impacting from the busier
centres dispersing people who then receive their test at a centre
further away. So clinics which historically did not have a lot
of HIV new diagnoses, might see them for that reason and also
because many of the individuals are seeking asylum and may be
being dispersed through the programme. Yes, the problems are increasing,
getting ever more complex as well as greater numerically and because
people are not dying, which is the wonderful thing about having
looked after HIV patients over the last seven or eight years,
the prevalence, the case load of individuals you are looking after
is increasing and placing an ever increasing burden on the services.
As those patients tend not to access general practitioners, preferring
to seek their treatment in the open access units which deal with
and specialise in HIV, that compounds the problem of us dealing
with many issues of their health care, some of which are related
to HIV, some of which might have been related to their HIV, but
it is placing a wider spectrum of care on the multi-disciplinary
team in HIV units. Yes, it is increasing. Yes, it is more complex.
(Dr Fakoya) Simon has made most of the points. Points
to add would be that it is recognised that at any one time about
one third of the cases are undiagnosed. There is always a pool
of people who have not been diagnosed and also that many of the
people who present actually present quite late, in the late stages
of their disease. There are questions as to how long they have
actually been in this country with the disease or whether it is
a newly acquired, whether they are newly arrived in this country
and whether transmission goes on in the different communities
within the UK. Those are the important points.
633. One of the points which has been raised
with us during the inquiry, is that because the prognosis for
HIV sufferers has improved significantly an indirect or possibly
direct consequence of that has been an increase in risky sexual
behaviour. Whereas perhaps in the 1980s and the early 1990s with
the knowledge of AIDS, and many of us would have known people
who died of AIDS, people were much more cautious in terms of their
sexual activity, the picture we are getting is that that now has
changed and that risky behaviour is quite prevalent, particularly
within the gay community. Is that a fair perception? I ask all
of you.
(Mr Collins) In terms of transmission risk, which
I guess is the key point in terms of the rate of new infections,
it does not tend to be from people who already know their HIV
status. The risk of infection is higher if you are not on treatment
and it is higher if you do not know your status and it is much
higher again if you have been recently infected. All those situations
occur mainly to people who are not aware of their sexual health
and are not aware of the implications of sexual activity. It is
not particularly fair to pick out gay men in this situation because
basically there is no increasing incidence amongst gay men. Generally
men who have been diagnosed HIV positive are well aware of their
status and are very unlikely to be the route for new transmissions.
634. I am not particularly singling out gay
men. The evidence we have received certainly reflects what we
were told in Manchester about their concern at the way in which
gay men in their area were involved in very risky sexual behaviour.
The whole idea of anonymous partners, not knowing who their partners
were, makes it very difficult for the GUM clinics who are treating
them to trace partners affected. That is the area of concern.
(Mr Collins) I would probably bring it down to public
health and sexual education in schools being a really important
issue. What you have is a generation which has not had that experience
of HIV from 20 years ago when all their close circle of friends
either became ill or they died much earlier than they should have
done. For example, several of the calls I have received this week
on the treatment phone line have been directly related both to
heterosexual and gay men who have no background in sexual history,
they have no understanding of sexual disease, they have no understanding
of risk reduction behaviour. I guess I take that back to providing
information in schools when people first become sexually active.
Something like 25% of new infections are in men who are under
25 and for me personally that is a very shocking statistic on
how to address that other than providing people with new information
they need in order to protect their health.
635. Clearly an issue we have looked at as a
committee is sex education and we are going to have a session
after Christmas specifically on this. It is an area where we have
lots of evidence. Do you feel, particularly in relation to young
gay men, that the current arrangements for sex education are appropriate
and do you have worries about the constraints there are within
the school system? Do you feel there are changes which should
take place, particularly as it relates to young gay men?
(Mr Collins) As I understand it, providing accurate
information is impossible within the current education system.
It knocks on both to providing information to gay men and to heterosexuals.
It is a very difficult subject and people have very little understanding
of how to protect their sexual health as they are developing.
636. Are you basically saying this is something
the Committee ought to take very seriously in our recommendations?
(Mr Collins) I am.
(Ms Green) I want to endorse that. It is extremely
important that we look at sexual health education within schools,
from the heterosexual point of view as well. We are certainly
seeing young girls coming into the GU clinics; there is an increase
in chlamydia and gonorrhea so you know they are having unprotected
sex. I really do believe that the young think it is somewhere
out there and does not affect them. They do not see the danger.
The reason for that is that we are very, very bad at giving sex
education in schools.
John Austin
637. I want to pick up two things Mr Collins
said. You were stressing the importance of good sex education
when people become sexually active. Would you think that is perhaps
too late and that good sex education may be necessary before people
become sexually active?
(Mr Collins) Yes, that is definitely a point of view.
That also links to the fact that the UK has one of the highest
teenage pregnancy rates, does it not? Yes, knowledge is important.
(Ms Green) There will be people who say you cannot
start sex education until a certain age and it is wrong and you
will be encouraging people to have early sex and things like that.
There are very specific ways in which you can teach really quite
young children about keeping their bodies safe, knowing about
their own bodies and in that way you can then lead on to sex education
and hopefully you will educate them before they are sexually active.
638. Are you aware of any evidence?
(Ms Wilson) There was a review in the BMJ this year
which looked at primary prevention programmes for teenage pregnancy
and found that the way to be effective, in fact they recommended
it, was to look at starting as young as five. That was one of
the recommendations in that report. It was a very big study.
639. Is there any evidence you know of which
suggests that early education actually leads to earlier engagement
in sexual activity or the reverse?
(Ms Wilson) No, the opposite.
(Dr Barton) We do know that the age at which people
start having sex is falling, even though the age at which they
receive sex education is not being reduced in most schools. If
you are going to keep up with events and prepare people before
they have a teenage pregnancy, before they acquire chlamydia,
the only mechanism is by dropping your age and doing that experiment.
That has not been done in any concerted, organised way. It is
left to individual schools to be brave and organise that locally.
2 Note by witness: The main focus of my present
role is support around adherence to highly active antiretroviral
therapy (HAART). I also support people with new diagnosis and
offer ongoing support. An increasing number of referrals come
via antenatal services and the paediatric unit. I take referrals
for any HIV positive people living in the boroughs of Hounslow
and Ealing. During the course of my work I liaise with both statutory
and voluntary service. I have strong links with both WMUH and
Ealing hospitals where I take part in
multidisciplinary adherence clinics. I also liaise with any acute
treatment centres that my patients attend. Back
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