Select Committee on Health Written Evidence


Memorandum by Dr A Menon-Johnsson (HA 17)



  Those not eligible for full NHS treatment:

    —  Students on courses for < 6 months.

    —  Those who have not yet submitted an asylum or refugee application to the home office.

    —  Those who have had an asylum application turned down and exhausted the appeals process.

    —  Illegal immigrants.

  Pollard and Savulescu, BMJ 2004;329:346-9

  Care available to those who are ineligible to full NHS care:

    —  Emergency treament.

    —  Services provided by A&E.

    —  Notifiable infectious diseases/STIs.

      —  HIV excluded.

    —  Family planning.

    —  Compulsory psychiatric treatment.

  Adapted from Pollard and Savulescu, BMJ 2004; 329:346-9

  Key arguments why all HIV patients should be treated are:

    —  Economic.

    —  Public Health.

    —  Duties/Ethics.

    —  Human rights.

  Spending money to save money:

    —  Primary care is cheaper than secondary care which is cheaper than tertiary care.

    —  Estimated cost to care for one HIV positive person per year in London = £10,000.

    —  Inpatient "hotel" charges = £300/night.

    —  "Hotel" costs alone for admission with an OI.

—  PCP 2/52 = £4,200

—  Tuberculosis 4/52 = £8,400

—  Toxoplasmosis 6/52 = £12,600

  These "Hotel" costs do not include cost of treatment for the above conditions. All patients who present with AIDS defining illnesses need to start HIV treatment too.

  HIV treatment costs:

    —  Drug costs/month (NHS)
    —  AZT,3TC,EFV = £666 (as Combivir)

    —  d4T, ddI, NVP = £606

    —  TDF, 3TC, EFV = £755

    —  TDF, 3TC, LOP/r = £882

      —  Drug price discounts based on time the drug is on the market, certain combinations and size of cohort.

      —  WHO estimated cost of generic first line Rx = £12/month.

      Public Health reasons:

      —  Transmission.

        —  Voluntary Counselling and Testing (VCT) uptake.

      —  Mother to Child Transmission (MTCT).

      —  Tuberculosis (TB).

      Barriers to HIV testing:

      —  For all patients:

        —  Stigma.

        —  Not aware of risk.

        —  Not aware of treatment.

      —  Additional barriers to the overseas visitor:

        —  Lack of knowledge of the healthcare system.

        —  Language barrier.

        —  Cost.

        —  Fear of disclosure.

      Voluntary Counselling and Testing (VCT):

      —  Patients are more likely to test if something can be done:

        —  Note experience of HIV testing in the UK prior to anti-retroviral treatment (ART).

      —  The NHS currently only provides HIV testing and counselling to those ineligible to full NHS care.

      VCT uptake:

      —  Experience of the NGO Partners for Health in the resource poor setting =

      —  VCT uptake initially poor and limited to those:

        —  Who are sick.

        —  Or sexual partners of the sick.

      —  VCT uptake rose significantly when offered:

        —  Primary care.

        —  TB screening.

        —  Antenatal services.

        —  Sexual Health screening.

        —  Free Anti-Retroviral Treatment.

      Mother To Child Transmission (MTCT):

      —  A number of trials have shown benefit of:

      —  Anti-retroviral treatment (ART):

        —  Zidovudine.

        —  Nevirapine.

        —  Stavudine.

        —  Didanosine.

      —  Caesarean section.

      —  Bottle-feeding.

      —  Reduce MTCT from 33% to 1%.

      —  Opt-out antenatal services now exist.

      TB: HIVs' most constant companion:

      —  Progression to AIDS and death is more rapid when an individual is co-infected with TB.

      —  HIV patients 100x more susceptible to develop active TB.

      —  HIV-positive persons are more susceptible to develop active TB after exogenous re-infection.

      —  Risk of poor response to TB treatment—including mortality and rates of relapse—is greater among HIV-positive individuals.

      —  ART, when indicated, can improve survival and decrease risk of progression to AIDS.

      —  In 2002: ~6,900 new cases of TB were diagnosed in the UK:

        —  3,000 of these new TB cases were in London.

        —  200 cases of TB in HIV infected persons per year.

      —  HIV screening is part of TB management:


      —  Duties of a doctor (General Medical Council):

        —  Make the care of your patient your first concern.

        —  Respect patients' dignity and privacy.

        —  Work with colleagues in the ways that best serve patients' interests.

      —  Moral principles:

        —  Principle of temporal neutrality.

        —  Duty of easy rescue.

      Human Rights:

      —  The relationship between human rights and HIV/AIDS prevention and control has proceeded through three phases:

        1.  Application of public health measures.

        2.  Recognition that discrimination against PLWHA reduced the effectiveness of public health prevention methods.

        3.  Vulnerability to HIV infection:

        (PLWHA = people living with HIV and AIDS).

      —  Vulnerability addressed through a Human Rights framework

      Universal Declaration of Human Rights (Key articles):

      —  Article 2:

        —  Everyone is entitled to all the rights and freedoms set forth in this Declaration, without distinction of any kind, such as race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status.

        —  Furthermore, no distinction shall be made on the basis of the political, jurisdictional or international status of the country or territory to which the person belongs, whether it be independent, trust, non-self-governing or under any other limitation of sovereignty.

      —  Article 25:

        —  Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.

        —  Motherhood and childhood are entitled to special care and assistance. All children, whether born in our out of wedlock, shall enjoy the same protection.

      Data from the FXB Center for Health and Human Rights at Harvard School of Public Health (1994) shows that the quality of public health delivery is directly related to human rights quality.

      Other important strategies in addition to HIV treatment include:

      —  Focus on improving home situation.

        —  Development funding:

    —  Hypothecated to the Healthcare sector.

    —  Including supply of affordable (free) treatment.

        —  Women's Rights.

        —  Support to civil society.

        —  Arms embargo when internal conflict /civil war.


      —  HIV is cheaper to treat in primary/secondary care.

      —  HIV treatment facilitates the uptake of testing + has significant public health benefits.

      —  Failure to treat a patient with advanced HIV disease is in conflict with duties of the doctor and moral principles.

      —  Health is a basic human right.

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Prepared 21 March 2005