Memorandum by Dr A Menon-Johnsson (HA
"ACCESS FOR ALL"
THE NHS SHOULD
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.
Pollard and Savulescu, BMJ 2004;329:346-9
Care available to those who are ineligible to
full NHS care:
Services provided by A&E.
Notifiable infectious diseases/STIs.
Compulsory psychiatric treatment.
Adapted from Pollard and Savulescu, BMJ 2004;
Key arguments why all HIV patients should be
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
"Hotel" costs alone for
admission with an OI.
||2/52 = £4,200|
||4/52 = £8,400|
||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)
||= £666 (as Combivir)|
| d4T, ddI, NVP
| TDF, 3TC, EFV
| TDF, 3TC, LOP/r
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 =
Public Health reasons:
Voluntary Counselling and Testing (VCT) uptake.
Mother to Child Transmission (MTCT).
Barriers to HIV testing:
Not aware of treatment.
Additional barriers to the overseas visitor:
Lack of knowledge of the healthcare system.
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.
Experience of the NGO Partners for Health in the
resource poor setting = www.pih.org
VCT uptake initially poor and limited to those:
Or sexual partners of the sick.
VCT uptake rose significantly when offered:
Sexual Health screening.
Free Anti-Retroviral Treatment.
Mother To Child Transmission (MTCT):
A number of trials have shown benefit of:
Anti-retroviral treatment (ART):
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
HIV-positive persons are more susceptible to develop
active TB after exogenous re-infection.
Risk of poor response to TB treatmentincluding
mortality and rates of relapseis greater among HIV-positive
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
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.
Principle of temporal neutrality.
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
Universal Declaration of Human Rights (Key articles):
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
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.
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.
Hypothecated to the Healthcare sector.
Including supply of affordable (free) treatment.
Support to civil society.
Arms embargo when internal conflict /civil
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.