APPENDIX 16
Memorandum by Dr Jane Anderson (HA 22)
1. This memorandum has been written by Dr
Jane Anderson, PhD, FRCP, an HIV specialist physician in East
London based at Homerton University Hospital Foundation Trust,
Hackney. I am currently the Director for the Centre for the Study
of Sexual Health and HIV at Homerton University Hospital NHS Foundation
Trust. I also hold positions as co-chair of the African HIV Research
Forum and as Honorary Secretary of the British HIV Association.
Having worked in the field of HIV medicine since 1984 and at consultant
level since 1990 I have direct experience of the impact and management
of HIV both before and after the availability of effective therapy.
My comments to the committee are based on my direct clinical experience
and my research work and have been formulated within wider discussions
with colleagues in both statutory and voluntary sector organisations.
2. Our clinic serves a cohort of 450 HIV
infected people a majority of whom are from overseas, particularly
from African backgrounds and many either have been or currently
are involved in the immigration process within the UK. My work
also encompasses research and I have been involved in large studies
on the experiences of African people living with HIV in London.
3. The policy changes that have been enacted
require that long stay visitors, those refused asylum or leave
to remain (but not yet removed from the UK) and all undocumented
people should be charged for every NHS hospital service other
than those carried out for emergencies or for those listed as
exempted conditions. It is my opinion that most Individuals who
will attract charges are those who are least likely to be able
to pay and this will impact on their access to care.
4. All sexually transmitted infections (STIs)
other than HIV remain exempted from the new charges, as is treatment
for tuberculosis. Putting HIV outside the regulations for all
other STIs and tuberculosis is inconsistent not only with good
clinical practice but also with the government's other policies
concerning the proper diagnosis, management and containment of
sexually transmitted infections and HIV.
5. Although no cure exists for HIV there
is now effective suppressive therapy. Since 1997 the evidence
that Highly Active Antiretroviral Therapy (HAART) reduces mortality
and morbidity in people with HIV infection has been substantial.
Based on published scientific evidence the British HIV Association
(BHIVA) produces clinical guidelines for the appropriate treatment
of people with HIV infection. These guidelines are now considered
by the medical profession and those who commission health care
to define the proper standard of clinical care for people with
HIV in the UK and are the benchmark for my own clinical practice.
6. There is now agreement that the outcomes
of therapy are improved in those patients who start treatment
before their immune system is too profoundly damaged. In consequence
the numbers of people dying from HIV or progressing to AIDS have
fallen dramatically in the UK in recent years. However, those
who are still dying of HIV and its complications are frequently
people presenting for the first time with advanced infection.
In the main they have been unaware of their HIV status and thus
failed to access appropriate therapy. National data from the Health
Protection Agency (HPA) and from a BHIVA audit reveal that a high
proportion of late presenters are from African backgrounds. This
is certainly true of the situation in East London and many of
the people who attend our service have very advanced HIV infection,
are frequently very sick and need immediate therapy.
7. HIV infection results in progressive
loss of immune competence which lays the infected individual open
to a range of serious and potentially life threatening complications.
Such complications present as emergencies and frequently require
prolonged and complex in-patient hospital stays which may necessitate
the use of intensive care facilities. Some, once established,
are incurable.
8. For as long as the individual remains
severely immunocompromised such emergency complications can occur
repeatedly, necessitating sequential hospital stays. In my experience
these admissions can last for many weeks at a time and patients
may need to be managed within the intensive care unit. There is
substantial evidence to demonstrate the role played by HAART in
allowing immune restoration and a subsequent fall in the complication
rate which in turn reduces the impact of HIV on inpatient beds.
9. Treatment of emergencies only with no
consideration given to reversing the underlying cause of the immune
compromise is not only inconsistent but also poor clinical practice.
This is particularly the case in an environment where effective
preventative therapy is readily available. To manage HIV infection
in this way would be in breach of the BHIVA guidelines and would
place individual clinicians in a very difficult position in terms
of proper clinical practice, and is likely to use significantly
more resources than would be the case if the HIV itself were appropriately
treated.
10. Tuberculosis and HIV co infection is
common in non UK born HIV infected people. The appropriate standard
of care for HIV/TB co infected patients includes antiretroviral
therapy. Tuberculosis is included in the list of exempted conditions
whilst HIV is not. A consequence of this legislation is that some
HIV/TB co infected patients (often within the same treatment centre
under the care of the same medical team) will receive optimum
treatment under current guidelines and others will not, based
entirely on their immigration status. There are significant ethical
issues that are raised for clinical staff working in this situation.
11. High rates of psychological distress
resulting from past life experiences are observed in migrants'
especially in those fleeing conflict. Many have seen the consequences
of untreated HIV in close family members. Uncertainty and complexity
of the asylum process fuels levels of anxiety and depression in
psychologically vulnerable individuals. The further burden that
charging for care will place upon an already psychologically vulnerable
population might be expected to result in additional psychological
morbidity. In my opinion the psychological impact of denying care
to such a population has not been documented but might be expected
to be substantial.
12. HIV and pregnancy poses particular issues.
The introduction of antiretroviral therapy in pregnancy, delivery
by caesarean section and avoidance of breast feeding can reduce
the risk of transmission of HIV from mother to baby from 25-30%
to less than 1%. In consequence government guidance has been issued
to recommend HIV testing to all pregnant women to allow them to
take advantage of these medical interventions. To make a diagnosis
of HIV in pregnancy and then to deny therapy which is readily
available within the UK on the basis of immigration status is
not only illogical on the basis of current government health strategy
but also ethically unacceptable.
13. If lack of treatment of a pregnant HIV
infected woman results in a baby being infected with HIV it is
possible that the baby would then receive treatment (for a largely
avoidable infection). At the same time the untreated mother's
health would be expected to deteriorate over time with a resultant
reduction in her ability to care for her child.
14. Withholding antiretroviral therapy has
a potential impact for onward transmission. A major determinant
of HIV transmission is the plasma viral load which is substantially
reduced when HIV infected individuals are taking effective antiretroviral
therapy. The Department of Health estimates that preventing one
new HIV infection saves between £0.5 million and £1
million.
15. Current government strategy seeks to
reduce the rate of undiagnosed HIV infection in the community.
This has lead to the promotion of widespread of HIV testing campaigns.
Early diagnosis allows for timely treatment interventions and
a negative test allows for safer sex messages to be promulgated.
Acceptance of testing is likely to be reduced for those patients
for whom no therapy will be forthcoming in the event of a positive
result. If therapy is unavailable to a proportion of the most
vulnerable people in the community, who are already hard to reach
it, is unlikely that they will elect to test. This will undermine
both treatment and prevention initiatives which underpin the current
government strategy.
In conclusion it is my opinion that the imposition
of charges for HIV for certain sections of the UK dwelling population
will have deleterious effects on the health, wellbeing and longevity
of some individuals and at the same time will potentially have
an impact on the wider HIV epidemic in the UK. It will place an
increased burden on the emergency services and on in patient hospital
beds. In addition clinicians will be asked to treat patients in
a way that is contrary to national recommendations and standards.
This will pose ethical problems for medical practitoners.
I would like to suggest that the committee recommends
that HIV be incorporated with, and treated in the same way as,
all other sexually transmitted infections and be exempt from charges
whilst individuals are in the UK.
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