Select Committee on Health Written Evidence


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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