Select Committee on Health Minutes of Evidence

Memorandum by the Health Protection Agency (HA 35)


  The Health Protection Agency is an independent body with the remit to protect the health and well-being of everyone in England and Wales. This includes protection from infectious diseases. Staff at the Health Protection Agency Centre for Infections include specialists in communicable disease control; public health specialists; microbiologists and epidemiologists—who monitor the spread of disease, including diseases caused by HIV and other sexually transmitted infections.


The consequences of the new and proposed changes in charges for overseas patients with regard to access to HIV/AIDS services

  1.  We are concerned that the new and proposed changes may impact on the clinical and public health management of HIV infection in overseas born individuals diagnosed with HIV in the UK.

  2.  Early diagnosis and treatment of HIV infection (where appropriate and according to clinical guidelines) is beneficial both to interrupt transmission of the virus in the community and to the health of those who are HIV-infected.

  3.  Surveillance evidence indicates that within the UK HIV epidemic a greater proportion of HIV infected patients who are diagnosed late in the course of their infection, die due to their HIV infection, or remain without their HIV infection being diagnosed, are overseas born—compared to those born in the UK.

  4.  Since 2000, CD4 counts made at the time of diagnosis of HIV infection show that those born overseas consistently present at a more advanced level of immune suppression than those born in the UK. (Data supporting these statements can be provided.)

  5.  Underlying HIV infection is an important consideration in the management and treatment of tuberculosis (TB) and failure to address this can lead to inadequate treatment of TB, running the risk of reactivation, the potential for developing drug resistant TB and ongoing potential for transmission. Since 2000 TB was diagnosed as an AIDS defining illness in two in five of those born overseas who were diagnosed with AIDS in the UK, compared with fewer than one in 20 of those diagnosed with AIDS who were born in the UK.


Progress to date in implementing the recommendations of the Committee's inquiry into Sexual Health (the Committee's Third Report of Session 2003-03)

  Evidence relates to recommendations in square brackets which are numbered as they appeared in the Recommendations and Conclusions of the House of Commons Health Committee Report "Sexual Health" Third report of Session 2002-03

  [Health Committee para 1. While we have some reservations about some of the detail in the Strategy (and indeed about areas where there is scant detail) we regard as entirely commendable the decision of the Government to produce the strategy. We would like to see measures going well beyond what it proposes, but would want to acknowledge that the Strategy represents an excellent starting point and a foundation which can be developed.]

  The Sexual Health Strategy included a number of goals and standards, which can be measured directly or indirectly through surveillance and prevention monitoring activities undertaken by the Health Protection Agency (Centre for Infections—Communicable Disease Surveillance Centre). These have been published in tabular form as an Appendix in the Annual report "Focus on Prevention: HIV and other Sexually Transmitted Infections in the United Kingdom—An update: November 2004".

  [Health Committee para 3. We recommend that the Army Medical Services forwards to the PHLS its figures for STIs. We also recommend that the PHLS looks at how a more comprehensive surveillance system can be developed to cover all areas of sexual health and possible service providers. This will give a more complete picture of trends, prevalence and service utilisation.]

  The Health Protection Agency has sought to widen its coverage of STIs diagnosed in primary care, in particular diagnoses of Chlamydia. HPA has been working closely with the DH on the development and piloting of the Sexual Health Services Common Dataset, an expanded patient-based dataset which, once approved as a mandatory information standard, will be collected from all sexual health services (this is likely to be as part of the National Programme for IT).

  [Health Committee para 5. In respect of the monitoring of trends in both STIs and HIV/AIDS we would like to pay tribute to the work of the PHLS. Their monitoring ensures that the UK has the best data in the world, and this in turn give great credibility to their research. It would be most regrettable if the absorption of the PHLS within the new Health Protection Agency were in any way adversely to affect its work. In particular, we would be alarmed if the close networks developed between the regional and local laboratories and clinicians and epidemiologists were to be impaired as a consequence of the move to NHS management of the laboratories.]

  Although it is still early in the history of the HPA and the earlier recommendation on statutory laboratory reporting has not been acted upon, to date HIV and STI surveillance activities have continued to a high standard. For HIV surveillance in particular this is tribute to the goodwill, and continuing collaboration of many laboratory and clinical colleagues who contribute to the voluntary reporting of this infection. Increasing workloads have increased the burden of this activity and HPA acknowledges and thanks reporters for their continuing participation. The roll out of the collection of more specific data from GUM clinics (disaggregate KC60 reporting) has been problematic but a revised surveillance system, described above, is now being implemented and it is hoped that this will proceed more smoothly.

  [Health Committee para 6. Although we support the Government's drive to improve sexual health services via the Strategy, without wholesale advances in sexual health provision these targets will be tokenistic.]

  We feel that given the further marked increase in clinic workload since the strategy was published—both in the numbers of patients seen and in the numbers being diagnosed and treated for HIV infection (both overall numbers markedly increasing and the complexity of the caseload)—this statement is even more pertinent than when it was originally written. The delay in diagnosis of HIV and STIs will result in further transmission and hence the need to strengthen sexual health provision remains urgent. This should be across a variety of clinical settings (including but not restricted to GUM clinics).

  [Health Committee para 10. While any increase in funding needs to be fully justified and accounted for, in the context of the current disastrous impact on public health of the nation's poor sexual health, these figures do not strike us as excessive. It should be stressed that there is not just a shortage of consultants: nurses with expertise and training in this area, health advisors and laboratory technicians are all needed and these should not be left behind in any increase in funding . . . ]

  HPA laboratories count among their activities: Bacterial and viral reference services, surveillance of incident HIV infection, HIV population prevalence studies, surveillance of antimicrobial resistance in gonorrhoea and antiretroviral resistance in HIV. Funding for these activities has not increased in line with increasing workload although some funding increase was obtained from the Department of Health to further improve HIV and STI surveillance in the 2002-03 financial year.

  [Health Committee para 13. We welcome the fact that the Department is developing a waiting times indicator as a means of monitoring the effect of its recent investment on access to clinics. However, this will merely duplicate existing activity since the PHLS and the Specialty Societies for GU Medicine already monitor waiting times, and evidence of the extent of the problem is not wanting. So we are unconvinced that this measure alone will do much to address what amounts to a public health crisis. We recommend that there should be a presumption that anyone wishing to access genitourinary medicine should be able to do so on the day of, or day after, presentation to a clinic. If a target of 48 hours to see a GP is appropriate then a target of 48 hours for the treatment of what is potentially a communicable disease is essential . . . ]

  The GU waiting times survey, was piloted and then conducted nationwide by the HPA in collaboration with the British Association for Sexual Health and HIV (BASHH). The first complete survey took place in May 2004. Results showed that lower proportions of women and young people were seen within 48 hours—and that nationally 72% of emergencies, 79% of walk-in patients and 18% of routine appointments were seen within 48 hours. The surveys will continue six-monthly and results are and will continue to be published on the HPA website:

  [Health Committee para 15. We do not think that it is necessary to wait for the results of the reinfection study before introducing nationally the chlamydia screening programme. Any additional information that the reinfection study provides is, in our view, likely only to lead to modifications in the programme rather than fundamental reforms. Accordingly we recommend that the NHS must as a matter of urgency, move to provide such screening in all family planning clinics, infertility clinics, termination of pregnancy clinics and GUM clinics and for women having their first cervical smears. We also believe that GPs should routinely offer testing to those aged under 25 years without attempting to second-guess patients' sexual behaviour.]

  Attenders at Genitourinary Medicine clinics have always been offered chlamydia testing as part of their routine sexual health screen. The decision to implement the National Chlamydia Screening Programme, which targets non GU settings, was taken by the Department of Health following recommendation by the CMO. HPA has closely collaborated with the DH in the initial roll out of the programme. The first phase of roll out included 10 areas, with a further 26 also included in 2004—coverage is now 30% of sexually active 15-24 year olds in England. The programme uses the sensitive NAATS (Nucleic Acid Amplification Tests). In the first phase of 16,500 screened (10% of women were positive and 13% of men). The Public Health White Paper clearly outlines chlamydia screening as a priority for improving sexual health, with a commitment of £80 million over the next three years to see this programme to full national coverage by 2007. The next report on chlamydia screening is scheduled to be available towards the end of summer 2005.

  [Health Committee para 18. We are concerned by the trends in HIV and support the Government in its aim to reduce the prevalence of undiagnosed HIV and in turn to safeguard public health. Early diagnosis of HIV not only reduces the chances of it spreading within the community but it also greatly improves outcomes for those infected. On the basis of the evidence we have heard . . .]

  Figures contained in our 2003 report suggest that nationally we have made some progress in reducing the undiagnosed fraction of HIV in the UK. This will continue to be monitored—especially through unlinked anonymous serosurveillance of newborn infant dried blood spots and attendees at selected Genitourinary Medicine clinics.

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