Select Committee on Health Minutes of Evidence


Examination of Witnesses (Questions 64-79)

DR DAVID ASBOE, DR BARRY EVANS, MS PAM WARD AND MR PETER NIEUWETS

27 JANUARY 2005

Q64 Chairman: May I welcome our final group of witnesses this morning and express the Committee's gratitude to you for your participation in this inquiry. Perhaps I could ask you to introduce yourselves briefly, starting with you Dr Asboe—a very interesting name in the current—

Dr Asboe: It is probably Scandinavian, but I am from New Zealand.

Q65 Chairman: We might be related!

  Dr Asboe: I am a consultant in genito-urinary medicine based at Chelsea and Westminster Hospital. I lead the HIV out-patient department there.

  Dr Evans: My name is Barry Evans. I am from the Health Protection Agency and one of the HIV epidemiologists within that organisation.

  Ms Ward: I am Pam Ward. I am co-Chairman of an overseas action and support group for overseas managers nationally.

  Mr Nieuwets: I am Peter Nieuwets. I am an HIV commissioning manager for West Sussex. I am the lead for Kent, Surrey and Sussex and I am the Chair of the national HIV and Sexual Health Commissioners.

Q66 Chairman: Thank you very much. Could I ask Dr Evans, first of all, what is the size of the problem regarding HIV patients who need treatment and care but are not eligible? You were present for the previous session, you have heard the evidence that we picked up there. What are your thoughts on the extent of the problem?

  Dr Evans: The data we have within the Health Protection Agency does not give us information on eligibility directly and we have to make assumptions across other data sets. We do know that the number of people who have acquired infection in Africa has been growing very rapidly over recent years. The number of people with heterosexual diagnoses was around a thousand in 1999 and about 4,500 in 2004—or will be once we get our latest reports in. That increase has been very marked. Also, with heterosexual new diagnoses, about 80% are in African people, people who acquired infection in Africa, about ten per cent in other parts of the world and 10% have acquired their infection heterosexually within the UK. One has to then make some assumptions about how many of the African people who have been newly diagnosed within a UK context may or may not have been eligible for treatment. So the numbers are rising very rapidly, the problem is in knowing how many of those people might or might not have been eligible for treatment.

Q67 Chairman: Do you have any observations on the evidence that we have heard in the first session? Would you concur with the picture that was portrayed by the witnesses?

  Dr Evans: I would concur with the problems around tuberculosis and the interaction on HIV and TB and of tuberculosis being an increasing public health problem and of not treating HIV-infected people. The majority of people from Africa will have come across tubercle bacilli sometime in their history—I mean, if they grew up in Africa. That does not mean to say they have active TB. But, in the presence of HIV and with the immune suppression of HIV, it is likely, when the immunity drops to such a level, to reactivate the TB and they will then become infectious with tuberculosis as well. If people are treated at the right time, hopefully they will not become infectious with TB, but if you do not treat them, they are going to reactivate their TB—and TB as an initial AIDS-defining illness is rising in the UK, even with current patterns. The other issue is an issue of concern with mother to child transmission. We have not talked about that in the evidence so far. It seems to me, if you are diagnosing women in pregnancy, you have at least the moral right to offer them treatment, and not just treatment in terms of preventing mother to child transmission but ongoing treatment, and yet if you do not diagnose them in pregnancy a significant number of those children will become infected. Round about 800 women in 2003 were infected with HIV and pregnant. The majority of those were diagnosed in that pregnancy; some were diagnosed previously; and some unfortunately did not get diagnosed at all during the pregnancy. The majority were diagnosed and consequently 100/150 children were prevented from becoming HIV infected by the treatments that were offered during pregnancy. Those children would become infected if one did not offer the antenatal screening. The NHS has done well in terms of rolling out. We go back to the days of the mid- to late-1990s, when the vast majority of pregnant women in this country did not have their HIV diagnosed, and that has consequences for the women and for the babies, about 25% of whom, if the women breastfeed, will become infected without treatment for their HIV.

Q68 Chairman: Coming back to your earlier point about TB and HIV, you do not dissent from the concerns expressed about the difficulties for public health if we have the kind of picture that was portrayed by some of these witnesses previously of people with TB and HIV disappearing as a consequence of being billed for the HIV elements of their treatment.

  Dr Evans: That is a serious concern. At the moment the overlap of the TB and HIV epidemics is not very great. The majority of our TB patients in this country have acquired TB overseas but are from the Indian sub-continent, where there is less of an overlap with HIV. With African patients, clearly there is some overlap, but less so. Five to 7% is our best estimate of the TB patients who are probably HIV infected, so there is not a big overlap, but there is sufficient overlap. And that will get worse if we do not treat HIV, so that TB becomes a bigger issue there. The exact qualification of all that I think is difficult but there is concern that it will get worse. There are concerns about multi-drug resistance if people are partly treated for tuberculosis. There are concerns that, even if one treated the TB, then people need their own immunity to completely eliminate the tubercle bacilli. If you do not treat them for HIV, they may at a later stage again react the tuberculosis.

Q69 Dr Naysmith: I was going to ask Dr Evans about the public health consequences of what happens if charging puts patients off under four separate headings. We have already dealt with two of them, mother to child transmission and the spread of TB, and presumably the same would apply to other sexually transmitted infections. I would just like to ask you what would be the effect, if this is a discouragement on people seeking treatment, on the spread of HIV within the wider population in this country—which you have partly touched on already—and also the impact of this policy on HIV testing initiatives.

  Dr Evans: I think in both those areas it is again difficult to quantify, but on the issue of the onward spread of HIV we have reasonable data now that shows that the spread of HIV is strongly related to viral load. Viral load rises with the progression of the infection. As the CD4 count, the level of immunity drops, the viral load rises, and with high viral load is much more likely to transmit. If people are not diagnosed and they continue to be sexually active, they are more likely to transmit the higher the viral load. There are other co-factors affecting transmission, including other sexually transmitted infections and so on, but viral load is a powerful indicator of transmission potential, so that if you do not treat individuals and they remain in this country and are sexually active in this country, then the transmission is bound to go up. The quantification of that and the total amount of transmission within the UK is going to be quite difficult and would need some fairly complex modelling.

Q70 Dr Naysmith: You said it is bound to go up. It will go up, of course, but it will be reduced a little bit if people use protective measures. What is the evidence that people coming to clinics will be advised about this as well as receiving treatment and will then not be advised about possible ways of limiting the spread of their own disease?

  Dr Evans: I agree with that: they can be advised. I think the advice, though, needs to be seen within a total care package and if you cannot offer treatment within a total care package then I think it becomes much more difficult.

Q71 Dr Taylor: Is there any argument in favour of charging for HIV treatment and not charging for the other communicable diseases? Is there any argument against? Is it purely and simply financial?

  Dr Evans: I think the only argument that I can find is that of public purse. We would not be here having this debate if with HIV treatment one could treat it for a fortnight and cure it, if it was like syphilis or other sexually transmitted infections which with a course of antibiotics or antiviral treatment you cure the patient. It is a public purse argument largely, and the complexity of HIV treatment and the need, as you are well aware, to keep people on treatment long term. We do not have a cure; we just have a means of suppressing viral load.

Q72 Dr Taylor: Do any of the witnesses have any idea how we get this across, that in fact it is not a money-saving exercise because of all the long-term consequences? How do we get this across?

  Dr Evans: The only thing I can think of, in terms of having thought and grappled with this—and we have had no evidence that this occurs—is, if people know they can get treatment, this issue of potentially could we be seen as a magnet to attracting more people in terms of treatment tourism in the future. There is no evidence that it is happening now—very, very small anecdotal reports, but nothing now—but if in the future the HIV epidemic worldwide continues, are we encouraging people if we are seen as offering treatment to everyone? That seems to me the only reason. There are powerful public health arguments against that. If people are living here, there are powerful public health arguments to treat them appropriately.

Q73 Dr Taylor: Have you hit on the real hidden reason? Because obviously one could see a government being absolutely terrified of attracting huge numbers of people to this country just because they get treatment free.

  Dr Evans: Then the issue of appropriate migration . . . Even people treated in this country, who come to this country and are treated, in general those are people who are going to get into work on treatment and who will contribute to the British economy. They are people who cost money in terms of their treatment, but the total public purse argument needs to be taken into account.

Q74 Dr Taylor: In a way you cannot separate it, as you tried to, from the whole immigration issue.

  Dr Evans: I am not a politician.

Q75 Chairman: Neither is Richard!

  Dr Evans: I am thankful I am this side of the table and not that one.

Q76 Mr Burns: As you are aware, there are a number of categories of groups of people who are now ineligible for free secondary care in this country and, possibly, depending on where the Government's consultations go, that might be extended to primary care. What advice did your agency give the Government in the consultation process on primary care and on the Government action on secondary care?

  Dr Evans: I am not sure what advice we gave and whether we submitted written advice. I am sorry, I should know that.

Q77 Mr Burns: Presumably, as the Health Protection Agency you did input to the Department of Health as part of the consultation process.

  Dr Evans: Yes, we did, and there was concern about the rising number of sexually transmitted infections and increasing diagnoses of HIV—and that was in the submission, I know—but I do not know the detail and I am fairly sure we did not raise the issue of migration.

Q78 Mr Burns: As part of your work, do you monitor what goes on elsewhere in the world to see if you can learn anything?

  Dr Evans: We submit the UK data to a European centre, and we look at what is happening in terms of other countries via UN AIDS data that comes out on a regular basis, yes.

Q79 Mr Burns: Are there any other countries in the developed world that you know of that will allow people to come from outside their borders then to get free treatment for things like HIV/AIDS?

  Dr Evans: There are some countries. There are countries who have screening at point of entry. There are some countries that it is difficult to know: they do not separate HIV from other long-term chronic illnesses. But, for instance, if people are seeking to emigrate to Canada, they would treat HIV as the same as they would renal failure—


 
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