Examination of Witnesses (Questions 64-79)|
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 Asboea very interesting name in the current
Dr Asboe: It is
probably Scandinavian, but I am from New Zealand.
Q65 Chairman: We might
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
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 2004or 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
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 historyI 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 TBand 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 countrywhich you have partly touched
on alreadyand also the impact of this policy on HIV testing
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
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
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 thisand
we have had no evidence that this occursis, 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
nowvery, very small anecdotal reports, but nothing nowbut
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
Dr Evans: I am not a politician.
Q75 Chairman: Neither
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 HIVand that was in the submission,
I knowbut 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
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