Memorandum by the British Association
for Sexual Health and HIV
Prepared by Dr Karen Rogstad1 and Dr Adrian
Palfreeman2
1. Chairman of BASHH Education Committee
and Chairman of BASHH Adolescent Special Interest Group, Consultant
Physician Sheffield Teaching Hospitals NHS Trust
2. Chairman of BASHH HIV Special Interest
Group, Consultant Physician, Leicester Teaching Hospitals
The British Association for Sexual Health and
HIV represents health care professionals with an interest in sexually
transmitted infections. This includes clinical care, laboratory
expertise, prevention and research. Most clinician members are
based in Genitourinary Medicine clinics, where the majority of
sexually transmitted infections including HIV are diagnosed and
managed, and also provide inpatient HIV care. Although most Consultants
in GUM are not TB physicians, there is a high rate of co-infection
with TB and HIV therefore they care for many dually infected patients.
Q1. A recent report on Communicable Diseases
by the UK Department of Health stated that "post-war optimism
that their conquest was near has proved dramatically unfounded".
What is your assessment of the overall position? More specifically,
is it simply that not enough progress is being made in reducing
the spread of such diseases? Or is the global situation actually
deteriorating? Would it be an exaggeration to talk of a crisis?
A1. HIV and STI disease control requires both
the identification of individuals with and without symptoms, appropriate
treatment for them, partner notification and preventative programmes
to reduce onward transmission either between sexual partners or
from mother to child. These systems are inadequate in the UK but
even more so in countries with less well resourced health care
systems, both for treatment and surveillance. Poverty and war
contribute to further spread.
2. What reliable data exist regarding the
numbers of people infected globally with the four diseases[15]
on which the Committee is focusing particular attention? What
trends are discernible in both the numbers infected and the patterns
of infection? And what are the main underlying causes of infection
and of any changes in its incidence and pattern?
A2. Data is available from the World Health Association
and the Health Protection Agency.
3. What intergovernmental surveillance systems
exist to give early warning of outbreaks of infectious diseases?
Are these systems adequate? And what improvements might be made?
A3. This can be answered by the Health Protection
Agency
4. Given the continuance of current or planned
intergovernmental programmes to prevent or control the four diseases,
what predictions can be made of their likely spread and pattern
over the next 10 years?
A4. Data can be obtained from WHO and the HPA.
HIV in the UK is likely to continue to increase because of ongoing
transmission particularly in MSM, but also IVDUs, heterosexuals,
and mother to child transmission. This is exacerbated by the large
proportion of approximately one third of infected persons in the
UK being unaware of their positive status. Immigration of infected
persons to the UK will also contribute to increasing prevalence
of HIV and TB. As people with HIV live longer in the UK as a result
of better therapy, then the overall number of infected people
living with HIV would increase even if the rate of new infections
(incidence) remained the same.
5. What do you consider to be the principal
blockages to achieving progress in the prevention or control of
the four diseases? And how might these blockages be removed by
more, or better-targeted or better-coordinated intergovernmental
action?
6. What role does your organisation play
in combating the four diseases? Do you believe that it is correctly
configured and adequately resourced to do the job? With which
other organisations do you collaborate? How would you assess the
degree of synergy?
A6. BASHH is involved with the detection, treatment
and prevention of HIV through our members. BASHH is also responsible
for policy formation, service delivery development, and education
for HIV.
Q7. What are the main non-health causes
(eg global warming, poverty, changes in land use, international
travel, lifestyle, population) of the spread of the four diseases?
To what extent can intergovernmental action in non-health fields
contribute to alleviation of their spread? What action is taking
place or planned in these areas? And what more needs to be done?
Do you consider that there is sufficient "joined-up"
thinking in approaching the problem?
A7. Poverty, war, urbanisation and resultant
social disruption and migration are drivers of HIV and thus also
TB transmission. They are also a mjor cause of STI increases,
which are known to increase HIV acquisition. A significant numbers
of STIs and HIV diagnosed in the UK are due to UK residents acquiring
infections whilst abroad either for leisure, work or visiting
families. Risk factors or STI and therefore HIV acquisition whilst
abroad include risky behavior in the UK prior to travel, drug
and alcohol use.
Q8. Cases of Tuberculosis fell progressively
in the UK until the mid-1980s but started to rise again in the
early 1990s. Around 6,500 cases are now reported each year, an
increase of about a quarter since the early 1990s. What are the
main factors of the revival of Tuberculosis infections in Britain?
And how could intergovernmental action help to reverse the trend?
A8. One major driver of increased TB is because
of coinfection with HIV, particularly in those who have recently
moved to the UK having acquired HIV infection in their country
of birth, where there is also higher risk of exposure to TB.
Q9. Tuberculosis is potentially curable
by long-term antimicrobial therapies. Yet the numbers of reported
cases worldwide seem to be rising. Are the necessary medicines
not getting through to patients? What are the barriers to effective
long-term therapy? Are we now seeing infections which stem from
other conditions—eg HIV/AIDS? Or are there other reasons
why a treatable disease should be spreading? How might intergovernmental
action help to deal with this situation?
A9. TB is often associated with HIV. There must
be support for countries with high prevalences to detect cases
of HIV and TB prior to the onset of clinical disease, which requires
adequate screeing. However case finding must be linked to adequate
availability of effective drugs for both, and an infrastructure
to provide and deliver these.
Q10. To what extent do you believe that
the 2004 Stockholm Convention limiting the use of DDT against
Malaria-carrying mosquitoes has been a factor of increases in
the spread of the disease? Has any risk analysis been carried
out comparing the relative dangers to human health posed by DDT
and Malaria?
A10. Not applicable to BASHH.
Q11. What intergovernmental action is planned
or in hand for early detection of the transmission of Avian Flu
from birds to humans and of human-to-human transmission in potential
source countries? Is this proving sufficiently effective to prevent
an Influenza pandemic? What more could be done?
A10. Not applicable to BASHH.
Q12. To what extent do you consider that
the rise in infections in the four diseases is attributable to
increased microbial resistance to antibiotics? What intergovernmental
action is taking place in this area?
A12. There is increasing resistance to HIV in
developed countries, and there is increasing evidence of the transmission
of resistant virus. The problem of resistance in third world countries
is likely to become a major health issue over the next few years
as HIV drugs are supplied to these countries, but in many cases
without the support mechanisms for patients regarding adherence
and the problems with an uninterrupted supply of drugs, particularly
for rural areas. The same factors are also relevant to TB drug
resistance.
Q13. In a number of countries, including
the UK, there is a problem with hospital-acquired infections.
What intergovernmental sharing of knowledge is taking place to
help bring this problem under control?
A13. Not applicable to BASHH.
Q14. Are there any difficulties with regard
to patents or intellectual property which are impeding the flow
of medicines or other control methods to those infected? Is intergovernmental
action needed to improve the situation?
A14. There is improvement in supply of HIV drugs
to under developed countries, but this is still limited and usually
the more modern, more effective drugs are unavailable.
Q15. What interchange exists between States
in regard to knowledge of and training in the diagnosis and treatment
of the four diseases or regarding preparations for dealing with
outbreaks? What improvements might be made through intergovernmental
action?
A15. More could be done with regard to training
health care professionals in the 3rd World by wealthier nations.
This support could include internet based learning, although access
to IT systems is often limited. Opportunities for training in
UK clinics could be provided. Immigration restraints have made
it more difficult for people to attend specialist STI and HIV
training courses in the UK
Q16. The International Health Regulations
2005 are intended to provide a global framework for the rapid
identification and containment of public health emergencies. How
effective do you consider this response system to be? Do improvements
need to be made?
A16. No opinion.
Q17. What intergovernmental planning has
been undertaken to cope with the impact of an outbreak of infectious
disease caused by deliberate release of micro-organisms into the
environment? Is there adequate liaison between the various agencies
involved, including intelligence, law enforcement and health care
professionals? How could action by intergovernmental bodies help
further?
A17. No opinion.
Q18. Though our remit is focused specifically
on known infectious diseases, we would be interested to know how
you view the global threat from new or previously unrecognised
ones and from the transmission of infections from animals to humans.
A18. There is a need to have adequate surveillance
systems in different nations for all sexually transmitted infections,
in order to predict spread through and between communities and
countries. Diseases that were uncommon can rapidly re-surge and
spread, particularly when there is deterioration in health systems
and/or increasing poverty, eg as was seen with increase in syphilis
in the former states of the USSR, which then spread to Western
European countries as a result of increased travel between countries
and migration. There has also been a rapid rise in Lymphogranuloma
venereum (LGV) in Westernised countries in recent years. This
disease was previously regarded as largely restricted to the tropics,
but has spread rapidly in men who have sex with men (MSM), and
is particularly associated with HIV positivity.
Q19. What resources (subscriptions, staff,
training, medicines etc) does the UK Government commit to intergovernmental
bodies to help in the fight against the four diseases listed?
A19. The Department of Health used to support
Registrars in Genitourinary medicine travelling to other countries
to gain additional experience in counries of high prevalence for
STIs. This would be beneficial educationally to the trainee and
the unit they subsequently were appointed to as Consultant. It
would also often foster long-term links between the medical units
in the 2 countries. This funding was withdrawn a number of years
ago.
Q20. Do you wish to provide any other relevant
information in addition to what you have said in answer to the
above?
A 20.
STIs as a major risk factor for HIV, and adolescent
health issues
It is essential that the link between sexually
transmitted infections and HIV transmission is fully appreciated
by governments and intergovernmental organisations. Too often
there is a dissociation of the two by policy makers and providers
of care both in the UK and elsewhere. Any attempts to control
HIV must be linked to STI prevention and treatment programmes.
Issues of stigmatisation, poverty, social upheaval must all be
addressed. There must be a focus on adolescent health issues,
as infection although not detected til later adult hood is often
acquired in adolesence, particularly in the third world. Also
education programmes on prevention are most effective if given
in childhood and early adolescence. The needs of those surviving
into adloesence with vertically acquired disease is becoming an
increasing issue due to effective therapies.
HIV in the UK
There are a number of challenges both in those
of us caring for individuals affected by HIV and those living
with these infections in the United Kingdom.
— The number of undiagnosed infections
remains at approximately 30% of the 70,000 individuals infected
in the United Kingdom and barriers to testing in care still exist.
Those perceptions reinforced by recent government announcements
that individuals whose asylum status is either uncertain or have
been refused asylum should not be entitled to receive medical
care. This may deter many individuals from seeking testing and
care.
— The consequences of this are that
many patients now present late to care with complications of HIV,
needing costly emergency treatment and prolonged hospital admission.
Recently reported cases such include that of a woman in London
who was denied HAART because she was not considered eligible and
was worried about the cost, and ended admitted as an emergency
to ITU. The cost of the ITU admission was conservatively measured
as equivalent to about 3.5 years of HAART.
— Patients who are deterred from seeking
medical care and remain unaware of their HIV status risk passing
on their virus to others. In the USA over 50% of new infections
are estimated to come from individuals unaware of their status,
and it has been shown in studies that knowledge of positive status
reduces risk behaviour.
— Patients who are co-infected with
other serious infections such as Tuberculosis cannot receive effective
treatment for these infections unless their HIV is treated at
the same time. They are therefore are more likely to pass on Tuberculosis
to other members of the community.
— The emergence of Multi drug resistant
TB in populations co infected with HIV has been a public health
disaster in South Africa. The key to control of this problem is
to treat both infections and contact trace and apply appropriate
public health measures. We need to learn from that experience.
— The dramatic success of the prevention
of mother to child transmission of HIV in reducing the number
of babies born with this infection in the United Kingdom to less
than 1.2% in the UK and Ireland. Of note, the audit by the NHS
AIAU (Audit Information Analysis Unit) which looked at transmission
that did occur, made recommendations in an executive Summary
October 2007 where they noted that some transmissions had occurred
because of confusion about entitlement to care for pregnant women.
The DoH states that treatment cannot be refused in this situation
but these women may still be liable for charges subsequently.
The audit goes further and in recommendation 31 states that "At
the next policy review, the DH should consider classifying HIV
prophylaxis for prevention of MTCT, and appropriate support in
pregnancy and for her infant, as emergency care. As such, care
should be free, regardless of immigration, asylum or residence
status".
February 2008
15 HIV/AIDS, Tuberculosis, Malaria and Avian Influenza. Back
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