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I realise that that will not be popular with some groups, but that is what we recommended. We also said that routine and opt-out testing should be offered in other circumstances that are related to the trend in the upward rise of sexually transmitted infections-hepatitis is one, or associated things such as TB. The Government's response to this was broadly welcoming, but speaking from my five years' experience as Chief Scientific Adviser first to Major and then to Blair as a permanent secretary embedded as a kind of

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anthropological tourist in a strange culture. I recognise, I am afraid, in the response to that recommendation, the caution and elevation of process over product that is characteristic of our well meaning and excellent Civil Service. I would like there to be a much more positive and unambiguous affirmation of the need to do that. I have resisted expressing that thought with colourful Australian adjectives.

Another of our recommendations is that we repeal the ban on home testing kits, with appropriate caveats. The Government supported us, but with subtle nuances of language they did not accept the recommendation, and said that they would review the policy. They will think about thinking about it. That is not good enough.

What is totally indefensible on ethical and common-sense grounds is our current policy that visitors or others without the right to live here can be freely diagnosed as having HIV but cannot be treated. This is ridiculous simply on common-sense financial grounds, much less unambiguous ethical grounds, because it demotivates people from even being tested. The government response did not agree with or even support us. It used the dread words "review policy". That is not good enough.

In general, we also recommended,

Here I shall go off-piste to offer a personal opinion on how best to do this. I am strongly of the view that wherever possible this sort of activity should be delivered though the NGOs, not the NHS. That is because some 10 years ago £400 million was put into a campaign on sexual health by the Department of Health. In the event, only 31 of 191 primary care trusts spent a penny of the money on sexual health, and none spent any of it on awareness campaigns. What fraction of that £400 million was given to NGOs? It was 1 per cent. It would have been much more effective if 1 per cent had been given to the primary care trusts and 99 per cent to the NGOs.

In summary, despite the negative tone of some of the things I have said, the Government have given us a welcoming response and they have a proud record in this, as we have heard. I was living in the United States when the committee of the noble Lord, Lord Fowler, was acting, and we watched in despair and distress as the same recommendations coming out of the US National Academy of Sciences to Ronald Reagan were seen as the kind of immorality you expect of a bunch of academics. I end by emphasising again that we have done well but we are not doing as well now. We have to put our foot back on the pedal and we have to be focused on effective prompt action, not on endless review.

5.34 pm

Lord Black of Brentwood: My Lords, like other noble Lords who have spoken, I warmly welcome the publication of this first-class and comprehensive report from the Select Committee, and I am delighted that we have an opportunity to debate it on such an important day.

If I may, I start with a personal tribute to my noble friend Lord Fowler. For nearly a quarter of a century, his name has been inextricably linked with this issue

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and he has courageously trod an often lonely path. The Don't Die of Ignorance campaign was a phenomenally bold move. Looking back on it 25 years later, we can see that it was a seminal moment in the history of HIV and AIDS that without any shadow of doubt saved countless thousands of lives. I say to my noble friend that I was just over 20 when the campaign was launched and was therefore part of a generation of gay men who, without the very stark warnings the campaign contained, could have fallen victim to what was then an untreatable disease. My generation owes an enormous debt to the foresight and courage of my noble friend, those who worked with him and the pressure groups that so assiduously supported him. They gave us the gift of life.

I wholeheartedly endorse the conclusions of this compelling report, in particular the emphasis on early and better testing. There is no doubt, as we have heard so often during this excellent debate, that the issue of late diagnosis is now the greatest challenge in dealing with HIV/AIDS. As the report makes clear, delays in dispensing antiretroviral therapy have grave health implications for the person diagnosed, as well as the risk of onward transmission. As the noble Lord, Lord Rea, touched upon, the figure in the report that 52 per cent of adults diagnosed with HIV in 2009 were diagnosed late is shocking. The problem is even higher among those aged over 50, at over 65 per cent. This is becoming not so much a problem of the young but a problem of the middle-aged.

When treatment of HIV is so effective and easily accessed, with rarely any of the problems of unpleasant side effects that once occurred, there can be no excuse for this. We need, therefore, above all else, to get to the roots of this issue. That is what I would like to concentrate upon, drawing heavily on the report.

There are undoubtedly many causes-after all, this is a very personal issue-but I would like to highlight three. One is certainly education. I do not just mean what is taught in schools, where the report has valuable recommendations on incorporating sex and relationships education into the national curriculum to ensure that children are taught about security in intimate relationships; it is more the importance of education throughout life. As the problem of late diagnosis among those aged over 50 is real and pressing, perhaps we need to find, for instance, novel ways to educate older audiences too, by deploying information through the media and the opinion-forming channels which influence those in middle age.

The second is the role of GPs and health professionals. The report rightly highlights how,

In other words, some GPs avoid recommending a test to those who might have HIV because of misconceptions about the need for counselling, time constraints and, above all, stigma.

When I was preparing for this debate I visited the excellent Bloomsbury Clinic within the Mortimer Market Centre in Camden a few weeks ago. I heard a dreadful story there of someone who made his way to the clinic after having been ill for two years with a variety of

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conditions that should have shouted to his GP "HIV" from the rooftops. This person had never been given a test by his GP; by the time it was discovered, when he found his way to the clinic, full-blown AIDS had set in and the person involved lived barely a few weeks.

That sort of situation, rare though it is, is completely unacceptable. I hope that the recommendations in the report on the need for practitioners to become more confident in identifying those at risk of HIV are acted on without delay.

However, perhaps the single most significant problem remains that of stigma, as many noble Lords have said, most movingly, perhaps, in the examples given by my noble friend Lord Lexden. Of course, there have been remarkable strides in addressing the fear and misunderstanding of HIV, which are the wellsprings of stigma. Enormous credit must go to those many organisations-we have heard about the National AIDS Trust and the Terence Higgins Trust, which do remarkable work-which have fought tirelessly to combat HIV, as well as to the wonderful clinicians who work with patients and give them the confidence to deal with it.

However, there is much more to do and it is absolutely central to the issue of diagnosis, because fear of stigma and fear of testing are inextricably linked. Consider this: in the 2009 People Living with HIV Stigma Index, as we have heard, one in eight HIV-positive people living in the UK reported being physically harassed in relation to their HIV status in the previous 12 months. More than one in five had been verbally assaulted or threatened.

My noble friend Lord Fowler quoted from the survey on public knowledge and attitudes undertaken last year by the National AIDS Trust, which does such fantastic work in this area, about how people would regard a neighbour who was diagnosed with HIV, quoting, quite rightly, "Love thy neighbour". There is an even more shocking figure in that survey that 20 per cent of respondents disagreed with the proposition that,

Therefore one in five would have a more negative view of someone in their own family who was diagnosed.

Four areas of action need to be taken to tackle stigma, and the report very helpfully points the way in some of them. The first relates to healthcare professionals; sadly, as the noble Baroness, Lady Masham of Ilton, said, half of all discrimination reported by people with HIV is in healthcare, particularly in the case of dentists and GPs. Yet those are the very people who should be encouraging testing then, when somebody is diagnosed HIV positive, ensuring that they get swift and effective treatment from experts at the brilliant HIV centres around the country. NHS staff need consistent, high-quality and, above all, continual training about not just the basic facts regarding HIV but the unacceptability-indeed, the unlawfulness-of HIV discrimination, and about the actions that need to be taken to ensure that patients with HIV have the respect and support they deserve. Here, the new NHS Commissioning Board has a vital role to play in requiring anti-stigma training, especially in primary care.



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The second area relates to general public information. Undoubtedly, "Awareness of HIV", in the opening words of the report, is "below the public radar". What that means is that public understanding of HIV transmission has also decreased significantly in the past decade. The Ipsos MORI surveys commissioned by NAT, which we have heard mentioned today, have over the past few years shown an increase in the number of people believing HIV can be transmitted through kissing. Less that half those questioned cite sharing needles as a possible route, although that is actually the second most common transmission method. These misunderstandings foster stigma because of the link between poor understanding of how the disease is transmitted and a judgmental attitude towards people living with it. Education in schools is obviously vital here, but so are local sexual health campaigns and information to ensure that, at the local level, people have accurate information on how HIV is and is not transmitted.

The third area relates to the media; here, I must declare my interest as executive director of the Telegraph Media Group. Undoubtedly, HIV scare stories in some small parts of the media still foster the fear that is the basis of stigma. While HIV and its ramifications are complex issues to report, not least because they can often become entwined with other emotive subjects such as immigration, there is never an excuse for inaccurate reporting when it can have a terrible human cost. Some progress has been made. The National AIDS Trust, working with the help of the Press Complaints Commission, has produced excellent guidelines for reporting HIV which have started to make an impact. They cover the law, the myths, the vocabulary and issues about testing. They are extremely important in tackling stigma and I encourage their wide dissemination in newsrooms across the media.

My fourth point relates to public policy. The Government's recent mental health strategy has, as one of its six objectives:

"Fewer people will experience stigma and discrimination".

The Government are, rightly, backing this with significant funding. HIV is in many ways comparable to mental health in terms of conditions that arouse fear and foster stigma: yet there is no strategy or funding in place specifically to tackle HIV stigma and its resulting harms to public health. As the noble Baroness, Lady Gould, said earlier, such a strategic policy could work across departments and disciplines, involving education and teachers, the police, social workers, the media and, above all, healthcare professionals to tackle stigma at its roots.

Of course, money is tight but investment in a strategy of this sort would be perhaps the most cost-effective money the Government could ever spend. Various noble Lords have quite rightly pointed out the simple maths, which I am afraid were never a strong point of mine. I would look at it this way: £1 million spent on an HIV stigma strategy would be recouped by preventing just four of the 2,656 confirmed UK-acquired infections diagnosed in 2010. It is just four; once we get to the fifth, we have started saving. If it were successful, the long-term savings to the public purse could be considerable. Taken together, these four steps could

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significantly help tackle the stigma, encourage more people to get tested early, help prevent onward transmission of the virus, and ensure a better quality of life for the 100,000 people who will soon be living with HIV.

In my closing comments, I want to mention those 100,000 people. Thanks to effective treatment, there is no reason that they should not lead long and healthy lives. However, we have to recognise that HIV is now a chronic illness, that our understanding is relatively new, and that we do not know what its long-term consequences might be, or the long-term effects of the drug therapies, particularly in terms of other conditions that those living with HIV might contract. If you have HIV, every illness that you get could potentially impact on your treatment regime. As people live longer, this is going to become a much more complex issue to deal with and the model of care, as the report notes, will need to change accordingly. That means a holistic approach to treatment, with regular access to specialists in the field for all those with HIV.

For a number of reasons, some of which I mentioned earlier, GPs may not be the best suited to this task. I am cautious of any moves to give them primary responsibility in this area when it is specialist care which is going to be increasingly vital as the health service copes with an increasingly elderly population living with HIV. Ideally under the new commissioning arrangements, designated centres of excellence for HIV treatment and care should be the ones responsible for ensuring the most effective, convenient, continuous and flexible therapy for all HIV patients. I believe this would be likely to offer better longer-term results in quality of care than the strategy of giving GPs shared responsibility with specialists.

In my remarks today, I have tried to touch on a wide range of subjects. I could go into nearly as much detail as the brilliant report that we are considering. That is a point that underlines how complex this issue is in public policy terms. We are fortunate indeed that this report has given us the opportunity for such an important debate. I hope that in its way it can be as effective as the original campaign 25 years ago-this time not just so much about saving lives, but improving the quality of those lives. That is the great and noble task ahead.

5.47 pm

Baroness Massey of Darwen: My Lords, I, too, thank the noble Lord, Lord Fowler, for securing this debate and I thank the Select Committee for producing such a timely and thorough report. I was not a member of that committee, but I want to make some general comments about prevention campaigns, then focus on prisons and schools and ask the Minister about the Department of Health's new sexual health policy framework. It is an honour to follow so many well-informed, even poetic, speeches. I know that all those noble Lords who have spoken today have a long-standing commitment to HIV/AIDS prevention and treatment. In thanking Lord Fowler, I have to say that he is one of my public health heroes.

At a time when HIV/AIDS was emerging as a health threat, when the public response was one of fear, confusion and prejudice which sought to stigmatise

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certain groups, the noble Lord remained calm and reminded us that this was a health issue that needed to be tackled firmly. I know this because I was working in public health at the time, and how glad we were that he was in post. Yes, there were, I believe, icebergs and tombstones-sometimes misinterpreted by the general public-and maybe we would do some things differently now. However, the noble Lord, Lord Fowler, certainly had a great impact on those campaigns of public awareness.

The rampant and unthinking prejudice which emerged then still has echoes in the ignorance and dangerous attitudes of some people who oppose sex education and sexual health promotion today. It is interesting that other public health issues, such as vaccination, smoking, wearing seat belts and so on, are not connected to sex, or are perhaps only marginally, and so are not fraught with the connotations attributed to HIV and AIDS. In the government response, the high cost of treatment is described as a compelling investment. In 2010, prevention could have saved over £32 million annually. I was pleased that the committee recommends both targeted, intensive campaigns and, very importantly, that awareness should be incorporated into wider national sexual health campaigns, with evaluation commissioned by the Department of Health.

There should certainly be a new national HIV prevention campaign targeted at the general public. Let me say briefly why this is important. There has not been such a campaign for a long time. The high profile of HIV/AIDS has decreased and the problem of HIV infection and other sexually transmitted infections is increasing. We are in a new era of communications. We now have the internet, social networking of many kinds and highly sophisticated mobile phone applications. All are wonderful but they can also be misused, as we have seen in grooming and internet and mobile phone bullying. I have sympathy with the support of the noble Lord, Lord May, for NGO involvement in such campaigns.

Apart from HIV and AIDS, there are other dangers, some rather curious. I was in Nottingham last week, discussing substance misuse and public health. I must declare an interest as chair of the National Treatment Agency. As I learnt in Nottingham, there is concern about the injection of steroids in relation not just to bodybuilding but to the desire for the body beautiful. There is also concern about the injection of a substance that will give a body tan that also enhances libido. In Nottingham, people were found who have contracted HIV/AIDS and hepatitis B through these practices. It is very worrying and a call to renew our look at how we campaign.

Prevention campaigns have to be part of general health campaigns, using ever more sophisticated and subtle means of communication with adults and young people. I am also glad that the committee has shown concern for future structures in public health. Such concerns were highlighted by the noble Baroness, Lady Tonge, and many others. As the report points out, sexual health has often been the poor relation of the health service. The voluntary sector has done an enormous and valuable amount to tackle HIV and AIDS. We all wait to see how drug, alcohol and sexual health services

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will fare in future public health services with a ring-fenced budget. They must not be lost among other demands. I know how ring-fencing has in the past enabled drug treatment to improve the numbers in treatment and waiting times. Health and well-being boards and other local monitoring groups must be vigilant about keeping HIV on the agenda.

The public health White Paper, Healthy Lives, Healthy People, spoke of working,

It points out that testing should be a priority of any prevention policy. Prevention has been spoken about a great deal today. The testing of pregnant women has been a success. Other testing, such as by GPs and home testing, could be effective, as many others have pointed out.

I now want to talk about schools, which were referred to by others, including my noble friend Lady Healy. Schools should be considered part of the community and, therefore, connected to community services. There have been good examples of older pupils in schools visiting Brook Advisory Centres as part of the PSHE programme. This encouraged them to seek advice, perhaps after leaving school. Schools should also teach about public health issues. The danger of HIV infection should be taught as a specific issue, not just in sex education-if it exists. I should like to see secondary schools teaching compulsory modules on public health. This would go alongside teaching about respect for oneself and others, decision-making, self-esteem and communication skills. All these skills can reinforce the ability to behave responsibly in relation to sex and substance misuse. I am not talking here about explicit sex education for five year-olds and I do not believe that schools are either. Those who rant about sex and five year-olds should visit some schools and inform themselves about the responsibility of school governors, some of whom are parents, for the curriculum.

We have suffered recently from a barrage of misinformation and prejudice about teaching sex education. Such misinformation is an insult to teachers, parents and school governors and it should have a health warning on it. Primary schools, including five year-olds, can discuss relationships with family, friends and the community. Children have rights and responsibilities. They can learn about keeping themselves and others safe. Later, this foundation of rights and responsibilities can be used to teach about drugs, alcohol and sex. Lack of information and misinformation are highly dangerous.

I turn briefly to offender health. People in prisons are a high-risk group in many ways. Among them there are significant levels of illiteracy and mental health problems. We know that some prisoners use drugs and have sex. But, significantly, prisoners leave prison and may spread infections. The recent report on prisons and drugs chaired by my noble friend Lord Patel of Bradford recommended: a cross-government strategy; a streamlined commissioning system; a framework for service delivery; user and carer involvement-that is very important; and links to the wider criminal justice and health and social care systems.

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For HIV we need all those things. We need guidance to prison governors and clarity on best practice in managing HIV in prisons, to include provision for prevention, testing and treatment and data collection. I hope that clinical commissioning groups will address, monitor and evaluate the outcomes of interventions in prisons. There must be continuity of care. The programmes to identify substance misuse and provide individual key workers to help with employment, housing and other social issues have proved highly successful.

The report on prisons highlights many significant issues for HIV and AIDS prevention and management of services. I very much look forward to following what happens in the new structures for public health. I hope that the Minister can give us a preview of the sexual health policy framework. I also hope that, perhaps in two years' time, the noble Lord, Lord Fowler, will reconvene a committee to look at the outcomes of these new structures and the impact of the sexual health policy framework. As usual he has done a great favour to those concerned for public health. I again congratulate him and the committee on this debate.

5.57 pm

Lord Gardiner of Kimble: My Lords, it has been a great privilege to serve on the Select Committee under the chairmanship of my noble friend Lord Fowler. It has been a particular privilege to serve with colleagues across your Lordships' House, our professional adviser and clerks, who all know so much more than I do about this devastating and serious virus.

I fear that I may have asked some all too obvious questions. My first was because I failed to understand-and still do-why antiretroviral drug prices need to vary across the country. I am a supporter of localism but surely it is desirable to procure nationally if this means that more competitive prices can be achieved across the country and significant savings can then be utilised on the front line of treatments or, indeed, on prevention measures. In the Government's response to the committee's report, it is acknowledged that beyond London regional procurements have been less successful. However, I do not see that rectifying this has been viewed as a priority. I hope that I am wrong. Predominantly, it has been a privilege to hear directly from exceptional professionals, dedicated volunteers and courageous and inspirational people who live with HIV.

Your Lordships have already heard that in this country the stark facts are that the number of people living with HIV is increasing-it is now more than 100,000-with treatment costing £1 billion a year. In the world some 34 million are now living with HIV/AIDS. The rate of infections in the world is thankfully slowing yet in the UK the rate is increasing, so now is the time for the UK to tackle this virus with renewed determination. With early diagnosis we can enable the majority of people with HIV to have as normal a life as possible. The drugs have transformed the prospects for so many. However, we must now concentrate even more tenaciously on prevention. This is the key to all our aspirations to defeat HIV/AIDS and eventually eradicate it.



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Some prevention measures in the UK have been outstanding successes. Many noble Lords have already referred to the clean needle programmes and routine antenatal testing of pregnant women. More generally, however, our financial commitment to prevention campaigns for too long has been disproportionately low. The lifetime cost of treatment of a single patient is nearly £360,000. Yet £2.9 million, as has already been referred to, is all we will spend on national prevention programmes in 2011-12. The Government in their response recognise the benefits that investment in prevention would offer. We need to do more than that. We need action. There must be a far more robust attitude, a sense of mission on prevention, which my noble friend Lord Fowler so admirably galvanised and led in the 1980s.

We must be bold about prevention programmes. Is the UK rate of infection increasing because we have not been? Of course our efforts should be focused on the parts of the community most at risk. But should not HIV also be seen as part of the overall sexual health campaign? The more we place it in that context, the wider the message reaches. I do not understand why the Government are so adamant that a national campaign aimed at the general public, which the committee recommended, would not be effective. I apologise to the Minister, but when the national campaign led by my noble friend Lord Fowler is universally acknowledged as having been extremely effective, I do not understand the Government's initial response. At the same time, the Government quite rightly accept that more needs to be done by all to address behaviour that increases the risk of HIV infection. I urge the department to look at this with urgency as it formulates the new sexual health policy framework. I am sure the department will be widely supported in being robust in considering all the options when prevention contracts end in March next year. I also hope that upon gaining new responsibilities, local authorities will prioritise prevention.

No responsible person underestimates the financial pressures we face in this country; new money is more than hard to find. However, we will fail to be cost effective if we do not direct scarce resources towards prevention. Even with the success of antenatal testing, last year over 70 babies were born HIV positive; that is, 70 children with the prospect of medication all their lives. It is a sobering and distressing thought and we must do better.

One element of serving on the committee which most affected me was learning about the consequences of late diagnosis in terms of quality and expectancy of life. Some 52 per cent of adults in 2009 were deemed as diagnosed late: heterosexual women at 59 per cent and heterosexual men at 66 per cent. Two-thirds of those over 50 were diagnosed late. That may be a profile that is not what many would have expected. Going further, 30 per cent of new diagnoses are in the very late diagnosis category. This is a frightening percentage with many adverse health implications.

In committee we discussed testing at some considerable length and received much evidence. The current situation surely warrants that we should look at the whole issue of testing and its expansion. Antenatal testing is now

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seen as a routine and uncontroversial procedure. Is this not the route we should now take? As part of tackling stigma and discrimination, should we not be looking to normalise as much as possible our approach to testing? Why cannot HIV testing on an opt-out basis-as the noble Lord, Lord May of Oxford, has already highlighted and as is recommended in our report-be routinely offered and recommended to new registered patients, to general and acute medical admissions and on entry to prisons? The wider we test, the more we can break down stigma. The more we do so, the more likely that people will come forward, be tested and, if necessary, receive medication. Therefore, I endorse the Government's comments that HIV testing should be within the competence of all doctors and nurses, and I welcome the department's review of the policy which bans the sale of home-testing kits. Echoing the noble Lord, Lord May of Oxford, I hope that the review will, in turn, move to action.

I came to the deliberations of the committee with a fresh mind. I can see, alas, that we in the UK have been faltering in our national efforts to conquer this dreadful virus despite the supreme dedication of superb professionals and volunteers. We need renewed vigour and courage to seize this moment. Every new infection of a baby, a young person, a man or a women takes its toll on the patient and on their family and friends. Medical advances since the 1980s have been dramatic, yet no cure is in sight. It is on our watch now that we must be innovative and bold on prevention and compassionate to the all too many people who live with HIV.

6.06 pm

Lord Collins of Highbury: My Lords, I, too, congratulate the noble Lord, Lord Fowler, on initiating this excellent debate. I have huge respect for the work that he has done and continues to do in raising awareness of HIV and AIDS.

I also pay tribute to all the members of the Select Committee for producing such an excellent and timely study. I say "timely" because only this week the Health Protection Agency warns that the virus is on the rise again in the UK. As we have heard in today's debate, more than 100,000 people will be living with HIV in the UK by the end of the year, and, as the noble Lord, Lord Fowler, said, more than a quarter of HIV infections remain undiagnosed-that is, in people who have not yet had a test and do not know that they are infected.

The HPA reported that new diagnoses of HIV in men who have sex with men have hit a record high, with around 3,000 men diagnosed in one year. That is the largest annual figure ever recorded. It was 1,820 in 2001, 2,660 in 2005, and 2,790 in 2009. As many noble Lords have said, it is time to break the silence and stigma around HIV, and this report is a very welcome step in helping us to do that.

Early diagnoses and the excellent treatments now available from the NHS mean that many have a chance of avoiding the worst consequences of this virus. As the noble Lord, Lord Fowler, reminded us, when the epidemic began 30 years ago, people with HIV swiftly became sick, developed AIDS and died of infections,

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such as pneumonia, which their bodies could not fight off. Today, combinations of antiretroviral drugs keep people alive and healthy, and can give them a relatively normal lifespan as long as they stay on the medication. This means, too, that the number living with the virus continues to rise.

Early preventive action not only saves lives but saves money. This is where I also want to amplify the conclusion in the report that a new priority must be given to prevention. As many noble Lords have said, spending on preventing infection is seriously inadequate-just £2.9 million compared with the £762 million treatment bill. I very much regret that the Government dismiss out of hand the committee's recommendation for an advisory committee for HIV prevention research. Such a committee might give us a clearer indication of the effectiveness of some of the public campaigns.

An area that I want to stress in particular, evidenced in the committee report, is the link between prevention strategies and treatment. As my noble friend Lady Gould and others have said, that link is tested. As I have said, more than a quarter of those with HIV in the UK do not know that they have it, which means that they may be unwittingly passing it on to others and may not be diagnosed until they are ill and treatment is more difficult.

As my noble friend Lord Rea said, in 2010, 50 per cent of all new diagnoses were made late-in other words when the CD4 cell count falls below the level at which treatment is recommended. The proportion diagnosed late is higher in heterosexual men-63 per cent-and heterosexual women-58 per cent-than among gay and bisexual men-39 per cent. Black African and Black Caribbean people are more likely to be diagnosed late than white people. People diagnosed over the age of 50 are more likely to be diagnosed late than younger people. While progress is being made, it is being made very, very slowly. At the current rate it could take 50 years to eradicate the late diagnosis and start treatment on time.

As the noble Lord, Lord Fowler, reminded us, of the 680 people with HIV who died in 2010, two-thirds were people who had been diagnosed late. On the other hand, the outlook for people who are diagnosed promptly is excellent, with life expectancy just a few years shorter than that of people without HIV. Will the Government do more, as the Select Committee and the HPA ask, to increase access to HIV testing? For example, the report advocates that such testing is routinely offered to new patients of GPs and at hospital general admissions in areas of the country where rates of HIV infection are high. While I welcome the Government's positive comments, including reviewing the ban on the sale of home testing equipment, I believe, as the noble Lord, Lord May, said so effectively, that more needs to be done to incentivise public health commissioners to prioritise HIV testing. With responsibility for HIV prevention moving to local authorities, it is vital to look for ways to ensure they are prioritising this issue and to invest in effective targeted prevention work. It must be a key performance indicator. Like others, I very much hope that it remains in the final public health outcomes framework. However,

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there are currently no plans to include a specific public health outcome measure on HIV prevention or sexual behaviour. I should like the Minister to respond to that.

This lack of emphasis from central government is exacerbated, as we have heard today, by the distribution of budgets and responsibilities in the new health structure proposed in the Health and Social Care Bill. As local authorities will not be paying for HIV treatment out of their budgets-this will be funded by the NHS Commissioning Board-like others, I am concerned that there is no cost-saving incentive to prevent further transmission. The Bill proposes significantly to increase the power of local authorities through health and well-being boards. While I am not opposed to greater local power in principle, I am concerned that the new structure opens the door for an ever-increasing politicisation of public health, which could have a severe impact on less socially acceptable health conditions, such as HIV. There are still considerable negative associations and stigma attached to HIV and a severe lack of knowledge about HIV among the general public, as the National AIDS Trust's recent Ipsos MORI research study report showed. This makes it particularly vulnerable to prejudice and can silence local voices of people with HIV. Stigma, prejudice, ideology or disapproval can threaten evidence-based interventions which meet the health needs of groups most at risk of HIV. There is potential for the increased role for elected officials to pose a threat to the continuation of the high-quality services needed to tackle the HIV epidemic in the UK. Indeed, in some places, HIV organisations have already begun to experience barriers when working with local politicians. Therefore, I urge the Minister to acknowledge how important it is for the Government to understand this and to build suitable protections into their reforms package. This should be through HIV-related outcomes in the NHS public health and social care outcomes frameworks. There should also, in relation to HIV and sexual health, be a detailed mandate from Public Health England to local authorities which sets out the essential elements of a comprehensive sexual health service, as my noble friend Lady Gould urged. It is vital that the Government ensure that stigmatising views of HIV, and around sexual health more broadly, do not affect decisions about local public health services.

As the Select Committee report said, stigma and lack of understanding can undermine HIV prevention efforts. Misinformation circulated about HIV, suggesting that it is a judgment or that it can be cured through non-medical methods, poses a threat to public health messaging. This is especially the case when such statements are made in faith-based settings, given the significant influence of faith leaders in some communities. As someone who still finds leaflets from local churches in Finsbury Park offering cures for AIDS, I know how important such work is, as the noble Baroness, Lady Masham, reminded us. I am therefore pleased that the Government agree with the Select Committee's recommendation about the valuable contribution that faith leaders and faith groups can make to HIV prevention and care services. When linked to projects such as the African Health Policy Network's Ffena programme, which has trained more than 100 people living with

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HIV to become advocates for understanding of the condition, we know the policy can make a real difference in our communities. These sorts of projects involving HIV-positive people as advocates and confident service users are a vital tool in addressing stigma through publicising the condition and encouraging dialogue. It is really important that the Government ensure continued support for this work, especially in these difficult economic times.

After recent research that showed that drugs can protect against the transmission of the virus, I also welcome the report's call for immediate reviews into the possibility of putting people on medication sooner and offering it to their uninfected partners. However, I fully accept that such a policy should be considered after detailed research into the particular circumstances pertaining in this country.

Finally, I want to turn to the Health and Social Care Bill's proposals on health and well-being boards. Many noble Lords have mentioned them in the debate. They will be central to the integration of services. However, I share the concerns expressed by many HIV/AIDS charities that the NHS Commissioning Board will not be routinely represented at all health and well-being board meetings. Without the presence at health and well-being board meetings of those commissioning HIV services, there is a real risk that the importance of HIV prevention, as well as the concerns of people living with HIV, will be sidelined in favour of areas where there is a direct financial benefit, and which, perhaps, are not as potentially controversial. I ask the Government to do more to ensure the presence of representatives from the NHS Commissioning Board at health and well-being board meetings and to guarantee that voices representing the needs of people with HIV are heard in the deliberations of those boards.

6.20 pm

Baroness Northover: My Lords, I congratulate my noble friend Lord Fowler on securing this important debate today, World AIDS Day. He has an outstanding record as the person who very much shocked us into an awareness of AIDS. He also deserves plaudits for his continuing interest in HIV and AIDS nationally and internationally, an interest that has done much to raise awareness inside and outside Parliament. As we know all too well, in issues such as this awareness is a significant part of the battle.

The report by the House of Lords Select Committee on HIV and AIDS in the United Kingdom, No vaccine, No Cure: HIV and AIDS in the United Kingdom, was most timely, given that it was 25 years ago when my noble friend led the Government's response to HIV and AIDS. I commend the outstanding membership of this Select Committee, many of whom have a long record of work in this area, as I know from when I was an officer of the All-Party Parliamentary Group on HIV and AIDS. This report will help to inform the Department of Health's new sexual health policy framework planned for next year.

In October, we published the Government's response to the report and made clear that we agreed with many of the Committee's recommendations on combating HIV and AIDS. World AIDS Day provides an excellent

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opportunity to reflect on the progress that we have made. Globally, there has been progress. The epidemic has stabilised in many regions. New infections have fallen by 21 per cent since 1997. Nearly 7 million people are on antiretroviral treatment-a more than tenfold increase over five years.

Today is also an opportunity to recognise the continuing challenges presented by HIV, both globally and at home. More than 34 million people are living with HIV and, as noble Lords have noted, there is no cure or vaccine in sight. Around 10 million people in need of treatment are not getting it. There are more than 7,400 new HIV infections every day, which is two for every person who begins receiving treatment. To compound the problem, HIV funding is flatlining, about which we can read more in today's papers.

While the scale of the epidemic is very different in countries such as the UK, as my noble friend Lord Fowler pointed out, we are not unaffected by the global picture. Effective treatment from the NHS can transform the lives of those living with HIV or AIDS, but there is no cure or sign of a vaccine and HIV still attracts considerable stigma, which is a huge challenge.

The Government's early response all those years back, led by my noble friend Lord Fowler, has helped to make sure that the UK has remained a relatively low prevalence country for HIV, particularly compared with some of our European neighbours. The early introduction of needle exchange and harm minimisation programmes, for example, has meant that we have very low rates of HIV in drug users who inject, unlike in other countries, as my noble friend pointed out.

Earlier this week, the Health Protection Agency published its annual HIV report for 2010. There are now around 91,500 people living with HIV, of whom around a quarter are unaware of their infection. This means that they are unable to benefit from highly effective treatment and risk unwittingly transmitting HIV infection to others. The HPA also reported that in 2010, new diagnoses in men who have sex with men-MSM-reached a peak of 3,000, and MSM remain the group most at risk of HIV transmission in the UK.

That is why I very much welcome the report's focus on the importance of HIV prevention. The Government agree that we need to be more effective in supporting responsible sexual behaviour. HIV prevention makes good economic sense too, as noble Lords have pointed out. The HPA estimated that preventing the estimated 3,800 HIV infections acquired in the UK in 2010 would have saved over £32 million annually, or £1.2 billion over a lifetime, in costs.

This year, the department has invested £2.9 million in a national programme of HIV prevention for men who have sex with men and for African communities, delivered by the Terrence Higgins Trust and African Health Policy Network. On top of that, the NHS provides many HIV prevention services, some funded separately and some funded as part of mainstream services such as testing and distributing information and condoms. The Department of Health is currently considering how national HIV prevention programmes

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might be taken forward when the current programmes end. The Committee's comments will help to inform what happens.

Of course, effective prevention requires effective testing. Late diagnosis is the most important factor associated with HIV-related morbidity and mortality in the UK. We agree with the Committee that HIV testing should be offered more widely and in various healthcare settings, particularly in areas of high prevalence. In September 2011, the HPA published its final report on pilots which the department funded in 2009-10 to help to reduce late diagnoses of HIV. The findings were encouraging and patients responded to being offered HIV tests. We are also funding the Medical Foundation for AIDS and Sexual Health to develop ways of helping GPs and primary care staff to offer HIV tests more routinely.

It is vital that the public health system is versatile and proactive enough to deal with HIV and AIDS. Reference has been made to how this is going to be structured in the future. Ring-fenced public health funding is central to our NHS and public health plans. This will allow us to plan spending on prevention without the money being raided for other projects. In today's restrictive financial climate, this is a very noteworthy commitment in this area.

Finally, I turn to the concerns raised by noble Lords about the current policy to charge some people for HIV treatment. As we made clear in our formal response to the Committee, we are concluding an internal review of our current policy-I know that review does not please the noble Lord, Lord May, but I hope he will be encouraged in the end-and expect this review to be completed by the new year, including any discussions with the other government departments that have an interest. The review is considering many of the issues raised today. These include the increasing evidence on the public health benefits of early diagnosis and the significant role of HIV treatment in reducing the onward transmission of HIV.

Promoting HIV testing to reduce undiagnosed HIV and late diagnosis remain important priorities for HIV prevention. We would be very concerned if our current policy was to deter people from being tested for HIV, even though testing has always remained free of charge to all. I acknowledge that a small number of vulnerable people will not be covered by the current exemptions and that they may be deterred from accessing HIV testing services because they cannot afford treatment or are confused about the entitlement to free NHS treatment. In considering any changes to our current policy we must avoid creating an incentive for people to come to the UK for the purpose of free HIV treatment, without compromising our overriding responsibility for public health. I hear the powerful case made by the right reverend Prelate the Bishop of Wakefield in this regard. The department's review has considered many of the issues raised today and we will conclude it by the new year.

I turn to some of the questions that noble Lords have put to me. The noble Lord, Lord Fowler, asked about supporting more HIV testing in general practice. I have made reference to the funding that we have provided to the Medical Foundation for AIDS and

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Sexual Health, which is working on a three-year project to try to support GPs and primary care staff in offering HIV testing. The noble Baroness, Lady Gould, also referred to that.

The noble Lord, Lord Fowler, and the noble Baroness, Lady Masham, asked about prisoner health. As they know, we do not routinely screen people in prison for HIV just because they are prisoners-rather, we have an active case-finding programme which encourages both prisoners and staff to consider whether their behaviour, current or previous, may have put them at risk of infection with HIV and provides them with an opportunity for testing. We respect the rights of prisoners to accept or refuse testing if they so choose, which reflects normal practice in the wider community.

The Department of Health offender health team has worked with the HPA to improve disease surveillance in prisons. We aim in the new year to disaggregate data on diagnosis made on people in prison. Condoms are routinely provided in prisons to prevent the transmission of STIs. NICE evaluated the evidence of effectiveness of needle-exchange programmes in prisons and stated that there was a need for more research on the added value. It felt that the condom programme was useful.

The noble Lord, Lord Fowler, and other noble Lords, including the noble Baroness, Lady Healy, spoke of the need for a new prevention campaign. The awareness campaigns of the 1980s, which targeted the whole population, were effective in raising the public's awareness of a serious public health threat at a time when we did not know how HIV would develop or the main routes of transmission. By the mid-1990s, it was clear that men who have sex with men and people from sub-Saharan African countries were disproportionately affected by HIV. That is why, since 1996-97, the Department of Health funded programmes that focused on those communities. This approach is supported by community organisations and others including the HPA. The previous Government also subscribed to this. I hear what noble Lords have said and this will no doubt continue to be assessed on an evidence-based approach.

The noble Lord, Lord Fowler, asked about home-testing kits, to which I think I made reference in my speech. We are reviewing our policy on banning the sale of home HIV tests. We recognise anyway that the current ban is probably not sustainable given that home-testing kits are already available from overseas on the internet. It is essential if there is any change that home-testing kits are quality-assured, including the provision of clear patient information on following up positive or unclear results. It is extremely important that those kits are reliable if they are going to be used at home.

The noble Lord, Lord Fowler, asked about national procurement of ARV drugs, as did others. The Department of Health is keeping this under wider review. We are very keen to ensure that we have clinical collaboration in ensuring there is leverage on price and that experience from procurements on a local and regional basis will be used in evaluating the ability to take this forward on a multi-regional or national basis. It will be under review.



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Various noble Lords, including the noble Lords, Lord Lexden and Lord Black, and the noble Baroness, Lady Gould, spoke about stigma. It is of course very much the case still that stigma is an enemy to progress. TB was a stigma in the 19th century and cancer in the 20th century and we have a problem here also when people are unwilling to come forward because HIV has the power to define a person in a way that an illness simply should not. Too many people with HIV still experience shame and isolation because of their diagnosis and that can manifest itself, as we have heard, in discrimination in all sorts of places.

The Department of Health's new sexual health policy framework planned for next year will consider how key partners involved in HIV care work and others can work together to reduce and challenge HIV stigma. The national HIV prevention programme for African communities, funded by the Department of Health, has contributed to toolkits for faith leaders and communities in this area and we want to develop this further; that is a very important message that comes out of this report.

The noble Baroness, Lady Gould, asked whether the Department of Health would consider the HPA's Time to Test for HIV report. The answer is yes and this will help to inform our forthcoming sexual health policy framework. She also asked about the public outcomes framework; we are considering responses to this, including a proposal on an indicator on late HIV diagnoses and we will publish that framework very soon. The noble Baroness also asked about tariffs on sexual health; as she probably knows there is ongoing work on tariffs and I will write to her in more detail about this.

My noble friend Lady Tonge expressed her reservations about our plans in general and this issue in particular. I can reassure her, at least in one or two areas. The £2.9 million on prevention that was flagged up as being inadequate excludes work done on prevention by the NHS, for example testing, condom distribution and local health promotion. There is more there than she might have felt. I will no doubt address many of her concerns on the health Bill more widely outside this Chamber, otherwise I am sure we will be here again until at least midnight.

My noble friend Lady Tonge, and the noble Baronesses, Lady Healy and Lady Massey, spoke about PSHE in school; I assure noble Lords that we recognise that children benefit enormously from high-quality PSHE which helps them make safe and informed choices. There is a slimming down of the statutory curriculum to give schools more freedom and space to teach a curriculum which engages pupils; however, we have launched a review of PSHE to identify the core body of knowledge pupils need and ways of improving the quality of teaching. I emphasise that we welcome representations, including evidence and examples of good practice, and I strongly urge noble Lords to feed into that process. As a result of the review we will be drawing up proposals, based on the evidence, and consulting on them.

The noble Baroness, Lady Masham, asked about the future of the HPA; we will be having further discussions about this in the health Bill. In fact, we

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almost came to it last night but I think it will now be discussed on Monday. As she knows, the HPA, along with a number of other organisations, will be brought together into Public Health England, which will be free to carry out research; it is an executive agency of the Department of Health that will be established in April 2013-always assuming your Lordships pass the health Bill. It can carry out research, it must give advice to the Government-it has that independence; those working will be able to apply for grants and so on. We will work to maintain the excellent quality of the HPA's current HIV surveillance programme when it transfers to Public Health England.

The noble Lord, Lord Lexden, referred to Northern Ireland, and it was extraordinary to hear of the difficulties that he perceived there. It shows how in many areas, not only geographically but by community, some communities can be particularly difficult and harder to reach than others. Nevertheless, I assure him that the Department of Health works with the devolved Administrations to discuss issues that are common across the UK, such as increased testing, and to share good practice on prevention and care.

There was some concern about possible fragmentation because of local authorities being much more involved now in public health and also the NHS Commissioning Board. Again, we will no doubt return to these issues in the Bill, but the Department of Health is already working, and will be working over the coming year, with key stakeholders to map out the integrated sexual health pathway that will address the concerns raised today. This debate will no doubt feed into those concerns to ensure that work on the issue is joined up.

I have referred to the HIV home testing kits, which the noble Lord, Lord May, flagged up. The noble Lord, Lord Black, and other noble Lords spoke about HIV awareness in the general population being very low. Although we wish to seek improvement in all kinds of areas, it is quite interesting to note that, according to NAT's Ipsos MORI poll, four out of five adults in the communities that are most at risk were aware that HIV can be passed on by having sex without a condom. In other words, the targeting of information, at least to those groups, is having an effect. I am pleased that that is the case.

The noble Baroness, Lady Massey, the noble Lord, Lord Gardiner, and others asked about the sexual health policy framework. We are seeking to take a life course approach-that sounds like a course that we are offering through PSHE-to sexual health needs, for young people through to old people, including people aging with HIV, and we are working with the Sexual Health Forum to agree this framework. That work is being undertaken at the moment.

The noble Lord, Lord Gardiner, asked about introducing HIV testing and learning from antenatal HIV testing. We have asked the UK National Screening Committee to consider the evidence on making HIV testing more routine. We await its response.

I hope that I have covered most of the points raised. If there are points that I have not answered, I will write to noble Lords. Clearly we have a tremendous amount to think about as a result of this report and there is still more to do. We all have a part to play in

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keeping HIV high on the agenda, and debates such as this and the coverage today in the media all help to raise the profile of the disease. I welcome the report and the extremely important cajoling from noble Lords today. I am aware that we shall return to some of these areas in the discussions on the health Bill. I look forward to being further cajoled and I hope that we can make progress in at least some of the areas that have been flagged up in this important debate.

6.44 pm

Lord Fowler: My Lords, it has been an excellent debate and I thank everyone for taking part in it. I repair one omission and give thanks to our special adviser, Anne Johnson, who was absolutely first class in her advice.

I said at the beginning that we had the first debate on HIV/AIDS 25 years ago this month in the Commons, and today's debate was very much in that tradition, with outstanding contributions. There was general agreement on the serious increase in HIV, the central importance of early testing and the importance of combating the stigma.

I thank the two Front-Benchers-the Minister and her shadow-for their contributions. On the Minister's reply, to use the famous words of the noble Lord, Lord May, there were quite a lot of reviews in what she was saying, but I agree with her that a ring-fenced budget is infinitely preferable to one that can be raided and which we have had in the past. I am encouraged by what she says about charges for people from overseas and on home testing. I am not quite so encouraged by what she says about prisons, which we will have to revisit. As for what she says about a general campaign in getting this message over, I will say only that, as I count it, the noble Baroness, Lady Massey, called for one, as did the noble Baroness, Lady Gould, with all her experience, and as did the noble Baroness, Lady Tonge. The noble Lord, Lord Gardiner, agreed that there should be one, as did the noble Baronesses, Lady Masham and Lady Healy. For what it is worth, I think that there should be one as well, so I think she might find herself in a slight minority in this House.

The right reverend Prelate the Bishop of Wakefield made a quite outstanding speech on the work of the Church of England, to which I pay tribute. I also pay tribute to Bob Runcie, who was archbishop at the time of the 1986 campaign. I agreed with everything he said about charging for HIV treatment.

The noble Lord, Lord Lexden, made an important speech and rightly reminded us of the importance of Northern Ireland and the challenge there. The noble Lord, Lord Rea, talked about HIV not being a death sentence any more but certainly being a lifetime of medication. The noble Lord, Lord May, in a masterclass on the background, history and origins of HIV, made an outstanding contribution. I hope he is right in his predictions on the development of a vaccine. Above all, I think his message was that there is no reason to take the foot off the pedal at this point, which I hope that the Minister heard very clearly.

The noble Lord, Lord Gardiner, made a crucial point in passing about purchasing policy on drug costs. The noble Lord, Lord Black, underlined the

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vast importance of involving general practitioners in the work, which, as his example showed only too well, has not always been the case.

There will be future opportunities for talking about these things. If I could put in a commercial for the right reverend Prelate and the noble Lord, Lord May, we have an amendment down on testing for overseas visitors and we might conceivably put the Minister under rather more pressure than she was under this

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afternoon. I thank her and indeed everyone for an important debate on World Aids Day. I hope that we can renew our efforts to combat HIV, which seems to be the message that has come through from the whole debate.

Motion agreed.

House adjourned at 6.49 pm.


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