CHAPTER 9: Recommendations
328. The Government should recognise the scale
of the HIV and AIDS challenge in the United Kingdom. Not enough
is being done to respond to a steadily growing risk to public
health. There are potentially huge cost implications in both the
short- and long-term in failing to deal effectively with the epidemic.
At a time when public health in the United Kingdom is subject
to major reform, the Government should ensure that HIV and AIDS
is a key public health priority. (para 34)
329. Funding bodies, both public and private,
should continue to support HIV vaccine research as part of their
research strategies. Cooperation with international partners must
be central to this work. At the same time, the Government should
consult with the pharmaceutical sector to determine whether improvements
can be made to existing models of working and regulatory processes
to better involve them in efforts to develop a HIV vaccine. (para
43)
330. Although the successful development of a
vaccine is crucial in the longer-term, the response to HIV and
AIDS in the United Kingdom must be based on the assumption that
none will exist for at least a decade. (para 44)
331. Further Government support for prevention
is required. Prevention should be at the forefront of the response
to HIV. This must be reflected in the Government's replacement
of the 2001 sexual health strategy. More resources must be provided
at national and local levels. The Government should monitor and
audit the use of resources so provided, to ensure they are used
for the purpose of preventing new HIV infections. (para 55)
332. We have highlighted the costs of treating
HIV, and the long-term savings which could be made through investment
in HIV prevention. The current levels of investment in national
HIV prevention programmes are insufficient to provide the level
of intervention required. (para 62)
333. Local prevention programmes, and the voluntary
sector bodies that deliver them, have played an important role
in tackling HIV. Local authorities, health services and other
funders should avoid undermining local HIV prevention work when
taking budget decisions. The ongoing trend of pressure on local
prevention services also underlines the importance of enhanced
Government funding for national HIV prevention programmes. (para
68)
334. HIV awareness should be incorporated into
wider national sexual health campaigns, both to promote public
health and to prevent stigmatisation of groups at highest risk
of infection. We recommend that there should be a presumption
in favour of including HIV prevention in all sexual health campaigns
commissioned by the Department of Health. (para 72)
335. We accept that levels of new HIV infection
would have been higher without the national prevention programmes,
and we support those delivering this work. We feel, however, that
more needs to be done to reduce dangerous and risky behaviour
that is leading to HIV infection. In part, more funding is needed
but, in addition, a broader range of evidence-based approaches
are required. (para 78)
336. Both targeted and national HIV prevention
campaigns have an important role to play. Given the concentration
of HIV infection in two specific groups, we recommend continued
targeted HIV prevention campaigning focused on these communities.
This should be coordinated at the national level. (para 84)
337. We recommend that the Department of Health
undertake a new national HIV prevention campaign aimed at the
general public. This will ensure that HIV prevention messages
are accessible to all of the population. (para 85)
338. We recommend that those delivering HIV prevention
campaigns, whether nationally or locally, should utilise the full
range of available media, including internet, social networking
and mobile phone applications. We note that national sexual health
campaigns, such as Sex: Worth Talking About, have been
sufficiently resourced to purchase advertising time with national
broadcasters. We recommend that messages around HIV are included
in these campaigns in future, ensuring the greatest possible exposure
for HIV prevention messages. (para 89)
339. Whilst we do not doubt the integrity of
current evaluation processes, we recommend that the practice of
HIV prevention providers commissioning their own evaluation of
campaigns be ended. The Department of Health should commission
evaluation, ensuring separation from delivery of prevention activity.
We also recommend that, once instituted, such independent evaluation
activities are used to inform, refine and reinforce subsequent
prevention campaigns, providing an evidence-led approach to influencing
behaviour. (para 93)
340. Given the significant cost savings that
can be accrued from successful HIV prevention work, the Department
of Health should prioritise HIV prevention research. We recommend
that the Department establish an advisory committee, to give leadership
and coordination to biomedical, social and behavioural prevention
research. (para 94)
341. A range of intensive interventions—including
group and individual counselling work—should be delivered
for those who are most at risk of either contracting or passing
on HIV. This should be set against a backdrop of national campaigns
and awareness-raising which is properly evaluated and refined
for effectiveness. (para 97)
342. Discrimination against those affected by
HIV is based, at best, on ignorance and, at worst, on prejudice,
and we unreservedly condemn it. This underlines the need for a
general public awareness campaign on HIV. (para 100)
343. Given the significant influence of faith
leaders in some communities, we recommend that the Government,
local authorities and health commissioners build upon work already
taking place with all faith groups to enlist their support for
the effective and truthful communication of HIV prevention messages.
(para 111)
344. We recommend that the Department of Health
ensures continued funding and support for work, building upon
that currently delivered by the African Health Policy Network,
which aims to develop the knowledge of faith leaders about HIV.
Such work is vital in supporting a wider range of interventions
which aim to address, prevent and treat HIV within all communities.
(para 112)
345. People living with HIV need to be empowered
to become advocates for understanding of the condition, in order
to help to address stigma. We understand the importance of peer
support networks and voluntary organisations in supporting this
work, and recommend that local authorities and other public sector
funders acknowledge the importance of this work in their future
funding decisions. (para 115)
346. Progress achieved over recent decades mean
that there are now many facets to HIV prevention. We recommend
that the full range of available interventions be used to prevent
new HIV infections. We call this approach combination prevention.
(para 118)
347. We support the continued provision of needle
exchange programmes. The Government should use their influence,
both through partnerships such as UNAIDS and their bilateral relationships,
to make clear the benefits of needle exchange facilities, and
encourage countries whose epidemics are driven by injecting drug
use to institute or expand such programmes. (para 125)
348. Ensuring that as many young people as possible
can access good quality sex and relationships education (SRE)
is crucial. We recommend that the Government's internal review
of PSHE considers the issue of access to SRE as a central theme.
Teaching on the biological and social aspects of HIV and AIDS
should be integrated into SRE. (para 139)
349. Whilst acknowledging that the review is
yet to complete its work, we recommend that the provision of SRE
should be a mandatory requirement within the National Curriculum,
to enable access for all. Such education should begin within all
schools from Key Stage 1, though this teaching must be age-appropriate.
(para 140)
350. There is an important role to be played
by external providers, but we recommend that SRE should be primarily
delivered by teachers, who must be trained to deliver this teaching.
This training must focus on all aspects of HIV and AIDS, to ensure
that teachers are confident on the subject. (para 141)
351. Procedures developed to limit the transmission
of HIV from mother-to-child have been an outstanding success.
We recommend that the Department of Health and commissioners ensure
that such services continue to be provided as required. For the
same reason, we also recommend that local authorities provide
free infant formula milk to HIV-positive mothers who have no recourse
to public funds.(para 146)
352. Treatment has an increasingly important
role to play in preventing HIV infection. We note research demonstrating
the potential for earlier antiretroviral treatment as a preventive
measure. We recommend that the Department of Health, National
Institute for Health Research, Medical Research Council and other
research funders provide support in order to examine the utility
of such approaches in the United Kingdom. In addition, the Department
of Health should keep policy in this area under review as further
research continues to emerge. (para 150)
353. We recommend that the Department of Health,
National Institute for Health Research, Medical Research Council
and other research funders support programmes of work which examine
the utility of pre-exposure prophylaxis. This research should
take place in both in the United Kingdom and in international
settings. We recommend that the availability of post-exposure
prophylaxis should continue to be determined by clinicians within
GUM clinics. (para 155)
354. We recommend that the Government pursue
its plans to commission offender health services centrally, which
would lead to better equity and continuity of care for prisoners.
(para 169)
355. Data on HIV in prisons must be improved.
The Health Protection Agency should utilise surveillance data
newly available to provide a robust estimate of the prevalence
and profile of HIV within the prison population. At the same time,
a review exercise into offender health services in public prisons
is underway. The Government should supplement this with a review
of the extent and nature of HIV prevention, testing and treatment
services within public prisons, to determine the levels of provision
across the country. (para 170)
356. We recommend that best practice for managing
HIV in prisons is made clearer. The Government should commission
NICE to produce guidance for the management of offender health,
which should include specific protocols for HIV prevention, testing
and treatment. (para 171)
357. In the meantime, the Government should draw
up a guidance note to prison governors to outline best practice
for managing HIV in prisons. This must stress the need for high-quality,
continuous treatment and care; robust testing policies, including
routine opt-out testing on entry into prison; and the provision
of condoms in a confidential manner. Governors should implement
these policies within their prisons as soon as possible. (para
172)
358. Earlier diagnosis ensures that those infected
receive timely treatment, saving money on the treatment costs
of more advanced infections and preventing onward transmission
of the virus. This is cost-effective in the long-term. We therefore
recommend that the Government endorse both the 2008 professional
testing guidelines and the 2011 NICE testing guidelines. The policies
recommended within those documents, and the recommendations made
in the interim Time to Test report by the Health Protection
Agency, should be implemented. (para 191)
359. In particular, HIV testing should be routinely
offered and recommended on an opt-out basis, to newly registering
patients in general practice, and to general and acute medical
admissions. This should begin with high-prevalence areas (where
prevalence is greater than 2 cases per 1,000 people). HIV testing
should also be made routine and opt-out in relevant specialties
where conditions are associated with increased rates of HIV infection,
such as TB and hepatitis. Finally, testing should be expanded
into the community. Local testing strategies must be put in place
to facilitate this. (para 192)
360. These testing policies should be supported
with financial and human resources from commissioning bodies.
HIV testing should feature prominently in local needs assessments
and testing strategies in high-prevalence areas. The Government
must ensure that the performance of commissioners and clinicians
is monitored through regularly commissioned audits now, and the
late diagnosis indicator in its Public Health Outcomes Framework
in future. (para 193)
361. HIV testing outside of GUM and antenatal
clinics must become more widespread. Professionals, most notably
general practitioners, must become more confident and competent
in offering and administering tests. Training and education are
important tools to use to achieve this; they should form an important
part of local testing strategies. Such training must incorporate
efforts to address HIV-related stigma, and develop understanding
of the needs of people living with HIV. (para 204)
362. Practitioners must be more confident in
identifying those at risk of HIV and those with symptoms of infection.
Undergraduate training and ongoing professional development for
medical practitioners should stress the importance of these skills.
This is particularly so for specialists dealing with hepatitis
and tuberculosis, where co-infection with HIV is more common.
(para 205)
363. Encouraging people to test, through the
provision of education, training and support, can have significant
benefits for the public. We support the development of local testing
strategies, recommended within NICE testing guidelines. Equipping
people with the knowledge and desire to get tested should form
an integral part of those strategies. (para 213)
364. The ban on HIV home testing kits, as laid
out in the HIV Testing Kits and Services Regulations 1992, is
unsustainable and should be repealed. A plan should be drawn up,
in consultation with clinicians, patients, voluntary organisations
and professional associations, to license kits for sale with appropriate
quality control procedures in place. The licensing regime must
make sure that the tests are accurate, and that the process gives
comprehensive advice on how to access clinical and support services
in order that those who test positive get the care that they need.
(para 214)
365. HIV treatment and care services should be
commissioned at a national level, given their high cost and the
variation in HIV prevalence nationwide. To ensure commissioning
is responsive to differing patterns of need across the country,
regional treatment and prevention service networks, appropriately
supported and resourced by the Government, should be established.
(para 223)
366. Existing procurement arrangements, where
antiretroviral drugs are locally procured, mean that drug prices
vary across the country. This should be changed. Antiretroviral
drug treatments should be procured on a national scale. This offers
the potential for significant savings by making use of the purchasing
power and economy of scale of the National Health Service, as
well as standardising prices nationwide. (para 229)
367. The costs of HIV treatment are best managed
by purchasing well-tolerated, easily adhered to drug regimens.
This reduces the likelihood of incurring the much higher costs
of inpatient care which result from poor adherence to treatment.
Under national commissioning structures, commissioners must procure
drugs that allow clinicians the flexibility to prescribe regimes
that best serve this long-term view. (para 230)
368. Continued monitoring of viral resistance
to drug treatments, currently carried out through the UK HIV Drug
Resistance Database, is essential. (para 231)
369. We recognise the concerns arising from the
proposed split in commissioning responsibility for HIV prevention,
treatment and social care services. We recommend that the Department
of Health place a duty upon those commissioning HIV services to
support the integration of all HIV services in their commissioning
decisions. (para 236)
370. We recognise the importance of prevention
efforts in relation to other STIs, and the role that they can
play in preventing the spread of HIV. The integration of STI and
HIV treatment services, therefore, is essential for prevention
efforts. We share the concerns of those who suggest that the proposed
NHS reforms may increase the fragmentation of services. We recommend
that the Department of Health place a duty to promote service
integration upon those commissioning sexual health and HIV services.
(para 237)
371. HIV treatment and care standards have an
important role to play in guiding commissioners and clinicians
in a complex area. We recommend that the Government commission
NICE to develop treatment and care standards for HIV and AIDS.
These should be developed in association with people living with
and affected by HIV, along with service providers, drawing upon
existing treatment guidelines. (para 247)
372. Treatment and care standards must take into
account psychological and mental health needs, and social care
needs more broadly. They should also reflect the value of interventions
from healthcare professionals, such as advice on reducing risk
behaviours, in preventing onward transmission of the virus. This
should happen immediately, as the required expertise is already
in place. (para 248)
373. Charging people for their HIV treatment
and care is wrong for public health, practical and ethical reasons.
We recommend that HIV should be added to the list of conditions
in the National Health Service (Charges to Overseas Visitors)
Regulations 1989, for which treatment is provided free of charge
to all of those accessing care, regardless of residency status.
(para 257)
374. There are a number of innovative ways of
delivering specialist services which should be employed more extensively.
These changes benefit patients by delivering treatment more conveniently
and closer to home, whilst relieving pressure on specialist clinics
and allowing closer working with those in primary care. These
include:
- Home delivery of antiretroviral
drugs;
- Flexible evening and weekend access to services;
- Patient self-management services, including more
extensive support materials;
- Virtual services such as telephone and email
clinics for stable patients; and
- Nurse-led clinics. (para 267)
375. Given the increasing proportion of HIV-positive
people on stable treatment regimens, commissioners and clinicians
(including GPs) should develop, after consultation with patients,
guidelines and protocols for the expansion of the above innovations.
This can free up human and financial resources for more complex
elements of HIV treatment and care. Protocols must, however, provide
for specialist consultants to monitor the conditions of all patients
at regular intervals. (para 268)
376. We recommend that the Government work with
specialists, GPs and patients to develop a strategy for GPs to
take on shared responsibility for the care of HIV-positive patients.
This work should include broader consideration of the appropriate
boundaries of responsibility between primary care and specialist
services. The results should form the basis of longer-term strategies
for expanding the role of GPs in the management of HIV-positive
patients. (para 277)
377. Upholding the confidentiality of patients
is essential in any medical setting. This is particularly so for
a condition as stigmatised as HIV, and in a setting as important
as primary care. Confidentiality must be taken seriously, and
shown to be taken seriously; general practice staff should make
clear to patients the weight they attach to it. This should include
clear and easily accessible confidentiality policies, and joint
work with specialist HIV clinicians to highlight to patients how
important confidentiality is considered within primary care. (para
284)
378. For better, more integrated HIV treatment
and care, general practices and specialist services should work
in partnership. We recommend that the Government work with professional
associations to commission an audit of information-sharing processes
and confidentiality policies in place between practices and HIV
specialist clinics, to ensure that good practice is widespread.
(para 285)
379. It is imperative that medical practitioners
have the knowledge and skills to manage HIV. Undergraduate teaching
and ongoing professional development should, therefore, incorporate
sufficient specialist training relating to HIV and AIDS. (para
286)
380. Commissioners should support managed service
networks where they already exist. This should involve the provision
of appropriate financial resources and the use of commissioning
frameworks. Commissioners elsewhere should consider whether sufficient
capacity is in place to move towards a networked model of care.
NICE should consider, as part of its remit in developing treatment
and care standards for HIV, the role of service networks as a
means of efficient and integrated care provision for HIV and AIDS.
(para 295)
381. Research should be funded, either by the
Government, National Institute for Health Research[542],
Medical Research Council or other research funders, to examine
whether service networks would allow for highly specialist care
to be delivered more effectively in fewer centres. (para 296)
382. The United Kingdom has an excellent system
of HIV monitoring and surveillance. Monitoring has been part of
the front-line response to HIV, with the HPA providing effective
delivery, leadership and coordination in this respect. In undertaking
reform, the Government must ensure that the surveillance of HIV
infections, at a national level, continues to be appropriately
resourced and managed. We recommend that Public Health England
should coordinate this work nationally. (para 306)
383. It is essential that Health and Wellbeing
Boards are able to draw upon the insights of those commissioning
HIV treatment. We therefore recommend that, in areas of high HIV
prevalence, the national NHS Commissioning Board be required to
provide appropriate representation on local Health and Wellbeing
Boards. (para 315)
384. Health and Wellbeing Boards will be required
to coordinate a wide range of public health interventions, many
of which affect large numbers of people. It is possible that areas
such as HIV, and sexual health more generally, may struggle to
compete for attention. We therefore recommend that, in areas of
high HIV prevalence, Health and Wellbeing Boards should be required
to undertake an annual review of the management, coordination
and integration of HIV and sexual health services. (para 316)
385. Health and Wellbeing Boards will be particularly
important for conditions such as HIV, where they provide the opportunity
to coordinate disparate service commissioners and providers. We
recommend that commissioners be placed under a duty to secure
the approval of Health and Wellbeing Boards before finalising
their commissioning plans. We also call upon the Government to
make clear the funding routes and mechanisms which will ensure
that Health and Wellbeing Boards can deliver their programme of
work. (para 317)
386. We recommend that Directors of Public Health
should be registered with an appropriate professional body. In
addition, local authorities should be required to appoint Directors
of Public Health to corporate management positions. More generally,
we recommend that the Department of Health should give greater
formal definition to the revised role and status of Directors
of Public Health. (para 323)
387. The Public Health Outcomes Framework indicator
on late HIV diagnosis will be vital in ensuring that HIV testing
is prioritised by local authorities in the new structure. We recommend
that it be included in the final adopted set of indicators by
the Department of Health, and that it be included in the health
premium calculation for all local authority areas. (para 327)
542 An NHS-led research institute, which commissions
and funds research. Back
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