HIV/AIDS and Sexual Health     (14/12/2006)

Lord Fowler: My Lords, we very much look forward to the maiden speech of the noble Baroness, Lady Paisley of St George’s. I also understand that last night it was announced that today may see the swansong speech of the noble Lord, Lord Warner, who I gather is retiring at the end of this year. I will make no jokes about him spending more time with his family but I would like to thank him for all the work that he has done in this House on health. In moving for Papers, I should mention that I am a trustee of the Terrence Higgins Trust and am connected with the National Aids Trust, which I set up.

When we speak of HIV/AIDS we almost automatically think of the global position— the position in Africa, India and south-east Asia. We think of the 25 million people who have already died, the 40 million people who are now infected, the millions who are infected and will die over the next few years for lack of drugs, and the millions who will be infected in the near future because there are no sensible prevention measures. We think of the orphans, the widows and the suffering that has been created. In short, we think of a global crisis, which in one way or another has affected virtually every country in the world. Perhaps the magnitude of the international figures takes away the focus from the deteriorating position in the United Kingdom.

This debate allows both the national and the international positions to be raised. If I were to say one thing on the international position, I would wish to pay tribute to the efforts of the Global Fund and Richard Feachem in tackling the situation worldwide. I want to concentrate on the national position, which I do for these reasons: too often, the sexual health crisis in this country is ignored and swept under the carpet; too often, over the past 20 years, politicians have been embarrassed to get properly involved; and too often, sexual health has come bottom in the priorities of health Ministers and health authorities. In this House a week or two ago, a speaker bemoaned the difficulty of getting the public involved in the issues of mental health; she should try to get support for sexual health clinics or better facilities for clean needle exchanges for drug users.

What is the position in the UK? There are now 70,000 people living with HIV. On present trends, the figure will reach 100,000 in three years’ time. We have already seen a threefold increase in the number of people accessing HIV treatment and care services since 1997. Compared with other west European countries, our position was once the best, but we now rest at the bottom of the scale. The Health Protection Agency now identifies HIV as one of the most serious infectious diseases facing this country.

On other sexual diseases, last year there were 110,000 new diagnoses of chlamydia, a 200 per cent increase since 1996; almost 20,000 new cases of gonorrhoea, a 50 per cent increase since 1996; and 2,800 new cases of syphilis, another big increase over the same period. Add to that the undoubted pressure that the GUM clinics—the sexual health clinics—are under and one can see why the professionals on the ground talk about a sexual health crisis in this country. Above all, they want serious and effective action to counter it.

I speak in this debate with the following experience. Exactly 20 years ago, I was launching the then Government’s public health campaign on HIV/AIDS. Just before Christmas 1986, we put up posters around the country on the theme, “AIDS: Don’t die of ignorance”. We followed that up with television and radio advertising using the tombstone theme and then the iceberg. We sent leaflets to every household in the country and, in spite of a great deal of opposition, we introduced clean needle exchanges for drug users. The results of that campaign were startling. Our follow-up campaign showed that, as a result, 98 per cent of the public understood how HIV was transmitted—the figures for today are not remotely as good as that—and 95 per cent of the public said that the Government were right to carry out a campaign of this kind, which should persuade the nervous in Whitehall to follow suit. Most of all, new diagnoses not only of HIV but of sexual diseases came down markedly as a result, while the free needle exchange undoubtedly saved lives, as it undoubtedly continues to do.

Contrary to much advice that we received—at that time we received a great deal of advice on how the campaign should be conducted—we did not preach at the public. We gave them the best medical advice that we had. We also gave them this advice on every poster: the more partners, the greater the risk; protect yourself; use a condom. That remains very much the advice today. Using a condom is the most effective means of preventing disease.

I am going to be critical of the Government’s policy in this area, but there is one comment that I applaud. The Prime Minister said in his interview on World AIDS Day that the Roman Catholic Church should change its attitude to the use of condoms and recognise it as a way of preventing disease and protecting lives. There is a curious contrast in attitude here. I remember going to New York during my campaign and visiting the Roman Catholic St Clare’s Hospital. There was some magnificent work being carried out there but, in those days, because AIDS was fatal, it was to ease AIDS patients into death. Surely it is possible to look at the use of condoms as a way of preserving life—which it is if you have no drugs—and of preventing disease and suffering. The good that could still be done by a change of stance by the church is considerable. So I welcome the Prime Minister’s lead here.

I wish that I could say the same for all the other policies that have been followed since the Prime Minister came to power. Incidentally, I do not in any way absolve my own Government from blame in this area, but it is obviously this Government who are in charge of policy now and who can change that policy. It took this Government four years from 1997 to publish a strategy, while all the time the position was getting worse. Then it took another three years for them to publish the White Paper Choosing Health. For the first time, it seemed as though the Government were getting serious and putting serious new resources—£300 million in all—into sexual health. Caroline Flint, the Minister for Public Health, said in July 2005 that,

“we remain committed to improving the sexual health of the nation and continue to make it a government priority. We have already invested £300m as part of our Public Health Paper—the largest amount ever for this area”.

Of course, the trouble was that they had not already invested £300 million. They had said that they would invest that money. They had said that they would allocate £130 million for modernising the clinics, £80 million for accelerated implementation of chlamydia screening, £40 million for contraceptive services, and £50 million for a new national advertising campaign. Take that £50 million for a national advertising campaign: a campaign was indeed launched last month, but it did not cost £50 million, £40 million or even £10 million. It cost £3.6 million. So far there has been absolutely no guarantee that the remaining £46 million will be spent, although we know how effective such spending can be.

Whatever may be the case elsewhere, this is a direct Department of Health responsibility. This is not down to the primary care trusts; it is down to the department and the Ministers. What of the other money? Much of that has not been spent either.

The Independent Advisory Group on Sexual Health and HIV, under the chairmanship of the noble Baroness, Lady Gould—to whom I pay tribute in the hope that it will not do her too much harm—carried out a survey of primary care trusts. I quote directly from the group’s report, which for some reason has not been published in full by the Government:

“Almost two-thirds of PCTs from whom we have received evidence have withheld some or all of their Choosing Health allocation for sexual health, primarily to address their financial deficits. This has affected all aspects of sexual health covered in Choosing Health: contraception, Chlamydia screening, and GUM services. Not even the high priority public service agreement (PSA) targets for chlamydia screening and 48 hour GUM access have protected these funding allocations, and contraception remains the ‘Cinderella’ service”.

The independent advisory group is not alone in making such comments. I have also received a joint letter from the presidents of the British Association for Sexual Health and HIV and the Faculty of Family Planning & Reproductive Health Care. They have been pressing the Government on this, and said:

“The result of this disinvestment is poor access to services, increases in waiting times and in some cases the closure of clinics, which will ultimately lead to further increases in sexually transmitted diseases, unplanned pregnancies and abortions”.

Similar points have been made by other organisations, such as the Terrence Higgins Trust, the National AIDS Trust and, again today, the independent advisory group.

Part of the tragedy is that no one can seriously argue that extravagance in sexual services provision has led to the financial problems of the health service. All too often, the clinics are housed in poor, almost rundown accommodation where the pressure of demand is constant and unremitting, yet precisely those services are being penalised. Doubtless, the hope is that economies here will not produce the same public outcry as they would in some obviously more popular medical services.

We should be under no illusion about the impact of the diversion of resources. It means not just that expansion money has been cut back locally, but also that regular budgets have been cut in some areas. The Wandsworth PCT issued a press release saying that, due to financial pressures, none of the new funding intended for sexual health was going to be committed during the 2006-07 financial year. In some way— ring-fencing, if necessary—we must ensure that money allocated for sexual health actually reaches these services. It is not enough to say that it is a local decision when the result is plainly unacceptable. The Government have a national responsibility for public health. What is happening today is clearly against the public interest. It means that there is even greater pressure on overstretched services, that infection spreads as patients waiting for appointments remain untreated and that the eventual cost to the health service will be not less, but substantially greater.

Ultimately, this is not a financial question, but a moral issue. Just as we know what works internationally, we know what can be done to bring down our figures in the United Kingdom. We know that a major national advertising campaign can be effective in changing behaviour, but we have failed to mount one for20 years. We know that modern clinics provide the right environment for advice and treatment, but we struggle on in outdated premises. We know that well staffed services can have a real impact in providing proper care, yet we are content to see cuts being made in the already inadequate. As things stand, there is not much here for your Lordships’ comfort. Political commitment will be necessary to change the position. I hope that such a commitment will be forthcoming. I beg to move for Papers.

Baroness Gould of Potternewton: My Lords, I thank the noble Lord, Lord Fowler, for initiating this debate on the crucial subject of sexual health and for his kind comments.

Today, the Independent Advisory Group on Sexual Health and HIV—which, as the noble Lord said, I chair; I therefore declare an interest—launched its third annual report. It makes many positive recommendations for the future. Key areas considered are what constitutes effective leadership for sexual health, commissioning frameworks, training and development, prevention, and health promotion. We also say that we welcome the constructive steps taken by the Government and the department.

The 2004 Choosing Health White Paper, mentioned by the noble Lord, Lord Fowler, recognised—crucially, for the first time—that sexual health was a public health issue. Important commitments were given to reduce GUM clinic waiting times to 48 hours by 2008, to ensure the inclusion of chlamydia screening in local development plans and to carry out a national review of GUM services. This week, the NHS in England operating framework for 2007-08 classified sexual health as a priority.

Those aims can be achieved only by drawing national funding into identified local delivery. The noble Lord, Lord Fowler, quoted the experience of £300 million of Choosing Health funding not reaching the front-line services for which it was intended. Experience has taught us that if the Government really want the money spent where it should be spent, it must be ring-fenced. Caroline Flint, the public health Minister, speaking at the annual conference of the Association of Directors of Public Health, hinted that the Government may consider ring-fencing funds for specific public health initiatives. Can my noble friend the Minister elaborate on that statement?

The National Strategy for Sexual Health and HIV, published in 2001, recognised the need to modernise and improve sexual health services based on the need for a holistic service. But there is a danger that the current reconfiguration and the introduction of payment by results encourages the fragmentation of sexual health services rather than the holistic approach envisaged by the national strategy. There are many benefits to the new commissioning structure and the modernisation initiative, not least the encouragement of innovative solutions to local problems. But against that background, and too often the lack of support at local level, the Government should ensure that sexual health services are protected and that the commissioning of services is reviewed on a national basis.

Ideally, there should be an over-arching, comprehensive strategy that incorporates all aspects of sexual health, similar to the extremely detailed strategy produced earlier this year on targets for reducing teenage pregnancy rates. Such a strategy is particularly important in light of the recent HPA report, A Complex Picture, which makes it clear that the current situation presents a substantial challenge to sexual health strategies across the UK. The problem is that the majority of PCTs have no formal strategy in place to address the rising STI rates or to maintain adequate contraceptive services.

The noble Lord, Lord Fowler, graphically presented the HPA findings and they do make disturbing reading. HIV prevalence continues to increase steadily, STIs diagnosed in GUM clinics in the UK have increased in the last year by nearly 23,000 and there is a further substantial increase in syphilis. There has in the past few years been a continuing decline in gonorrhoea but a disproportionate number of young people are affected by it as they are by genital warts and chlamydia. Over 100,000 young people have chlamydia, part of the200 per cent increase which the noble Lord, Lord Fowler, mentioned. Overall, however, the picture is much more complex as there are many cases of co-infections of HIV, syphilis and gonorrhoea.

The 48-hour target for GUM access is an immensely powerful lever, but the rising HIV workload, estimated at 20 per cent, can have a disproportionate impact on access to GUM. There is clearly a need for existing capacity in both GUM and community services to be maximised and, where possible, for new services to provide greater capacity. The PCTs are also having to manage the increasing cost of HIV treatment and would be assisted by separating HIV commissioning and budget management from general GUM.

The publicity surrounding World Aids Day highlighted the global picture of the HIV/AIDS pandemic affecting nearly 40 million people,2.3 million of whom are children under 15 and with 8,000 deaths per day. In the UK, 70,000 people are living with HIV, with more than 7,000 new infections in 2005. One-third of the cases are undiagnosed and one in five people present late. Late diagnosis has been the cause of 35 per cent of HIV deaths. The reasons for late diagnosis are complex but one reason without any doubt is the prejudice and stigma faced by many people with HIV.

That prejudice and stigma can surface in many settings: in the media, with inaccurate stigmatisation and press coverage and the misinterpretation of statistics; in the workplace; and, extremely disturbingly, in the places where people go for care—in the NHS and other public services. Some healthcare for HIV has been moved from specialist services to GPs, who have had little or no training in the use of antiretroviral drugs or on the crucial need for confidentiality. That has resulted in the inappropriate disclosure of HIV status by having “HIV” written on patients’ files or flashing up on computer screens. It is essential that all those working in primary care are given clear basic guidance on how to respond appropriately to people with HIV.

There are some 16,000 HIV-positive women in the UK who face rejection by their families, friends and communities and who often suffer domestic violence as a result of HIV diagnosis. But HIV sometimes comes from within the family, when women receive it from their partner. Gender inequalities within relationships make women vulnerable to HIV infection by their male partners because they often have no power to insist on safer sex and condom use. It is particularly problematic for African women in the UK and I praise organisations such as Positively Women that support and train women in the skill of negotiating safe sex.

Mother-to-child transmission has been reduced by the Government’s successful HIV antenatal testing programme. If a women tests positive for HIV in pregnancy, the risk of HIV transmission to the child is dramatically reduced by using antiretrovirals, a caesarean delivery and not breastfeeding. Now women living with HIV can become mothers knowing there is little chance of onward transmission. That is a perfect, classic example of effective prevention. We need to spend a little more time focusing on the prevention of sexually transmitted diseases.

Does good sexual health matter? Yes, it matters. Poor sexual health costs lives, particularly because of HIV. Lack of contraceptive services can increase the level of abortion and have a negative impact on teenage pregnancy. One pound spent on contraceptive services saves £4 for the NHS. STIs are transferable infectious diseases and so go round the cycle of transmission to infect ever more people. Each HIV infection that is prevented saves between £500,000 and £1 million over a lifetime. The prevention of unplanned pregnancies would save £2.5 billion per annum. Chlamydia screening can reduce the cost of infertility treatment in future. One could give many other examples but the answer to the question is that, yes, good sexual health matters. It is a crucial ingredient in the overall good health of the nation. If we are to see a downward trend in the levels of STIs and HIV, we have to ensure that money is ring-fenced; that there are targeted interventions, targeted health promotions and early testing; and that we increase awareness of the dangers of unprotected sex.

Finally, my noble friend Lord Warner is making his last contribution as Health Minister in your Lordships’ House. We have not always agreed on this issue, and I have argued with him that we have not gone far enough, but I wish him all the best for the future.

Baroness Northover: My Lords, I, too, congratulate the noble Lord, Lord Fowler, on once again raising the subject of AIDS and on his long commitment to ensuring that the UK faces up to the realities of that disease. He simply refused to be silenced or embarrassed. Other noble Lords may focus on the UK, where, as the noble Lord, Lord Fowler, and the noble Baroness, Lady Gould, said, there are major issues to address, but I, as spokesperson on international development for the Lib Dems, wish to look at the wider world and at what the UK Government are doing to combat AIDS worldwide.

Whatever happens in the wider world affects us here. The number of AIDS cases is rising in Britain—not surprisingly when we see that the epidemic is growing most rapidly in eastern Europe. It is also brought in by some of those who have travelled abroad or who have arrived from abroad, including some who are working in the health service. I am waiting for the epidemic to hit our universities, as gap-year and other students return from their travels. Of course, there are other ways in which AIDS will affect us, by increasing instability in those areas where AIDS is knocking out a generation, undermining societies and economies. We are surely in the early stages of seeing those effects. The increase in the number of street children being drawn in as soldiers in the DRC, for example, relates especially to the incidence of AIDS there.

There are, as we heard, just on 40 million people living with HIV worldwide, with 4.3 million new infections this year alone, 65 per cent of which happened in sub-Saharan Africa. There are a few areas where the disease seems to have been checked—Kenya and possibly Zimbabwe, although we cannot be sure of what is happening there. There is a decline in Cambodia and Thailand, which shows that effective action can make a difference. However, right across sub-Saharan Africa, despite massive efforts—for example, by Gates and Merck in Botswana—things are not yet turning around. We know that HIV/AIDS is increasing significantly in China and most of India, where only 10 per cent are receiving treatment. The Russian Federation has the largest epidemic in Europe, with a twentyfold increase in less than a decade.

One of the millennium development goals relates specifically to combating AIDS, recognising as it does that the enormous suffering the pandemic causes is also a threat to the achievement of all the other MDGs. At Gleneagles last year, the G8 made the extremely important pledge that everyone who needed it should be on treatment by 2010. We are making some progress, but not at a rate that the impending catastrophe deserves. We need at least one Lord Fowler in every country around the world if we are going to tackle this disease.

Only 20 per cent of those needing treatment are receiving it and the numbers of those who are likely to need treatment are growing very fast indeed. There is still opposition to the use of condoms. The abstinence programme, however well meaning, clearly does not recognise reality, and people die as a result. Unfair trade rules are still preventing cheaper generic drugs becoming available. Inadequate health systems need to be strengthened to cope with the crisis. Immediate support needs to reach those who are currently suffering.

Children are particularly affected, often silently. There are 2.3 million children living with HIV worldwide and less than 5 per cent of them are receiving treatment. Most of those not receiving treatment are in developing countries. Save the Children, the Tearfund, UNICEF, UNAIDS and others all argue that children, especially girls, are among the worst affected by AIDS in developing countries. Young people may live at high risk of HIV, they may live with a chronically ill parent or they may be required to work and put their education on hold as they take on household or caring responsibilities. Their households may experience greater poverty because of the disease. They can be subject to stigma and discrimination, because of their association with a person living with HIV. Ultimately, these children may also become orphans, losing one or both parents to AIDS-related illnesses.

At the moment there are no drugs specifically for those children with HIV. They are given a half or a quarter of the drugs given to an adult. It is not finely worked out for their age or weight—if they receive anything at all. Drug companies are reluctant to work on drugs for children because they reckon the market is limited. If mother-to-child transmission is halted through drug treatment, they feel that their market will shrink. That gives little hope to the children, of whom I have seen many, who lie in hospital beds dying from lack of treatment, which seems an extremely inhumane way of going about things. What incentives are being given to drug companies to research and develop drugs specifically for children?

Women have been especially vulnerable to AIDS. In sub-Saharan African, 60 per cent of those who are HIV positive are women. In some areas of southern Africa, two-thirds of those in the 15 to 25 age group who are HIV positive are women and girls.

The United Nations describes marriage as a risk factor for AIDS. Women are often unable to negotiate the use of a condom or even whether they have sex at all—so much for ABC, abstain, be faithful or use a condom. If anything positive should ever come out of this epidemic, it will be that gender relations have been transformed. I welcome all those who seek to improve the rights of women and girls as they seek to reduce the impact of this disease. What further plans do the Government have to protect and treat women and girls, and what support, such as cash transfers, will be provided in the community? Will there be a timetabled, funded programme for getting treatment to all who need it to meet that goal in 2010?

We have a humanitarian responsibility, but we must also protect children from being orphaned, and societies and economies from being undermined. On money, the UK has rightly emphasised that there should not be a plethora of donors demanding this and that from the countries to which they are contributing. There should be one channel and one national plan. I was therefore surprised when I discovered quite how much of our aid goes bilaterally rather than through the global fund, which is a well respected and carefully audited body. What is the situation now? I know that the gap has narrowed and I should like to have details of how that trend is moving. How much aid goes bilaterally? What is the plan to ensure that the global fund has what it needs?

Health systems, social systems and cash transfers need to be addressed if the AIDS epidemic is to be turned around. If AIDS was hitting the UK in the way that it is in some parts of the world, we would surely be up in arms. I welcome the moves that the Government are making, but I have to urge even greater commitment and that they persuade their US and EU allies to take this as seriously as it deserves.

Baroness Paisley of St George's: My Lords, an anonymous Ulsterman is reputed to have said at the beginning of a speech, “Before I speak, I want to say a few words”. As an Ulsterwoman, I understand what he was trying to say. I should like to preface my remarks with words of sincere thanks to my noble friends Lady Boothroyd and Lord Molyneaux who very kindly honoured me by being my sponsors. I have also been touched by the warmth and friendliness extended to me by so many Members, both before and since my introduction. It would be remiss of me not to mention the officers and staff in every department who are always so helpful and patient. Needless to say, I am deeply conscious of the immense honour and privilege it is to be a Member of this House. I look forward—although others may not—to contributing to its debates in future days.

When I was first elected to public office as a councillor in the Belfast Corporation, which is sadly now degraded to a mere city council, I counted myself privileged to serve not only my constituency ofSt George’s, but also people from other areas of Belfast who were living and working under similar circumstances. Today such people would be classed as underprivileged, and rightly so, but in 1967 the word “underprivileged” was unheard of and never used by these hardworking and industrious people. Like their parents and grandparents before them, they were used to working hard and long hours for low wages and they just carried on with the business of living. Thankfully things have changed to a large extent. It is because of the trust that they placed in me to represent them that I chose the title “St George’s” to be mine on entering this House. As it is an English name— St George is the patron saint of England—I doubted whether I would be allowed to use it, but I am grateful that I have been.

The subject before us today is most serious and we cannot afford to treat it lightly. The noble Lord, Lord Fowler, gave us many statistics and I expect that the statistics that I have written in front of me here will overlap his and those of others that have been given today. The scourge of HIV/AIDS is invading the entire world at breakneck speed. I have been looking at some of the statistics, which are frightening to say the least. In the United Kingdom the number of cases reported up to the end of June this year totalled 80,500, which included more than 7,000 new cases. The age group to which those figures refer covers adults. The statistic includes 15 year-olds, which I hardly think is right, but people aged between 15 and 59 are covered by the total of 80,500. One third of them were unaware that they were infected.

There have also been 22,281 diagnosed cases of AIDS. More than 17,000 HIV sufferers have died and at least 80 per cent of those deaths followed an AIDS diagnosis. The three main risk groups have been identified as, first, men who have sex with men; secondly, those who inject themselves with drugs; and thirdly, those who receive treatment with blood products. Between the mid-1980s, when HIV first came to public knowledge, and 1997 there was a decline in the number of cases, but since 1999 there has been a steep increase. The major cause has been heterosexual acquisition. The infections last year amounted to more than 4,000 compared with 840 nine years earlier.

In the same period infections acquired by homosexual and bisexual men were almost 2,500 compared with 1,500 in the same period. That figure was the highest ever among these men. Worldwide figures reveal that 40 million people are currently suffering from AIDS and one in every thousand people from 15 to 49 years of age already has AIDS. The more we examine the figures the more alarming they become. I was not aware until recently that8 million children have been orphaned as a result of AIDS and that 48 per cent of all sufferers are women. In 2001, 3 million people died from AIDS. I do not know how many have died in the intervening years.

We cannot afford to be morally righteous about this subject, because anyone, whatever their lifestyle, can fall victim to these infections, and so it is imperative that an effectual and effective remedy is found quickly. We are grateful for what has been done and what is being done, but it appears that the malady is overtaking the remedy and it is also overtaking the advice that has been handed out to them daily through television adverts and notices. All kinds of information has been given to these people but they still continue in their path.

It worries me deeply that so many unborn children are at this moment already infected. What a dreadful life is ahead of these little ones. Babies were not meant to be born diseased. It is time enough when disease overtakes children who are already born and have entered this world but it is terrible to think that their little bodies are already suffering from this dreadful infection before they are born.

We call ourselves a Christian nation yet, to a large extent, we have forgotten God. When we listen to these statistics and to bulletins about what is happening throughout the world and see the toll of death in so many places, I believe that individually and as a nation we should be calling on God to give wisdom to the doctors and those seeking to help the people who are in such a dreadful physical and mental condition—because this disease affects people mentally. John Donne said, “No man is an island”. That is exactly what is said in the Bible, because the word of God says: “No man lives unto himself”. That is true whatever lifestyle we choose. Whatever we do and whatever we say has an effect on other people. John Donne also said: “Any man's death diminishes me”. How diminished we must be today when we think of all the dreadful deaths that are taking place unnecessarily throughout this beautiful United Kingdom of ours.

I also call on the Government to do all in their power to give help, sustenance and support, and any kind of aid that is necessary to help to relieve the dreadful situation in which we find ourselves as a country. Again, I believe that we need to call on God. I was touched by the Prayers earlier today. One of the verses in that reading said: “I called on God, and he heard me, and delivered me out of all my troubles”. That is what we need to do individually and as a nation if we are to succeed in what we are trying to do today. I thank noble Lords for their patience and for listening to me.

Baroness Flather: My Lords, I begin by congratulating the noble Baroness, Lady Paisley, on her maiden speech. I am sure that, like me, all other noble Lords found it to be very moving. It was from the heart and I have always found speeches in this House that are given from the heart, with personal conviction, to be very much more effective and moving. I thank the noble Baroness for her maiden speech and look forward to hearing from her on many occasions. May I also add that perhaps we will get to know the better half of the Paisley duo?

The next person I would like to thank is my noble friend Lord Fowler. I remember him well because I was quite active in the party when he was Secretary of State for Health. I always found him receptive, effective and very caring, so it is no surprise to me that he has initiated this debate, which is timely and necessary. I thank him for doing that.

For my part, I will start by posing three questions. First, who is suffering the most? Secondly, where is the greatest need? Thirdly, what can be or is being done? The answer to the first question is staring us in the face. The noble Baroness, Lady Northover, has already touched on it. Women and girls are bearing the brunt of this pandemic; there is no question about that. The UN has already said that more than 70 per cent of all those who are infected are females—females rather than women, because some of them are not yet women. It is extremely important for us to keep in mind that more than 70 per cent of all those infected are females. We must not lose sight of that.

Where is the problem occurring? We have heard that the UK is not immune, although it is a highly developed and wealthy nation. We have not been able to do enough in this country. But what is happening in the rest of the world, in Africa and India? It does not even bear thinking about. The noble Baroness, Lady Northover, referred to sub-Saharan Africa. Let me emphasise that three-quarters of all females in sub-Saharan Africa are living with AIDS. Ever younger girls are being raped, at home and outside, by their teachers, neighbours and church leaders—by all the people who should be taking care of them, not raping them. Even babies are being raped. It is a world that is unbelievable. In Cape Town, which I visited this year, there is a rape every 10 seconds. In India, in most cases it is the married monogamous women in the villages who are infected. When they are infected, they are not allowed to attend clinics because then everybody will know, and that will bring shame on the family. The husbands, especially those who drive for a living, are the ones who infect their wives. It is the girl child, especially in Africa, who looks after the ailing parents and the siblings—not just the younger siblings but all of them, especially the male ones. The boys can play outside but the girls have to do all the work and look after their parents and the boys. On a documentary that I saw on the BBC, a girl had been working from dawn till midnight, when she was about to go to bed. The interviewer asked her something and she said, “Life is awful”. Life is unbelievably awful for these girls.

In Swaziland, 30 per cent of all health workers are infected, because they, too, get raped. We know that good sex education is necessary for adolescents, but condoms are also necessary. The only issue with condoms is that, although in this country they should provide us with an opportunity to avoid AIDS, in Africa these poor women do not have the power to make the men use them. That is where the education of the men becomes important. We must educate the men rather than the women; we can tell the women about safe sex but, if they cannot make the men use condoms, it is not much use. Sadly, the female condom has either not been provided sufficiently or people have not been taught how to use it; either way, it has certainly not become an accepted means of protection.

The only way forward that I can see lies with microbicides. So many people that I speak to about microbicides do not have any idea what they are; it must be the best-kept secret in the world. I am sure that everyone in this Chamber knows what microbicides are. The British Government are funding a lot of trials in Africa and Asia, and others, such as Gates and Buffett, are also doing their bit.

Microbicides are up to 70 per cent effective already. Some people say that they are only 70 per cent effective. When you start from zero, does 70 per cent not sound pretty good? They probably will never be 100 per cent effective. It is time for us to put all our efforts behind microbicides to prepare for when they arrive—I hope it will be in 2009. A great deal of money is needed now to prepare the ground for the arrival of microbicides. Anything that arrives on the scene requires preparation of the area in which it is going to be used. That is where everyone now should be putting their efforts, to make sure that there is enough money either with the NGOs or with the government agencies so that people are ready to use microbicides as soon as they arrive on the scene. I propose a name for microbicides: “Protect”. It is easy on the tongue and it carries the power that microbicides will carry. I hope that that name will be accepted.

People say, “Let’s wait for the vaccine”. We have vaccines for malaria and TB—are we able to deliver them to everyone? Are we going to vaccinate every person on planet Earth, even if we had a vaccine for AIDS? No, it is not possible. Figures have already been given, but I will repeat them. Since the start of the pandemic, 65 million people have been infected, and 25 million have died. As the noble Baroness, Lady Northover, said, over 4 million people have been infected this year alone.

That is the world that we are in, yet there are people who absolutely dispense with all rational thought and say that instead of providing condoms the money should go to retrovirals. Is it really possible that Cardinal Murphy-O’Connor is thinking, “Never mind, let people get the disease, then we will give them the medicine”? Surely, prevention is the key to the control of disease, not the provision of medicine. He tells us about monogamous relationships; not one person in this House would disagree with what he says on that. Some of us probably have monogamous relationships and would not think of doing otherwise. But which world does he inhabit? I do not know. Does he know that the birth rate of Italy has dropped to1.2 children per couple? Something must be happening somewhere there.

The cardinal says that the African bishops say that condom use increases promiscuity. In a continent where rape is endemic—it is an everyday situation for all women and girls—what is promiscuity? What does he mean by promiscuity? Have we got any figures? Catholicism is a male-dominated religion, and it does not think about women. Women are not at top of the Catholic religion’s agenda. If this sounds like an attack on the cardinal or the Catholics, then I do not apologise. It is time that they understood that what they are doing breaches the human rights of every woman in this world, and time that we took them to task on that.

Baroness Massey of Darwen: My Lords, I, too, thank the noble Lord, Lord Fowler, for securing this debate, for introducing it with such passion and for his continuing advocacy of sexual health issues. I add my congratulations to the noble Baroness, Lady Paisley, on her incisive maiden speech.

I remember when the HIV/AIDS pandemic first became an issue in this country. I was at that time working for what is now the Health Development Agency, and the noble Lord, Lord Fowler, bravely and consistently spoke about this issue as a health issue that demanded responses from health services and not just moral speculations. I have remained eternally grateful to him for that. Speaking as a humanist, I call not on God but on Governments to act firmly on this issue.

Today, I want to address sexual health and HIV from the standpoint of health education and promotion. I shall ask the Minister to respond to the suggestion that personal, social and health education should be a statutory part of the school curriculum. I recognise that that is an education matter rather than one in his field, but departments do talk to each other. I shall ask him to respond to the suggestion that sexual health services should have ring-fenced funding at a local level—my noble friend Lady Gould, whom I salute as the chair of the sexual health advisory group, has already raised that issue, as that group consistently does, for which we should be grateful. I shall also ask when the NICE guidelines on injecting-drug use will be available for consultation. I shall add a little about transmission through the route of injecting drugs.

First, I turn to sexual health education’s importance within a planned programme of personal, social and health education. We have debated that issue before, pursuing it recently in relation to the Education and Inspections Bill, where we did not get very far. Sexual health education is not simply about biology, nor is it simply a clinical issue. For girls and boys—and I take the points raised by the noble Baroness, Lady Flather—health education is about fostering good, non-exploitative relationships. It is about learning to care about another’s feelings and about the risks to another of irresponsible sex, which may lead not only to emotional hurt but to infection or an unplanned pregnancy. Sexual health education is also about helping young people to make informed decisions about their behaviour, while encouraging them to avoid being exploited by others. That rests on building self-esteem in young people, not only about sexual behaviour but generally. Decision-making skills and self-esteem can transfer from one activity to another; school programmes can and do help, as I have witnessed firsthand.

Schools can, of course, also encourage aspiration in young people—and those who have aspirations in life are less likely to get into difficulty with health behaviours. Aspiration and, indeed, self-esteem may be encouraged by parents, family members and communities, as well as by schools. So education and nurturing are important in enabling young people to be healthy—and sexually healthy. That all starts very early, and while I am not talking about giving explicit sex information to five-year-olds, I am talking about helping and supporting very young children to make confident and informed decisions.

I add a word about risk-taking behaviour, which was mentioned earlier: we all take risks, but people have first to know about a risk to decide whether to take it and whether they will mitigate that risk by some action—for example, wearing a rope when mountain climbing, or using a condom. There are protective factors related to risk-taking, including the encouragement of aspiration and family and community support, as I mentioned. Another is to have the right information at the right time—for example, telling young people where they can get help with health and sexual health issues. Some schools engage a nurse to talk about services; others have taken young people to visit a Brook Advisory Centre, which can, as evidence shows, help them to seek advice about sexual health more readily.

I turn to behaviour change as encouraged by health promotion, which as part of public health can either help to change people’s behaviour or help them to reject unhealthy behaviour. The first component is through laws that are enforced and the appropriate implementation of policies. There are good examples here in laws on smoking and seat-belts. Another component is through changing what is socially acceptable, where again smoking is an example—as is diet, to a certain extent. Health promotion or behaviour change communication has been defined, and this applies to sexual health as much as to any other health area, as a set of interventions, activities and changes in the social environment which help to move people towards a healthier life by changing behaviours. Health promotion and sexual health promotion need to be targeted, consistent and repeatedly reinforced. Front-line staff, such as teachers, GPs and those in clinics, are crucial. They need support, funding and adequate resources of all kinds.

Political will is, of course, an extremely important influence here. I give an example of this from my current professional activity. I chair a special health authority, the National Treatment Agency for Substance Misuse, which has been given political support and money to carry out activities to improve drug services at a local level. That includes ensuring that all drug action teams have plans to deliver and monitor drug treatment, and that funding is essentially ring-fenced. The approach has been successful, as the number of users in treatment has risen, waiting times for treatment have decreased and the workforce has grown dramatically. We have hit our PSA targets two years early. Focused and funded intervention works, which is why I am asking about ring-fenced funding for sexual health services. That is absolutely crucial if any strategy is to succeed.

Strategy is not a one-off intervention, but must be a process that encourages this kind of model. Someone has pre-contemplation about health behaviour—for example, a young man hears about AIDS but does not think that it applies to him—before moving on to contemplation, believing that he and his friends are at risk and that he should do something. That is followed by a decision, to get and use condoms. Then comes the maintenance of that behaviour, where the buying and use of condoms becomes a regular habit. This approach needs policies, services, education, campaigns and advocacy. As I said, it must be targeted, consistent, reinforced and funded.

HIV can of course be spread through drug use, and that has not been mentioned much today. Injecting drugs accounts for 5.6 per cent of reported HIV diagnosis. The overall prevalence of HIV among injecting drug users is relatively low, at one in 50 infected, but the prevalence in London is much higher, at one in 25. The recent increase in HIV among such users outside London is of great concern, as there has been a sixfold increase in two years—from one in 400 in 2003 to one in 65 in 2005.

Those figures are extremely worrying, so when will the NICE guidelines be produced for consultation, and how can we improve that situation? Again, we need to bring about focused activity to tackle a specific problem. This will mean identifying those most at risk and those who can best help and giving them training, support and funding. Lessons learnt from international interventions and experience show that, in addition to the need for political will, targeted health promotion and behaviour change is the most effective approach. Services and facilities must be in place, while service providers must be geared to tackle real and expressed needs and be sensitive to local cultural norms. Multifaceted interventions are the most successful, which means combining health promotion techniques with education techniques in a variety of settings and using public health measures across agencies—for example, in housing, employment, transport and education—to effect change and maintain healthy behaviour.

My noble friend the Minister is aware of these issues and much has been done to tackle them, but it is still the case that statutory personal, social and health education in schools and sufficient ring-fenced funding for services would have an enormous impact.

Baroness Miller of Chilthorne Domer: My Lords, I speak in this brief intervention as chair of the All-Party Group on Street Children. My noble friend Lady Northover has already referred to the situation of street children and child soldiers in the DRC and I should like to highlight the situation facing that particularly high-risk group. The Consortium for Street Children is the umbrella body for 45 UK-based charities working or supporting work with street children in 76 countries throughout the world. In 2005, its members agreed that one of the most serious situations facing street children was HIV/AIDS. The consortium has made that one of its key issues for work in the next five years.

With that in mind, the consortium sent a small team to the world AIDS conference in Toronto. The consortium agrees with the conclusions from the youth group at the conference that there needs to be more representation of youth from marginalised groups including street-involved youth. The conference notes on outreach and prevention among marginalised groups contain no mention of street children. On the whole they are not covered by the term “orphans” because, although they may be street-working and street-living, they have families. They are not mentioned in the notes but they are among the highest risk groups for a number of reasons including drugs, sex at an early age, and, crucially, lack of awareness. A number of surveys have been carried out and I shall mention just a few. In 2001, Médecins du Monde, from Sweden, conducted a survey in the Russian city of St Petersburg among a sample group of 1,200 street children. It showed that 67 per cent of the children tested HIV positive. A survey in India, where some children had to turn to prostitution to survive, estimated that 90 per cent of the street children in Mumbai were sexually active. The survey was conducted by a group of Indian NGOs that comprise the HIV/AIDS forum there. Awareness of the disease among that group of children in India was similarly astoundingly lacking. A study by UNICEF in Namibia in 2004 found that less than 50 per cent of street children sampled had heard of the disease at all, in a country where a high proportion of the adult population are infected.

The picture is particularly depressing because, in 1992, an adviser to the Pan American Health Organisation wrote: “we are confronted by the fact that one particular subpopulation, that of homeless youth, has received little attention in regard to their risk of exposure to HIV infection and other sexually transmitted diseases ... Street youth are often not included in traditional institutional networks for providing health care and social services”.

Today, 14 years later, the situation has not changed and street children world-wide continue to have little or no access to HIV/AIDS services. As the Government look to contribute to programmes, regardless of whether they are global or bilateral, they must bear in mind that situation and develop policies to address it. DfID currently allocates a percentage of the£150 million it will spend to meeting the needs of orphans and other children. But will it ensure that street children are included and money is specifically allocated to meet their needs? It is crucial that HIV/AIDS education programmes reach out to street children and that donor Governments such as ours support the development of prevention, care and treatment services to be delivered to those children in the most appropriate way by the Governments of those countries. There is often a mountain to be climbed in persuading the Governments of various countries of the crucial need to include street children in the provision of other services such as education. The situation regarding HIV/AIDS is a little different because the case can be strongly made that by not including street children in all those programmes the effects will spread rapidly to the rest of the population.

I appreciate that a health Minister is to respond to this debate, but I hope he will encourage his colleagues in DfID to look at these issues, particularly because the world AIDS conference did not address this sector. An urgent reply is needed.

Lord Colwyn: My Lords, I was expecting to see the noble Lord, Lord Winston, rush in, tearing off mask and rubber gloves, fresh from yet another life-saving situation or media engagement, but I now assume that he has withdrawn from the debate, which has been so well introduced by my noble friend Lord Fowler. As Secretary of State when HIV/AIDS first came to our attention, he must take much of the credit for many of the preventive measures that were introduced. I know that he does not agree with me, and I suspect that no one else in the Chamber will agree with a word I have to say, but I shall take advantage of this short debate to air my views once again.

One of the most important assumptions underlying our current understanding of AIDS is that it is a new disease caused by a new virus that appeared in Europe and America only during the later half of the 1970s. The recognition of AIDS as a distinct disease entity during the early 1980s supports that assumption. Yet hundreds of AIDS-like cases in people, some of whom have turned out to be infected with HIV, were documented in medical journals for decades before the recognition of AIDS.

The public face of AIDS research that is meant to reassure still maintains that HIV— the human immunodeficiency virus—causes AIDS, and that when we can learn how to vaccinate against HIV or develop a medicine to treat HIV infection then AIDS will be cured. The best-kept secrets about AIDS are the questions unanswered, the puzzles unsolved, the contradictions unrecognised and the paradoxes unformulated.

There is no doubt that AIDS itself, as distinct from HIV, is at least a century old, with many cases of Kaposi’s sarcoma, pneumocystis pneumonia, cytomegalovirus infections and other opportunistic diseases in patients matching the definition of AIDS being reported in North America and Europe in the 50-year period preceding the perceived arrival of AIDS in the 1970s. Those diseases in this period have not been accounted for in our current theories of AIDS. If HIV is new and a necessary cause of AIDS, as most researchers argue, what was the cause of these pre-1979 AIDS-like cases? Are there causes of acquired immune suppression other than HIV that may explain AIDS? What might those immunosuppressive agents be? Or is HIV much older than anyone has been willing to consider? If HIV is old, why has AIDS become epidemic only within the past 20 years? Have modes of transmission suddenly increased? No matter how one tries to examine these questions, the answers are disturbing.

There was massive consternation during the 1990s caused by reports that HIV may be neither necessary nor sufficient to cause the syndrome. The key experiments had been performed in the laboratory of the discoverer of HIV himself, Luc Montagnier of the Institut Pasteur in Paris, and he announced that HIV alone is not sufficient to cause AIDS. Since then many clinicians have reported similar cases of HIV-free AIDS.

Suddenly AIDS without HIV became big news because too many cases had surfaced to be ignored. There is no longer any doubt that HIV is not necessary to cause acquired immunodeficiency. The question is whether the causes of HIV-free AIDS are also at work in people with HIV, and therefore what role HIV plays in causing AIDS in anyone. Do we believe that everyone is equally susceptible to infection with the retrovirus and its consequences? If HIV is sufficient to cause AIDS, then everyone should be at equal risk and AIDS should develop at an equal rate among different risk groups once infection has become established. Clearly that is not the case.

Researchers realised by 1987 that the threat of AIDS to non-risk groups was very small. Some calculations place the figure of contracting AIDS from a heterosexual without risk behaviours as low as one in 1 million—about the same risk as being struck by lightning. On the other hand, the high-risk groups are still high risk. The cumulative incidence of AIDS seven years after HIV infection in drug abusers is over 40 per cent, and about the same in homosexual men. The average latency period for the development of AIDS is about 10 years. In other words, one would expect that about half of all HIV-positive individuals should develop AIDS within 10 years, if drug abusers and homosexual men are typical of the entire population. But, of course, they are not.

What am I trying to say? Some people are far more susceptible to AIDS than others and the reasons are clear: immunological exposure to semen, blood or other alloantigens; multiple, concurrent infections; prolonged medical or illicit drug use; malnutrition. Those are all serious factors that considerably weaken the immune system. Resistance to AIDS is about having an efficient, intact immune system. I believe that there should be a much broader approach to AIDS that includes specific remedies for malnutrition, elimination of all drug use, proper hygiene, safer sex measures and behavioural modification. These can all have profound effects on AIDS risk and the development of overt disease, even among people who are already seropositive.

If, as I suggest, AIDS is not caused by a simple HIV infection but is a syndrome requiring multiple, concurrent causes of immune suppression, then the tremendous drop in the incidence of sexually-transmitted diseases associated with safer sex means that the risk of immune suppression due to multiple infections and allogenic exposure decreases drastically, the risk of autoimmunity decreases even more and the probability of developing an HIV infection concurrent with an appropriate cofactor infection diminishes. In other words, the same measures that are meant to control the spread of HIV are necessary to control the spread of allogenic and infectious cofactors in AIDS.

I believe that the incidence of AIDS itself, as distinct from HIV seropositivity, will decrease much more quickly than the rate of HIV infection. More and more HIV seropositive gay men will live longer and healthier lives. The fact that the latency period between HIV infection and AIDS has been increasing yearly indicates just such an effect. The latency period should continue to increase until many HIV seropositive people are living healthy lives for several decades. Then we will finally recognise that HIV does not equal AIDS and that current treatment methods should be reassessed.

In view of the Minister’s recent announcement, today is probably the last time I will have an opportunity to debate health matters with him. I am grateful for all he has done, particularly with the introduction and defence of the new dental contract, and I wish him well for the future.

Baroness Barker: My Lords, what a privilege it is to take part in today’s debate. I pay tribute to the noble Baroness, Lady Paisley of St Georges, and thank her very much for her contribution. It was full of compassion, which many noble Lords really appreciated, and I wish her very well.

I also want to take this opportunity to thank the noble Lord, Lord Warner. He and I have faced each other across the House for some time now. Very rarely have we agreed on things, but he has always been true to the issues and an exemplary Minister in how he has dealt with them. I wish him all the very best.

I always like to take part in debates initiated by the noble Lord, Lord Fowler, not least because I always have to stop and think as I prepare for them. Thinking about today’s debate, I found myself wandering back over the past 25 years. Twenty-five years ago we did not even have a name for this disease, and it then went through a variety of different names. If I look back over those 25 years, when friends have been affected by this in many different ways, two things stand out for me. One is that advert. If he does not mind my saying so, the noble Lord, Lord Fowler, may become the only man in history—I hope in the very distant future—to have a tombstone on his tombstone. The advert stands out.

The other thing that stands out is a book—it was also made into a film—called And the Band Played On: People, Politics and the AIDS Epidemic by Randy Shilts, an American who attempted to track the development of the disease in America from the first patient. The most important point in the book is when staff at the Centers for Disease Control and Prevention (CDC) in Atlanta have discovered that the disease is blood-borne but do not know what it is. They try to persuade the organisations involved in blood transfusions in America to take on board their messages, but they will not do so because they do not want to damage what is a big business for them. At one point, a man asks at a meeting, “When doctors become businessmen, where does somebody who needs a doctor go?” Throughout the past 25 years, that has focused my mind very much on the different parts that the health service, public opinion, journalists and so on have to play. Today’s debate is about the role of politicians in this campaign.

Today many noble Lords have talked about the figures in the Health Protection Agency report A Complex Picture—a very good title because the picture is complex. I do not want to repeat the figures that other noble Lords have set out but I will give just two. One is the rise in all STIs and how cross-infection makes the management of HIV, in particular, more difficult. That should concern us. The Health Protection Agency says that prevention makes good sense for individuals and public health. Some STIs are easily treated; others are lifelong and recurrent, with serious consequences, including infertility. The coincidence of HIV with other STIs makes managing that more difficult. The Health Protection Agency goes on to say: “The continued rises in diagnoses of HIV [and] ... acute STIs, attendance to sexual health services and sexual risk behaviours ... suggest that a scaling up [of] our prevention responses to a level that will have an impact on the current trends is urgently needed”.

I contrast that with the findings of a survey of sexual health clinic services, conducted recently by my honourable friend Sandra Gidley in another place. The survey shows that fewer than 33 per cent of clinics provide appointments within 48 hours, with over half of patients having to wait five days or more for an appointment, and that the average wait is more than seven days. Furthermore, many clinics reported restricted opening hours during the working day, often amounting to fewer than 20 hours a week, and many opened irregularly. That is hardly a strategy for encouraging people to come forward for testing. If you have plucked up the courage to go along for what may be a life-changing interview only to find that the place is closed, I dare say that that will put you off going back again. Most worryingly of all, as other noble Lords have said, those same clinics reported that funding is being cut to plug NHS deficits. Community, outreach and voluntary sector services designed to promote sexual health have been cut, even when they have been extremely effective in the populations whom they seek to serve.

The noble Lord, Lord Fowler, will forever be associated with one of the most effective advertising campaigns in history—that first national campaign. Since then, there has been a huge amount of research about what works in public health campaigning. There is now a body of overwhelming evidence from across the world that what works in this field are short general messages to the public, repeated over and over again, coupled with specific messages to sub-populations who are at risk. I am afraid that at the moment we are not doing that. Out of the £50 million that they promised in 2003, the Government currently have in place one short £4 million campaign aimed at teenagers. It is very good but it is so short that it will be over before it has an effect. I strongly urge the Minister to take on board that there is a need for a consistent message, coupled with other messages for distinct populations. That will truly help us to make a difference with the group of people who do not remember the tombstone campaign because they were not old enough at the time to see it.

I turn briefly to the international scene, which I do not get to talk about very often, and to one aspect in particular. I agreed with some of what the noble Lord, Lord Colwyn, said, although by no means all of it. I hope that we do not follow some of the conclusions of South African Health Ministers; however, I agree that, where there is a chronic shortage of doctors and nurses, particularly female health workers who can go into rural districts, it is inevitable that treatment, for women in particular, will be diminished.

I should also like the Government to focus on the case being brought by Novartis against the Indian Government in relation to ARVs. If successful, the ongoing legal action against that Government could restrict the production of generic ARVs in India. The impact of that would be felt not only in that country but all across sub-Saharan Africa, because one-third of all ARVs used by people in developing countries are generic versions produced in India. I hope that we can support the Indian Government in resisting that action. If we do not, many of the things that my noble friend Lady Northover and the noble Baroness, Lady Flather, talked about will only get worse.

Finally, I want to talk about one thing that has not been mentioned in this debate. The results and consequences of the mid-term election in the US brought a number of welcome changes. There is one that noble Lords may not yet have noticed and I bring it to their attention. The Democrats on the House Committee on International Relations have signalled that they wish to investigate funding for faith-based HIV/AIDS and abstinence-until-marriage initiatives, which receive funding under the President’s Emergency Plan for AIDS Relief. At the moment in the US, by law, one-third of HIV-prevention funding under PEPFAR must be used for abstinence-until-marriage programmes. Whatever the moral case may be for such an approach, the case against it is that it simply does not work. Two-thirds of 18 year-old girls in South Africa have HIV, but such messages do not, and never will, work in those cultures. The noble Baroness, Lady Flather, talked about that most tellingly. Given that the appropriateness and efficacy of such programmes has been challenged repeatedly, I hope that the Government will use their special relationship to support those within the US Administration who seek to challenge something which, when there are 14,000 new infections every day, cannot be right and cannot be sustained.

The noble Lord, Lord Fowler, is absolutely right to have raised this issue again. He, perhaps more than anyone else, embodies the role of government in this. That role is to keep banging on with the messages that no one else wants to hear or to make, to keep doing it when everyone else has gone away and taken their attention elsewhere, and to persist with something which is unpopular and derided by the media but which could make a big difference. It was most important that he and his Government released that advertisement all those years ago; it could not be more important now for this Government to carry on that persistent message about HIV.

Lord McColl of Dulwich: My Lords, I, too, congratulate the noble Baroness, Lady Paisley of St Georges, on her splendid maiden speech, and we hope that we will hear many more. I also thank my noble friend Lord Fowler for initiating this debate, and I pay tribute to him, as have others, on his extraordinarily successful campaign in the 1980s. When you now speak to people who were teenagers at that time, they say that their overwhelming impression was the creation of fear. That, of course, has gone.

The World Health Organisation defines sexual health promotion as, “any intervention that improves a person’s physical or psychological wellbeing”.

We agree with the Government in their stated aim in the first National Strategy for Sexual Health and HIV, published in July 2001, to, “reduce the transmission of HIV and STIs”, with interventions that include increasing access to condoms, HIV education, needle exchanges for drug users, and a target of 48 hours for GUM clinic access.

Unfortunately, five years later, the Government’s target of a 25 per cent reduction in HIV/AIDS has been quietly buried. The reality is that the increase in cases has been 10 per cent per year since 2000, with a doubling between 1997 and 2005. That is published in Communicable Disease and Public Health, 2002,vol. 5, page 97.

In 1992, the then Conservative Government published Health of the Nation,a strategy for health in England, which identified HIV/AIDS as one of the five priority areas, with specific objectives set. Itwas accompanied by a high-profile public health television campaign warning people of the dangers. There was an initial drop in the rate of STIs but, since then, they have been rising exponentially, with the national strategy having no discernable effect.

Between 1997 and 2005 the number of cases of syphilis increased by 1,653 per cent, gonorrhoea cases increased by 44 per cent, chlamydia cases by 147 per cent, herpes by 16 per cent, genital warts by 17 per cent, and HIV cases by 110 per cent. In contrast, between 1989 and 1997 the number of syphilis cases declined by 62 per cent and gonorrhoea cases declined by 29 per cent. Between 1991 and 1997, cases of HIV declined by 8 per cent. Expenditure on sexual health campaigns between 1997 and 2005 totalled £53 million, whereas in the eight years leading up to 1997, expenditure on sexual health campaigns totalled £122 million. Incidentally, we need to be cautious and use only Global Fund statistics on HIV, as some of the others can be somewhat dubious.

In his 2002 report on the NHS for Gordon Brown, Sir Derek Wanless warned that the extra cost to the NHS of not engaging people in public health might reach £30 billion by 2022. In his annual report on21 July 2006, the Chief Medical Officer, Sir Liam Donaldson, served warning that the Government were following Wanless’s worstcase scenario. Two per cent of the health budget is devoted to health promotion, which is half that of Germany. Sir Liam Donaldson explained in the annual report that public health budgets are being raided to solve financial deficits in the acute sector. Only 36 per cent of primary care trusts—the bodies charged by government with overseeing the majority of public health interventions—believe that they have sufficient capacity and capability to deliver public health care effectively. The number of full-time equivalent doctors inthe public health, medicine and community health services sub-group of the NHS workforce has fallen from 312 in 2000 to 252 in 2005, a decline of 19 per cent. The Faculty of Public Health reported on 29 March this year that four of England’s 13 medical deanery regions had cancelled their spending on public health training completely for 2006-07. As this is the noble Lord’s last appearance as Minister, he might like to take the opportunity to comment on his statement, reported at col. 1290 of the Official Report, that there are now 122,000 more doctors. Incidentally, we are sorry to hear that he is going. We wish him all the best and thank him for his hard work, for which we are very grateful.

As my noble friend Lord Fowler pointed out, funding for sexual health services was to be £300 million. In August 2006 the Department of Health’s Independent Advisory Group on Sexual Health and HIV reported that much of the extra money earmarked for the Government for sexual health services had not reached the front line. To be precise, 33, or 17 per cent, of the 191 primary care trusts that it surveyed said they had withheld some or most of the funding, while 51, or 27 per cent, had absorbed the entire allocation into their general budget.

As my noble friend Lady Flather emphasised, there have been successes with prevention in some countries—Uganda, Kenya and Botswana—with the ABC campaign. It has been criticised quite a bit in the House today, but there is no doubt that it has saved lives and substantially reduced the number of HIV/AIDS cases in pregnant women in Uganda, from 25 per cent to 6 per cent. Those are hard data.

However, there are problems, as the noble Baronesses, Lady Northover and Lady Flather, mentioned. Condoms are not always successful in preventing pregnancy, let alone HIV, which is not surprising given that the virus is a fraction of the size of sperm. Also, many men refuse to wear condoms. Secondly, being faithful in marriage may fail because the wife may be faithful while the husband is not. Thirdly, as mentioned, in many societies women do not have the option of abstaining, especially when they are forced into marriage at an early age. As my noble friend Lady Flather mentioned, the United Kingdom Campaign for Microbicides (UKCM) may give women much more control over the situation, and it is to be hoped that that will continue to develop. Bill Gates said something very interesting in this sphere: “No matter where she lives or what she does, a woman should never need her partner’s permission to save her own life”.

Further to the subject of abstinence, politicians tarnish their reputation somewhat with rather ill-judged sound bites. The late and distinguished Baroness Young asked Her Majesty’s Government at Question Time why they did not present the whole picture, a comprehensive, preventative picture: condoms, be faithful in marriage, abstinence. The Minister at the time laughed and simply said, “Abstinence does not work”. That is what psychiatrists call incongruity of affect. I presume the Minister meant to say that abstinence on its own does not work as a national policy. That is obvious.

On another occasion, when the same question was put, another Minister said, with a laugh, that only old people recommended abstinence. He is wrong because young people are now taking the law into their own hands and devising their own policies. It will be interesting to see what happens. I was impressed with what the noble Baroness, Lady Massey of Darwen, said so sensitively and thoughtfully. An interesting article in the New Statesman pointed out: “Reva Klein, a journalist who has done extensive research into progressive education in the US and UK, emphasises that the most effective sex education programmes aim to build young people’s self-esteem and ‘discourage them from seeking affirmation and escape through sexual relationships’. She tells of one example of a ‘social and emotional development curriculum’ ... where teenagers have been trained as peer educators and sex education classes are run without adults present. Within seven years, teenage pregnancy rates plummeted in this deprived urban area”.

We ought to give great credit to the young for taking the law into their own hands, and to give them all the support they need.

The Minister of State, Department of Health (Lord Warner): My Lords, I am grateful to the noble Lord, Lord Fowler, for leading this debate on such an important subject. I am also grateful to him and to others for their kind personal remarks. I reassure noble Lords that I shall still be active. I shall be able to speak on a much wider range of subjects and keep a beady eye on the Benches opposite.

I pay tribute to the noble Lord, Lord Fowler, for his contribution and leadership 20 years ago and for his commitment to this subject. I am sure that one of the reasons we have not experienced the rates of HIV seen in many other European countries is his early action in introducing needle exchange schemes and other preventive measures. I congratulate the noble Baroness, Lady Paisley, on her compassionate maiden speech. I hope she will understand if I do not follow her down the path of religion in my speech. I hope I will not upset the noble Lord, Lord Colwyn, if I say, neutrally, that it is 25 years since HIV/AIDS first clearly appeared in the United States, Africa and Europe. That is about the best I can do not to get into a scientific tangle with him. We need to recognise what has been achieved since those days as well as facing up to what remains to be done. I wholeheartedly recognise that more needs to be done.

Last month two new reports were published: one from UNAIDS on the global picture, and one from the Health Protection Agency in its annual report for 2005 on HIV and sexually transmitted infections in the UK. I fully agree that both make sobering reading. As noble Lords have highlighted, the sheer scale of the AIDS pandemic worldwide is daunting, with an estimated 39.5 million people now living with HIV, of whom an estimated 4.3 million were new infections this year. An estimated 63,500 adults live with HIV in the UK, of whom an estimated 20,000 or 32 per cent are unaware of their infection. In 2005, there were 7,400 new HIV diagnoses. Those are sobering figures.

However, there have been successes. Needle exchanges, on which the noble Lord, Lord Fowler, has already done so much work, is a success story. In the UK, we are seeing the results of 10 years of antiretroviral therapies that have reduced AIDS diagnoses and deaths and transformed people’s lives and we have some of the best treatment outcomes in the world. Introducing routine HIV screening for all pregnant women has been a success and in England and Scotland we estimate that around 95 per cent of HIV infected women were diagnosed before delivery.

In Europe, our world-class HIV surveillance, developed over 20 years and managed by the Health Protection Agency, means that we can monitor the impact here and take action on emerging epidemics such as in eastern Europe and countries bordering the European Union. In 2005, eastern Europe saw the largest number of newly diagnosed HIV cases—53,000 cases, over twice that reported in western Europe with 22,700 cases.

I very much welcome the priority the European Commission is giving to action on HIV/AIDS in member states and neighbouring countries through its communication agreed earlier this year and, in particular, the setting up of an AIDS think tank of which the UK is an active member through the Department of Health. HIV is a priority for Germany’s presidency, from 1 January, and we are working with Germany on the high-level conference it is planning on HIV prevention next March.

We have had some successes in our international response to HIV/AIDS. The UK has been working actively with country partners and the rest of the donor community to scale up the international response to HIV/AIDS and has committed £1.5 billion over three years to support that effort. The UK led the G8 to support universal access to treatment by 2010 at Gleneagles last year. We also supported the strengthening of this commitment at the UN in June when all Governments agreed to work towards achieving universal access to comprehensive HIV prevention programmes, treatment, care and support by 2010. We led donors to agree that for all poor countries, no credible, costed, government plan to tackle AIDS should go unfunded.

The noble Baroness, Lady Northover, asked what we have done with the pharmaceutical industry. The majority of pharmaceutical companies have developed some form of differential pricing for their product ranges. Most companies producing ARVs make them available more cheaply to developing countries, but DfID thinks that differential pricing needs to be extended to more drugs and to a larger range of countries than at present and is working on that with the pharmaceutical industry.

The noble Baroness, Lady Flather, spoke about microbicides in her feisty and, I thought, rather compelling speech. We are seeing progress in that area. DfID’s funding for microbicides now totals £50 million provided by two main funding streams: the development programme to which DfID has committed around £40 million since 1999 and the international partnership for those products to which it has committed around £10 million since 2002.

In Africa, recent work includes investing £100 million in Malawi over six years, part of which aims to double the number of nurses and triple the number of doctors, and retain them through better pay and conditions, with salary increases of 50 per cent. That support is already helping to stop the outflow of health workers and recruitment has dramatically improved. Since April 2006, 700 nurses have returned and training schools have increased intakes to double the number of nurses and treble the number of doctors in training. Other recent work includes the start of a £25 million programme in Zimbabwe to protect the lives of mothers and newborns affected by AIDS. The programme aims to increase access to family planning services, newborn care and reduce exposure to HIV infection during pregnancy, delivery and breast feeding.

On stigma and discrimination, DfID is supporting approximately 100 projects and programmes including an anti-stigma mass media campaign in Zimbabwe, and the Champions for Change programme in the Caribbean. We recognise that gay men and African communities continue to bear the brunt of HIV in the UK. They are the focus for our national health promotion work. This year we have strengthened our national response by investing an additional £1 million for 2006-07 in work delivered by the Terrence Higgins Trust and the African HIV Policy Network. We are also funding, over two years, three innovative projects aimed at reducing stigma and discrimination linked to HIV.

On the wider sexual health agenda, sexual health is a key plank of the public health White Paper, Choosing Health: Making healthy choices easier, published in November 2004, to which a number of noble Lords referred. I recognise the concerns expressed in the debate about funding for sexual health services. However, it is government policy, on which we remain of the same view, that the local NHS must be free to make its own local priority setting and spending decisions within the national guidance and standards that have been issued. We have no plans to reintroduce ringfencing at the moment. It is important that the NHS gets back into overall financial balance during this year and achieves continuing, sustainable financial balance locally in the future. However, that does not reduce our commitment to improving real outcomes from local investment. That is why we have introduced sexual health into the local delivery planning process, including GUM access, reducing gonorrhoea rates, teenage pregnancy and chlamydia screening. That will enable us to see where real improvements are being delivered in areas such as waiting times and rates of infection. Of course, the Healthcare Commission will remain active in assessing local trusts’ performances against national standards. The White Paper, Our Health, Our Care, Our Say, set out our commitment to modernise services, including for sexual health, looking at new models of service delivery, particularly in the community. The move to practice-based commissioning, which will operate extensively in 2007-08, will support these developments and local innovation, resulting in flexible, high quality services for patients from a much wider range of providers, and in settings closer to home or more convenient to them.

In our national chlamydia screening programme, screening is taking place in a range of traditional health venues as well as more innovative settings, such as Army bases and nightclubs. In the third year of the programme more than 100,000 screens were performed, of which 18 per cent were screens for men. One in 10 people tested positive. We have also contracted with Boots to offer a free and confidential chlamydia screening service in all its London pharmacies. To date, more than 29,000 kits have been issued, with a return rate of nearly 50 per cent. The positive rate is around 8 per cent.

We welcome the Independent Advisory Group’s report on sexual health, which also covers HIV. We will publish a full response as soon as possible. I take this opportunity to pay tribute to my noble friend Baroness Gould, chair of the group, and her colleagues, for their valuable work in raising the profile of sexual health.

Sexual health and access to genito-urinary medicine clinics is one of the top six priorities for the NHS. Our target is to ensure that everyone who needs an appointment at a clinic is offered one within 48 hours by 2008. We have not in any way backed away from that ambition and we are making excellent progress towards it. Data published by the HPA today show that in November 65 per cent of patients were seen within 48 hours, and a further 4 per cent were offered an appointment, but chose not to attend. In May 2004 only 38 per cent of attendees were seen within 48 hours. That is progress of some considerable measure.

In November we launched a new sexual health campaign, “Condom Essential Wear”, to tackle the five major acute sexually-transmitted infections: chlamydia, syphilis, gonorrhoea, genital warts and herpes, as well as HIV. The campaign, which targets18 to 24 year-olds, who are most at risk of contracting STIs, focuses on the invisibility and prevalence of STIs, and the importance of using a condom. Its aim is to normalise condom usage in order to prevent the spread of STIs and unintended pregnancies. Preventing unintended pregnancy is a key aspect of improving sexual health. The Choosing Health White Paper highlighted the variation in access to contraceptive services and the range of contraceptive measures. We have undertaken a national baseline review of contraceptive services to ensure that we are clear, locally and nationally, on how best to meet the gap in services, ensure that the full range of methods are available, and that best practice is shared. We will shortly publish the results of this review as well as best practice guidance on reproductive healthcare.

My noble friend Baroness Massey mentioned the issue of PSHE. The Government remain to be convinced that making PSHE statutory would, in itself, make PSHE better. Much PSHE content is already statutory. There are already specific statutory requirements for sex and relationship education, drugs education and careers education and guidance. We believe that a new statutory subject would not sit comfortably with the 14 to 19 flexibility needed at this stage of the curriculum. The noble Baroness mentioned the issue of NICE and the needle exchange schemes. These are still in the early stages of the NICE topic selection process. My understanding is that NICE’s consideration panel discussed this at a meeting on 24 November and the paper will proceed to the next stage of topic selection. There are a number of steps to complete before NICE takes on a proposal. If successful, we would expect a formal referral to NICE in April 2007. We are making good progress in this area but I acknowledge that there is still much more to do in order to reduce STIs and HIV prevalence and unintended pregnancies.

HIV is still a life-threatening illness, for which there is no cure. New infections continue to occur in the UK. We need to recognise, too, that changing behaviour is not an area where government action alone is sufficient. We need to work continuously with the NHS, local government, the voluntary sector, the commercial sector and individuals to ensure a sustained and focused effort to improve sexual health. No one, however, would doubt our commitment to seeing through the necessary improvements to this important area of public health.

Where I have not answered noble Lords’ points satisfactorily, I will study Hansard and write to noble Lords on those points I have missed.

The noble Lord, Lord McColl, drew attention to the fact that as I galloped through my closing speech in last week’s debate on the NHS, I garbled a number of statistics. I would like to take this earliest possible—and, indeed, my last—opportunity at the Dispatch Box to correct those figures. We have certainly increased the number of NHS staff over the past five years; that essential point was correct. The correct figures I should have given are as follows: there are 85,000 more nurses since 1997, and there are more than 404,000 in total; there are 32,000 more doctors, and there are more than 122,000 in total; there are 16,000 more allied health professionals, and more than 61,000 in total; there are nearly 2,500 more radiographers, and 12,700 in total; there are 1,800 more healthcare scientists, and more than 30,000 in total; there are nearly 4,700 more GPs, and more than 32,000 in total. I hope I have put right the record in respect of those misleading figures given previously, for which I apologise to the House.

Lord Fowler: My Lords, I thank all those who have taken part in this debate. It has been, in many ways, an outstanding debate, with some important contributions, matching the importance of the subject, from the Back Benches. The noble Baroness, Lady Paisley, in her excellent maiden speech, rightly said that the more we examine the figures, the worse the picture becomes. She is entirely right on that. On the national position, we heard from the noble Baroness, Lady Gould, and the noble Baroness, Lady Massey, both of whom spoke with authority on their own experience.

We also heard from the noble Baroness, Lady Barker, who made a very important point about campaigns. They have to go on, month by month and year by year. To have a campaign 20 years ago and then go off the air in the interim makes no sense.

On the international position, we heard from the noble Baroness, Lady Northover, my noble friend Lady Flather and the noble Baroness, Lady Miller, who rightly pointed out the impact on women and children. Then my noble friend Lord Colwyn added his own view on HIV. I have no doubt that we will continue to debate this subject for many years.

I should like once again to thank the noble Lord, Lord Warner. I already detect a new zip in his step as he gets ready to depart. I make one small point: before the noble Lord goes he might like to answer my Written Question of 20 November, which is in the sin box, published today to Ministers. The Minister spoke of the efforts made by DfID in this area. The real question is whether the Department of Health is doing as much as the Department for International Development. There will be many who are rather disappointed by his reply on ring-fencing sexual health resources. If we do not do something like that in this area, the position will not improve. Local trusts will always find sexual health an easier option for cutbacks than other alternatives.

The message of this debate is that national and international policy on HIV and sexual diseases needs higher priority if we are to prevent death and suffering. Today’s speeches establish that we are not doing enough to combat either HIV/AIDS or sexual disease generally. The tragedy is that we know what works and what can be effective and, therefore, what should be done. We will not be forgiven if we do not take the action open to us today. Having said that, I beg leave to withdraw the Motion for Papers.

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