The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)
My Lords, this has been a very good debate and everyone who contributed to it has had something of interest to say. For me it has been a wake-up call. As has been reflected in a number of speeches, I thought this problem had somehow been sorted out, but clearly it has not been. My noble friend Lord Maude talked about the tragedy of his own brother, and of course for him it was not sorted out. I had thought that since then we had made huge progress, and of course we have done so. I would like also to echo the comments of my noble friend Lady Bottomley about our new Lord Speaker because I can feel his presence glowering down at me on this issue. He said to me not all that long ago that when he took up his new role he would not be able to pester me about the long-term sustainability of the NHS. But I can feel his presence this evening.
My noble friend Lord Black made an outstanding speech, which brought all the threads of the arguments together. Perhaps I may pick out a few of the individual points that have been raised. I know Jonathan Fielden, the deputy medical director at NHS England. He is a very humane, decent and experienced doctor and I think he would be horrified to feel that what he said or how he said it—I have not seen his exact words—would be interpreted in the way it has been. I will write to him with a transcript of this debate and I will leave how he would like to respond to it up to him. I am sure that the last thing he would want to do is leave the impression that he clearly has with the noble Lord, Lord Scriven, and indeed with the noble Lord, Lord Hunt.
My noble friend Lord Maude talked about the cross-government and cross-ministerial issues and how difficult it can be for one department to bear the cost when the benefit is being received by another. It is worth saying that in this case the cost of treatment lies with NHS England, so it seems entirely reasonable that the cost of prevention should also lie with NHS England and that they are kept within the same budget. The noble Lord, Lord Patel, suggested having a cross-government Minister. All my experience of cross-government Ministers has been that they are not all that effective because the silos that we have created in British Government are very strong. The noble Lord also drew a comparison with the strategy for hepatitis C. In a sense we face the same problems dealing with hepatitis C as we do with PrEP and countless other drugs: there is a limit to the money we have available. There is a cost. The noble Lord says that it will all end up with the taxpayer, but the fact is that the taxpayer has given us a certain amount of money for the NHS. We would like to spend a lot of it on treating hepatitis C, on PrEP and on other drugs, but we simply do not always have the money to spend as we would like.
Perhaps I may turn to the speech that I had prepared beforehand. It falls short in some respects of what I have been asked to do this evening. I was struck by that when listening to the quality of the debate, but noble Lords will have to be the judge of my speech more than I can be myself. I am hugely impressed by what has been said this evening and I am sure it will have a big impact outside the Chamber as well as within it.
It is worth restating that the NHS provides excellent treatment and care for people living with HIV. The success of our treatment services means that the UK is already ahead in meeting two of the three ambitions set out in the UNAIDS 90-90-90 target: 90% of people with HIV being diagnosed; 90% on ARV treatment; and 90% viral suppression for those on ARV treatment by 2020. In 2014, of all those attending for care, 91% were on treatment, of whom 95% were virally suppressed and very unlikely to be infectious to others. So we have achieved more than 90% on two of those UN goals.
There are other positive indicators of success. Late diagnosis of HIV, defined as a diagnosis made after the point at which treatment is recommended, has declined from 50% of diagnoses in 2010 to 40% in 2013, but that is still too high. Reducing late diagnoses remains important since people who are diagnosed late have a tenfold increase in the likelihood of death in the first year of diagnosis compared with those diagnosed more promptly. Reducing late diagnosis is included as an indicator in the public health outcomes framework. We are also reducing the proportion of people with undiagnosed HIV, which was down to about 17% in 2014 from an estimated 25% in 2010. More progress is needed to reach the global goal, but things are improving in the right direction.
I had been doing a bit of work with a colleague of the medical director of NHS England, Bruce Keogh. She is a specialist in HIV. She sent me a note. I should say that she is very supportive of PrEP. I would not want to mischaracterise her view. She said that around 80% of HIV infections in men who have sex with men are transmitted by the 20% of individuals who are unaware that they are HIV positive. She tells me that people who are not aware of their diagnosis do not make the same effort to modify their behaviour—for example, the consistent use of condoms—to reduce transmission. Undiagnosed individuals are not on treatment, so have high levels of HIV in their blood, which makes them more likely to pass on the infection to others. There is no dispute between us on the importance of early diagnosis.
Overall, new diagnoses of HIV remain stable, with an estimated 6,151 new diagnoses in 2014, up very slightly from 6,000 in 2013. Of course, we must not be complacent. We know that much more needs to be done to reduce the new number of HIV infections, especially in men who have sex with men, where we continue to see increases in new infections. We also know that transmission is continuing among black African men and women who are acquiring their infection within the UK.
So what are we doing? To really tackle rates of HIV infection we must increase regular HIV testing and promote safer sexual behaviour, particularly condom use. In England, the Government continue to invest £2.4 million each year in national HIV prevention. This funding is allocated across three main areas. First, funding has been allocated to seven new innovative local HIV prevention projects. Activities being undertaken include providing full sexual health screening in saunas and other similar premises, to working with faith leaders to promote HIV prevention and testing among black and minority ethnic communities. A further round of funding for 2016 and 2017 was announced in June this year. The successful projects will be announced in September. We will be building on learning from the year one projects.
Secondly, we know that early testing and diagnosis reduce the risk of onward transmission of HIV. This is the basis of the new HIV home sampling service, which my noble friend Lord Black referred to. It is one of the first of its kind. Some 27,173 HIV self-sampling kits were ordered between November 2015 and May 2016; 13,992 kits were returned, of which 197—1.4%—were reactive. This is encouraging, given the challenge of identifying those living with undiagnosed HIV. Central funding was provided through PHE until January 2016, when the service transitioned to local authorities. Eighty are now signed up to funding the service. PHE will look to build on these numbers.
The third and final strand of funding is from the Terrence Higgins Trust, which has been awarded a new contract to lead and manage a national partnership to deliver information and resources to improve the proportion of individuals in highest-risk populations able to make safe and sustainable sexual health choices and reduce HIV incidence. The programme will focus on social marketing and local HIV prevention activity, as well as monitoring and evaluation activities.
I turn to PrEP, which, as most noble Lords will know, is a new use of HIV drugs that has shown clinical effectiveness in research trials at preventing HIV in people at higher risk of getting HIV. The trials recruited men who have sex with men engaged in high-risk behaviours and people with HIV positive partners—this is the PROUD clinical trial. As noble Lords mentioned, it has been extremely successful. It is important to note that the drug used for PrEP, Truvada, is not yet licensed for this use in the UK. It is licensed only for treatment, not for prevention. However, progress is being made with an application to the EMA and a licence is expected to be granted very shortly.
PrEP should not be seen as a silver bullet. It is only one of a range of activities to tackle HIV. As with any new intervention, PrEP will need to be properly assessed in relation to clinical and cost effectiveness, including how it compares with existing cost-effective approaches, to see how it could be commissioned in the most sustainable and integrated way. The NICE evidence review is considering the published evidence on PrEP and will be published shortly. We know, however, that cost-effectiveness is very sensitive to HIV incidence in the target population and effective targeting; the adherence to taking the medication, which affects clinical effectiveness—although I was interested in the comments of the noble Lord, Lord Patel, about intermittently taking the drug—and the cost of PrEP drugs.
Time is running out. There has been criticism about the handling of this by NHS England. NHS England has provided an assurance that all the proposals considered as part of its prioritisation process will be subject to the same robust assessment of clinical and cost effectiveness and relative prioritisation within the resources available, as well as the impact on people from vulnerable and protected groups.
I felt that the leader in the Times got the balance about right when it said:
“There are reasons, however, to resist the conclusion that HIV prevention should be left to the HIV-positive. Few would be comfortable if the state stepped back from HIV treatment altogether, just as it would be thought indecent of a society to let smokers die of lung cancer or allow the obese to succumb to heart disease on the basis that such illnesses are behaviourally induced”.
There is no intention at all on the part of NHS England or the Government to discriminate in any way against the use of PrEP because of people’s lifestyle choices. I can give that absolute assurance to noble Lords. The appeal is taking place on 15 September and I cannot comment further on the court case, but I can assure noble Lords that the decision on whether or not to use PrEP will be assessed in an absolutely normal way.
I will make just one last comment, which I do not expect some Members of this House to agree with. The decisions about which drugs to prioritise and how to prioritise drugs should surely be made by clinicians and NHS England, not politicians. The noble Lord is shaking his head but that is the whole thrust of the way that the NHS has been set up, and the involvement of politicians in picking one drug against another is surely not the right way forward. I have to leave it as it stands.