Recently published data covering surveillance information on HIV and other sexually transmitted infections in the UK, paints a depressing picture. By the end of 2003, an estimated 53,000 people were living with HIV in the UK. Over a quarter were unaware of their infection, but data from tests on unlinked blood samples suggests that the figure is a good estimate.
New diagnoses of HIV are rising steadily, and have done so since 1998, after a few years in which the numbers remained fairly stable. There were over 6,600 new diagnoses in 2003, more than double the total for 1998. Whereas in the earlier years of the epidemic in the UK, men who have sex with other men were consistently the group showing the largest number of new diagnoses, in each year since 1999 they have been outnumbered by infections acquired through heterosexual sex. The majority of the new infections among heterosexuals are believed to have been acquired in sub-Saharan Africa, currently the epicentre of the world epidemic.
However, the trends are bad for virtually every group of people at risk of infection. There has been a slow but steady rise in infection rates for homosexual men, so that the new diagnoses are over 30 per cent higher now than in 1999. Heterosexual infections probably acquired in the UK are still relatively small in number, but rising. In 2003 an HIV prevalence of 0.8 per cent was found among drug users who had started injecting within the last three years – the highest level recorded since 1990.
There are areas of good news. No transmission of HIV through blood transfusions or blood products now occurs in the UK, although a few cases each year continue to be diagnosed that are attributable to blood transfusions performed abroad. The ante-natal screening of pregnant women has been very successful in reducing mother to child transmission of HIV, although it has not been completely eradicated.
All the data indicates how short-sighted it would be to regard HIV as a problem that we in the UK do not have to worry about; that this is an issue for the developing world, but not for us. It is clear that the campaign on sexual health that the government is now undertaking has to include HIV, and that prevention of infection has to remain a high priority.
The availability of anti-retroviral drugs has, of course, had a huge effect in the UK and other developed countries. Death rates from Aids and Aids-related infections have dropped dramatically. What this does mean, though, is that more and more people are living with the virus, with a number of consequences.
Firstly, it means that the pool of potential infection is growing. Crudely put, more people living with HIV means that more people can pass on the infection. While prevention strategies quite rightly focus on informing uninfected people about staying free of the virus – such as how to practise safe sex and how to minimise risks – it seems to me that not enough work is done with those who are already infected. It is simply not realistic to say to someone who has HIV that they must remain celibate for the rest of their lives. Some of the organisations for people living with the virus do an excellent job of educating and informing those who are newly infected on how to remain healthy and how to avoid transmission. More needs to be done, however, by the public sector in this field.
The second important effect of greater numbers of HIV positive people, is the stress this places on the NHS – especially in those areas of the country with the highest incidence of HIV. Traditionally, London has had the largest number, and still has, but policies such as the dispersal of asylum seekers have had the effect of suddenly increasing the workload of clinics in other parts of the country, often without a commensurate increase in resources. For a small clinic outside London, 15 or 20 extra cases may be enough to cause problems.
The rapid rise in heterosexual infections originating outside the UK, predominantly in Africa, has led to calls for mandatory testing of those coming to settle or work here. The implication of this is that a positive test would lead to the person concerned being denied entry. Such a policy is superficially attractive, and the argument that it would stop the drain on NHS resources is a seductive one. It ties in with recent policy changes to bring in charges for overseas visitors and others without residence rights in the UK, which are also impacting on failed asylum seekers. The health select committee will shortly undertake an inquiry into the effects of this policy on HIV.
Calls for testing ignore both the potential public health impact and the effect on the individuals concerned. We know that the stigma attached to HIV infection is one of the major drivers of the worldwide epidemic. People who are fearful of being identified as having HIV are much less likely to test. They then are much more likely to pass on the infection: a clear public health risk. They are also likely to present at hospitals much later in the progression of the infection, when they are becoming seriously ill. They are then much more expensive to treat.
All the international organisations working on HIV, such as UNAIDS, remain vigorously opposed to imposing mandatory tests. There is also a moral dimension. If a rich country such as the UK sends out a negative message, as mandatory testing would, what does that say to poorer countries about how they should behave? The evidence from those countries which have imposed testing regimes on some of those wishing to enter the country, is that they have not been successful in reducing infection rates.
What we have to realise is that we are not somehow separate from what is happening in the rest of the world. We cannot simply put up barriers around the UK. Africa is currently the centre of attention in relation to HIV. We now recognise the devastating effects of the disease on this continent; it is not just a health issue, it is destroying development gains which have been made, it impacts on security, on human rights and on women in particular.
New epidemics are springing up. In Central and Eastern Europe and the Commonwealth of Independent States (mostly the former USSR), UNAIDS estimates that as many as 280,000 people contracted the virus in 2003, bringing the total of those infected to as many as 1.8 million. This region includes several countries which are either EU members, or will be quite soon, whose people will be able to travel freely in Europe.
All the data suggests that the Russian Federation, Latvia, Ukraine and Estonia are now experiencing some of the fastest growing HIV epidemics in the world. The all-party parliamentary group on AIDS recently hosted a visit from a cross-party group of MPs in the State Duma of the Russian Federation, which has been established to work on HIV. They want our cooperation in developing policies to deal with the spread of HIV while there is still a chance of containing it. At present, injecting drug use is the main driver of new infections, but with an HIV prevalence rate approaching one per cent of the population, Russia and other East European states are at the point where this could tip over into a rapidly growing generalised epidemic.
It is not only Eastern Europe where there are dangers. Almost five million people are infected in India. China has a growing problem. If nothing is done, some of the estimates for new infections in these countries over the next 10 years are horrendous, with numbers greater than the current total of infections in the world being predicted.
The publication of a new HIV strategy earlier this year by DfID was widely welcomed, as was the commitment to increased spending on HIV announced by the chancellor. The prime minister has spoken about his intention to put HIV firmly on the agenda at the meetings of the G8 and the EU, and to use the UK presidencies of both of these bodies to drive forward international policies on HIV.
What we cannot sensibly do is to have a set of policies at international level that do not sit well with our domestic policies. Internationally, we are stressing the need for better treatment, for the wider availability of anti-retroviral drugs and for the building of healthcare and social care systems alongside this. We stress the need for work on women’s rights, for addressing stigma and discrimination. We stress the need for international co-operation to deal with what is so obviously an international problem. We cannot do that with any authority if we adopt domestic policies based on exclusion and restrictions.
