EXECUTIVE SUMMARY OF RECOMMENDATIONS

  1.  The National AIDS Trust believes that the health inequalities agenda must look at the UK population in a variety of ways, including specific ethnicities, sexual orientation and residency status, as to better capture the various forms of inequality that exist.

  2.  Accepting that the Public Service Agreement target on reducing health inequalities will be with us until its timeline is completed, the National AIDS Trust believes that the Department of Health should look at how to incentivise a more inclusive consideration of health inequalities within local PCTs and nationally, so that the wider social determinants of health and those that cause health inequalities are also examined. This will rely on strong and effective partnership across Government agencies, local authorities, community organisations and other key stakeholders.

  3.  The National AIDS Trust asks the Health Committee to reaffirm its recommendations on charging as outlined in its New Developments on Sexual Health and HIV/AIDS Policy report, to end the discrimination against people with HIV in sexual health services, ensuring free treatment for all. This must be one of the Department of Health's primary concerns, providing free treatment for all to protect public health.

  4.  While much of the treatment of HIV infection is specialised, the National AIDS Trust believes that the Department of Health should look at how to scale up the important role GPs and primary care teams can play in the prevention, diagnosis and management of HIV infection.

  5.  The National AIDS Trust recommends that the Health Committee identify prison healthcare as a key opportunity and intervention to address health inequalities. In particular, prisons should support safer sex and safer injecting practices, both within prison and for the future life after custody, and provide accessibly clean needles and condoms to those who need them.

INTRODUCTION

  1.  The National AIDS Trust is the UK's leading policy and campaigning charity on HIV and AIDS. The National AIDS Trust develops policies and campaigns to halt the spread of HIV, and improve the quality of life of people affected by HIV and AIDS, both in the UK and internationally.

  2.  The National AIDS Trust welcomes the opportunity to provide input into the House of Commons Health Committee inquiry on the extent to which the National Health Service (NHS) can help to achieve a reduction in health inequalities, particularly for vulnerable people living with HIV.

  3.  This brief memorandum contains a background on the current situation as related to HIV in the UK and considers, in turn, four specific points: how inequality is assessed; whether this assessment adequately addresses the unequal burdens of ill health around long-term conditions, such as HIV; structural causes within the NHS of health inequalities; and prison health.

BACKGROUND

  4.  The National AIDS Trust commends the Department of Health (DH) for putting the reduction of health inequalities high on the agenda of the NHS, both in terms of delivery and working with other agencies across Government, and for establishing a national Public Service Agreement (PSA) target in 2001 on reducing health inequalities. The PSA sets out to, by 2010, reduce inequalities in health outcomes by 10 per cent as measured by infant mortality and life expectancy at birth.

  5.  This commitment to reducing health inequalities is reinforced in the NHS Operating Framework 2008-09.[59] The Operating Framework outlines reducing health inequalities as one of five key national priority areas for Primary Care Trusts (PCTs) by working with providers and their local partners. In fact, reducing health inequalities has featured as a key national priority each year in the Framework since 2003[60] and was highlighted as a key theme during the UK presidency of the European Union in 2005.[61]

  6.  Despite these commitments, there are still unacceptable variations in the health status within and between different communities, and the gap for some may, in fact, be widening.[62] It is now estimated that there are 73,000 people living with HIV in the UK, the highest number ever. Disadvantage and health inequalities are key issues for those most vulnerable to HIV infection, including migrants and men who have sex with men (MSM). For example, 40 per cent of black Africans and black Caribbeans living with HIV in the UK are diagnosed late. Gay and bisexual men show records rates of HIV infection, with an estimated 2,700 new diagnoses in MSM in 2006.[63] In addition, research suggests less than half of people living with HIV are in paid employment, despite the effectiveness of treatments[64] and one in three people diagnosed with HIV in the UK have experiences severe economic hardship.[65]

ASSESSING INEQUALITY

  7.  The DH "breaks down" inequality by looking at the areas with the worst health and deprivation as compared to the population as a whole. This agenda alone does not adequately address the experience of some groups in the UK. For example, black Africans, migrants and MSM are particularly vulnerable to HIV infection[66], but the current inequality "break down" fails to analyse inequality by ethnicity or sexuality. To give a further example, evidence from a recent Confidential Enquiry into Maternal and Child Health report, Saving Mothers' Lives, shows that black African women, including migrants, have a mortality rate nearly six times higher than white women and that HIV is a condition that contributes to maternal death.[67] This inequality is currently overlooked by the DH's approach. It is therefore vital that health inequalities are considered in terms of specific ethnicities, sexual orientation and residency status.

  8.  Such an approach could bring many benefits. As well as providing better data, it could facilitate important connections. For example, if gay men are also experiencing health inequalities around mental health problems, or drug and alcohol abuse, then this evidence could be used to develop a more holistic approach to addressing health promotion and HIV prevention messaging.

  9.  The National AIDS Trust believes that the health inequalities agenda must look at the UK population in a variety of ways, including specific ethnicities, sexual orientation and residency status, as to better capture the various forms of inequality that exist.

UNEQUAL BURDENS OF ILL HEALTH AROUND LONG-TERM CONDITIONS

  10.  The current agenda to reduce health inequalities does not appear to adequately examine the kinds of health conditions most closely associated with inequalities. A PSA which focuses on infant mortality and life expectancy at birth may not catalyse effective consideration of unequal burdens of ill health around long-term conditions, such as HIV, which nevertheless involve significant morbidity.

  11.  In the UK, with the widespread availability and uptake of antiretroviral drugs among those who need them, HIV positive individuals are able to live long, healthy lives. HIV is now a chronic, manageable condition for many, and there has been a dramatic increase in life expectancy.

  12.  However, underlying factors like poverty, employment, housing, education and HIV-related stigma and discrimination affect people's long-term chances of staying well. Poverty is a principal source of ill health, particularly for those living with HIV, as health can be undermined by poor living conditions, below standard levels of support and a sense of powerlessness.[68]

  13.  Accepting that the PSA target will be with us until its timeline is completed, the National AIDS Trust believes that the DH should look at how to incentivise a more inclusive consideration of health inequalities within local PCTs and nationally, so that the wider social determinants of health and those that cause health inequalities are also examined. This will rely on strong and effective partnership across Government agencies, local authorities, community organisations and other key stakeholders.

STRUCTURAL CAUSES OF HEALTH INEQUALITIES WITHIN THE NHS

  14.  There can also be structural causes of health inequalities within the NHS. The most significant of these is the denial of free NHS care to refused asylum seekers and other undocumented migrants. To charge the, often, destitute for their care is deterring vulnerable people from continuing to access the vital treatment they need, with possibly fatal results and serious consequences for public health. There is increasing evidence that these regulations, potentially affecting up to half a million people not entitled to free NHS care, are causing harm.[69]

  15.  Denying free NHS care to certain vulnerable communities is a key concern previously raised by the Health Committee in its report New Developments in Sexual Health and HIV/AIDS Policy.[70] Who should be allowed into the UK and who should be removed is an important policy issue, but one which should be treated separately from healthcare provision. If people are living in the UK, there are fundamental human rights, community cohesion and public health reasons why they should be able to access the care they need.

  16.  The National AIDS Trust asks the Health Committee to reaffirm its recommendations on charging as outlined in its New Developments report, to end the discrimination against people with HIV in sexual health services, ensuring free treatment for all. This must be one of the DH's primary concerns, providing free treatment for all to protect public health.

  17.  In addition, the National AIDS Trust believes that doctors are missing valuable opportunities to diagnose HIV in some vulnerable groups who are disproportionately affected by health inequalities. It is estimated that around one-third of those with HIV infection in the UK have yet to be diagnosed, many of whom are from black African communities, even though they are using primary care services. As HIV-related mortality is greater in those who are diagnosed late, early diagnosis is critically important.

  18.  While much of the treatment of HIV infection is specialised, the National AIDS Trust believes that the DH should look at how to scale up the important role GPs and primary care teams can play in the prevention, diagnosis and management of HIV infection.

PRISON HEALTH

  19.  The National AIDS Trust also believes that effective healthcare in prisons is an important public health opportunity to reach often severely marginalised sections of society. For example, a substantial majority of injecting drug users (IDUs) immunised against hepatitis B have been immunised in prison. The Government is also committed to the principle of equivalent healthcare in prison to that available in the community. However, from the HIV perspective, there are two glaring instances of unequal healthcare provision—the denial of needle exchange for IDUs in UK prisons, and the inadequate access to condoms in prisons (apart from Scotland, where condom vending machines have recently been approved).

  20.  The National AIDS Trust recommends that the Health Committee identify prison healthcare as a key opportunity and intervention to address health inequalities. In particular, prisons should support safer sex and safer injecting practices, both within prison and for the future life after custody, and provide accessibly clean needles and condoms to those who need them.

CONCLUSION

  The National AIDS Trust commends the Government for putting the reduction of health inequalities high on the NHS agenda. However, the National AIDS Trust believes that the DH should take a wider approach by considering how inequality is assessed, the unequal burdens of ill health around long-term conditions, structural causes within the NHS of health inequalities and prison health. This will allow the NHS to develop the holistic approach needed to effectively tackle health inequalities.

National AIDS Trust

January 2008

60   Department of Health (2002) Priorities and Planning Framework for 2003-06-Improvement, expansion and reform: the next three years,www.dh.gov.uk/prod_consum_dh/idcplg?IdcService=GET_FILE&dID=10880&Rendition=Web; Department of Health (2004) National Standards, Local Health: Health and social care standards and planning framework 2005-06-2007-08,http://www.dh.gov.uk/prod_consum_dh/idcplg?IdcService=GET_FILE&dID= 7148&Rendition=Web; Department of Health (2006) The NHS in England: Operating framework for 2007-08,http://www.dh.gov.uk/prod_consum_dh/idcplg?IdcService=GET_FILE&dID=115714&Rendition=Web. Back

61   Further information from the Department of Health can be found atwww.dh.gov.uk/en/Policyandguidance/International/ EuropeanUnion/EUpresidency2005/DH_4114083. Back

62   Shaw et al (2005) "Health inequalities and New Labour: How the promises compare to real progress," British Medical Journal, 330: 1016-1021. Back

63   Ibid. Back

64   Elford et al (2007) "In the era of HAART how many people living with HIV are employed?" British HIV Association Spring Conference, Abstract P122. Back

65   National AIDS Trust (2007) Poverty and HIV: Findings from the Crusaid Hardship Fund 2006,www.nat.org.uk/ document/207. Back

66   Cook et al (2007) Ten Years of Monitoring HIV & AIDS in the North West of England,http://www.nwpho.org.uk/10yearhiv/HIV_10years.pdf. Back

67   Confidential Enquiry into Maternal and Child Health (2007) Saving Mothers' Lives 2003-2005,http://www.cemach.org.uk/getattachment/ee9ca316-2a9a-4de6-9d48-ecaf5716e2b4/Why-Mothers-Die-2000-2002.aspx. Back

68   National AIDS Trust (2007) Poverty and HIV: Findings from the Crusaid Hardship Fund 2006,www.nat.org.uk/ document/207. Back

69   Examples from the National AIDS Trust of charging can be found at www.nat.org.uk/document/336. Back

70   House of Commons Health Select Committee (2005) New Developments in Sexual Health and HIV/AIDS Policy. Back