1.  Terrence Higgins Trust (THT) is the UK's largest non-statutory provider of HIV and sexual health services. THT provides diagnostic, care and prevention services for HIV and STIs and works to reduce the stigma and discrimination encountered by people with HIV and poor sexual health.

  2.  Inequality impacts upon people with HIV and poor sexual health in a number of ways, both legal and societal. It both contributes to poor sexual health and is, in turn, exacerbated by that poor sexual health, creating a cycle of inequality. In many areas, the NHS can make a positive contribution; in some, unfortunately, it is also capable of making a negative one.

  3.  This submission highlights three areas of health inequality where THT believes a small change could have a large impact upon both public and individual health and on reducing existing health inequalities. It also addresses the cost-effectiveness of targeted HIV prevention work as a public health intervention.

DISCRIMINATION

  4.  Many people with HIV encounter discrimination as a result of their condition. In a survey of 1385 people with HIV in London (Elford et.al. 2007), almost a third had encountered direct discrimination. Within this group, half had been discriminated against in a healthcare setting and the most common situations cited were dentists and GP settings. THT regularly speaks with people who have been refused dental services, put to the end of minor surgery waiting lists or otherwise treated inequitably, often explicitly because of their HIV status. We would be happy to provide the Select Committee with case studies giving examples of this.

  5.  Many people with HIV are reluctant to inform their GP of their HIV status and, in general, most people who test for HIV prefer not to do so at their GP surgery, despite Government policy and CMO advice urging GPs to increase their offers of HIV testing. Similarly, many people are reluctant to approach their GP if they suspect or fear that they have a sexually transmitted infection. While in part this is due to misinformation, it is also true that levels of understanding of sexual health issues are generally low in GP practices and this can lead to stigma and, in some cases, discriminatory behaviour from GPs and other practice staff.

  6.  THT believes that appropriate training for GPs and other primary care staff such as dentists would reduce the discrimination currently faced by people with HIV and STIs in those settings. Where people with HIV have a good and trusted GP or dentist, this is a major positive contribution to their overall health and welfare.

CHARGING FOR TREATMENT

  7.  The current NHS policy of charging certain groups of people resident in the UK for hospital and outpatient treatment is a major source of health inequality. People refused asylum but remaining in the UK because their country of origin is too dangerous for deportation, and other undocumented but resident migrants, are currently charged for all hospital treatment. There is no data to show that this system is working and, indeed, a previous Health Select Committee Inquiry on Sexual Health in 2005 recommended that charging for HIV be scrapped on the grounds of both public health and the public purse. HIV is the only STI which is not exempted from the charging regulations for public health reasons—itself an inexplicable inequality.

  8.  However, we understand that the Government is planning shortly to announce not the reduction but the extension of charging, to also cover primary care. This will, amongst other impacts, greatly exacerbate health inequalities for some migrants.

  9.  While the Government states that immediately necessary treatment should always be given, with charges being made later (in particular for maternity services), it is THT's experience and that of the people we support that this is often not happening. Again, THT can give case studies of people who have been refused maternity and other services unless they pay in advance; people who have been wrongly told that they must pay; and people who have abandoned needed treatment because they cannot pay.

  10.  This system is particularly inequitable because those administering it are often untrained and inexperienced and there is no monitoring of their decisions by the DH. THT has experienced people eligible for free treatment being refused; people being treated freely by one hospital and not another; and people reluctant to ask for treatment because of the fear and shame of refusal. An extension to primary care is likely to increase these inequalities.

  11.  THT submits that reform of the charging scheme, based upon evidence of efficacy and consideration of public health impact, would do much to address a considerable area of health inequality currently being perpetuated.

YOUNG PEOPLE'S SEXUAL HEALTH

  12.  The sexual health of young people in the UK is amongst the worst in Western Europe, in terms of teenage pregnancy rates and sexually transmitted infections. There are clear health inequalities within this based upon geography, social class and educational attainment.

  13.  THT believes the NHS has a major role to play within the reduction of this problem. Many young people gain little accurate information at home or in the schoolroom about sexual health, though they are often subject to considerable misinformation within their peer group. In the absence of compulsory comprehensive Sex and Relationships Education, a school nurse in every school, supplied by the Primary Care Trust or Health Board and trained to give confidential advice and support to young people as they grow to adulthood and are faced with sexual choices, would have a major role to play.

  14.  The NHS also has a role to play in supporting peer education initiatives amongst young people which seek to dispel misinformation and provide young role models for sexual health improvement, such as THT's Young Leaders Project which was recently commended by the Prime Minister as "inspirational". Joint work with these initiatives not only benefits the young people involved but also provides the NHS with useful insights into the priorities and needs of young people around their sexual health, which in turn can be used to further reduce health inequalities.

COST EFFECTIVENESS OF TARGETED HIV PREVENTION INITIATIVES.

  15.  With the rise in availability of effective treatment for HIV in the last decade there has been a more than unfortunate decrease in the local funding allocated to, and the relative priority accorded to the prevention of onward transmission of HIV. However, there is a very strong case for the cost effectiveness of some targeted interventions to prevent HIV transmission.

  16.  The DH's National Strategy for Sexual Health & HIV states that the lifetime cost per case of HIV in the UK is around half a million pounds per transmission. The National Institute for Clinical Excellence has considered the efficacy of HIV prevention technologies and interventions and has stated that there is good evidence for the efficacy of a range of HIV prevention interventions, from condom useage to groupwork. These interventions are considerably less expensive than ongoing transmissions, and yet the current emphasis within NHS planning at a local level is often to deprioritise HIV and STI prevention. This is demonstrated by the way in which Government money allocated to PCTs in England for sexual health and HIV work in the past two years was widely diverted to other priorities, as documented by the Sexual Health & HIV Independent Advisory Group and others.

  17.  THT believes that commissioners of sexual health services within PCTs need improved guidance and in-service training from the NHS, or the DH, in order to be able to plan and negotiate HIV and sexual health services locally that are evidence based and cost effective.

January 2008