Charging Migrants for HIV Treatment

posted: 04/04/2011

The government has said it will soon change the rules about charging people from abroad for most treatment at NHS hospitals in England. At the moment the rules do not affect many people in North West England with HIV but that is likely to change. New Rules will probably appear in June.

The government has also announced another, bigger review of NHS charges. This will look at anything and everything and is intended to save the NHS a lot of money.

The next step is the department of health will publish the new rules for NHS hospital and clinic charges and guidance quickly – probably before June.

They have just published their response to a public consultation so now we know something about what the new rules from June will probably say. George House Trust gave evidence and comments to this consultation.

The Department of Health's plans for the June rules are 

• They won’t change which treatments will be charged for yet – but may do so later.
• The rules will be changed to make it clear that refused asylum seekers who get Section 4 and Section 95 payments do not pay for NHS treatment
• Unaccompanied children will no longer have to pay, but children with parents here can be charged
• They will make clear in the new rules that anyone who has begun HIV treatment that is free of charge (e.g. because they have an asylum claim which has not been finally decided) will continue to receive free HIV treatment
• They will keep putting up posters about charging for treatment in hospitals and clinics, even though they know this frightens some people that need treatment away and can lead to discrimination by hospitals
• They will change the guidance that tells doctors to think about the cost of treatment, because this encourages discrimination
• They will start a new system of telling the UK Borders Agency about the people who owe the NHS money. This will mean people will be refused permission to stay longer, applications for citizenship may be refused and people will be refused a visa to return to the UK if they leave
• They will consider introducing a rule that will force visitors from overseas to have health insurance
• They will look at charging people for primary care (treatment by family doctors)

Free HIV treatment for all?
The Government still has not decided whether to make HIV treatment free for everyone who needs this on public health grounds, like for all other sexually transmitted infections. They say they are still considering this and will report “in due course”.

Next, an even tougher review
They have also announced another major review which is designed to save the NHS a lot of money. This will look at

• Changing the residence rules, including the definition of ordinary residence
• Changing some or all of all the types of treatment and types of people who do not have to pay for NHS treatment
• Making people pay for primary care (that is treatment by family doctors and dentists)
• Changing which bit of the NHS has to pay when people cannot pay
• Making the procedures for checking who should pay tougher before treatment begins
  Making the procedures for collecting charges tougher
• Using new ways to collect charges 
• Requiring migrants to have health insurance 
• They will consider anything and everything else.

They try to soften this tough new cost-saving review by saying “the NHS is, and must remain, ultimately a humanitarian organisation. In undertaking the review, we will be mindful of the NHS’s core values, in particular its obligations to provide urgent treatment to any person irrespective of their status or ability to pay, to protect the vulnerable and respect our obligations on healthcare provision under international treaties . There is no intention to consider policies that would deny access to any group, only whether an individual should be charged. It will consider the full benefits and costs of introducing new charges including risks of deterred or delayed treatment and any other societal costs. In addition, we will ensure that public health considerations are fully factored into proposed rules and processes (ensuring in particular that access policies do not compromise the identification and control of infectious diseases).”

A comprehensive package of confirmed proposals will be put to full public consultation on completion of the review work, in 2012. We may consult separately at an earlier stage on some options, such as primary care charging.
 

You can read the details of the government's proposals for the June regulations and this new review here. The new review details begin on page 24. 

Proposals and Review report

Disadvantage Affects HIV Futures

posted: 25/01/2011

Low incomes and social disadvantage strikingly affects the life and health prospects of people newly diagnosed with HIV, according to a multi-national study.

An international team wanted to find out if sex and ethnicity affect the outcomes people can expect from their HIV treatment and care. The study looked at people in Australia, Brazil, Canada and the US, and found that sex and ethnicity make often striking differences in health prospects for women and men, and for ethnic minority people compared with white people.
 

Lesson - deal with disadvantages

The lesson the study teaches us “is that socioeconomic factors are a critical influence in determining the likelihood of engaging patients in care. As a result, these factors cannot be overlooked when developing programs that aim to increase the percentage of HIV-infected patients on therapy with undetectable viremia [Viral Load].”
 

The editorial in the Journal of Infectious Diseases says that social and economic disadvantages “represent complex challenges that are beyond the traditional influence of public health,” but the failure to deal with these, undermines attempts to deal effectively with HIV.
 

UK – we have the tool but refuse to use it
In the UK, the tool in the policy toolbox that could make a real difference, the new legal socio-economic equality duty on public bodies, has been locked away by the new government. The conservative led government has decided not to implement this part of the new Equality Act.

The government has also introduced a programme of major cuts in welfare benefits, and in funding for the NHS, Councils and community sector, which will all deepen the HIV disadvantages among people in the UK that we already see.
 

Do sex and ethnicity make a difference with HIV?
The new study looked at eight years in the life of people who were diagnosed very soon after getting HIV. They found that women do worse than men, and people of ethnic minority backgrounds living in the South of the USA have the most HIV-related illnesses.
 

Even when people take HIV tests and become diagnosed, poverty and social disadvantage remain real barriers to many people attending clinics, taking treatments properly and having a reasonably healthy lifestyle.
 

This was an observational study of over 2250 people who were diagnosed with early-stage HIV between 1997 and 2007, in Australia, Brazil, Canada and the US. The people were followed for up to eight years.
 

Women and men
Only 5% of the people in the study are women and most of the women (55%) were of ethnic minority backgrounds. Women had a significantly lower Viral Load (VL) count to start with than the men, but significantly higher CD4 counts (not surprising, since women tend to have higher CD4 counts than men). Three quarters of the men were white.
 

It seems there were few women in the study because the women were half as likely as men to have symptoms typical of early HIV infection, and so women were much less likely to be diagnosed than men at this early stage of HIV.
 

Treating women and men
Similar proportions of both women and men began HIV treatment, and their CD4 cell counts matched when treatment began.
 

But women and men of ethnic minority backgrounds were less likely to start HIV treatment than white men and women. And anyone living in the southern states of the USA was significantly less likely to start HIV treatment.
 

Six months after treatment started, men and women were as likely to have their viral load fall below 400 and have similar increases in CD4 counts.
 

Untreated women and men
However, the investigators then analysed changes in the viral load and CD4 cell count of the people who did not start HIV treatment for up to three years. “Despite the fact women had higher CD4 cell counts and lower viral loads at study entry, they subsequently experienced significantly more combined HIV-related and AIDS-defining events,” emphasise the investigators.
 

Nothing to do with biology: it’s poverty and social disadvantage
After they did their detailed analysis there found no grounds for believing biology is causing women to develop HIV-related illnesses. Instead these illnesses “are the result of socioeconomic conditions.” These include “access to health care, health behaviors, lifestyle and environmental exposures.”
 

Stark ethnic treatment divide

Stark significant ethnic differences are plainly seen in the numbers of people getting HIV illnesses or an AIDS diagnosis.  Eight years after diagnosis

• almost 8 out of 10 (78%) of ethnic minority people in the Southern states of the USA got either an HIV-related illness or AIDS,
• compared to less than 4 out of 10 (37%) of white people living in the same states, and
• compared with a quarter (24%) of white people living elsewhere, and
• about two out of ten (17%) ethnic minority people living outside the South.

USA HIV strategy has three goals: cutting the number of people who are undiagnosed; getting more people to clinics and on effective treatment; and cutting HIV-related health inequalities.
 

But the editorial points out “the findings from this study threaten the success of each of these pillars.” They therefore call for “a collaborative policy and research effort across all levels of community, government and science.”
 

Source Aidsmap has references and links to two free journal articles

House of Lords to Investigate HIV

posted: 21/12/2010

The House of Lords today set up a new Committee on HIV and AIDS, chaired by Lord Fowler. Lord Fowler was the Secretary of State for Social Services with responsibility for public health, at the start of the HIV epidemic. He was a key figure in the first national public HIV awareness campaign.

Investigating and reviewing HIV in the UK

The new House of Lords Committee will look in detail at HIV in the UK. They will ‘call for evidence’ in the New Year, inviting written evidence from everyone. They will then hold public evidence sessions, before producing a report next summer.

Prevention, Testing, Treatment, Discrimination

The committee is interested especially in reviewing prevention, testing, treatment and discrimination.

After the creation of the Committee Lord Fowler, said
 

"The Committee's report will appear almost exactly a quarter of a century since the 'Don't Die of Ignorance' campaign in 1986. This is a good time to review the success of prevention and treatment policies. In the last 25 years, various efforts have been made to check the spread of the infection. Nevertheless today the number of people living with HIV is nearing 100,000. The committee will examine whether public education has been effective and how it might be improved; and also the importance of early diagnosis. Currently about 27 per cent of those with HIV do not know that they are infected. The committee will examine what improvements can be made in testing and consider evidence of discrimination. A call for evidence will be issued in the New Year."

The Committee will have a webpage within the House of Lords Committee section of the Parliamentary website. The HIV Select Committee webpage is here

HIV Committee membership:

• Lord Fowler (Chairman)
• Baroness McIntosh of Hudnall
• Lord Gardiner of Kimble
• Baroness Masham of Ilton
• Baroness Gould of Potternewton
• Lord May of Oxford
• Baroness Healy of Primrose Hill
• Lord Rea
• Baroness Hussein-Ece
• Baroness Ritchie of Brompton
• Lord McColl of Dulwich
• Baroness Tonge
   

Reasons for Travelling to Clinics

posted: 09/12/2010

Most people with HIV in England live within 5km (3 miles) of a specialist HIV clinic, according to a new study. The average distance people travel to their clinic was 2.5km (just over 1.5 miles). However, fewer than 1 in 10 people with HIV use the clinic that is nearest to their home. Why do people travel to a clinic further away?

Researchers wanted to see how far people live from a HIV clinic, and understand why some people travel further than they have to for HIV care.
 

Choice and advice on chosing clinics

People have the right to choose which HIV clinic to use and the British HIV Association recommends people who require routine, uncomplicated care to use their local clinic, and that people with more complex needs should use a more specialised clinic.

Not much has been studied about travelling to HIV clinics in the UK, nor about the social, demographic or clinical characteristics associated with people's choices about travelling to a HIV clinic.

Over 46,000 people studied
To get a clearer understanding of clinic travel, researchers looked at data on 46,550 HIV-positive adults who received HIV care in England in 2007. They pinpointed the closest HIV clinic for each person. All clinics within 5km of a someone’s home are considered ‘local’.

They looked at the wealth in each person’s borough of residence, and the person’s ethnicity, HIV risk category, length of HIV diagnosis, and HIV treatment status.

What they found – urban and often poor

Most (66%) of the people were men and 50% were white. The great majority (95%) live in an urban area, and 42% live in an economically deprived area. Almost three-quarters (73%) were on HIV treatments.

The median distance travelled to their clinic was 2.5km; but this ranged from less than 1km to 80km (50 miles). People in London travelled less than everyone else (2km vs. 3.7km).

Clinic access is good: 81% live within 5km of a specialist HIV clinic, and 93% live within 10km.
In London people had an average choice of three clinics within 5km, but those living outside the capital average just one local clinic.

The average distance travelled by patients to their clinic was a little under 5km. Overall, 73% use a local clinic. However, only 9% used the clinic closest to where they lived.

Reasons for travelling further
Haemophilia - People who were infected with HIV by blood products (mainly haemophiliacs infected during an old UK blood scandal) were most likely to travel further (51%). “These patients may need to attend specialist services that are not provided locally,” comment the authors.

Urban – People living in urban areas were significantly more likely to attend a non-local clinic than those who live in rural areas (44% vs. 22%) – people in major towns and cities are more likely to have a local choice. People living in rural areas and smaller towns have less or no choice nearby. Travelling to the next clinic is also less practical.

Ethnicity - Black African and black Caribbean people were statistically rather less likely to travel beyond their local service than white people.

Length of diagnosis - How long people have been diagnosed also affected travelling distance. People who had been diagnosed for at least a year were 50% more likely to use a clinic over 5km away service than those diagnosed within the last year (27% vs. 20). The investigators suggest “this may be because patients may not become aware of the choices available to them until they have adjusted to their HIV diagnosis.”

Poverty - Wealth also significantly affects the choice of clinic. People who lived in the better areas were twice as likely as those living in the poorest districts to travel further for treatment (42% vs. 21%). The investigators suggest that “financial difficulty” may prevent some people from travelling to clinics further away. Another recent study showed that almost a third of people with HIV in the UK did not have enough money to meet their needs and that 10% had difficulty meeting travel costs.

Help with paying to travel

If you have a low income or are on benefits, you may have a right to help with the costs of travelling to your clinic. Here's information on help with hospital travel costs.

“Barriers to service choice are likely to related to poverty and unfamiliarity with the options for HIV care,” conclude the authors, “consequently, provision of local services remains vital.”

Source including reference details

 

More Disability Tests for Benefits

posted: 08/12/2010

All 3 million people with disabilities and long term conditions such as HIV, including pensioners and children, who are getting Disability Living Allowance will soon be forced to have medical tests.

Ministers announced yesterday plans to end the automatic right to disability living allowance, worth up to £70 a week for care and up to £50 a week for travel needs. This benefit will soon be called the 'personal independence payment'.

Waiting and testing

Claimants will have to wait for a year for the new "personal independence payment" and then face a series of medical and other tests focusing on "an individual's ability to carry out a range of key activities necessary to everyday life".
 

Medical tests already under fire

The existing system of medical tests that are used to judge people claiming sickness and disability benefits (Incapacity Benefit and Employment Support Allowance) is already under review after mounting evidence that people with serious illnesses like HIV are being judged fit to work, when they are not. The tests for the replacement 'personal independence payment' will be based on these.

Many claim that the disadvantages of the medical tests will outweigh any benefits. The medical tests system is often very wrong and very inefficient. 40% of people who appleal the decision win their appeals.

"We have fundamental concerns that the cost of the administration will mean there is no saving here. Claiming these benefits mean at the moment filling out a very long form. I don't think the answer is a whole new process of interviews, which many disabled people may find intimidating," said Guy Parckar of the Leonard Cheshire disability charity.
 

Do what we say

Welfare support will also be conditional on disabled people acting on government instructions to "better manage or improve their situation if appropriate".
 

Behind the changes - cuts of £1 billion from Disability Living Allowance

Charities said they were "deeply concerned" about the proposals – the government plans to save £1bn from DLA in the June budget.
 

"There's no evidence of widespread fraud and no evidence to back up claims that the benefit acts as a barrier to work," said Richard Watts, of the Essex Coalition of Disabled People.
 

Department of Work and Pensions announcement 

Consultation proposals

Consultation on the proposed changes - response deadline 14 February 2011

Source