Comment: HIV policy has collapsed and gay men will not escape the legacy

Illustrated rainbow pride flag on a white background.

In a comment piece for, Stuart Home says those in charge of setting and delivering HIV policy are now in danger of presiding over managed decline.

In the past few weeks several pieces of research have been published that illustrate the current nature of the HIV epidemic in the UK. As a brief overview, the data from the Health Protection Agency (HPA) unfortunately reinforced what anyone following this issue for several years already knows. Gay, bisexual, and other men who have sex with men (MSM) continue to be disproportionately affected by the spread of HIV; accounting for almost half of all new cases. It reached an all-time high in 2011 with 3,010 cases reported in the group.

Some of the rise can be attributed to increased HIV testing – but not all of it. The HPA’s 2012 HIV report shows that a worryingly high number of new infections are still taking place. When you consider that the proportion of MSM who failed to use condoms increased by 26% between 1990 and 2010, the overall reason for the onward march of the virus becomes clear to see.

As someone who has studied at close hand the way policy makers deliver and respond to health announcements, I found the media briefing carried out in February regarding the Medical Research Council and the HPA’s condom statistics intriguing. Yusef Azad, director of policy at the National AIDS Trust described the fall in condom use as “depressive reading” – as he cited “a decade” of HIV prevention work for MSM.

The Terrence Higgins Trust, the UK’s largest voluntary provider of HIV and sexual health services sent out a press release titled: “Condom use has stopped over 80,000 new HIV infections among gay men.” This statement, constituting an important part of the research, is absolutely true and rightly deserves to be mentioned – but at the cost of eclipsing the key message concerning the fall in condom use with such prominence I personally found questionable.

For those unaware the Terrence Higgins Trust (THT) has occupied an enormous role in the UK’s response to the HIV epidemic ever since it received charitable status in 1984. THT aims to “minimise the spread of HIV and sexually transmitted infections, by encouraging people to value their sexual health and by leading innovation to increase access to local sexual health services.”

Under successive governments THT has been given huge responsibility in steering HIV prevention policy and the vast majority of its budget has come through the tax payer via statutory funding. However, statutory income fell in 2012 from £15 million to just over £13.3 million, and the charity has made no secret that it faces an uphill battle in preventing further reductions as a result of public spending cuts and financial changes to sexual health services.

From a Whitehall perspective I have no doubt that THT will continue to receive full respect and sincerity from both the current and future governments; yet I also believe it will simply find it harder and harder to be heard in the years ahead against a backdrop of multiple other large-scale health charities all pleading desperately for their statutory funding not to be cut further as well.

Unfortunately THT is not operating on a level playing field in the health sector. I take the unscientific view that you can see where a government has confidence or possibly depth in its policies in the keenness shown to talk about them readily on the airwaves and in print. Cancer, IVF, obesity, and elderly care get continuous ‘flagship’ promotion by the government, yet HIV does not feature in that media mix.

It is partly because of the natural desire of government and shadow ministers to match the rather narrow band of key health interests of the mainstream media, but there is also another sociological reason why; namely: all governments, past and present, have felt completely ill at ease when it comes to dealing publicly with the HIV epidemic among gay men.

This is wrong but also understandable. The lethal nature of the HIV epidemic in the 1980s and throughout the early 1990s – before the arrival of successful treatment – saw governments at home and abroad respond in a way that either directly or indirectly marginalised the gay community through disproportionate and alarmist legislation. In the UK this was crystallised by the arrival of Section 28 of the Local Government Act in 1988. Introduced under the then Conservative Prime Minister Margaret Thatcher it stated that a local authority “shall not intentionally promote homosexuality or publish material with the intention of promoting homosexuality” and that schools “could not promote of the acceptability of homosexuality as a pretended family relationship”.

Section 28 did great damage to the reputation of the Conservative Party in the eyes of Britain’s gay electorate and it is no secret that much of David Cameron’s support for introducing same-sex marriage has come from wanting to show renewal from this damaging legacy. However, despite being repealed almost a decade ago, Section 28 still permeates through to the present day when it comes to gay sexual health.

It has meant that all governments have continually lacked confidence in navigating through this area for fear of perceived homophobia – despite genuine sincerity – this lack of confidence is still present at the top of the UK Government and undoubtedly in other administrations throughout the West. I have found that when you talk to ministers and their advisers about HIV they show genuine concern, empathy, and some even share their own private stories about gay friends and family members who lives have been hit by the epidemic. However, when attention turns to gay men’s health policy and suggested steps that should be taken by the state – the conversation falls away – and silence takes over.

Lord Norman Fowler, health secretary at the height of the epidemic in the 1980s and a person who has dedicated much of his career since leaving office to the area of HIV and AIDS, extensively documented the failures of successive governments in diverting enough resources and attention to HIV prevention in a 2011 report. Lord Fowler’s verdict was that efforts so far have been “woefully inadequate”. The government spent £2.9 million on HIV prevention programmes in 2011; a figure dwarfed by a treatment budget of £762 million. In the next few years, the gap between the two figures will only get larger. I see no new evidence to suggest that the current situation is any less ‘woeful’ in 2013.

For too long sexual health policy has been allowed to drift under a growing blind spot. Against a backdrop of ever rising HIV infection rates and squeezed statutory funding, the wholly unrealistic expectations on THT to change the UK’s current health prognosis concerning gay men and HIV is coming under renewed strain from both within and outside of the gay community. Regardless of whether it is appropriate or not, the failure to curb HIV infections is increasingly being dumped at the trust’s door.

As mentioned earlier in my observation about the condom statistics, THT often responds to the criticism with the ‘glass is half-full’ technique; political shorthand for “Yes it’s bad, because it could be even worse.” This reaction, which is completely understandable, plays heavily into that narrative of presiding over managed decline – an instinctive desire to limit strategic ambition. Again this is no surprise: service providers such as THT and other smaller HIV charities are now finding themselves being pre-occupied with their own survivability.

Recent political history, including examples such as the failure of Northern Rock and the collapse of the East Coast Mainline franchise by National Express in 2009 once again shows that the state reasserts itself in areas previously deemed to be off limits for direct intervention only when forced. There continues to be no impetuous shown from government to assert itself in the area of gay sexual health – and this will only happen if the relationship between itself and the Terrence Higgins Trust is radically changed – but for that to happen – someone has to blink first.

As with all comment pieces the views expressed do not necessary reflect those of