AS LIONEL BART might have said, ‘fings ain’t what they used to be’. In Soho there have always been drugs on sale if you knew where to go. Twenty-five years ago it was the traditional illegal selection of heroin, cocaine, ecstasy and, of course, cannabis. Today a new variety is up for sale, and by their very nature they pose a new threat. These are the ‘ChemSex’ drugs, which have the effect of prolonging sex, removing inhibitions and all too often leading to unprotected sex. They consist of methamphetamine (crystal meth) and mephedrone, as well as a number of other drugs like GBL. According to one survey, many of the drug users are HIV positive, many share needles to inject the drugs, and many have several sexual partners during a weekend of drug use. In short, ChemSex drugs can be a sure way to spread HIV.

The ChemSex drugs all have the same effect; the difference between them is price. The most expensive is crystal meth at about £250 a gram while mephedrone at £30 a gram is regarded as the poor man’s substitute. A few years ago the experts were saying that crystal meth did not pose a threat in Britain, but in 2007 it was reclassified as a Class A drug – in the top league of British illegality. But according to those working in the field the ban has made little difference to supply and both drugs are ‘readily available’.

There is no doubt who are the predominant users in Britain: men who have sex with men. And with the new drugs have come a new kind of injector. David Stuart, Substance Use Adviser at the Soho Sexual Health Clinic, told me:

Men who have sex with men are today the chief source of HIV in London, and Soho is one of the undoubted centres for what some say has become the gay capital of Europe. It is not that gay people live in the narrow streets between London’s theatre land on Shaftesbury Avenue and the big stores of Oxford Street but Soho is a place where they can meet and drink – and drink. There are said to be fifty gay clubs and pubs in a 500-metre radius of Dean Street. You only have to walk in the streets on a Saturday night past the crowds spilling onto the pavement to see Soho’s popularity. But it is not the only gay centre in London. Just south of the Thames is the ‘Vauxhall gay village’, complete with clubs and saunas. In the autumn of 2012 two gay men died after overdosing in a sauna and there are persistent stories of ambulances each week taking three or four drug users away for emergency treatment at the nearby St Thomas’ hospital. Dr John White, a consultant at the hospital, confirms that ‘new drugs are coming along all the time’ and also confirms the danger of a highly addictive drug like crystal meth. ‘One month they have a good job,’ he says. ‘A few weeks later they have fallen apart. It’s very rapid. They get captured.’

The truth is, however, that today you need neither clubs nor saunas. The internet age is transforming the position. Private parties are arranged in flats – not so much in the public housing in the heart of Lambeth but in the smart £1 million-plus flats nearer the river and conveniently placed for the offices of the City or the West End. HIV has always included the affluent as the celebrity deaths down the years have proved. The middle-class drug users are doubtless living next door to the very people who so commonly today ask about HIV: ‘You don’t hear much about it these days. Is it still a problem?’

The internet today provides new opportunities for men to get together which did not exist twenty-five years ago. There is a proliferation of online sites and mobile apps used by gay men to find sex partners. With a few clicks on a smartphone or site you can find photographs of a large selection of men, ready, willing and also near. Just to avoid confusion, adverts come complete with tags like a dollar sign to indicate a sex worker, or ‘BB’ to indicate bareback, or unprotected, sex. Connecting with casual sexual partners is easier than ever; the trouble is that in connecting they often forget (if they were ever taught) about the dangers of shared needles.

At this stage I should make one point absolutely clear. The position I describe is not typical of the lives of gay people generally. I remember one gay man saying to me that if only the public knew how ‘ordinary’ so many gay lives were, there would not be so much emotion generated. He had been with his partner for over fifteen years, was in a civil partnership and wanted now to marry. He said: ‘The great thing is that in the evening you can come home and talk about the stresses of the day.’ Just like any other couple. Nor are ChemSex drugs a feature of huge numbers of gay men’s lives. Paul Steinbeck, a prevention expert working in Lambeth, says: ‘It is not the case that everybody is doing it. It is a significant problem for a small number of gay men.’

The point is that ChemSex drugs symbolise the new challenges that are forever arising. When I mounted my Aids campaign in 1986 the internet had hardly been invented and the smartphone was still to come. Since then all experience has shown that you ignore new developments in HIV at your peril and it is better to overreact than ignore. In the case of the ChemSex drugs there is no inherent reason why their use should be confined to gay men, and the dangers of risky sexual practices are no different from the ones I warned about thirty years ago.

For decades Britain has become accustomed to minuscule figures for HIV caused by shared needles. Clean needles and methadone remain the foundation of policy, but policies that have worked well for the traditional group targeted by clean-needle schemes – injecting heroin users – will not necessarily be as effective for the middle-class ChemSex users sharing needles and having sexual marathons in the privacy of their Vauxhall flats. As one doctor said, ‘You won’t cope just by a van at the side of the road dispensing condoms and needles.’ It is just as well, then, that we are seeing today the emergence in London of a new breed of sexual health clinics.

For decades sexual health has been a ‘Cinderella’ subject inside the health service. For years the clinics’ services were not even named as sexual health, but labelled under the deeply unappealing banner of Genito-Urinary Medicine (GUM). Too often the clinic was placed in the most inaccessible and unattractive part of the hospital. One consultant who moved to Soho said that he came from a hospital where the clinic was in the basement – and that to reach it you went past the mortuary. Today that is changing. You can hardly believe that the clinic at 56 Dean Street, with its bright and imaginative design, is part of the National Health Service which, for all its merits, has never been accused of being stylish. The same can be said of the purpose-built clinic in Burrell Street, just south of Blackfriars Bridge in Lambeth’s neighbouring borough, Southwark. At the Homerton University Hospital at Hackney in East London, the clinic may still be at the rear of the hospital but the newly opened Jonathan Mann centre has transformed the public offering. Rather than being viewed from outside as places of blame and shame, London’s sexual health clinics are now being seen much more as places for treatment and advice.

And there is no doubt that advice is needed. At Dean Street, David Stuart says that some of young men who come in are isolated and unsure about their sexuality. ‘The task is to take them from promiscuity to a relationship,’ he says. ‘You can enjoy sex but there are alternatives to the bar and club scene.’ Another belief that needs to be punctured is that there is no great drawback to HIV these days. The obvious warning of what one doctor called ‘the walking skeletons and the dying’ has disappeared. The dangerous new belief is that all that is needed these days is one daily pill.

Countering this Professor Jane Anderson at Homerton, who is one of the most committed clinicians in the country, says:

The first need, in London as elsewhere in Britain and the rest of the world, is for more effective testing and it is this which the clinics are trying to provide. The Dean Street clinic has taken the tests into the gay bars with surprisingly good results in persuading men who have never tested before. At the clinic itself, tests can be done very quickly and the results confirmed within thirty minutes. The Burrell Street clinic operates a seven-day-a-week service, with the result that at a weekend the clinic can see 200 patients, with people waiting at the door when the doctors arrive in the morning. Such efforts and more are needed throughout London. Late diagnoses (leading to late treatment) remain responsible for the bulk of Aids-related deaths.

According to a 2013 paper commissioned by the directors of public health in London, about one in five Londoners living with HIV is undiagnosed, but they are responsible for over half of all new HIV infections in the capital. So unless you tackle the issue of the people who are not aware that they are HIV positive, the position continues to deteriorate. You need a policy that will bring in not just the men having sex with men but also the Black African and Black Caribbean populations (where most cases are heterosexually acquired), many of whom live south of the river in Lambeth and Southwark. Together they make up the second largest group affected and also pose some familiar problems.

One of them is stigma. According to one consultant in Southwark it is one of the main reasons why persuading people to test can be so difficult:

He could, of course, be speaking in Entebbe. There is only one fear greater than being known to be HIV positive and that is to be identified as a man who has sex with other men.

It is almost a relief to turn from the complexities of the new drug injectors and the seemingly intractable problem of hostility to gay people to the traditional sex workers of Soho and another of the HIV priority groups. Or rather, it is a relief until you discover the complexities and the changes that have taken place here too.

An objective view of those changes comes from Central London Action on Sexual Health (CLASH), an unusual but highly effective part of the health service. It was formed in the late 1980s specifically because of HIV, and specifically to make contact with the hard to reach, high risk groups like sex workers and the homeless as well as men who have sex with men. At that time, these groups certainly did not go near the health service. The first work of CLASH was to provide free condoms and free needles, particularly to the street-based sex workers. Today it has developed to a drop-in centre just on the western edge of Soho, not far from the designer shopping of Regent Street and Savile Row. It has a clinic twice a week and provides advice and treatment. The health position of the sex workers at present is that HIV is ‘very unusual’ and although there have been increases in chlamydia and gonorrhoea they only match the increases in the general population. Such results are a compliment to CLASH and other organisations like the Terrence Higgins Trust, with which it works closely.

A pen picture of the sex workers who come to CLASH would be this. Most come from Eastern Europe and are between about eighteen and thirty. Most have children and many have partners, although not necessarily with them in Soho. They operate from walk-in flats with their own maids – women who may have been sex workers themselves and who keep an eye on the CCTV to check on the clients coming up the stairs. The cash however goes straight to the sex worker who will almost certainly be paying an exorbitant daily rent for the rooms – up to £350 a day. Even with these outgoings the sex worker makes substantially more money than she would in a bar or serving in a restaurant. The money earned might go home to help her family, or to buy a house, or even to take out private health insurance. Many try not to tell their families about their work and some look back sadly to their previous lives as ‘when I was normal’.

According to CLASH the public health danger is that competition among sex workers is fierce. Prices have basically not increased for ten years and unprotected sex is the extra that can be offered for a higher price. As one CLASH worker told me:

In its heyday there were perhaps eighty or a hundred flats dotted around Soho used for sex work but over the last few years there has been a drive to close them down. The sex workers say that a deliberate policy is taking place to hand the buildings over for development. Whether that is true or not there is no doubt that at the beginning of 2014 there was a raid involving 200 police many in riot gear and accompanied by dog units. According to Nikki Adams, the spokeswoman for the English Collective of Prostitutes, the sex workers were subjected to ‘a very serious and abusive form of policing’. Around forty police forced their way into one flat and one woman was paraded in the street in her underclothes. The press were invited to watch – in spite of the fear that sex workers have of being photographed.

In The Observer the actor Rupert Everett who was there at the time of the raid described the scene: ‘Flashing police vans blocked the road … It was an image of war, replete with entrenched photographers and journalists.’ More support came from Simon Buckley the vicar of St Anne’s in Soho, who protested to the Bishop of London at the action. Personally I would have thought that the Metropolitan Police had enough enemies just now without being portrayed as persecuting women. The result is that almost twenty flats were closed down. Closures like this are a matter for the magistrates’ courts and a matter of civil law which does not require that cases are established ‘beyond reasonable doubt’ as in the criminal law. This is probably just as well for the police. They might have been hard pressed to convince a jury on trafficking and rape which was the apparent reason for the raid.

You may ask, however, whether it is legal in any event for sex workers to operate from flats in the way they have been doing for years past. Chris Higgins of CLASH defines the legal position succinctly: ‘All the activities around prostitution are illegal but selling sex is not.’ A little more than fifty years ago if you went into Hyde Park from Paddington you passed a line of five or six sex workers touting for business. After a famous report by Sir John Wolfenden in 1957 soliciting for business was eventually banned. So too was advertising for clients including placing cards in telephone booths which used to be obvious and common in London. I noticed however strolling through Soho that it was still possible to put up in neon lights a less than enigmatic notice simply saying ‘OPEN’ at the entrance to a flat.

I thought in my innocence that although the law might not be entirely clear on soliciting and advertising, at least it should be pretty simple for it to define a brothel. It is not so of course. According to the Crown Prosecution Service, ‘The definition of a brothel in English law does not require that the premises are used for the purposes of prostitution since a brothel exists wherever more than one person offers sexual intercourse, whether for payment or not.’ I had always thought that the whole basis for legislation was to combat criminally organised prostitution. Apparently not but it explains why sex workers operate from their own rented flats in Soho. Provided that she and her maid do the organising and no one from outside is involved then it is legal. It is also legal if different women work in different flats in the same building provided there is no common organisation. Sex work is the archetypal small business – just banned from growing larger.

At this point I have to confess a certain sympathy for the police creeps in. How on earth are they expected to enforce such a hotch-potch of law and at the same time carry out their essential job, which is to prevent the violence and worse which is all too often the fate of sex workers in London today – and even more so outside the capital. The Home Office funded scheme Ugly Mugs allows sex workers to report attacks anonymously, and The Guardian reported that in the twelve months after its launch in July 2012, 400 incidents had been reported. Of those, 106 were sexual assaults and sixty-eight rapes.

I imagine that very few can believe the present legal position is satisfactory. There is no doubt what most sex workers in Soho and elsewhere would want. They would want something like the decriminalised system in New South Wales or in New Zealand (where the law was changed in 2003). Their case is that they sell sex of their own free will. They may have been driven to do so by poverty in their own country, but they deny that trafficking is a major issue. To my mind this all adds up to the need for an absolutely objective inquiry to review the general position of sex work in the capital, including the impact on public health – another Wolfenden inquiry which, as well as changing sex work, paved the way for the eventual decriminalisation of homosexuality – at a time when over 1,000 men were actually serving prison sentences for the ‘offence’.

What is needed is an inquiry first to establish what exactly is happening in Britain today. Why is there the violence? How have we had 144 murders (to date) since 1990? What is the evidence for trafficking? What is the evidence for exploitation? A properly independent inquiry would also examine the arguments put forward in favour of the Nordic solution (in which the buyer, not the seller, is prosecuted) backed not only in Sweden and Norway but, at the beginning of 2014, by the European Parliament. It is a solution which recognises the rights of women, but the price is that it creates a new criminal offence which has to be enforced by the long-suffering police. The other fear is that sex work would go underground – and that really would pose a problem for public health.

So is HIV still a problem in Britain and in London? The figures speak for themselves. In 2012 there were 100,000 people in the United Kingdom living with HIV and in that year there were almost 6,400 new diagnoses. Men having sex with men accounted for over half of the new cases and the estimated total of 3,250 was the highest number ever reported. Around a fifth of the people living with HIV remained undiagnosed and during the year there had been 500 deaths – many the result of late diagnosis and the delay in coming forward for testing.

There is no doubt where the problem is greatest. In London in 2012 there were 32,000 people living with HIV who were diagnosed and having treatment and an estimated further 6,000-plus who were undiagnosed. Eighteen of the twenty local authorities with the highest HIV prevalence were in London. The worst placed was Lambeth with a prevalence of 1.4 per cent. As with Washington DC, the comparison should not be exaggerated, but such a prevalence is on a par with some sub-Saharan African countries. Yet Lambeth is just over the river from the Houses of Parliament and in easy sight from the windows of both the House of Commons and the House of Lords. Just as in the United States, it seems that the biggest problem is in the shadow of the very seat of national government.

Of course it is true that if you take the British figures as a whole they are not on the scale of sub-Saharan Africa – and the same applies to the vast majority of West European countries. We might remember, however, that if you put all the countries of Western and Central Europe together, UNAIDS estimates that there are now approaching a million people living with HIV. In France there are probably about 150,000; in Italy around 125,000; and in Spain between 140,000 at the lower estimate and 170,000 at the higher. As for prevalence the UNAIDS estimates show Germany at 0.2 per cent; United Kingdom at 0.3 per cent and France at 0.4 per cent. Only Estonia and Latvia break the 1 per cent measure – although Portugal comes close. If you were to ask for one common problem it would be the fifth to a quarter who are undiagnosed, and if you ask for a common solution it would be more testing.

But is more testing the only way forward? Surely if you provided antiretroviral drugs right from the beginning when a man or woman is most infectious, that would cut the onward transmission rate dramatically. In other words, give antiretrovirals as soon as the man or woman is infected rather than wait until their CD4 count reaches some WHO threshold. In 2013 the incomparable Health Protection Agency produced a report on a five-year study of men who have sex with men. It went to the heart of the central issue in this book. How do you reduce the infectivity of this group? Can transmission of HIV be controlled by universal access to antiretroviral drugs?

The agency (now part of Health Protection England) found that about a quarter of men having sex with men were undiagnosed and many others who may have been diagnosed, for one reason or another, were not adhering to their treatment. Self-evidently, these two groups would be largely unaffected by a policy of antiretroviral drugs for everyone and this substantially reduces the potential for the success of any policy of extending treatment. If, on the other hand, the policy was combined with improving the numbers of the tested and ensuring more frequent testing and adherence then that would substantially reduce the number of undiagnosed. Interestingly, Dr Andrew Phillips of University College London came to almost exactly the same conclusion using a mathematical model. His research, based on the figures of men having sex with men, showed that, by itself, the extension of drug provision would have limited effect. However, if you increased testing and also provided immediate and universal antiretroviral treatment then you could achieve a dramatic fall in HIV transmission.

Some will say that it is a big ‘if’ to assume that substantially increased testing can be achieved – and so it is on the basis of past experience. But perhaps all that proves is that past campaigns have been low profile and frankly lacklustre. I do not remember a campaign in London on the Washington model of ‘Come together DC – Get Screened for HIV’. I cannot remember posters setting out such a message. I cannot recall when the health service was last given the budget to attempt such an obvious step forward. I wonder just how many in London actually know anything about the undiagnosed let alone the importance of people living with HIV sticking to their treatment.

In the absence of a vaccine my own view is that a further extension of antiretroviral treatment holds out the best hope of making a dramatic reduction in new infections. In the next chapter I set out the policies that I believe would help further. For Britain I stress two. The need to lift the generally abysmal level of sex education in schools; and the need for government to support the excellent research which will never be taken on by the commercial pharmaceutical companies. There is one further point that needs to be underlined. The National Health Service has come in for more than its fair share of criticism in the last few years. Yet, in the case of public health it is one of the reasons why Britain has a relatively high proportion of people living with HIV who have an undetectable viral load and who, other things being equal, will not pass on the infection. As Professor Anderson says,

In several other respects the British contribution has been substantial. In 2014 Action for Global Health, an organisation of fifteen non-government organisations and charities based in Europe, examined the contribution that six European Union countries – France, Germany, Italy, the Netherlands, Spain and Britain – make to the health systems of overseas countries. Generally it found that ‘most European governments are either decreasing their overseas development assistance for health as a percentage of gross national income or their contributions are stagnating at low levels’. Britain was the only country to have steadily increased its health contribution.

At home a massive step forward was taken to reduce the prejudice against gay people by introducing the 2013 equal marriage legislation. For the Prime Minister, David Cameron, it held no party advantage – as the resignations from local Conservative associations showed – but the big majorities in the House of Commons and House of Lords must surely have given encouragement to those who were prevented by fear and stigma of accessing medical treatment. Another important measure was the decision to give free HIV treatment to political asylum applicants straight away rather than after a six-month wait – which was a policy that had made no sense and simply allowed HIV to spread. Of course, not all the advances have come from the government or the health service. Britain has been immeasurably helped by a whole series of civil society organisations, ranging from service providers like the Terrence Higgins Trust to the skilled campaigners of the National Aids Trust, to the multitude of big and small organisations outside government that are too numerous to mention. Some have been working since the 1980s, often against a background of stretched financial resources, and without their contribution we would not have managed.

All told Britain has a decent record – which makes it all the stranger to come across palpably bad decisions like the cuts to the funding of vaccine research, and by an odd reluctance to proclaim what the government is doing. There was no minister at the World Aids Conference in 2012 to set out British policy, and the government shows acute nervousness about announcing policies that could offend those who oppose giving overseas aid. Even more extraordinarily, the doubling of the contribution to the Global Fund in late 2013 was barely publicised domestically. At the health department, I saw for myself the nervousness with which preparations were made to accept what happened to be my amendment in the House of Lords for extending HIV treatment for asylum seekers. The spin doctors went to work; the pitch was rolled; the public should be prepared. The result was a pre-announcement in the Daily Telegraph with the splash headline ‘Foreigners to be Offered Free Treatment for HIV on the NHS’.

Perhaps the nervousness results from the criticism aimed at David Cameron in the wake of the marriage equality bill. If so I think it is profoundly mistaken. The spin doctors will always advise caution on money going to what they perceive as unpopular causes. My view would be that the only chance you have of winning this argument is to take it full on and come out fighting.

A more fundamental question which waits to be decided is the outcome of the government’s decision on the organisation of public health. It decided to ring-fence the public health budget which (provided the budget is adequate) is a sensible change. More contentious is the decision to hand over responsibility for public health to local councils. Supporters of the change say that local councils are in the best position to make decisions on the public health needs of their own areas. It seems based on the premise that the National Health Service is not capable of being local, which in my experience is nonsense. The concern is that HIV expertise is firmly inside the health service and the fear is that some councils will not give the priority to HIV, drugs and sex work that the health service has done over the years. It also runs the risk of being a recipe for confusion and a disjointed, patchy approach. There are thirty councils in London alone, and funding is provided against a backdrop of shrinking resources for local government. It is a policy that needs to be kept under close review and it would help also if there was some consistency in Whitehall itself; since 2000 there have been no fewer than nine public health ministers.

My (doubtless naïve) ambition in 1986 was to make Britain an example of what could be achieved in tackling HIV and Aids. Under different governments, we have made undoubted progress. Back in the 1980s almost everyone with HIV died; today in Britain almost everyone with HIV infection lives. The position has been transformed but we must not give up now. Our problems are obviously less than sub-Saharan Africa or Eastern Europe, but that gives us an opportunity to show what can be done. We should see how more people with HIV can be persuaded into treatment, how HIV can be further prevented and how treatment can be extended and improved. We should face down the discrimination and prejudice there is against sexual minorities as well as against drug users and sex workers. So it seems to me that the answer to my question in the title of this chapter is that, self-evidently, HIV – and all the issues around it – continues to be a problem in Britain. We have made undoubted progress since the 1980s, but there is a long way to go. HIV may have slipped out of the headlines, but we should avoid any false assurances that the battle is almost won or HIV is no longer a problem. Any politician or minister at Westminster who attempts to claim that it is should be unceremoniously dumped in the Thames and told to swim over to Lambeth.