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January
2006:
Delivering the goods: HIV/AIDS
and the provision of anti-retrovirals
Introduction
1. The
HIV/AIDS pandemic is a
global health emergency. Coordinated international action is imperative,
both to prevent further transmission of HIV, and to provide care and
treatment for those living with AIDS. Without such comprehensive action,
progress towards meeting at least 6 of the 8 Millennium Development Goals
(MDGs) by 2015, will be significantly retarded.
2. Establishing clear global
agreement on the goal of universal
HIV/AIDS treatment for
all those who need it by 2010 has, therefore, been one of the key
achievements of the UK government's focus on development during its
European Union (EU) and G8 presidencies in 2005. We commend DFID for the
important role which it played in securing the G8 commitment to universal
anti-retroviral treatment provision by 2010.
Global
targets for HIV/AIDS
treatment
3. The last global
HIV/AIDS treatment
target was WHO's '3 by 5' campaign, which aimed to get 3 million people in
developing countries onto ARVs by 2005. Although it is unlikely that this
target will be met,[2]
the initiative has been significant in providing: "proof of concept
— proving that you could bring combination therapy that had been proven in
rich industrialised countries and make it work in resource-poor
settings."[3]
In their memorandum to the Committee, DFID told us "The target has served
as an effective advocacy tool for increased political commitment to
treatment, and mobilising countries and communities to respond", but that
"There have been criticisms of the '3 by 5' initiative that it has been
highly 'vertical' — imposing new targets on countries that may not accord
with existing planning processes."[4]
Mr Ben Plumley from UNAIDS told us that the strategy which UNAIDS and WHO
are developing to achieve the new 2010 universal treatment goal aims to
avoid this pitfall by using a 'bottom up' approach based on individual
country plans for increasing ARV provision.[5]
4. It is right for UNAIDS and
WHO to emphasise the importance of country ownership in the design of
their strategy to achieve the 2010 universal treatment goal. But this
approach should not allow an abdication of responsibility for meeting the
goal at a global level. G8 governments must acknowledge that in making
their commitment to universal treatment, they also took on responsibility
for ensuring their commitment is realised.
5. We intend to scrutinise
the contribution which DFID makes to realising this global goal over the
next five years. This will be difficult unless DFID undertakes to publish
data on progress towards the goal between now and 2010. We accept that
simple numerical targets for the number of people on treatment may not be
the most appropriate measure of success, and that progress towards the
target may be initially slow, as healthcare systems and other
infrastructure are established. We recommend that DFID establishes a
transparent monitoring system which will allow year-on-year external
evaluation of how many people are being treated and whether they are
getting access to quality treatment. In addition, we recommend that DFID
considers the inclusion of a target on access to
HIV/AIDS treatment when
it formulates its Public Service Agreement for the next comprehensive
spending review period, 2007 to 2010.
Gaps in
existing HIV/AIDS treatment provision
6. Much of the evidence given
to the Committee identified gaps in existing provision of ARVs, including
access to drugs for nomadic groups,[6]
intravenous drug users,[7]
men who have sex with men,[8]
and children. Many of the written memoranda we received focused on issues
which hamper the provision of drugs to children, including:
- a
lack of investment in the development of paediatric ARVs by
pharmaceutical companies,[9]
for whom research into paediatric formulations: "always comes
second";[10]
-
paediatric formulations of ARVs currently available are up to 6 times
more expensive than equivalent adult treatments,[11]
and Polymerase Chain Reaction (PCR) tests for diagnosing HIV in infants
under 18 months are not affordable;[12]
-
ARVs are not packaged in child-friendly doses (adult pills must be
crushed, or children persuaded to swallow unpleasant tasting syrups);[13]
-
limited availability of antibiotics (particularly cotrimoxazole) to
treat opportunistic infections in children;[14]
and,
- a
lack of age-specific data on children who could benefit from ARVs,[15]
and of research on the distribution, metabolism and efficacy of ARVs in
young children.[16]
7. We commend both the
decision of the United Nations Children's Fund (UNICEF), under the
leadership of Ann Veneman, to launch its global campaign 'Unite for
Children, Unite Against AIDS', and the support which DFID has given to
this campaign. We encourage DFID to continue to raise the profile of
children's access to HIV/AIDS
care and treatment in its interactions with national governments, UN
agencies and other donors. We recommend that DFID also makes an effort to
ensure that the HIV treatment needs of other vulnerable groups, including
nomadic groups, intravenous drug users and men who have sex with men, are
not neglected in the international push to expand access to ARVs.
User fees and
access to ARVs
8. We heard evidence from Dr
Mandeep Dhaliwal of the International
HIV/AIDS Alliance, and
Ms Sandra Black of the WHO, that user fees are an additional and
unnecessary obstacle to treatment access, and to the efficiency and equity
of treatment programmes.[17]
As Ben Plumley pointed out, there is some evidence that users are more
likely to use condoms when they are required to pay a small charge to
obtain them,[18]
but the Committee heard no evidence that adherence to ARV drug regimens is
improved by user fees. User fees do not contribute significantly to the
cost of ARV programmes, and therefore do not improve the long-term
sustainability of ARV programmes.[19]
We were surprised to discover that UNAIDS' position is not in line with
the emerging global consensus on removing user fees for
HIV/AIDS-related
treatment. We are aware that international statements are in no way
binding on national and international bodies. However, we believe that an
international policy statement supporting the principle of free access to
HIV treatment at the point of service, would be influential in the global
debate. We therefore recommend that DFID works with WHO and UNAIDS to
issue such a statement, and more importantly, to translate this into
practice.
Policy
coherence on HIV/AIDS
9. In 'Taking Action: the UK
Government's strategy for tackling HIV and AIDS in the developing world',
published in July 2004, DFID emphasised the importance of 'comprehensive
HIV programming'; that is, coherence between
HIV/AIDS policies and
wider poverty reduction and governance strategies. In its memorandum to
the Committee, the Stop AIDS Campaign[20]
expressed its concern:
"…about the translation of [DFID's]
commitments at a country-level. Many of our partners are experiencing
problems with DFID's in-country delivery, finding DFID offices are not yet
oriented towards comprehensive HIV programming, let alone a concern to
reach universal access to treatment by 2010."[21]
Ms Robin Gorna, from DFID,
reminded us that priorities for
HIV/AIDS programming are determined at a country level by
in-country DFID teams, rather than dictated from London. She added that
the Department is planning to undertake an interim evaluation of the
implementation of 'Taking Action' at the end of 2006, which will examine
the degree of coherence between DFID's HIV programming and its poverty
reduction and governance work. It is essential that the progressive
policies set out in 'Taking Action', DFID's strategy on tackling HIV and
AIDS in the developing world, are reflected in the
HIV/AIDS policies and
programmes which in-country DFID teams implement. We await the outcome of
DFID's interim review of 'Taking Action'. In the meantime, we urge DFID to
address any possible disparities between their policy and practice on
comprehensive HIV programming.
10. Although DFID is the lead
Department on HIV/AIDS
in Whitehall, the issue cuts across the work of several other Departments.
We were encouraged to hear about the examples of cross-Whitehall working
on HIV/AIDS
undertaken by the 'Cross-Whitehall Coherence Group on Tackling HIV and
AIDS in the Developing World' and the 'Cross-Whitehall Group on Access to
Medicines.'[22]
We were told, however, of a lack of coherence between the Home Office, the
Foreign and Commonwealth Office (FCO) and DFID in relation to the
provision of free ARV treatment to individuals who have failed in their
asylum applications, and the deportation of those living with HIV who have
no right to reside in the UK.[23]
We were concerned to hear that the Home Office only "occasionally"
consults DFID and the FCO regarding the availability of ARVs in countries
to which they propose to deport individuals living with HIV.[24]
Robin Gorna told the Committee that this subject would be addressed at the
next meeting of the cross-Whitehall group on HIV in developing countries.
We accept that cross-Whitehall working on
HIV/AIDS is in its early
days, and commend the progress which has been made thus far. We request
that DFID informs us of the outcome of the discussion in the
cross-Whitehall group on HIV in developing countries, regarding the
coherence of HMG policy on individuals with no right to reside in the UK
and HIV/AIDS
treatment.
Intellectual
Property Rights and access to ARVs
11. The agreement on
Trade-Related Aspects of Intellectual Property Rights (TRIPS), introduced
in 1995, requires countries to grant patent protection to pharmaceutical
products for a minimum period of 20 years. In November 2001, the WTO
agreed that TRIPS: "…does not and should not prevent Members from taking
measures to protect public health", implying that poor countries should be
able to manufacture, buy and import cheap generic copies of more
expensive, patented drugs if they perceive a threat to public health. In
August 2003, the WTO announced a new temporary agreement, intended to
allow generic copies made under compulsory licences to be exported to
countries that lacked production capacity, provided certain conditions and
procedures were followed. In their submission to the Committee, DFID
described the August 2003 agreement as: "a balanced framework that
respects the importance of intellectual property rights and the need for
countries to have the flexibility to import generic medicines where
needed."[25]
Others, including Médecins Sans Frontières, have argued that the August
2003 solution is too complex to be used by developing countries.[26]
Mr Daniel Graymore, from DFID, admitted that:
"…following the agreement in
Cancún to waive the clause that made it difficult for countries which do
not have their own industry to import copies, that the process has been
fraught on occasions. It is a very complicated agreement and there are
lots of different levels that need to be addressed."[27]
Mr Graymore went on to
explain that the TRIPS-waiver had deliberately been agreed in advance of
generic-producing countries, such as India, beginning to implement TRIPS
after becoming fully compliant with the agreement on 1 January 2005. He
suggested that it is therefore too early, as yet, to judge the real impact
of the waiver.[28]
12. We strongly encourage HMG
to lobby the European Commission, to make representations in the WTO, that
the WTO should undertake a review of the implementation of TRIPS, to
assess whether the agreement has compromised public health to any degree.
We further recommend that DFID continues to work with other donors to
build the capacity of low- and middle-income countries routinely to use
TRIPS safeguards, such as compulsory licences and government use
provisions, to facilitate the production and export of affordable
medicines, particularly second-line ARVs.
IMF influence
on public health investment
13. According to ActionAid,
fiscal constraints imposed by the IMF are discouraging government spending
on public health in low- and middle-income countries.[29]
This issue was raised in oral evidence by Dr Tom Ellman, Medical Adviser
to Médecins Sans Frontières (UK).[30]
Mr Hans-Martin Boehmer, from DFID, explained that the IMF may advise
countries against planning to pay for long-term commitments, such as
recruiting more health workers, using unpredictable sources of funding,
such as donor financing (as opposed to more predictable flows, such as
domestic tax revenues).[31]
Mr Boehmer went on to say, that if a country went against IMF advice and
decided to finance the recruitment of health workers using what the IMF
judged to be an unpredictable source of financing,[32]
the Fund could withdraw its support for a country's fiscal framework.
This, Mr Boehmer admitted, could have very serious consequences for a
country's receipt of funds from other donors:
"Donors do not have the fiscal
capacity to assess: "Is this a sound fiscal framework or not?" But they do
provide budget support or other support through the national budget. If
the IMF says, "We do not advise that this is a sound fiscal framework,"
many donors would shy away from putting their money into the budget."[33]
14. The Committee understands
the IMF's rationale for encouraging countries to minimise risks when
designing their fiscal framework. We are, however, concerned to hear that
IMF fiscal advice may dissuade countries from investing in their public
health infrastructure, particularly since this is key to the expansion of
ARV programmes. We encourage DFID to continue working with the IMF and
other donors to increase the coordination and long-term predictability of
donor funding for HIV/AIDS,
in order to enable countries to use donor finance to fund long-term health
infrastructure commitments.
The
significance of prevention
15. We hope that the G8
commitment to universal ARV provision by 2010 will add valuable impetus to
the case for rolling out ARV treatment in the global South. But the
relatively new focus on treatment should not be allowed to displace the
important work which has been done on HIV prevention. We were surprised to
hear, for example, that only 20% of the US$15 billion committed by
President Bush for the President's Emergency Plan for AIDS Relief (PEPFAR)
will be spent on HIV prevention, while a total of 70% will be spent on HIV
treatment and palliative care.[34]
Many of the witnesses who gave oral evidence to the Committee stressed
that HIV prevention and treatment are 'two sides of the same coin',[35]
and that in a best-case scenario, treatment, prevention and strengthening
health systems should work together in a virtuous cycle.[36]
Expanding access to HIV treatment should not be seen as a simple,
technical fix to the pandemic. We believe that a scaling-up of HIV
prevention must form an integral part of all programmes to expand access
to treatment. We commend DFID for the important role it played in securing
international agreement on UNAIDS' new prevention policy 'Intensifying HIV
prevention',[37]
and urge the Department to continue to balance its work on HIV treatment
with sustained attention to HIV prevention.
16. Sandra Black, Ben Plumley
and Mandeep Dhaliwal told the Committee that there is a strong body of
research supporting the 'ABC' approach to prevention.[38]
The 'ABC' approach refers to comprehensive HIV prevention programmes which
promote Abstinence, Being faithful to one partner and using Condoms.
However, written memoranda received by the Committee emphasised the
continuing need for research into the complex range of factors which
affect HIV transmission and determine the efficacy of HIV prevention
strategies.[39]
The Committee is convinced that it is essential for all HIV prevention
programmes to be firmly evidence-based, and encourages DFID consistently
to analyse the HIV prevention work it undertakes, in order to determine
what works.
17. We were concerned to hear
that the United States' emphasis on abstinence within its HIV prevention
work[40]
risks undermining a comprehensive response to HIV transmission,[41]
particularly given that the US is the largest donor on
HIV/AIDS. As Mandeep
Dhaliwal told us: "An over-emphasis on one of the letters of ABC is not
evidence-based prevention".[42]
The current US preference for building bilateral donor relations
also risks undermining the coordinated approach promoted by multilateral
agencies and instruments, such as UNAIDS and the Global Fund to fight
AIDS, TB and Malaria. The Committee recommends that DFID maintains its
"very lively dialogue with the US"[43]
on the issue of HIV/AIDS,
and does all it can to support national governments to maintain ownership
of their individual country plans to tackle
HIV/AIDS. In any
situation where evidence-based policy is not being implemented, we expect
DFID firmly to express their concern.
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