HIV/AIDS     (11/05/06)

Sir Nicholas Winterton (in the Chair): I call the distinguished Chairman of the Select Committee, Mr. Malcolm Bruce.

Malcolm Bruce (Gordon) (LD): Thank you for that encouraging introduction, Sir Nicholas. It is genuinely a pleasure and a privilege to present the International Development Committee’s first report of this Session, which, appropriately, we published on world AIDS day.

The Committee was extremely appreciative of the international community’s commitment to eradicate AIDS. When we published the report, however, it was clear that the international community’s first target—getting 3 million people on treatment by 2005 as part of the “3 by 5” campaign—would be missed. I have no intention of delaying hon. Members by quoting from the report, which they can all read, but I shall pick up a couple of points to which I hope the Minister can respond.

The Committee had quite a debate about how to achieve the 2010 target progressively, and the hon. Member for South-West Surrey (Mr. Hunt) will have something to say about interim targets if he catches your eye, Sir Nicholas. We recommended that the Department consider including a target on access to treatment when formulating the public service agreement for the next comprehensive spending review, which is currently under discussion, and I would be interested to hear what progress the Minister can report.

We identified a particular problem with the treatment of children. There is not enough investment in paediatric antiretroviral drugs—the issue was raised at International Development questions yesterday—and the pharmaceutical companies have no real commercial interest in the issue, although the international community, the children and their families do have an interest in it. However, the relevant drugs, where they exist, are up to six times more expensive than equivalent adult treatments and are not designed for children. Antibiotics are also not always appropriately targeted at children with HIV/AIDS. Again, we would be anxious to hear what progress has been made on that.

The witnesses who came before the Committee raised several issues, and the Government addressed them in their reply. Although I accept withoutdemur the Government’s real commitment to putting resources into tackling the problem and their determination to meet the end target, there was concern about a possible mismatch between the Department’s global ambition and individual out-turns in different countries. The Government rightly respond that it is up to each country to set its targets, but they are the major provider of support in many countries, and we are looking for a partnership. We expect the Department to be able to define its targets progressively so that we can monitor how well we are doing. We do not want to reach the end of the process, only to find that we have missed targets, when we could have identified the problem earlier and taken appropriate action.

My last point relates to the role of the International Monetary Fund. I raise it because the Government agreed with us, and particularly because their policy is to use budget support as a major way of funding recipient countries. Some glib things are said about the IMF, but the fund and the World Bank are major institutions, which operate in a much more complex fashion than some of the more simplistic arguments might suggest. Nevertheless, there is concern that the IMF, in its overall policy of trying to ensure that countries operate within a sound financial framework, may inhibit the diversion of resources to deal with the AIDS problem in a particular country. The Government agreed that that was a cause for concern and hoped that the IMF would not do that.

A comment from the Minister would be helpful on how our role in providing budget support can come alongside the IMF or act as a buffer between the two. If we provide a country with money specifically to achieve its own HIV/AIDS target, presumably there is no reason why the IMF should try in any way to interfere with that.

The international community has set itself ambitious targets. Our Government are committed to being one of the leading contributors in tackling the problem and I am sure that the House is looking for leadership from the Department for International Development, as I am sure is the international community in many ways, although there are one or two contentious aspects of that to which I shall come later.

The Committee published the report at the end of last year and there have obviously been continuing developments. The statistics are still serious and the Committee had a chance to make visits, particularly to Africa where we saw some of the issues at first hand. Interestingly, we visited Botswana and the Botswana programme was mentioned in the House yesterday. What we saw was impressive in one sense. It is one of the richest, least corrupt, most competent and most well-run countries in Africa. However, it has one of the highest incidences of AIDS, and if it does not deal with that it will cease to be one of the most successful and dynamic countries in Africa. We saw an impressive hospital, which provides impressive treatment, encourages people to come in and reaches out to provide treatment throughout the country. However, two or three issues arose which I think are worth recording.

The first, which is obvious, is that when a huge amount of resources go into dealing with one major problem such as HIV/AIDS, which requires the combined commitment of health resources, clearly other health problems fall down the pecking order. One point of concern is that it is diverting a huge health resource from other problems in the country, which are receiving attention but not the same attention as would otherwise be the case. Botswana is a rich country and the problems are multiplied in poorer countries.

The second issue is that in subsequent meetings with representatives of the Government and Government agencies we asked some probing questions about what was being done to reach some of the prime victims and problem areas, particularly homosexual men and those engaged in sex traffic and the sex trade. The answers were a little disturbing to say the least. In a nutshell, we were told that such activities are illegal, and the clear implication was that there is no programme to reach those people, despite the fact that they are a prime source of the problem.

Someone in the diplomatic community—I shall not identify them—said that in the process of employing a domestic member of staff they asked about her health, to which she said: “I understand what you are talking about and my health is fine. I have been tested and I am negative. However, my husband works in the mines in South Africa so he is away for weeks on end and I have no idea what he gets up to, but when he comes home he expects me to behave as any wife would so how long I will stay in that condition is indeterminate.” That raises another issue: the sharply rising incidence of AIDS among women and girls and the fact that they have much less control over circumstances than they should. They need to be empowered to enable them to take more positive control over the situation.

John Bercow (Buckingham) (Con): I agree, as so often, with everything that the hon. Gentleman has so far said. May I support and reinforce his observation about targets? Its importance seems to be underlined by what he has just said about the attitude of particular states to personal behaviour. Does not he agree that the Government need to take care not to overdo localism and decentralisation? If we are providing money, we are entitled to stipulate in some measure of detail what we expect by way of its effective use. In respect of disaggregation, does not he agree that it should not be necessary continually to press the World Health Organisation for disaggregation of data? What is the rocket science? It ought to be done.

Malcolm Bruce: I thank the hon. Gentleman for that intervention, and more will be said about that.

It would be fair to say that there was not entire agreement on the Committee—although there was no fundamental division—about the exact role of targets. However, we agreed that we needed to quantify what we were doing and pull it back together. One cannot leave these things to every country and hope that that combination will deliver what we have set. We agree about the objective, even if we have not focused on how best to achieve it. That is about attitudes.

There are some issues surrounding a survey that was conducted in South Africa about people’s knowledge and behaviour in relation to AIDS. It produced two or three disturbing statistics. Many answers represented what one would expect, and people’s knowledge was clear. However, one statement was:

“You can reduce the risk of HIV by having fewer sexual partners.”

Although 67.3 per cent. of both sexes agreed with that, 24.4 per cent. did not agree, which is an alarmingly high figure.

Within the survey, we also received an indication that the percentage of young women and men who have had sex before age 15 is high—on average about 25 per cent. It seems to be true of many affected countries. The other statement that was highlighted was that the percentage of young women and men aged 15 to 24 reporting the use of a condom the last time that they had sex with a non-marital and non-co-habiting sexual partner was 69 per cent.

In the context of Botswana, that statistic raises a contentious issue. Although DFID is supporting Botswana through the Southern African Development Community, we do not have a heavy engagement programme, because it is a middle-income country. As a consequence, the Americans are heavily involved in Botswana. The Gates Foundation is fine, but the President’s Fund is not quite so fine, because the American contribution through the President’s Fund places a heavy emphasis on abstinence and moralising. The statistics demonstrate that a significant number of people will not be reached by that approach. I know that the British Government do not share that approach, but if we are not there, for example, there are problems because we leave the field clear. When we are there together with the Americans, there is tension.

Although none of us has a problem with the basic idea that people should be encouraged to be monogamous, an over-moralising attitude will not reach many people. As the Secretary of State precisely and starkly said yesterday, we do not agree with the American position; and, as he put it, people should not die because they have sex—even in circumstances in which people disapprove of the fact that they have had it. If we are trying to deal with the problem on that scale, we must be realistic and we must engage robustly with those who tell us otherwise.

That approach did not work with drugs. The “Just say no” campaign has not stopped the advance of drug abuse, and it will not stop the advance of HIV/AIDS. Prevention is as important as cure, although our report is concerned to ensure that we get treatment to those people who need it.

Joan Ruddock (Lewisham, Deptford) (Lab): I want to share with the hon. Gentleman some information that I received yesterday. It is relevant to how we tackle the issue. In Zambia, where DIFD is involved in a great partnership on primary education, the removal of school fees has enabled girls to go to school, and there has been a shift: among girls receiving primary education, there has been a reduction in HIV infections, whereas for those who have not received primary education, infections continue at similar levels. Primary education—for girls, in particular—can have an impact, and is relevant to the issues that the hon. Gentleman has raised.

Malcolm Bruce: I am grateful to the hon. Lady for that intervention, because it reinforces the fact that the AIDS problem can be tackled successfully. There is some evidence of that across east Africa, and not just in Zambia. I received similar information on the situation in Uganda, where it is not only education about HIV/AIDS that makes the difference; it is the fact that the girls are in school, and therefore less vulnerable to being preyed on than when they are out in the communities. So there was a double benefit from their being in schools. That is an immeasurable result, in terms of bringing the epidemic under control and reversing it.

I have one final comment on attitude. The acquittal of Jacob Zuma in a contentious trial in South Africa highlighted the cultural and social problems involved. I picked up a press report that says that, after his trial, he apologised for not having used a condom. That was an acknowledgement that he had been a bad role model, and a sign that he wanted to do something right. Indeed, the report says that

“he became visibly upset when a journalist challenged him on his admission made in court and widely reported in the media, that he had showered after sex to reduce the risk of HIV infection. ‘If you’ve been in the kitchen, my dear, peeling onions, you wash your hands afterwards,’ he said.”

That is not a very sensitive and sensible comment, but at least he has had the grace to acknowledge that, apologise, and state what he should have done; that is a step in the right direction.

I now come to the completely different issue of TRIPS—trade-related aspects of intellectual property rights—and patent rights. Again, that is a concern for the Minister. There is a Financial Times report about a march on the Indian Parliament yesterday against the application for a patent on an antiretroviral drug from Gilead Sciences. Such a patent would be completely contrary to the spirit of what we are trying to negotiate, which is the right for generic drugs to be manufactured to deal with the problem in individual countries. The final point in the report is:

“Indian drug companies, such as Cipla, have developed a low-cost generic version of tenofovir, priced in India at a seventh of international levels and would be likely to have to cease production or pay steep royalties if a patent was granted.”

Clearly, we have not completely won that battle, and I hope that the Government will use whatever influence they have to stop that sort of litigation. That litigation could lead to the deaths of tens of thousands of people by denying them affordable access to drugs, or could divert resources in the Indian budget away from where they are needed.

I am conscious that a number of hon. Members wish to take part in the debate, so I shall not take the matter further. I conclude by saying that the international community has made an ambitious commitment to tackling the problem. The United Nations is demonstrating a determination to keep on top of that, and at the turn of the month it will monitor where we are on the issue and will make further progress. From that, I hope that we will get an idea of what we have succeeded in doing and where we have failed, and that a recommended course of action is pointed out to help us to achieve our end.

We—and certainly our Committee—will have to take on board that for many of the countries involved, the problem is social, humanitarian and economic. The economic problem has social dimensions. There is a suggestion that, by 2010, some 50 per cent. of all children in Zambia will be orphans. There is a huge issue of responsibility, in terms of who will look after those children, and how they will be brought up and maintained. That is assuming that they are not infected themselves or, if they are, that they can get treatment. A country such as Botswana could see its entire economic success wiped off if it does not get on top of the problem. I hope that the countries concerned have the capacity to do that.

With the greatest respect, although there is no difference of view between us and the Department, the Committee is so concerned about the need to demonstrate commitment that we shall put the Department under continuous review by publishing an annual report on our judgment of what progress has been made, in the hope that that will apply additional pressure. The Department might feel that that is unnecessary, but we think it desirable to ensure that there is an annual parliamentary report saying how well we are doing in achieving the overall objectives.

Mr. Jeremy Hunt (South-West Surrey) (Con): Does the hon. Gentleman agree that GDP growth figures often underestimate the economic impact of AIDS? They cannot encapsulate, for example, the effect of a reduction in life expectancy or the fact that a huge proportion of a country’s health service has to be devoted to tackling the scourge of HIV/AIDS rather than to other things. In that sense, even though the reductions in growth figures for African countries that are affected by HIV/AIDS might be relatively small, the impact is much greater.

Malcolm Bruce: The hon. Gentleman is right; indeed, the problem is even worse than that, because in many cases there is substantial under-reporting.

The negative effect of too much moralising—I do not deny that moral education has a value, but there can be too much of it—can add to the stigma and discourage people from coming forward. I see that ex-president Clinton—I think that President Clinton is still his title in the United States—has called for mandatory screening in all countries and has demonstrated that that gets rid of the stigma, because it happens to everybody. People who need treatment are identified and they receive it. I do not know whether that is the answer, but it is an interesting contribution to the debate. We need to identify the problem, quantify it and solve it. That will require every sinew of every major country in the world, in partnership with the countries most affected, to deliver those end products.

The Committee is proud of what the Government are doing. We appreciate the commitment and the lead role that we are playing. We hope that they will use that lead role to help shape the outcome in ways in which we have more confidence than the largest donor to the programme does, the United States. We have to work with the United States, but we have to make it clear that we have a reason for our different approach and that our approach must reach the people that otherwise will not be reached.

Dr. Gavin Strang (Edinburgh, East) (Lab): I am grateful for the opportunity to follow the hon. Member for Gordon (Malcolm Bruce). I pay tribute to his chairmanship and to the Committee for its report, the first of the Session and on an important subject.

I do not intend to speak for too long but, on average, for every minute that I do, nine people in the world will become infected with HIV and six will die from AIDS. At least one of the newly infected people will be a child and so will one of those who dies. I sometimes wonder whether the shock-horror statistics—40 million people living with HIV, five million new infections, three million deaths a year—might be too much or difficult to comprehend. There is a danger that people might become overwhelmed by the scale of the crisis and conclude that the battle is lost.

It is important to remember that progress is possible and in some areas has been made. The global response to AIDS has improved significantly since the world’s leaders agreed the 2001 UN General Assembly special session’s “Declaration of Commitment on HIV/AIDS”. The special session’s declaration followed the millennium declaration and set targets for prevention, treatment, care and support. The “Declaration of Commitment on HIV/AIDS” will be reviewed at the UN high-level meeting in New York at the end of this month.

Total funds available for HIV work in the developing world have more than quadrupled since 2001 and are in the target range set by the special session. Progress on the ground can be seen in some areas. Prevention work has reduced the spread of HIV in some countries, including Uganda, Senegal, Thailand and Brazil. With respect to treatment, the “3 by 5” campaign was launched by UNAIDS and the World Health Organisation, with the target of giving 3 million people access to drugs by the end of 2005. That target was missed. The number of people getting HIV drugs in the developing world nearly doubled last year to 1.3 million. It is clear that far more needs to be done. For every five people in the developing world who need HIV drugs, only one gets them. Last year the G8, led by the UK, made a commitment to getting as close as possible to universal access to HIV treatment by 2010. I join the Select Committee in commending the work of the Department for International Development in securing that commitment, which was adopted by world leaders at the UN.

Nobody in this Chamber needs to be reminded that if we are to meet the 2010 commitment, catching up with the epidemic will require a huge increase in the scale of the effort. For every one person in the developing world who received antiretrovirals last year, eight people were newly infected.

There has been an increase in funding, but the resources available at present to address HIV/AIDS still do not match the scale of the crisis. As cited by DFID in its written evidence to the Select Committee, it is estimated that $15 billion is required this year to meet prevention, treatment and care objectives, yet only $9 billion is available. The UN Secretary-General has warned that the rate of increase in HIV-funding appears to be slowing, yet $22 billion will be needed for 2008.

I am sure that my hon. Friend the Minister will remind us that the UK has increased the money that it makes available: at least £1.5 billion will be spent in the current three-year spending round, including £100 million each year for the global fund to fight AIDS, tuberculosis and malaria.

I had the privilege of initiating a debate on the global health fund a year or so ago. At that time, the drive was to get round 5 launched. I was pleased that last month’s board meeting agreed to launch round 6, and that the UK was given much of the credit for the decision. However, I understand that no money is yet available for round 6, as all existing finances are required to cover the costs of previous rounds. Of course, that means that new pledges are needed from donors. I would be grateful for an indication from my hon. Friend the Minister as to how he sees that developing and how we can get an adequate response from donors. I welcome the acknowledgement of the Chairman of the Select Committee about the contribution that the Government have made in this area. Indeed, this country is a world leader.

Access to drugs was the centre-piece of the Select Committee’s excellent report. One strand in the effort to get drugs to those who need them has dealt with prices. There have been moves to reduce the cost of antiretrovirals in poorer countries through differential pricing and the availability of generic drugs. Such steps have had a noticeable effect on the prices of first-line drugs. However, as resistance becomes more prevalent, there will be more need for second and third-line treatments, whose prices remain high. In his report to next month’s high-level meeting, the UN Secretary-General has called on donors to work with their pharmaceutical industries to reduce the prices of second and third-line drugs, and I would be grateful if the Minister could outline where discussions on the matter are in the UK.

Bearing in mind that pharmaceutical companies need an income to finance research, I would be grateful for an insight from my hon. Friend the Minister into how well we are doing at ensuring that lower-priced drugs remain in the developing countries for which they are intended. DFID noted in its framework for good practice in the pharmaceutical industry how important it is to “avoid leakage and diversion”. I believe that there is broad consensus in this Parliament that we must enable drug companies to make profits if they are to develop new drugs.

The hon. Member for Gordon referred to trade-related aspects of intellectual property rights. As we know from the Government’s response, they do not share the Select Committee’s view that they should lobby for a review of TRIPS at this time. However, I wonder whether my hon. Friend the Minister could indicate whether he is of the widely held view that the TRIPS safeguards are too onerous and too complicated for developing countries seeking to get access to vital drugs.

On the affordability of treatment, the Select Committee considered the effect of user fees and concluded that it had heard no evidence that such fees improve adherence to drug regimes. I would be interested to hear the Minister’s assessment of the reliability of the data on that point, and his response to the call by the Select Committee to work with the WHO and UNAIDS to issue a statement supporting the removal of user fees.

I note that the UNAIDS paper “Towards Universal Access”, published at the end of March, set a target date of June next year for countries to reduce or eliminate user fees for AIDS-related services including treatment. I wonder whether we can anticipate progress in the direction hoped for by the Select Committee. Again, what is the Government’s view?

Meeting the 2010 target—the target for universal access—will require action from many agencies at international, regional and national level. The global steering committee, which is co-chaired by the UK, has called for an integrated approach through implementation partnerships involving not only the Government but other key leaders in society, including private sector employers.

I shall say a few words about the need for the private sector to meet its obligations. The World Economic Forum warns that businesses are doing too little, too late, in the battle against HIV/AIDS. The organisation conducted a survey of businesses worldwide and found that some firms have responded to the needs of their work force. Globally, 17 per cent. of responding firms provide antiretroviral drugs. That rises to 38 per cent. in the countries that are hit hardest by HIV. The private sector delivers antiretrovirals to 60,000 people in South Africa. However, the response is still inadequate. Kofi Annan described the level of provision as lamentable. I should be grateful if my hon. Friend the Minister would outline what is being done to secure a strengthening of the private sector’s response.

Getting antiretrovirals to everyone who needs them is not merely a matter of securing adequate quantities of affordable drugs. For a start, health workers can treat only those people who have tested positive for HIV. Access to testing and counselling services more than quadrupled between 2001 and 2005 in more than 70 countries surveyed, but UNAIDS reports that only a fraction of the 40.3 million people who are currently living with HIV are aware of their infection. Yet the health infrastructure in many countries has been weakened. Many health workers have been lost to AIDS. In some countries pay for health care and other key infrastructure staff is below subsistence levels. Added to that is the pull of richer countries that rely on health care workers from the developing world.

The broader health infrastructure of many countries that have been hit by the epidemic will need to be strengthened if the world is to meet the 2010 commitment.

Joan Ruddock: Does my right hon. Friend agree that there may be real scope for the international community to give much more support to health workers in relation to financial assistance, social payments or some means to enable them to remain in their own countries to provide the services that are required? In Africa we saw that it is, as my right hon. Friend says, not just the availability of drugs that matters, but systematic testing and monitoring of the people receiving the drugs. That requires an enormous input from health workers. If there are not sufficient health workers—as is true of all the countries in question—we need a way to assist them in acquiring greater numbers, perhaps by training but certainly by support.

Dr. Strang: My hon. Friend raises an important and topical point, because as hon. Members are probably aware, a change in the regulations on medical staff means that people training in the medical field from outwith the European Union will find it difficult to get employment; everything is now swinging in favour of doctors trained in eastern Europe. On Sunday, I spoke to the Bangladeshi postgraduate association in Edinburgh, and although we were not, in particular, pursuing the present subject, we discussed the question of how to provide the correct incentives. What should our attitude be to the doctors and nurses who come to work in our health service?

The answer is that we live in a global world, and that they must have the opportunity, if they want it, to work in this country. However, as my hon. Friend says, we should surely try to provide incentives and encouragement to them to go back, even if only for five years, to make a contribution, having been trained to a high standard in this country. I think, also, that we must be prepared to employ them. We cannot just train them and tell them to go home immediately.

John Bercow: Of course, substantial subvention by the Department for International Development of key cadres of health service staff is taking place to the great advantage of Malawi—a fact that we discovered on a recent visit. Further, however, in response to the intervention of the hon. Member for Lewisham, Deptford (Joan Ruddock), does the right hon. Gentleman agree that on the assumption that we cannot finance staff or anything else for ever, it is incredibly important that we accept the need not only to finance staff now but to train the future trainers of staff?

Dr. Strang: Again, I am grateful for the intervention; it is a complex area and perhaps the Minister will throw some light on it. Certainly we are all aware of the objectives. We want, as the hon. Member for Gordon said, to reverse the process that is going on to an extent in some countries of an implosion of the health infrastructure, for which there are several reasons, not least of which is HIV itself.

I congratulate the Select Committee on addressing prevention in their report on the treatment target. As I have said, last year an extra 630,000 people in the developing world received HIV drugs, but there were also almost 5 million new infections in that year. Without improving prevention work, we do not have a hope of reaching the 2010 commitment.

Many of the people most at risk are not being reached by the HIV prevention programmes. Throughout the world, less than one person in five has access to basic HIV prevention services. Less than a third of young people in the developing world can correctly identify ways of preventing HIV transmission, as against the 90 per cent. target set by the special session. The United Nations population fund estimates the gap between the supply and the demand of condoms to be 50 per cent. It is also important to reduce maternal transmission of HIV. Only 9 per cent. of HIV-positive pregnant women receive antiretroviral drugs; that is still very low. The failure to provide treatment to pregnant women is one of the factors leading to 1,800 infants becoming infected with HIV every day. The Department for International Development’s written evidence to the Select Committee cites estimates that a comprehensive HIV prevention package costing $4.2 billion annually by 2007 could avert 29 million of the 45 million new infections expected by 2010. I urge my hon. Friend the Minister to do all in his power to secure additional funding for the world’s prevention efforts.

All Members present are aware that reaching a consensus on prevention work presents challenges, most notably in respect of the use of condoms. I was interested to read the evidence given to the Committee in support of the ABC approach—abstinence, be faithful and use condoms. However, I share the Committee’s concern about an over-emphasis on abstinence; the Chairman, the hon. Member for Gordon, referred to that. If ABC is to work, the three strands must work together. We must not allow the moral attractions of A or B to lead us to exclude from HIV prevention work the very people who need to be reached.

In that context, Members will have seen reports that the Catholic Church may be prepared to consider whether the use of a condom is a lesser evil than the transmission of AIDS. According to the media coverage, the specific circumstances currently being considered involve the use of condoms by a married couple when one of them is HIV-positive. I am sure that we all look forward to seeing these deliberations proceed.

At the end of this month, a high-level meeting will review achievements against the targets set five years ago in the declaration of commitment on HIV/AIDS. As I suggested at the beginning of my remarks, despondency is as much our enemy as complacency. Behind the missed targets and depressingly high infection rates lie grounds for hope for the 2010 commitment to universal access. To miss the “3 by 5” target was desperately disappointing, but the progress made in response to the initiative showed that antiretrovirals can be administered in deprived areas, that adherence is good, and that the necessary public health policies can be put in place.

I shall conclude by quoting directly from Kofi Annan’s report to the forthcoming high-level meeting:

“Although the epidemic and its toll continue to outstrip the worst predictions, the foundation for an extraordinarily stronger and sustained response is largely in place. For the first time ever, the will and means needed to make real headway have been secured.”

We can be proud of the British Government’s contribution, and I am glad that my hon. Friend the Minister will be in place in the next few crucial years. I am sure that he has the experience to continue to contribute to ensuring that we progress.

Several hon. Members rose—

Sir Nicholas Winterton (in the Chair): Order. Before I call the next speaker, I remind Members that we have to conclude the debate by half-past 5. Quite a large number of Members wish to speak, including some who have not given notice to the Speaker’s Office, and I would like to allow as many Members as possible to contribute to this important debate—if not all of them who wish to do so.

Mr. Jeremy Hunt (South-West Surrey) (Con): It is a great pleasure to follow the right hon. Member for Edinburgh, East (Dr. Strang). He followed me in a disability debate last week in the main Chamber and said that my tone was very much in line with the new leadership of the Conservative party. I have been trying to work out whether he considered that to be a compliment. In any case, it is a pleasure to follow him again.

It is also a pleasure to follow the Chairman of the Select Committee, the hon. Member for Gordon (Malcolm Bruce), who made an excellent contribution. Under his chairmanship, the Committee has not fallen into the trap of thinking that we have solved the HIV/AIDS problem with the Gleneagles declaration. It has remained a high priority on the Committee’s agenda, which I welcome and thank him for.

I also commend the hon. Member for Walthamstow (Mr. Gerrard) on the work that he does as chair of the all-party group on AIDS. I worked closely with him on the successful early-day motion on interim targets which was signed by 250 Members. As a new Member, I reflected on whether the secret to success was to form an alliance between old left and new right, although I suspect that such an approach would not find favour in either of our parties.

Last month, in Nairobi, I attended the funeral of Christobel Wanju, an HIV-positive orphan. She was 13 years old, and I met her a couple of years ago on a visit to Kenya. She was a delightful girl, and was apparently healthy, although she was HIV-positive. She had an undetectable viral load; her CD4 count was perfectly adequate. Five weeks ago, she had severe headaches and was rushed to hospital. Tragically, on 4 April, she died. The reality is, unfortunately, that antiretroviral drugs alone are not the answer. From time to time, even children such as Christobel, who was in the controlled environment of an orphanage and was getting all the care and medicine that she needed, are cruelly snatched away just because the virus makes them weak. That is particularly the case for orphaned children, who do not receive the care that they need in their early years, although they might receive it later.

The slow-burn effect of HIV/AIDS means that it is not like a famine or tsunami, so it usually does not hit the headlines in the same way. When these children keep dying, we must remember the figure put out by UNAIDS: one child dies every minute. Last year, 570,000 children died from HIV/AIDS. Let us compare that with the tsunami which occurred at the turn of that year. We are talking about two tsunamis’ worth of deaths from HIV/AIDS of children alone. Let us add the relevant figure for adult deaths, and we are talking about eight tsunamis’ worth of deaths from HIV/AIDS, not as a one-off event, but every year.

The tragedy of the epidemic is that it is getting worse. For every child that dies from HIV/AIDS, 1.3 children are being born with it. We have almost managed to eliminate mother-to-child transmission in the developed world, but in many African countries the relevant figure for it is still more than 35 per cent.

Some people understandably ask, “Why AIDS? What about all the other killer diseases, such as tuberculosis, malaria and smallpox?” The best answer to that was given by Professor Alan Whiteside of the university of Natal. He described HIV/AIDS as an “involutionary” event. For him, involution is the opposite to evolution. He describes how most viruses extinguish themselves because they end up killing the host that is carrying them. The evil genius of HIV/AIDS is that the host—the person who is infected—remains apparently healthy for long enough to be able to transmit the infection to many other people before they themselves become ill.

As HIV/AIDS is a sexually transmitted disease, the effect on young people is particularly devastating. A prevalence rate of 25 per cent. in a country means that the likelihood of a teenager getting the virus in their lifetime is 50 per cent. If the prevalence rate increases to 35 per cent., their likelihood of getting it increases to between 80 and 90 per cent. South Africa is heading in that direction. At current rates, by 2010 it is predicted that three quarters of its teenagers will not be able to expect to live until their 60th birthday.

In that context, the Government should be extremely proud of what they achieved at Gleneagles last year. The 2010 universal access commitment was championed by the UK and was not easy to achieve. I congratulate the Minister and the Secretary of State on their personal commitment to that. I am grateful that interim targets have become UK Government policy, and am pleased to see that they are one of the proposals that we hope will be adopted from the submissions that are going before the UN for the high-level meeting on 2 June. What is the Minister’s candid assessment of the chances of interim targets and milestones being adopted at that meeting?

If we are to achieve universal access, it will not be a question only of declarations and high-level commitments from the world community; a number of practical challenges will also need to be addressed, and I should like to touch briefly on some of them. The first challenge is money. This week, the Minister stated to me in a parliamentary answer that there will be a funding shortfall of $18 billion in anti-AIDS programmes during the next two years—only half the period between now and 2010. The international community is still not putting its money where its mouth is. What will the Minister do to try to persuade G8 countries other than the US and the UK, which have taken a leading role in the battle against AIDS—the Italys, Frances Germanys and Japans—to play their role and contribute what they should to the battle against HIV/AIDS?

I do not want to pre-empt the hon. Member for Northampton, North (Ms Keeble), who is a great expert on paediatric drugs, but the second big challenge is the supply of paediatric drugs for HIV-positive children. The HIV virus is unusually and particularly aggressive in children, whose immune systems are undeveloped, yet fewer than one in 20 of the children who need antiretrovirals can expect to get them. When they do get them, by and large the portions, which have been chopped up, are not sized for them, but for adults. The regimen for antiretroviral drugs has to be administered extremely carefully, and that is a bad way of ensuring that children get the correct dosages. They very often have to rely on syrups and solutions, which, again, are not ideal because the dosage can be wrong and they have to be refrigerated.

As the shadow Secretary of State for International Development pointed out yesterday in the House, there is no market for such drugs in the west so drugs companies have been very slow in developing them. The point of his question was this, and I ask the Minister to respond to it: if the Secretary of State asked to see the heads of the drugs companies, that would provide a major impetus for getting them to raise paediatric AIDS drugs up their list of priorities. Although I strongly welcome the discussions between the Department for International Development and the drugs companies, if such meetings were attended by the Secretary of State, the bosses of those companies would attend too and we would be far more likely to get progress.

The final challenge has not been talked about a great deal. How will fragile states in the poorest African countries, particularly conflict and post-conflict zones, reach the 2010 universal access target? Hank McKinnell, the chairman of Pfizer, one of the companies that manufactures a lot of antiretroviral drugs, said that if the cure for HIV/AIDS were simply a glass of clean water, we would not be able to get it to half the people who need it.

The development of health infrastructure is appallingly bad in such countries as Burundi, where there are only 300 doctors, a great majority of whom are in the capital. The Clinton Foundation recently estimated that if it were to get antiretroviral drugs to 57,000 people in Rwanda, it would need to double the number of doctors there. In the Democratic Republic of the Congo, where I went recently, outside Kinshasa there is only one doctor for every 30,000 people. That compares with one doctor for every 600 people in the UK.

There are two particular problems in conflict zones. First, there are food shortages. Some 17 million of the 53 million people in the DRC face such shortages, and antiretroviral drugs do not work properly if people do not receive proper nutrition. The second problem in conflict and post-conflict zones is the explosion of sexual violence. Indeed, while I was in the DRC, I went to one of the world’s only rape hospitals. The problem is a real challenge, and it, too, must be addressed.

It is easy to be overwhelmed by the problems, but I want to conclude on a slightly more positive note because I believe that AIDS can be defeated in our lifetime. Although we are unlikely to find a cure—unfortunately, HIV/AIDS changes the DNA of cells and is incredibly difficult to unravel—we can have much better prevention programmes. Hopefully, those will involve microbicides, which offer great hope.

We can also have a much bigger roll-out of testing programmes. We need to look at what is happening in Lesotho, which has an opt-out testing programme. The programme is not mandatory, but every child is automatically tested at the age of 12 unless they opt out. That happens to everyone, so the stigma of testing is removed, which is a positive step.

We need to bring down the price of antiretroviral drugs much further. In particular, we need partnerships between pharmaceutical companies and generic drug manufacturers. Just imagine what would happen to the price of antiretroviral drugs if China started manufacturing them. That would have a huge impact, and it is potentially round the corner.

Finally, we might find a vaccine for HIV/AIDS. Michael Gottlieb, who discovered the virus in 1981, said that we could be trialling a vaccine by 2010 and that it could be widely available by 2021. My question, therefore, is simply this: given that we have the drugs to prevent AIDS deaths now, how many people will have died needlessly by then?

Mr. David S. Borrow (South Ribble) (Lab): I am grateful for the opportunity to contribute to the debate. I congratulate the Select Committee on producing its report. I am an officer of the all-party group on AIDS, so I take a particular interest in the subject, and I am pleased that the Committee gave it high priority.

Other hon. Members mentioned Botswana, and I want to speak a little about that country. I have visited Botswana three times since I entered Parliament. I went once in 1999, on a Commonwealth Parliamentary Association visit, and again in 2004. At the end of March this year, the Government of Botswana invited me to visit, and I spent four days looking at their HIV/AIDS programme. Over those three visits, I have been struck by how a country can change its reaction to HIV/AIDS.

In 1999, I spoke to the Minister of Health in Botswana, and there was a sense that HIV/AIDS was not a problem. However, I also spoke to the manager of a diamond mine who had just completed the anonymous testing of the work force and discovered infection rates of 25 to 30 per cent. Clearly, there was a problem, and the Government of Botswana quickly changed their approach. A few years ago, they reached an agreement with the Bill and Melinda Gates Foundation and Merck to put in place a full programme of antiretroviral treatment for the population. That involved a $50 million contribution from Merck, the foundation and the Government. The Merck Company Foundation also provides the programme’s two basic drugs—Crixivan and Stocrin.

When I went to Botswana two years ago, the country was beginning to build the delivery mechanism. I visited the Princess Marina hospital in Gaborone, which was the main clinic at the time, and it was treating about 24,000 patients. When I went there a few weeks ago, it had rolled the programme out across the country. Drugs are being distributed at more than 30 centres, and there are more than 50,000 people on the treatment programme, which is provided free. In addition, just under 10,000 people are probably being provided with drugs by their employers—mainly the diamond mine corporations in Botswana.

It is interesting that 300,000 people out of a population of 1.7 million are estimated to be HIV-positive. The Government feel that if they can reach 110,000 through the drugs programme, that will meet the needs of those people who require the drugs. They aim to reach that target in the next couple of years, but because of the spread of the disease and the fact that some of those who do not need the treatment at the moment will need it in the future, they will eventually need to deliver the programme to 150,000 throughout Botswana.

Botswana, as has been said, is a middle-income country with stable government and good infrastructure, and its health service is probably better than those of many other countries in Africa. Even with the deal that has been done, the money that has come in, the ability to deliver a drugs programme and a series of new testing centres, it is beginning to run into capacity problems in trying to use a western medical model to deliver the testing programme and the treatment programme throughout the country. I sense that even in Botswana they will struggle to have the capacity to do so.

Malcolm Bruce: The hon. Gentleman quotes a good case, and the Select Committee was in the same hospital just a few weeks ago. We were concerned to be told that 52.4 per cent. of Botswana’s development aid programme is going on the HIV/AIDS programme. As he says, the Government are struggling in one of the most privileged countries. That shows the scale of the problem and why it is such a challenge. He is right: Botswana is a success story in comparison with most other places.

Mr. Borrow: One of the things that I picked up and sensed from the visit was that if there is bound to be a struggle even in Botswana, we need to encourage new systems and new models of delivery of care.

We need to engage with the medical professions to see whether we can deliver pharmaceutical products, do the testing and so on without relying on everything being done by pharmacists and doctors, and to see whether there is a way of working with people with lower skills and qualifications to deliver what is needed. If we cannot succeed in Botswana, the chances of being able to succeed in the rest of Africa, however much money is given for drug treatment, are not very large. It is not simply a matter of getting drugs for free, or for very little, and providing millions of dollars in aid. In the end, each country has to use its human capacity to put in place the medical system to deliver the drug treatment programme.

We need to begin to see whether it is possible to develop a different type of delivery mechanism to the one that we would expect to see in western Europe and north America. That problem has to be tackled in Botswana. It will apply across the whole of the developing world, because I do not understand how we can reach our aim to allow everybody who needs treatment to get the drugs unless we find a different mechanism for delivery. That is one of the lessons that I have picked up.

The Chairman of the Select Committee, the hon. Member for Gordon (Malcolm Bruce), raised my next point, which is the approach to prevention and how we challenge people’s assumptions—ABC is the shorthand. A few years ago I was involved with UNAIDS and the Inter-Parliamentary Union in developing a handbook for parliamentarians on the subject. In all those discussions, what came across was the need to take a human rights approach to HIV/AIDS and to ask what in our legislation and prejudices gets in the way of tackling the disease. What do we as parliamentarians here, in Botswana, in India or wherever, need to do to enable AIDS to be defeated?

On a visit a few years ago to look into HIV/AIDS, I remember speaking to people in New Zealand, an affluent, western country. They faced a challenge in the late 1980s which meant they had to make decisions about drug users and men who had sex with men. It was necessary to change the law and change what was done to enable the problem to be tackled. I remember when the question of men who have sex with men was raised in Botswana, and the attitude was similar: “That is not something we really talk about.” It is difficult to challenge that in many African countries.

Ann McKechin (Glasgow, North) (Lab): My hon. Friend makes a thoughtful speech, but does he agree that cultural attitudes about the role of women—I have noticed this particularly in sub-Saharan Africa—are a major contributor to the problem? Many women are kept deliberately ignorant of how to protect their sexual health, and they are certainly not encouraged to seek the information. We need to build up a civil society movement for women in those areas if we are effectively to deliver treatment of the sort he describes, and introduce the mechanisms that will enable our goals to be achieved.

Mr. Borrow: I agree. I am always struck when I visit sub-Saharan Africa by the strong imbalance between the sexes, and the frequency of sexual relationships between older men and younger women. Economic imbalance feeds the spread of the disease. Older men have many sexual partners, who are often very young women, and that creates problems because of the women’s inability, as a result of the sexual imbalance in society, to insist on condoms or to say no. It is a challenge for us to ask countries in which the development has been different from ours to examine many of their belief systems when they get in the way of tackling HIV/AIDS.

John Bercow: The continued and extensive incidence of sexual violence, not least rape, is a related and legitimate cause for concern. Does the hon. Gentleman agree that donor countries must help recipient countries to address that problem, not least in the light of the fact that it is not merely the male rulers of those countries who regard that state of affairs as unexceptionable; it is a depressing reality that a large proportion of female citizens apparently still think that it is something up with which they have to put?

Mr. Borrow: I agree. A few years ago I visited a hospital in Addis Ababa in Ethiopia and spoke to women there. A culture clearly existed in which if a man wanted sexual relations with a woman or wanted to go out with a woman and she said no, it was legitimate for him to rape her, because she would then be no use to anyone and would have no choice but to become his sexual partner. That attitude was common, as was the attitude that a wife should expect to have nine children. That problem is particularly acute in the Ethiopian context, in which boys are fed much better than girls and women tend to be very small. As a result, many problems associated with the physical size of the woman occur in childbirth. I am well aware of that difficulty.

On a different matter, I am patron of a charity, the Naz Foundation International, which does work in south Asia to do with men who have sex with men. The Department for International Development contributes to projects there, and I hope that my hon. Friend the Minister, who is, I know, hoping to visit India in the near future, gets the opportunity to see some of those projects. In the south Asian context, it is interesting that infection rates are significantly higher among men than among women. That is a reversal of the situation in sub-Saharan Africa. It reflects a different pattern of sexual transmission. Although there is not what would be seen by western society as a gay community, it is not uncommon for men who are married and who have children to have sex with other men. That may be one of the links that creates the different pattern.

The legal situation in most of south Asia is not conducive to tackling the problem, which brings us back to the human rights issue and the fact that parliamentarians can put in place a proper legislative framework to help tackle such problems. I urge my hon. Friend to raise the matter if he visits India, because with that scale of population we need to do everything that we can to prevent an explosion of HIV/AIDS in south Asia. The risk is that such an explosion would be much larger than the explosion in Africa.

Several hon. Members rose—

Sir Nicholas Winterton (in the Chair): Order. Again, I want to help hon. Members. If they discipline themselves when speaking, I hope that everyone will have the chance to speak. It is important that all who hope to speak can do so, given that they have been patient and have prepared for the debate.

John Barrett (Edinburgh, West) (LD): This is an important debate. We have heard a number of thoughtful contributions from all parts of the House. As the Select Committee report says, the HIV/AIDS pandemic is a full-blown global health emergency. When we consider the figures, it is impossible to disagree. The sheer scale of the problem is sobering. Since 1981, more than 25 million people have died of AIDS, and by the end of 2005 more than 40 million globally were living with HIV/AIDS. Of that number, 60 per cent. were living in sub-Saharan Africa, where the situation is most severe, and of the 5 million new infections recorded globally in 2005, 3.2 million were in sub-Saharan Africa.

Figures like those are difficult to appreciate fully, but they help to underline the scale of the problem. However, although Africa is bearing the brunt of the disease, no part of the world is immune to the pandemic. HIV/AIDS is not restricted to a particular country, age group or section of society. It is a global problem, and it requires and deserves a global reaction. It is in that context that I welcome today’s debate on the report “Delivering the Goods” and the Government’s response.

It worth remembering that since 1999 there has been a steep rise in the number of HIV diagnoses in the United Kingdom. Reports show that at least 6,700 people in the UK were diagnosed with HIV during 2005, and that number is expected to rise. The welcome and rapid scaling up of antiretroviral treatment programmes in Africa, driven by international advocacy and supported by unprecedented global funding, offers hope to millions of HIV-infected Africans. It is important to realise how far the issue has moved up the priority list in the international community, which I welcome wholeheartedly.

I join those who have already spoken in commending the work of the Department for International Development, in particular its success in securing the G8 commitment to ensuring universal antiretroviral treatment by 2010. However, although Her Majesty’s Government are a worthy contributor to the battle against HIV/AIDS, one of DFID’s key roles must be to influence the approach of other nations, to ensure that the funds mobilised are used in the most effective manner.

I shall be brief, and I shall try to avoid repeating what has already been said. I wish to focus on the importance of prevention and the need to steer international efforts towards a greater appreciation of a more balanced approach to treating HIV/AIDS. First, I add my voice to those who have argued that prevention and treatment are two sides of the same coin. As “Delivering the Goods” makes clear, expanding access to HIV treatment should not be seen as a simple technical fix to the pandemic. A major scaling up of HIV prevention must form an integral part of all programmes to expand treatment. It could be argued that the overall international investment does not fully reflect that. In that regard, the Department’s approach is difficult to fault.

I was delighted to see the important role played by DFID in securing international agreement on UNAIDS new prevention policy and to see the Government throw their weight behind emphasising the importance of a properly balanced approach in that regard and the recognition that prevention must remain the cornerstone of a comprehensive response to AIDS. DFID has a crucial role to play, not simply to fill the gaps left by the US, as some have put it, but to lead and inform the US policy and approach. As the Committee repeatedly heard in evidence, continued research is needed on the complex range of factors that affect HIV transmission and determine the eventual success or failure of HIV prevention strategies. The crucial point is that any such strategies must be firmly based on evidence; there should be no political agenda to them.

As many hon. Members will know, the US Government’s PEPFAR fund—the President’s emergency plan for AIDS relief—has a strong emphasis on the provision of treatment and care for people with AIDS, with only one fifth of the money used for HIV prevention work. Many groups and workers on the ground have rightly been dismayed by the requirement that one third of those prevention resources be ring-fenced for spending on programmes promoting sexual abstinence before marriage. That is a good idea for those to whom it is applicable, but it does not work for all.

The emphasis on that idea has been the subject of considerable discussion, particularly with regard to the effectiveness of such an approach at the apparent expense of other initiatives, such as the distribution of condoms. PEPFAR’s five-year strategy document mentions condom provision and promotion only for those who practise high-risk behaviour; condoms are not mentioned as a strategy to help young people in general. Clearly, that approach differs significantly from previous US policy and the policies of other donors, including the UK. The European Union and the Global Fund to Fight AIDS, Tuberculosis and Malaria have a similar view to that of the UK. Often, the ABC approach—abstinence, being faithful and condoms—is advocated by the US, but sometimes it is over-weighted in favour of the A and the B. Hon. Members will know that there have been reports of organisations refusing US funding because they believe that condoms should be promoted beyond high-risk groups. There is a fear that the approach will lead to the restigmatisation of condoms and promote the notion that they do not work as a form of HIV prevention. Such stigmatisation is a side effect that we can ill afford.

The medical journal The Lancet has published an editorial calling PEPFAR’s approach to preventing sexual HIV transmission “ill-informed and ideologically driven”, and calling for a complete reversal of the policy. The editorial concludes:

“Many more lives will be saved if condom use is heavily promoted alongside messages to abstain and be faithful”.

I could not agree more. The essential problem is that PEPFAR sets other funding restrictions that are not necessarily based on evidence of what is most effective in combating HIV and AIDS. Thankfully, DFID’s approach has been quite the reverse. It is crucial that we use what leverage we have to steer US policy towards what works and away from what will satisfy the conscience of the American Christian lobby.

One further issue that warrants serious discussion—it has been mentioned—is the potential use of HIV testing as a medical routine for any patient whose symptoms may be due to HIV and as routine for all individuals with tuberculosis. There is a growing feeling that that could be justified, not only in the interests of the patient but in the broader interest of HIV prevention. As hon. Members will know, HIV has a long incubation period; many years can pass with no symptoms apparent. As a result, individuals can unwittingly pass on the disease to many people. Clearly, one major challenge is identifying those individuals at an early stage.

Sir John Crofton, a distinguished Edinburgh scientist and the pioneer of the DOTS—directly observed treatment short course—programme for TB, is one of the growing number of cheerleaders for routine testing. Sir John recently pointed out to me that many years ago, when syphilis was a major health problem, it was routine to test for syphilis all patients complaining of almost anything, as syphilis has such a wide variety of symptoms. Similarly, if we are to treat HIV as a public health emergency, which it undoubtedly is, routine testing could make a major difference in preventing the spread of the disease and improving early diagnosis and treatment. Having to ask every patient for permission to test for HIV can give rise to much unnecessary anxiety, as many patients will undoubtedly be negative. There is also the danger that the practice only reinforces the stigmatisation of HIV that has been such an obstacle to progress.

The contrast between the treatment of tuberculosis and the treatment of HIV is also worthy of some consideration. TB prevention and control programmes have epitomised the public health approach, where controlling transmission of the disease has been a paramount aim, with less focus on patient-centred goals. In contrast, HIV programmes have tended to focus on an individual approach to HIV testing that is private, confidential and voluntary, but which has placed little emphasis on interrupting chains of transmission.

We have to ask ourselves whether that approach is sustainable. In a region where such a large proportion of the population is living with HIV, public health must be the priority. Fewer than 10 per cent. of African patients with TB are tested for HIV. I would be interested to hear the Minister’s thoughts on the introduction of universal HIV testing for patients with confirmed or suspected tuberculosis. TB and HIV go hand in hand so often that it would make sense for treatment and prevention to do likewise.

We should also be sensitive to the relationships among TB, malaria and HIV. In the countries with the highest HIV prevalence, more than 75 per cent. of TB cases are HIV-associated. Those three diseases are interconnected and it is important that responses are tailored to reflect that. I am pleased that a truly co-ordinated approach towards TB and HIV is now recognised at the highest levels. Many members of the Committee and other hon. Members have met too many people who have suffered from HIV and AIDS. One is one too many, but fortunately the provision of antiretrovirals provides a light at the end of the tunnel. We must ensure that, through the report and this debate, we continue to tackle the problem and keep it at the top of our agenda.

Ms Sally Keeble (Northampton, North) (Lab): I shall keep my remarks brief, because I appreciate that other hon. Members want to participate. I should also like to say what a pleasure it is to follow the excellent speech made by the hon. Member for Edinburgh, West (John Barrett).

I shall focus on two points. The first is the report’s recommendations on children and the second is delivery on the ground. In commending the report, which above all is focused and concise—that strengthens its recommendations—I am pleased to see its recommendations on the need for more attention to be paid to children with HIV and AIDS, particularly in connection with the research on new paediatric formulae and diagnostics. I shall not repeat the remarks that the hon. Member for South-West Surrey (Mr. Hunt) made in his excellent speech, but I should say that he set out clearly the problems faced as a result of the lack of paediatric formulae; indeed, I understand that only one combination of drugs is prepared specifically for children.

The issue of diagnostics is desperately important. Anyone who goes to homes and street shelters in sub-Saharan Africa will find children who have been abandoned at the steps for other people to bring up. The carers have no idea of the status of the children or sometimes of the background of the parents. There is no way in which the carers can establish such status because of the lack of research on effective diagnostics for children. I have seen children who were clearly ill, but whose illness it was impossible for the carers exactly to determine.

UNICEF gave evidence to the Committee—it made an excellent submission—and at one stage it was proposing to establish a special fund to look at the development of paediatric formulae and of diagnostics. I would be interested to hear from my hon. Friend the Minister whether UNICEF is still pressing for that fund and if so, whether the Government will contribute to it, as it would seem an important way to plug one of the gaps in HIV/AIDS provision.

I also want to deal with the effectiveness of aid and access to antiretrovirals, because there are two sides to treatment: the roll-out of antiretrovirals, and ensuring that people can access drugs and take advantage of them. We must focus on both aspects. I commend the work of Save the Children in this regard. In an excellent report on blockages in the international aid system, it identified such blockages and, in particular, identified money that goes into national Governments and does not come out again. It was a real credit to Save the Children that it also found that money goes into large NGOs and stays there without reaching the community organisations.

I should also like to draw attention to the work emerging from the technical consultation in London organised by the consortiums working group on orphans and vulnerable children. My hon. Friend the Minister knows about that work, which specifically considered such issues, and about the research that World Vision has just set up to analyse in practical terms in the field the way in which funding gets through. I hope that DFID will take on board all that work to ensure that aid is more effective.

I have recently returned from Nairobi in Kenya, where I spent two days at a conference that the Department for Education and Skills sponsored to consider children’s issues and, in particular, young carers in relation to AIDS. It was an excellent and well-organised conference. I encourage DFID to liaise with DFES and to pick up the recommendations from the conference and find some way to carry them forward. They focus largely on the details of child care using a child-centred approach, and they do so from the perspective of child policy, which sits within DFES but has profound implications for international development policy.

I also took the chance to visit Kibera and speak to the Kenyan Network of Women with AIDS, with which I work, as my hon. Friend knows. The network still has financial problems. It is grateful to DFID for the funds that have been provided, which amount to about £10,000, but it needs a budget of $300,000 to run a total of eight centres, so there is still a substantial shortfall.

Having spoken to the network in some detail, I understand that the World Bank and the Global Fund to Fight AIDS, Tuberculosis and Malaria are not funding the Kenyan Government, because of the problems in that Government. One can say that we should not put funds through a government with traceability and accountability problems, but in practice it means that in Kenya, which has one of the highest prevalence of HIV/AIDS, either 300 or 3,000—I cannot remember how many noughts were on the figure—community-based organisations are without money. Some have shut down, while others such as KENWA have been able to beg, borrow and cadge to get enough funds to keep on going. However, they have had to retrench people, reduce payments and refuse to take on new cases, and in the Kenyan context, that is desperate.

Cynics might ask what the funding of community-based organisations has to do with the roll-out of antiretrovirals. The answer is simple: those organisations work in the slums where the high incidence rates are. Kibera has an infection rate of about 40 to 50 per cent., according to MÃ(c)decins Sans Frontières. The organisations have credibility in the community, and they can deal with the problems of stigma and provide an holistic approach for people. They will provide people with food and ensure that their rent is paid and that they are strong enough to withstand the rigours of antiretroviral treatment, which, as the hon. Member for South-West Surrey said, is a major issue.

Funds and treatment need to be provided, and everyone recognises that there has been enormous progress in that area, thanks in particular to the UK Government, who have played an influential role. At the same time, however, the pull of demand is required at the other end. We need people to come forward and access counselling and treatment in the most disadvantaged areas where infection rates are highest. I understand that at the UNGASS meeting next month, the community-based organisations are going to bring up the fact that funding at community level is not there.

Mr. Hunt: Does the hon. Lady agree that one problem for community organisations is the fact that DFID is reluctant to fund small organisations in countries such as Kenya, because it prefers to fund big programmes? Often, some of those important community organisations, which can be very effective on the ground, find that they cannot get the support that they need.

Ms Keeble: I am grateful to the hon. Gentleman for making that point. This is a complex issue. It is understandable that a large, bilateral programme is not well placed to fund an individual, small-scale community-based organisation. There is a need to have local ownership. UNICEF also provides funding: it provides some of the £150 million earmarked for orphans and vulnerable children. There is an issue regarding how the consultation methods are set up; it is about people knowing how to get access to those funds when they are provided through other organisations.

There is a major issue with situations in which there is a corrupt or problematic Government through whom funding is supposed to be going, and we should probably consider whether there is some arms-length way of dealing with that problem. I completely understand that the global fund and the World Bank do not want to put enormous amounts of our constituents’ money through corrupt Governments, but it is unacceptable for our constituents to think that money has been earmarked and then find out that there are 300 or 3,000 organisations at grass-roots level that are desperate to help some of the poorest and most vulnerable people, but simply cannot get access to the money. It is not surprising when such organisations say, “Excuse us for being just a tiny bit cynical; we hear about the money being spent but we simply don’t know how to get hold of it. In the meantime, we are laying people off, the kids are going hungry, we can’t get people on to treatment and people are dying.” That is a serious issue.

Dr. Strang: I think that hon. Members are impressed by my hon. Friend’s involvement in the situation and her knowledge. She is clearly making a distinction between bilateral support from the UK Government and the global fund. I am sure that she will agree that it is important to maintain the credibility of the global fund. Does she agree that there is a danger that if projects are not properly tested and people are not confident that the Government are delivering, the global fund will begin to lose credibility?

Ms Keeble: I take that point. The funding issue is too complex to go into within the confines of this debate. My hon. Friend the Minister has been helpful by listening to me moaning at him about this matter for quite some time. I appreciate his patience in that, and the detail of his responses. I assume that he is going to the meeting that I mentioned, and I ask him to take time to meet the organisations, listen to what they say, take it seriously, and find a way to deal with the red tape that prevents people from getting the money that everyone wants them to have to produce the results that everyone agrees are a desirable goal. If he can do that, there will be real progress on the ground and, given that the UK Government have been so good about giving out all the money, the roll-out of the antiretrovirals will be effective and will reach some of the most vulnerable people, whom we see when we visit those communities, and ensure that they and their children have the benefit of these miracle drugs—longer life and better health.

I apologise, Sir Nicholas, that because some constituents have been waiting to see me for rather a long time to talk about health issues, I shall have to duck out of the debate for a while. I apologise also to whichever hon. Member speaks after me, but I shall return.

Alistair Burt (North-East Bedfordshire) (Con): It is a pleasure to take part in the debate and to be reacquainted with friends on a Committee that I still miss very much. The work of Her Majesty’s Opposition has taken me in a different direction for the past couple of years.

It is also a pleasure to listen to a series of speeches that would, if they were more widely available, do much to combat the rather smart cynicism of modern politics and our commitment to people. The compassion and knowledge shown by members of the Committee and hon. Members who speak about the topic never ceases to amaze me, not least the contribution of my new colleague, my hon. Friend the Member for South-West Surrey (Mr. Hunt). Every now and again, contributions come along that make one appreciate politics in general and the fact that one’s own party is in good hands for the future, and do much to contribute to such a belief.

What personal and slight knowledge I have of the topic tends to come from my work with World Vision, a visit to Mozambique last year and the challenging and interesting contributions from my hon. Friend the Member for Buckingham (John Bercow). World Vision took us to see children orphaned by AIDS and I want to base my brief contribution on the part of the report that covered that.

I am sure that we have all experienced the same feeling on such visits: a mixture of a distressing and an uplifting experience. What one sees is distressing, as is one’s feeling of inadequacy at walking away from almost unbearable life situations which the throw of the dice has given to others. Yet, it can be uplifting because of the extraordinary commitment of those who work with such families and the spirit of those who are infected but find a way to live which would challenge the presumptions of most of us.

I, too, found the difficulties relating to diet that my hon. Friend the Member for South-West Surrey mentioned distressing. In the small district that we visited, 80 people had been diagnosed with HIV/AIDS, none of whom was receiving treatment because the available diet would not have sustained the treatment that could have been had at some of the local clinics.

Children who are orphaned by AIDS present a series of problems. Food and care must be found for the family and the children must do that, so their education suffers. The number of children in families with HIV/AIDS who are dropping out of the education that is available on a greater scale than ever before is a worry for us all.

World Vision has long had a focus on children orphaned by AIDS and I pay tribute to the work of that Christian-based organisation. Some of the issues surrounding HIV/AIDS are tricky, but I want the compassionate voice of Christians who work in the area to be heard. There are some difficult mindsets to be thought through, not particularly in Africa but certainly in the United States. Plenty of Christian believers can cut through those and work with compassion. If we want to see Jesus in our world today, we should expect to find him not in the harsh words and angry controversies of men dancing about on pinheads of doctrine, but rather in the sweet voices and kind hands of those who touch the broken and the hurt.

To give an example of that and to reflect on something said by the hon. Member for Gordon (Malcolm Bruce) in his opening comments, I draw hon. Members’ attention to the “Hope” initiative that World Vision has been running for some years. It is deliberately targeted at some of the most vulnerable people and those whose behaviour is on the margins to which the hon. Gentleman referred. The “Hope” initiative in Mozambique concentrates particularly on drivers who take goods from the centre of the country to the ports. They follow particular routes and are away from home for great lengths of time. Their vulnerability to HIV/AIDS and the danger that they pose to others through their conduct can, of course, lead to them being at the very edge of society. They are perhaps not on everybody’s first list of those who need care and support, but World Vision is providing that care, and it thinks it very important to work with sex workers, truck drivers, miners and those in particularly high-risk situations. It works through prevention, through offering care and, increasingly, through advocacy. World Vision sees that as not only a social and health issue, but a human rights issue, too, as the hon. Member for South Ribble (Mr. Borrow) mentioned.

I wish to make two brief points on our concerns about children, an issue highlighted yesterday in the House, and today in this debate. I welcome the attention that the Committee paid to the needs of children, and to making sure that children are not missed out from efforts made to increase provision of, and access to, treatment for HIV/AIDS. In particular, I draw the Minister’s attention to targets; I hope that we will firmly press for country plans to include targets. If money has been ring-fenced to deal with children with AIDS and those orphaned by it, it is essential that it actually gets through. Plenty of countries have made commitments in the past, but things have not always worked out, because it is easy for those without voices—children orphaned by AIDS are often precisely those with the smallest voice—to be missed in a rough-and-tumble situation where there is much demand for scarce resources. I would appreciate it if we looked hard at the issue of appropriate, measurable, transparent and achievable targets, and if that could be covered in the reporting-back process that the right hon. Member for Edinburgh, East (Dr. Strang) mentioned.

Secondly, when considering affordable medicines, please take note of the need for affordable diagnostics, too. The most commonly available, easy-to-use diagnostic test is inaccurate for children under 18 months. Infants must be diagnosed through a more complicated test that measures the HIV virus instead of antibodies. Unfortunately, current tests require technical expertise as well as costly equipment. As it stands, many multinational diagnostic companies have shown little interest in developing accurate, simple, fast and affordable tests for diagnosing children. There are similar arguments on the production of necessary vaccines, tablets and other medicines. In much the same way, colleagues refer, in the report, to the very amateurish attempts to break down adult doses into something apparently more compatible with children.

Again, proper diagnostic testing needs to be done—not in an ad hoc way, but in a proper, scientific manner. We should get those who can provide such tests to engage in the subject, and to realise the importance of their products to the most vulnerable. It would be most welcome to have a commitment to ensuring that when treatment is considered, diagnostics will be considered, too.

In general, that is a further area where the work of the Government and the Department for International Development has been excellent over the past few years. There is a general welcome for many of the things that the Department does. It has raised the bar for everyone and has produced a degree of consensus on the work done that is entirely appropriate when dealing with some of the world’s problems. There will continue to be challenging questions for those doing that work, but in general there is much to be proud of. I just mention to the Chairman of the International Development Committee that it has played a significant role over the years, and it is excellent that that work is continuing. On behalf of the children most affected by this appalling plague, I hope that their voice also will be heard in the next stage of the work done to alleviate this dreadful suffering experienced by so many.

Chris McCafferty (Calder Valley) (Lab): I, too, congratulate the Select Committee and its relatively new chair, the hon. Member for Gordon (Malcolm Bruce), on the great deal of hard work done on this important report, and the Government on their response.

HIV/AIDS threatens to destroy a generation of leaders, workers, parents and young people and has created a generation of orphans in the worst affected countries. In many countries, the infection is creeping through the population and is preparing to strike full force. I think that prevention is about striking first. Sexual and reproductive health information, education services and supplies enable people to avoid HIV infection and to protect themselves, their partners and their unborn children from this deadly virus. We know that prevention works and we have a consensus among nations about the need for action. I, too, commend the Department for International Development on the important role that it played in securing international agreement on UNAIDS new prevention policy, “Intensifying HIV prevention”, and the EU-adopted statement, “HIV Prevention for an AIDS Free Generation”.

However, let us face it: it is widely recognised that without a massive scale-up of HIV prevention, the upward trend in the number of people infected will simply continue. That will pose a major threat to the affected countries’ ability to sustain progress in tackling the epidemic, to prevent an explosion of the disease, and to provide AIDS treatment. The EU statement underscores the fact that prevention of new infections must remain the cornerstone of a comprehensive AIDS response.

I agree with the Select Committee report: the relatively new focus on treatment should not be allowed to displace the important work that has already been done on HIV prevention. We must talk about HIV/AIDS openly, honestly and directly and act to guarantee prevention, care and treatment for all those who need it. However, the reality on the ground is very different. There is limited funding available for HIV, prevention, treatment and care. I urge DFID not only to continue to balance work on HIV treatment with sustained attention to HIV prevention, but to continue to make prevention its top priority in a comprehensive AIDS response, with linkages between existing sexual reproductive health and rights, HIV/AIDS and health care services and systems.

As the Government’s response states, critical components of a comprehensive evidence-based response are: universal access to sexual and reproductive health information and services for women, men and young people; provision of accessible and integrated health promotion and harm-reduction services for drug users; reliable access to essential sexual and reproductive health commodities, including male and female condoms; universal access to education and the provision of life skills and sexuality education; the integration of HIV prevention interventions, including voluntary counselling and testing for HIV, into other health services; action to confront and address gender-based violence and to provide protection and support to victims of violence; and supporting investment in modern methods, such as microbicides and vaccines.

The ABC approach—abstain, be faithful, use a condom—adopted by the Bush Administration to assist prevention is not evidence-based. Research from Africa and Asia shows that marriage is not a protective factor. In fact, in some areas, married women are more likely to become infected with HIV than their unmarried counterparts. In marriage, abstinence is not always an option and women are unable, as we heard earlier, to ensure their partner’s faithfulness, or condom use. The ABC approach is further eroded by the Bush Administration’s promotion of abstinence-only programming. Many NGOs receive substantial funding for HIV prevention, but with restrictions against comprehensive programming, particularly condom use, ABC fails to recognise the complex realities of comprehensive promotion. Therefore, prevention may need to be reinvented to place a greater emphasis on how each new HIV infection takes place within its own political and socio-economic dimension.

That brings me to vulnerable groups and access to treatment. Children, intravenous drug users and men who have sex with men are all mentioned in the report, but women are omitted. I draw hon. Members’ attention to the Global Coalition on Women and Aids, which makes the point that at least 57 per cent. of adults with HIV are women, and young women aged 15 to 24 are three times more likely to be infected than young men. Despite that alarming trend, which was mentioned earlier, women know less than men about how HIV/AIDS is transmitted, and they know less about how to prevent infections. What little they do know is often rendered useless by the discrimination and violence that they face within and outside the home.

High numbers of pregnant women visiting antenatal clinics are HIV positive. In many southern African countries, more than one in five pregnant women are infected with HIV. The overwhelming majority of children with HIV contract the infection from their mothers during pregnancy or delivery, or through breast feeding. The 700,000 new infections among children in 2003 represent an unacceptable and almost entirely preventable component of the epidemic.

In the UK, mother-to-child transmission has been reduced to less than 2 per cent. due to voluntary counselling and testing, antiretrovirals, elective Caesarean sections and alternatives to breast feeding. In too many places, VCT is still completely absent, and a mere 1 per cent. of pregnant women in heavily infected countries have access to services aimed at preventing mother-to-child transmission.

I commend DFID for the important role that it played in securing the G8 commitment to universal antiretroviral treatment provision by 2010. I hope that in the meantime antiretrovirals will reach poor women and their unborn children, as well as young children and wealthy men, and that prevention remains the cornerstone of all activities included in the comprehensive approach that is essential to tackling HIV.

Jo Swinson (East Dunbartonshire) (LD): Last week, the nation was shocked by the revelation that 10 new cases of HIV had been discovered in the space of a single month in St. Ives, Cornwall. Headlines grew more hysterical as the story unfolded of a single perpetrator who had, perhaps knowingly, spread the infection through the small town. An expert team of medics was sent directly, a helpline was set up, two new testing clinics were established and my hon. Friend the Member for St. Ives (Andrew George) issued a call for calm. My thoughts are with those 10 people and their families, whose anxiety must be unbearable.

However, it is not to belittle their suffering to say that that is the reality every single day for many families throughout the world. In the UK, about 19 people are infected with HIV every day. As my hon. Friend the Member for Edinburgh, West (John Barrett) said, that is still far too much, and it is worrying indeed if the trend of recent years has been an increasing infection rate. Perhaps the safe sex messages that were so strongly accepted in the 1980s and early 1990s are losing some of their resonance.

We are, of course, concerned about cases in the UK, but compare 19 a day with the figure for Africa, which is 8,800. Even taking into account the huge difference in population size, there is a clear disparity. Per capita, if the UK’s infection rate was the same as Africa’s, every day in our country almost 600 people would be contracting HIV. That would be a major public health emergency. We would be dealing with it at the highest levels of Government. However, in Africa and in many other places in the world there is a much greater problem.

Botswana has one of the highest HIV rates; 37 per cent. of the adult population is HIV-positive. For those people there will be no crack team of medics, no special clinic, no helpline, and their contraction of HIV is by no means headline news. The sad fact is that for many communities in Botswana and across the world HIV is part of the daily reality. Having contracted the infection, the 10 people in St. Ives can expect an average of £15,000 a year to be spent on their care. In Africa, the average per person is £7.

The Government’s commitment to funding antiretroviral drugs must be commended, and the Minister and the Secretary of State are to be congratulated on their work in pushing this issue up the agenda. The UK is the world’s second biggest bilateral donor on HIV and AIDS. In 2004, DFID said that over the next three years the UK would spend at least £1.5 billion on AIDS-related work. However, it is already clear that that is not enough. In June 2005, UNAIDS and the World Health Organisation estimated that 6.5 million people in developing countries needed immediate antiretroviral treatment, and of those only 15 per cent. were receiving it. While the Government’s commitment to aid is substantial, it is still out of balance with their spending on war; the £1.5 billion pledged to aid is dwarfed in comparison with the £3 billion already spent on the war in Iraq, and that figure is likely to rise to £5 billion by the end of the year. Our country must redress the balance of our spending on war and aid. Thirty years late, we ar