HIV/AIDS     (04/02/05)

Baroness Northover asked Her Majesty's Government:

What further plans they have to help tackle the AIDS epidemic and support the increasing number of HIV/AIDS orphans in Africa and elsewhere.

The noble Baroness said: My Lords, I am very grateful to noble Lords who have stayed to play a part in this debate so late in the parliamentary week. There is surely no greater challenge facing development than the HIV/AIDS pandemic, which is why we are here today. As the noble Lord, Lord Hannay, pointed out when introducing the debate on Wednesday on the UN high-level panel, poverty has to be seen as part of the security agenda, and state failure is part of the development agenda. He said:

"Pandemic disease threatens to destroy the very structure of states".—[Official Report, 2/2/05; col. 249.]

AIDS is therefore a global catastrophe that affects us all.

This is a key year for the UK and its international agenda. The presidency of the G8 and the EU should give it especial leverage with other developed nations. This year, we measure how far we have come in reaching the millennium development goals. Are we on course? We know that we are not. HIV is spreading rapidly across the world. In China, India, the Ukraine and Russia, infection rates are rapidly increasing. But the worst situation is in Africa. The incidence of HIV/AIDS in southern Africa is now at catastrophic levels. In Botswana it is 40 per cent, with a rate of more than 60 per cent in some mining communities. By 2010, life expectancy there may have fallen to 29.

The MDGs were never going to be easy to achieve. Now AIDS threatens to throw them all off course. Young men and especially young women are dying, children are being orphaned, and health services, education and economies are imploding. In its report published this week on where we are with the MDGs, DfID includes among its targets getting 3 million people into treatment, rapid implementation of the three "ones" on donor and recipient government co-ordination, and national plans in place to meet the needs of orphans and other vulnerable children. It wishes to be:

"On track to slow the progress of HIV and AIDS by 2015".

But is that enough? Are we on course even for that?

As one South African academic told me, in that country,

"the treatment rollout is glacial".

Only 18,500 people are now in treatment. It was supposed to have been 53,000 by March 2003. He even wonders about triage and perhaps selecting health workers for treatment first. Of course there are special circumstances in South Africa, but there are special circumstances everywhere. We have to overcome those challenges. HIV is like a ticking bomb. The infection may be contracted, but it is a decade or so before the person develops symptoms. Meanwhile, they may have transmitted the disease to partners and children. Then they get ill, fall further into vulnerability and poverty, and die, often leaving young children behind.

The scale of the problem of orphans and vulnerable children is something to which the world woke up late. Around 12 million children in sub-Saharan Africa have lost one or both parents to HIV/AIDS. By 2010, that is likely to have grown to at least 18 million, with 25 million worldwide. By 2010 in many southern African countries, 20 per cent of children will be orphans. Many are living with grandparents who are already struggling to survive. Those children tend to be poorer than children living with their immediate families. They face a higher risk of malnutrition and death, even if they themselves are not HIV positive. They are less likely to attend school, more likely to suffer violence and sexual abuse, and more likely to be at higher risk of HIV infection. Girls suffer disproportionately. Values and experience are not always passed down to those children. The UN warns that agricultural practices are being lost because of the death of parents.

The disaster is therefore clearly about not only those infected, but those who depend on them, and their wider society. Research on vaccines and microbicides, prevention and education are all key to the battle against AIDS. I welcome the statement by Cardinal Georges Cottier, a senior official in the heart of the Vatican, who accepted the position that the commandment "Thou shalt not kill" justifies the use of condoms. Condoms can prevent death as well as the conception of life. But that still is not protecting young women within marriage or partnerships. In southern Africa, the highest incidence is among that group. As Thoraya Obaid, executive director of UNFPA, asked here on Wednesday, what is the use of ABC to such women? They are in the main faithful, but because they are married cannot abstain and cannot force their partners to use condoms. If anything positive comes out of this tragedy, it must be greater gender equality.

ActionAid and others are right to urge the G8 to accept that we have to move rapidly towards universal access. Yes, it is expensive; yes, it is difficult, because you must improve health provision generally and alleviate poverty in order to do that but, with 6,000 children orphaned every day, there is surely no other choice.

Chris Smith was diagnosed as HIV positive in 1987. But no one would have guessed that when he was a Cabinet Minister. I welcome Nelson Mandela's brave statement about his son, but Chris Smith has made an even more important announcement. He has bravely shown and now shared the fact that you can live with HIV and participate in society to the full. As he has said, we have to give that hope and opportunity to those in other parts of the world.

I met a group of HIV positive women in the township of Khayelitsha outside Cape Town in September and their fears, which are so profound, are especially for their children. We know that they should not need to have that fear. We can start by protecting children, where their mothers are HIV positive, by preventing transmission to the infant. In South Africa it is reported by Dr Debbie Bradshaw and others that probably 75 per cent of children who die under the age of five are dying from AIDS.

I visited one centre which was caring for children with AIDS. Those looking after them pointed out that the South African Government never counted the cost of looking after these very sick children when they reckoned that they could not afford the drugs that would have prevented their mothers passing on the disease. We must pursue the provision of treatment to their mothers so that they can continue to care for their children, way beyond the 3 by 5 initiative. The US should set aside protecting its own industry here; cheap generics and the relaxing of trade rules are required. Huge investment in health services is also needed. Meanwhile, how do we care for children who are already orphaned?

Children on the Brink, published in 2002 by UNAIDS and UNICEF, pointed out that:

"Care provided in institutional settings often fails to meet the developmental and long term needs of children".

Also, child-headed households are vulnerable. The preferred solution to this terrible problem is to accommodate children in the extended family. But this, too, is difficult. Families are put under immense strain trying to use their limited resources to pay for additional children. Often children are forced out to work, cannot attend school or are abused. Aged relatives, often lone grandparents, with many children in their care, reach breaking point and desperate poverty. Money needs to follow those orphans if the families are not to go under. Plans have to be made for what happens when a grandparent dies.

Yet at the moment, UNICEF estimates that less than 3 per cent of these children receive public support for basic services, so there is a long way to go. Last year DfID published a strategy on tackling HIV/AIDS in the developing world and the commitment in that to closing the funding gap, strengthening political leadership and improving the international response, is very welcome.

However, in addition to hearing an update on the areas that I have covered, I have a number of specific questions which I would be grateful if the Minister would answer. DfID's strategy committed £1.5 billion to AIDS over the next three years. Of that £150 million is for children affected by AIDS, with 80 per cent for orphans in Africa, much of which will go through DfID country programmes. Could he please say whether that £150 million is all new money, or had some of it already been pledged before? How will the money be allocated between different countries? When will DfID's revised country assistance plans for the relevant countries be completed and will DfID's field offices be producing detailed action plans for orphans in addition to these?

What steps are being taken to help to increase the capacity of the often marginalised ministries in these countries, which are responsible for protecting the rights and meeting the needs of orphans? What is being done to ensure that civil society organisations in developing countries can access resources to help those children? How will the money be tracked and its effectiveness monitored?

Finally, the Global Partners Forum, convened by the World Bank and UNICEF, aims to intensify the global response for such children by highlighting progress and identifying challenges. In light of the importance that the DfID strategy attaches to political leadership, will the UK Government be hosting the Global Partners Forum in 2005?

This is a key year for the UK on the international stage. It set up the Commission for Africa and it says that Africa and climate change are at the top of their agenda for the G8 and the EU. The UK has much to do to persuade the US in particular to join with it in tackling world poverty in a way that most benefits the poor rather than US industry. I look forward to hearing noble Lords' expertise in this huge and challenging area and hearing what the Minister has to say about a catastrophe which, more than Boxing Day's tidal wave, threatens to sweep away so many across at least one continent.

Lord Rea: My Lords, although I am sorry that it had to be on a Friday, I congratulate the noble Baroness on securing time for this important Unstarred Question. She was one of the 17 Members of Parliament and Peers of the all-party groups on Africa and AIDS who took part in the inquiry that led to the very readable document, Averting Catastrophe, published last year. Its findings and recommendations are too many to list now, but the noble Baroness has covered some of them. The Government have also published their response, as well as their own group of documents, referred to by the noble Baroness, outlining their HIV/AIDS strategy and action plan.

Another all-party group, that on population and reproductive health, of which I am a member, also published its report last year following its hearings on the "missing link", emphasising the obvious link that should exist between HIV/AIDS policies and programmes and reproductive health and family planning services. It is very wasteful to fund the two lines separately, when both complement the other. The need for that linkage has been accepted by DfID, UNAIDS and UNFPA, and our report was welcomed in the same speech by Thoraya Obaid, the executive director of the UN Population Fund, a few days ago mentioned by the noble Baroness. The problem is to ensure that reproductive health in general, which should be the basis of treatment and preventive services for all sexually transmitted diseases, including HIV/AIDS, is not swamped by "vertical" programmes directed specifically at HIV.

The impression gained by reading some of the many documents published by governments, NGOs, all-party groups and multilateral agencies, is that there are many plans and projected actions, most of which are laudable, but there is a dearth of reports describing and evaluating what has been done and measuring the effects of those actions. Of course, many projects are only just getting off the ground and it may be several years before significant effects can be seen, but the problem is vast and efforts to contain it are still inadequate in scale. Even if all the millennium goals, the 3 by 5 initiative, the Global Fund and all the other goals were reached on time, the problem would still be with us—although, of course, if we could achieve those goals we would be in a better position to make further progress. I am here emphasising the comments of the noble Baroness.

The progress that has been made in containing the epidemic in certain countries—for example, Uganda, Senegal and Thailand are three of the best known; and, on a minor scale, I should mention the UK itself—in every case has occurred because their governments have recognised the scale of the problem and have not been afraid to spell it out and share it with the people. Sustained, frank and effective campaigns of health education, designed to change behaviour, are the basis of improvement and change. That has to come from within each country.

The care of adults and of children left orphaned by HIV/AIDS is far better when a community, whether in the developed or the developing world, comes out of denial and stigma is removed. That is why it is so important when highly respected statesmen and personalities, such as Nelson Mandela and Chris Smith—the same two names mentioned by the noble Baroness—are honest about their situation.

My experience of the HIV epidemic comes from my chairmanship a few years ago of the non-governmental organisation called Healthlink Worldwide, which supports and shares experience with primary healthcare workers in the developing world. I also visited Kenya two years ago, where I spent 10 days with ICROSS, a charity supporting primary and home-based care in western Kenya.

My lasting impression is of the strength, resilience and mutual support to be found in local communities in the face of poverty and disease, and of the appreciation that they have of quite simple care given by members of their own community who have received appropriate training. Orphans do much better if they can remain in their own communities, but those communities and their adopting parents or grandparents need financial support. That is best provided through local organisations working with charities or non-governmental organisations, such as ICROSS, which have established a mutually trusting relationship.

One of the best pieces of evidence that the all-party group received was that from World Vision. I want to quote one paragraph from that report under the heading "Caregivers":

"Caregivers, also known as home visitors, are individuals living in the same community with the [orphans or vulnerable children]"—

OVCs—a horrible term—

"who provide them with care and support. They may be nominated by the church, OCV coalition members, or self-nominated to provide care to OVCs on a day-to-day basis. Most caregivers will likely be women and men who are already visiting vulnerable family members and neighbours on their own or as members of a church group, a women's group, a youth group, or some other community body. These caregivers, who volunteer their time to support [orphans and vulnerable children] and affected households, form the backbone of a strategy for care and support".

These home visitors, who are literate but have no other qualifications, receive support and training from World Vision and—the organisation that I visited—ICROSS members.

However, I am concerned that DfID, with its country assistance plans aiming to strengthen the health infrastructure through government structures, which may not be working well, may not fund the community-based organisations such as those I have mentioned. These are usually non-governmental organisations which have developed working relationships with people on the ground and understand local beliefs and social structures and, most importantly, can be trusted to manage finances honestly.

To sum up, of course more money is needed. It is a scandal that most people with HIV/AIDS in the developing world will not receive anti-retroviral therapy for many years. The cost of one year's ART—I am sorry to use the jargon—using generic drugs is now down to less than 200 dollars per person per year. To treat the 8 million Africans with AIDS would therefore cost 1.6 billion dollars a year, and to treat the entire 20 million people in Africa with HIV or AIDS would cost 4 billion dollars—that is every year, on and on. Of course, the health infrastructure also needs to be built up so that the programme can be administered. I meant to indicate earlier that that might well be done much more simply than we think by using specifically trained local workers to monitor the treatment that is being given.

I shall make one final point. The President of the United States recently asked Congress for 80 billion dollars to support US forces in Iraq for the current year. That would be enough to treat the 8 million AIDS victims for 50 years. However, if the United States insisted on the full price being paid for its patented drugs, it would treat sufferers for less than half that period. I suggest that that is not only morally outrageous but also very short-sighted. Eight million or possibly 20 million able-bodied people who may now die could enrich the world, including the USA.

Baroness D'Souza: My Lords, I, too, wish to thank the noble Baroness, Lady Northover, for securing this debate. I shall speak briefly on two very different aspects of HIV/AIDS: what field research has revealed about the effects of HIV/AIDS on household income; and the role of broadcasting in educating people about HIV/AIDS more generally. These two separate themes I shall attempt to weave together seamlessly.

A great deal of research has been undertaken since AIDS was acknowledged as a major factor in determining the viability of small communities, especially in southern Africa. Clearly there are methodological difficulties in carrying out studies of this kind. How do you know who is HIV positive, for example, and how do you measure the effect on income levels in a given household? More recent work has overcome some of these problems and begins to show interesting results.

For example, a study sponsored by the Department for International Development of HIV/AIDS in a small rural community in Swaziland, where the HIV prevalence was, I think, 38 per cent, aimed to identify the main factors affecting income levels in both HIV and non-HIV households. One conclusion was that not all households affected by AIDS were necessarily poorer. The death of a non-employed person, sadly, could—temporarily at least—increase the disposable income of a family. Nevertheless, households in which a young adult had died within the past five years and/or which had accepted an orphan from outside the household—both pretty clear indicators of the presence of HIV/AIDS—were also among the poorest. But the very poor also shared certain characteristics, such as less access to land, more unemployment and more low-paid employment, irrespective of HIV status.

The conclusions suggest that in rural areas, at least, it is still poverty rather than HIV/AIDS alone that must continue to be tackled. One has to avoid the practice of what is called "AIDS exceptionalism", whereby households affected by HIV/AIDS receive special subsidies, such as assistance with primary school fees. In this particular community, school dropouts were not predominantly from HIV households but from the very poor, non-HIV households.

This study, among others in the region, again shows that small inputs at the local level can be very effective. Examples include free schooling, targeted food distribution to the poorest households, school feeding projects, the promotion of local formal sector employment and support for agricultural inputs, such as seed and fertiliser.

Poverty is poverty, however caused, and too often results in early maternal deaths and orphans. The local capacity to absorb orphans into extended family or other households may, of course, become saturated, as is more likely in the urban rather than the rural context. But, at present, the local traditional solution is by far the most constructive. If that means subsidising orphan households, that, again, is both do-able and relatively inexpensive.

More long-term solutions require more substantial inputs over an extended period and, of these, perhaps one of the most important is educating both adults and particularly the young on HIV/AIDS avoidance. This is where another UK initiative comes to the fore, and I speak of the BBC World Service and the BBC World Service Trust, which have taken on a highly effective public service broadcasting role on this issue.

Let us consider the numbers. The World Service has a faithful audience of some 180 million people around the world. It broadcasts in 43 languages. One of its strongest audience areas is sub-Saharan Africa, where it is estimated that weekly listeners amount to something like 68 million adults.

The World Service works collaboratively with the World Service Trust, which many here will already know is an independent charity that aims to reduce poverty in developing countries by means of innovative use of the media. These services ran a highly successful HIV/AIDS season in 2003, with programmes on the history of AIDS, its impact on the economy and society, and its health implications. They also broadcast direct advice on sexual practices. Listener participation systems were developed and thousands of people told their personal stories, often, one suspects, for the first time. A poll on knowledge of, and attitudes towards, HIV/AIDS was organised in 15 countries and the results were revealed and discussed in a special programme.

Further campaigns are planned for sub-Saharan Africa, following a successful mass media campaign in India. At least 125 million people watched an interactive TV detective drama, which not only solved crimes but dispelled myths about HIV/AIDS. An equally popular youth reality show followed young people travelling around India on a bus promoting AIDS awareness. There were phone-in facilities, and it is estimated that something like 1,000 individual programmes were aired, together with TV adverts reaching 43 million people. The cost per viewer was minimal, given the economies of scale, and the behavioural change was indicated by a 25 per cent increase in condom use and a 35 per cent increase in discussions on protection against sexually transmitted diseases.

I wax fervent on these matters, but I do so deliberately. No one who has been in downtown Khartoum—or in almost any major city in Africa or elsewhere—at lunchtime can have failed to notice that everything stops for the BBC World Service news. It is a remarkable medium for information and education, and it has shown itself capable of flexibility and imagination in addressing one of the scourges of our time. In this debate, I wish to underline some of the relatively low-cost, but highly effective, ways in which AIDS awareness can be maintained, children can be educated on how to avoid infection and, one hopes, victims of HIV/AIDS can be provided with sufficient information to begin lobbying for antiretroviral drugs.

Baroness Falkner of Margravine: My Lords, I thank my noble friend Lady Northover for this opportunity to discuss one of the greatest challenges facing developing countries—the spread of HIV/AIDS. My thinking in this area is much influenced by having worked for Students Partnership Worldwide, a medium-sized international NGO which runs youth-led peer education programmes in rural communities in five African and two Asian countries severely affected by HIV/AIDS. I will confine most of my remarks to the economic impact of the pandemic and the role of civil society and youth in this area.

Many in civil society welcomed the Government's consultation last year on the UK strategy on HIV/AIDS in the developing world. There is much need for joined-up thinking, as one can see from the players in the field. An NGO working on HIV/AIDS has to contend with strategies from, for example, the World Bank, the IMF, UNAIDS, the Global Business Coalition on HIV/AIDS and our own DfID. The list goes on and on.

As other noble Lords have mentioned, there is little doubt of the need for engagement, given the impact of the pandemic. A World Bank report last year, The Macroeconomics of HIV/AIDS, found that in the absence of any government intervention, an otherwise growing economy severely affected by HIV/AIDS could contract to about one-third of its size in three generations. It found that it affects not only the accumulation of human capital—that is, people's life skills, knowledge and experience—but also negatively exacerbates poverty and inequality, debilitates welfare programmes and impacts on economic growth overall.

The importance of young people to prospects for economic development cannot be overstated. As the Prime Minister's commission for Africa notes, half of the African population is under 18 years of age and so the potential for the pandemic to escalate is horrific, if current trends of new infections continue and if action is not taken now. Yet precious few strategies exist which focus principally on ensuring that young people are given knowledge on prevention from the disease, are provided with access to care and are empowered through life skills so that they can become members of the workforce despite having contracted HIV/AIDS.

I quote a powerful statement from the World Bank report:

"The simple fact that AIDS kills young adults can have profound implications for the whole economy. By killing young adults, often in the prime of their lives, AIDS has an effect not only on its victims, but on their children. Children of AIDS victims are less able to attend school, and also miss out on the life-skills that parents teach their children. In this way, AIDS cuts off the mechanism by which human capital—the engine of long-term economic growth—is transmitted from one generation to the next. If the outbreak of AIDS causes the next generation to be less educated, it means that they, in turn, are less able to provide for their children's education, and so on".

While important work has started, belatedly, on strategies on orphans, there are other significant groups of young people who remain outside most framework strategies. They are rural young people in some of the poorest regions of their countries in Africa. The rural youth—and the figures show young girls in particular—from the ages of 10 to 24, is the most vulnerable group to new HIV/AIDS infections. Therefore, prevention programmes specifically aimed at that age group are crucial for a lasting solution to the pandemic.

Many NGOs working on youth-focused programmes find that where prevention forms part of the strategy, there is a growing trend on the part of some international donors to concentrate on abstinence as the bulwark of their preventive programmes. There is great value on exhorting young people in the most deprived rural communities to abstain from sexual activity, but it does not work. It reinforces stigma and discrimination against those who are infected as well as their families. So programmes must provide a full range of information and services which allow young people to make informed choices if and when to commence sexual relations.

This is an area where youth-to-youth peer education and life skills has proved to be most successful. I mentioned earlier the SPW approach. This NGO trains young volunteers to deliver programmes which mobilise a community response to HIV/AIDS. The volunteers deliver basic information relating to HIV/AIDS to combat myths and misinformation, and they work with young people to develop their life skills and to combat stigma and discrimination. The volunteers do not come from the developed world alone. They do not all come from SPW and VSO. The emphasis is on recruiting as volunteers young people from within the country and the regions who work alongside young people from the developed world.

They work together out of the local school, with the local health clinic, community leaders, church groups and others to ensure that there is community-wide support system for improving preventive strategies and teaching life skills. The local volunteers remain committed to the cause and retain the skills they have learnt as they become adults, so the experience and knowledge-base remains within the community and in the country.

The problem with community-based approaches such as these is the ever-pressing issue of funding. Many international donors are not sufficiently flexible or pro-risk to support rural community-based initiatives. So the criticism I would have of DfID's approach is that it does not focus sufficiently on youth and community-based programmes in this regard. While the call to action is explicit in its commitment to reducing infection rates among young people, the strategy is being developed separately from DfID's sexual and reproductive health strategy. My concern is that adolescent sexual and reproductive health and the important role of education, in particular peer education, are not fully covered in the HIV/AIDS strategy pursued by DfID.

Overall, I very much welcome the new approaches adopted by the Government, but I urge greater joined-up thinking, particularly with respect to the role of civil society in working with young people.

Lord St John of Bletso: My Lords, I join in thanking the noble Baroness, Lady Northover, in bringing this critically important issue to the attention of your Lordships' House.

The noble Baroness and the noble Lord, Lord Fowler, have played an important role in your Lordships' House in keeping this serious threat to the survival of poor countries at the top of the political agenda. This has been a good week for African affairs in the Chamber. The debate follows the four hour debate by my noble friend Lord Hannay of Chiswick, in which he made reference to the millennium development goals review and the causes of conflict in Africa.

I wish to focus my remarks exclusively on the AIDS epidemic in southern Africa and several of the initiatives to support the increasing number of HIV/AIDS orphans. It is a stark statistic that sub-Saharan Africa has just over 10 per cent of the world's population but is home to more than 60 per cent of all people living with HIV. The AIDS epidemic update, published in December last year, gives the number of those infected in the region at over 25 million, with at least 3 million people newly infected last year and 2.3 million who, sadly, died of AIDS last year.

I join the noble Baroness, Lady Northover, in applauding the openness of Nelson Mandela in openly declaring the tragic loss of his son to the virus and also the announcement last week by Chris Smith that he has lived with the virus for over 18 years. Chris Smith's case has thankfully shown that the provision of antiretroviral treatment can transform AIDS from a death sentence to a manageable condition. While I welcome the fact that the South African Government have eventually agreed to start the distribution of retroviral drugs to patients with a CD count below 200, it is unfortunately only a drop in the ocean and way below their target of treating 50,000 patients per year.

I was alarmed to read this morning in a brief I received from the HIV/AIDS campaign of ActionAid International UK that the World Health Organisation is currently facing a 2 billion US dollar shortfall, which could knock off course its commitment to put 3 million people with AIDS on antiretroviral treatment by the end of 2005.

It appears that the most reliable estimates of the number of AIDS orphans and vulnerable children are given in the UNICEF/UNAIDS Children on the Brink report, published last year. As the noble Baroness, Lady Northover, has already mentioned, that report estimates that AIDS has orphaned 12.3 million children in sub-Saharan Africa. This orphan population will certainly increase dramatically in the next decade.

In the poverty stricken areas of Kwazulu—Natal, in South Africa—the HIV/AIDS pandemic has caused a serious breakdown in the traditional family and community structures. With the absence of a father figure, the availability of the wide range of addictive drugs on the streets, coupled with peer group influence, youth—in particular, young boys—has become vulnerable to crime and drug abuse. Research has shown that the 15 year-olds are the most vulnerable.

In order to address the long-term effects of these social problems, it is not sufficient simply to feed, clothe and educate these children, although those are obvious priorities, it is imperative to empower, support and protect these vulnerable young children. I stress the word "empower". I have been particularly impressed with the remarkable work of Heather Reynolds who, some 10 years ago, set up an NGO in Kwazulu, Natal, called God's Golden Acre, to care for the increasing numbers of orphaned children in a rural outreach programme in the valley areas supporting more than 750 orphaned children.

Among her remarkable work she has launched a junior soccer league that involves over 100 teams around the surrounding region. The active participation of these children in an organised soccer league has both empowered them and provided a social venue while drawing them away from the grips of drugs, alcohol and violence. It is heartening to know that the chairman of our FA premier league, Dave Richards, has thrown his full support and his organisation behind this most worthwhile initiative by providing footballs, coaching and other support.

The debate reminds me of the very moving speech some two years ago in Westminster Hall celebrating the 100th anniversary of the Rhodes Scholarship Trust when Nelson Mandela drew a comparison between the blight of leprosy 100 years ago and the AIDS pandemic today. In a moving account he relayed how he had visited a township just outside Johannesburg where AIDS orphans were almost isolated into an exclusion zone. He relayed how he had personally physically embraced these children and adopted several of them, and the difference that it made to their lives over the ensuing years. He paid tribute to the work of the late Princess Diana, who, through her love and physical affection of many AIDS orphans, had almost empowered them and made them feel like normal human beings.

It is encouraging to hear that our Government are committed to spending at least £150 million over the next three years on programmes to meet the needs of orphans and other children, particularly in Africa, made vulnerable because of HIV and AIDS. I applaud the recent pledge by Bill Gates and our Chancellor to provide more vaccine treatment.

It is not just the blight of AIDS that we need to address. I understand that more than 350 million Africans contract malaria every year, and yet malaria medication is not proclaimed as a basic human right.

HIV/AIDS awareness campaigns are almost non-existent in many squatter camps and rural areas in South Africa. I entirely endorse the sentiments of my noble friend Lady D'Souza that the BBC World Service can play a very important role in getting that message across. More campaigns such as the LoveLife Campaign are required to address the persistent behavioural trends, particularly by the truckers in South Africa, who are largely to blame for the spread of the disease in the rural areas.

In conclusion, I am encouraged by the framework publication for the protection, care and support of orphans and vulnerable children living in a world with HIV and AIDS. The five key strategies are a good start. It is also encouraging that there are new funding commitments from the 2004 start up of the President's Emergency Plan for AIDS Relief from the US Government, UNICEF, UNAIDS and the Global Fund to fight AIDS, tuberculosis and malaria. That is a good start, but much more is needed.

Baroness Neuberger: My Lords, I am delighted to wind up for my party in this debate. I, too, congratulate my noble friend Lady Northover on securing the debate, which is of great importance—would that it were not happening on a Friday. Many noble Lords who are not here have said how much they would have liked to have taken part in this debate. Perhaps next time we might be given another day.

I am no great expert in this area, but I do have a particular concern about what happens to children and the questions that arise concerning their treatment if they are either diagnosed as having AIDS or are HIV positive, as many AIDS orphans sadly turn out to be. Like other noble Lord who have already spoken in the debate, I have received enormous amounts of briefing from a variety of organisations. I am hugely grateful for that and to my noble friend Lady Northover, who organised much of its delivery. I have also had an opportunity for a brief conversation with one of the world's acknowledged experts in the field, Professor Michael Adler, who has attempted to impose some rigour on my thinking.

As the availability of antiretroviral drugs increases in Africa and elsewhere, and as we head towards hitting the target, or at least we hope we shall, of "3 by 5"—3 million treated with ART drugs by the end of this year, 2005, out of an estimated 9 million who could benefit from the drugs—how will we ensure that, as a nation involved in funding some of these programmes and involved in the G8 countries that have debated these issues, enough of this therapy will go to women and children? That question has been raised time and again during the debate. The all-party parliamentary group has done sterling work, as the noble Lord, Lord Rea said. In southern Africa, it is true that, as the noble Lord, Lord St John of Bletso, said, with the drugs being made available only to those with a count below 200, what is happening is not enough. There is a shortfall. What are we as a nation going to do about that?

Secondly, given that we know that the number of Aids orphans is still rising exponentially and that a proportion of them will be HIV-positive, what is being done to ensure that that generation, already so appallingly afflicted by the loss of parents and, in some cases, grandparents, will not simply die as their parents have done? How can the UK Government, in their work through DfID or with other agencies, ensure that AIDS orphans, whose voices will not be among the loudest in the clamour to get access to treatment and who may well not even have enough money to travel to treatment centres, get access both to the drugs and to the prevention programmes that are essential in slowing the spread of the disease? As we know, those are the ones who do not get to school, as the noble Baroness, Lady Northover, said. They are in the poorest families where there has been the death of a young adult or an orphan has been adopted, as the noble Baroness, Lady D'Souza, said.

Some people are beginning to say that AIDS vaccine is so near to development and wide availability that we need to stop worrying about treatment and put all our resources into vaccination. But that philosophy will simply sentence another generation to death before the effects kick in, even if the vaccine is as near as some are saying and even if it were possible to vaccinate sufficiently widely to prevent the spread of the disease. That is not to respond with anything but great praise for what Bill Gates and our Chancellor, Gordon Brown, are proposing, because that is admirable in its own right.

The questions for the Government—genuine questions, as no one seems to have all the answers—is what DfID can truly do through its programmes and what the Government can do through their partnerships with other agencies involved to ensure various things. The Government's strategy so far has been impressive, but does not go far enough. Here is the list.

First, ART therapy for those children and young people who have been orphaned and are voiceless and who are not so immuno-compromised already that such treatment may be of little use. Secondly, prevention programmes running alongside that treatment programme, targeting especially young women and girls and including sexually-transmitted infections along with AIDS. That way, sexual behaviours may change; whereas proclaiming abstinence will not work. Young women may be less vulnerable to sexual advances from older, infected men, including, as the noble Lord, Lord St John, said, the truckers in southern Africa, and women and girls may learn to take sexually-transmitted infection seriously, because they render do people even more liable to AIDS and HIV infection than if they were clear of infection altogether.

Also important are reproductive health, family planning, as suggested by the noble Lord, Lord Rea, and, of course, great public health campaigns, as suggested by the noble Baroness, Lady D'Souza. The work of the World Service has been absolutely stunning in that regard, but there is clearly a great deal more that it could do, had it the funding to do it. I ought to declare an interest as a somewhat infrequent broadcaster on the World Service.

Thirdly, what other programmes might the Government, in association with other agencies, devise to target young women and girls, who are so often excluded in many developing countries from health care programmes in general? What can be done or arranged to be delivered to ensure that women and girls understand that they are entitled to treatment and, particularly where AIDS drugs are still in short supply, as they are throughout the developing world, to ensure that women take precedence over men where, otherwise, the children would be orphaned?

Fourthly, given the "3 by 5" promise, will the Government consider working with others to make generic drugs more widely available, following the example of CIPLA in India, for instance, by providing drugs for little or nothing? Will they work with the other G8 countries to ensure, as Action Aid is asking, that the right to public health and treatment for Aids takes precedence over pharmaceutical patents in this area and allow the growth of the manufacture of generic drugs in the very countries and areas worst affected by the disease? For that—bringing down the price and producing the drugs locally—might have the most powerful effect on availability of treatment to women and children of all measures available.

So I wait with real interest to hear what the Minister says in reply. It is not as if we oppose each other in any sense; everyone is here with the best of intentions to do the best that we possibly can. But we want to know whether DfID's strategy is really on track to slow the progress of the epidemic. We want to know whether the £150 million for orphans is new money and how it will be allocated. Will that be done through the DfID field offices? We want to know what are the plans for working with the most local of local institutions and voluntary bodies, as the noble Lords, Lord Rea and Lords St John of Bletso, suggested.

Those are questions that the Government have to answer and with which a whole variety of voluntary organisations and people across this House and elsewhere want to be involved. I very much look forward to hearing what the Minister has to say in reply.

Baroness Rawlings: My Lords, I, too, add my thanks to the noble Baroness, Lady Northover, for securing this important debate. From the debate of the noble Baroness, Lady Whitaker, last week, it was clear that we cannot hope to tackle poverty on a global scale without addressing HIV/AIDS. We on these Benches welcome this opportunity to discuss this significant problem in more detail.

As many of your Lordships have highlighted, the number of people affected by what the WHO assistant director described as,

"the premier disease of mass destruction",

is astounding. At present, more than 39.4 million people in the world are HIV-positive. According to the UN, 5 million contracted the disease in the last year alone and 3 million died of AIDS. In that Malthusian context, the UN has revised down its forecast for world population growth due to the current prediction that nearly 300 million people will die of AIDS before 2050, and that is excluding those who are infected who will die of secondary illnesses due to a weakened immune system.

Although we welcome the work that Her Majesty's Government have been doing on the issue of HIV/AIDS, kicked off by the Call for Action strategy in 2003 and revitalised by our leadership of the G8, it is clear that the virus is a major contributing factor jeopardising the achievement of the millennium development goals by 2015. As reported last week, they are already well behind schedule.

The National Audit Office has stated that, from UN Development Programme estimates, the proportion of people living in absolute poverty in Burkina Faso, Rwanda and Uganda as a result of HIV/AIDS will actually increase by 2015. Funding to counter the spread of the virus has tripled since 2001, but it still falls well short of the 12 billion dollars that the UN estimates is needed. What pressure are Her Majesty's Government putting on the US Administration, as mentioned by the noble Lord, Lord Rea, to increase untied targeted funds for HIV/AIDS projects? Although, as I see from last week's presidential briefing, President Bush has increased the funding fourfold since 2001 and his emergency five-year plan of 15 billion dollars is on the way, we will obviously need more.

The highly critical National Audit Office report last year suggested that there was still much to be done here at home. According to the report, a significant number of DfiD strategy papers and country assistant plans failed to mention the virus at all, and at the time of the report, only two of the seven planned guidance notes on HIV/AIDS programmes had been published. Other principle criticisms involved poor money management and inadequate communication to donor countries. What steps have Her Majesty's Government taken to address those concerns? What developments have there been to ensure that the financial support for this issue is ring-fenced for targeting HIV/AIDS by the recipient countries?

As I have already mentioned, more money is needed to address the problem, but, as we all know, that is of little use unless the funds are spent effectively and efficiently. It is vital that the spending is supported by the political will to make it work where it is most needed. We all know of examples in Africa where leaders do not even acknowledge that the disease exists. Indeed, Kofi Annan has distressingly said that he is not,

"winning the war [on AIDS] because I don't think the leaders of the world are engaged enough".

As the noble Baroness, Lady Northover, has already emphasised, the virus has a particularly distressing effect on women and children. Over half of all AIDS sufferers are now women. An estimated 3.2 million children under the age of 15 are also living with the virus, while 14 million children worldwide will have been orphaned by the epidemic by 2010.

For every male child infected with HIV in Africa between three and six girls are infected. It is a self-perpetuating cycle of disease, poverty and regressive development. The very programmes aimed at empowering and educating women and children to help prevent the spread of the disease is undermined as children are withdrawn from school to care for ill relatives. That was illustrated clearly by the noble Baronesses, Lady Falkner and Lady Neuberger. It is widely recognised that there is a need to address the cultural factors and gender inequalities that fuel this epidemic in Africa and Asia.
 
It is also important proactively to try to prevent the transmission of HIV from mother to child. Cameroon recently saw a sharp rise, doubling HIV prevalence among pregnant women. What steps are Her Majesty's Government taking to ensure that antiretroviral drugs are available and administered properly to pregnant women? Have they had discussions with the Global Health Fund on the purchase and supply of drugs for this specifically affected group?

It is natural that a lot of this debate—and, indeed, in the current climate, most debates of this kind—should focus on Africa. HIV/AIDS is the continent's biggest killer, particularly among those who play key roles in society, such as teachers, farmers and health workers. However, we must not lose sight of those other parts of the world which also suffer the disease. As the noble Baroness, Lady Flather, highlighted last week, and the noble Baroness, Lady Northover, mentioned today, the problem is rapidly spreading to India; it is also prevalent in China and other poorer parts of Asia. It is there that more proactive reactions are needed.

If the current growth of infection continues in India, by 2010 there will be even more people living with the virus in Asia than there are in Africa. Surely, we must do all that we can to stop this. Can the Minister inform the House what percentage of the funds spent on HIV/AIDS programmes goes to non-African countries?

As a nation, we need to encourage an integrated approach between the BBC World Service Trust, as we heard from the noble Baroness, Lady D'Souza; NGOs; businesses; pharmaceutical companies and the WHO. As the noble Lord, Lord St John of Bletso, said, everyone has a responsibility to help.

I am proud of King's College London: I must declare an interest as chairman of council. Archbishop Tutu opened major new infection and immunity laboratories—financed by HEFCE, the Wellcome Trust, the Dunhill Trust and the Guy's and St Thomas' Charity—at our Guy's campus to carry out research in the area while he was a visiting professor of post-conflict societies at King's in 2004. That research is led by Professor Michael Malim, head of the Department of Infectious Diseases, who investigates the genetic basis of susceptibility and resistance to disease.

We need to advocate holistic approaches to tackling the virus within the developing countries, build up the infrastructures necessary to administer medical care and access to clean water and sanitation, as well as focusing on drugs. Most of all we need the international political will to win the war on HIV/AIDS.

Lord Triesman: My Lords, first, I, too, would like to thank the noble Baroness, Lady Northover, for introducing this debate and other noble Lords for their contributions. I have spent most of my working life turning up for work on Fridays: I have never thought that it was a disbarment to other people to do so as well. I agree with the assessment made by the noble Baroness, Lady Northover, and her comments about the contribution made by the noble Lord, Lord Hannay, last week. I, too, am full of admiration for my good and right honourable friend Chris Smith who has demonstrated what treatment can guarantee; that is, a fine and active public life. We all owe a debt to President Nelson Mandela for his openness and leadership.

The sheer scale of the AIDS pandemic is well known to us all. The statistics are staggering and increasing year on year. In 2004, more than 3 million people died and nearly 5 million people were newly infected with the virus. Today, almost 40 million people are living with HIV.

The noble Baroness, Lady Northover, rightly raised the tragic plight of children and AIDS. Millions of children have been made vulnerable or orphaned by AIDS. As the noble Lord, Lord St John, emphasised, the worst affected region is sub-Saharan Africa, which has the greatest proportion of children who are orphans. In 2003, an estimated 12.3 million African children were orphaned as a result of AIDS. The worst, as many noble Lords have said, is yet to come. The number of children orphaned by AIDS is expected to rise to 18.4 million by 2010. As the pandemic unfolds, a growing number will be double orphans—children who have lost both their parents.

The impact of HIV and AIDS on children presents a serious, growing challenge to families, communities and societies, and to the achievement of the majority of the millennium development goals. As I said last week, there will be a detailed assessment of where we are on those goals within a few weeks. However, as noble Lords have said, by any measure there is a plain risk that civil society is unravelling and at risk as a result of what is happening.

The orphan crisis exacerbates extreme poverty and hunger, undermines progress towards universal primary education, increases child mortality and accelerates the spread of HIV. As other noble Lords have noted, thousands of children—especially girls—are pulled out of school when the breadwinner dies. Girls and women are affected most harshly.

The noble Baroness, Lady Neuberger, asked about the input in relation to the funding of education for young women and girls. That has been one of the key focuses of government policy, which is the right policy. Evidence from 17 African countries and four Latin American countries shows that better-educated girls hold off longer from sexual activity and are more likely to require their partners to use condoms. In short, they act in a more informed and effective way. Women with some schooling are nearly five times as likely as uneducated women to have used a condom the last time that they had sex. The case speaks for itself.

AIDS results not only in growing numbers of orphans, but also increases more generally the vulnerability of children living in families and communities affected by the disease. The majority of these orphans are between the ages of 11 and 15 years—young adults who have their own sexual health and reproductive rights needs. Although it is not always commented upon, to assist the aid effort there is also a plain need to understand the research being done on the psycho-social impact of AIDS orphaning. What research has been done is at an early stage, but there is clear evidence of depression and anxiety states and even where high levels of that kind of distress are not reported, young people are much more likely to suffer from physical ailments and to find it hard to sustain the social fabric of the communities in which they live. We need to work in that area as well.

The challenges are enormous and worse impacts on children are yet to come. To date, the burden of the tragedy has been borne largely by families themselves. In countries like Uganda, up to one-third of all households are caring for at least one orphan. In May last year the Select Committee on International Development held a special hearing on orphans and vulnerable children. My honourable friend Gareth Thomas, the Minister at DfID, gave evidence, as did many of the NGOs. Mr Thomas was honest to admit that the UK and the international community in general are not doing enough to mitigate the crisis around orphans and children made vulnerable by HIV and AIDS. We must acknowledge that. He pledged that the new UK strategy on tackling AIDS would address this.

We therefore fully endorse the UNICEF framework for the protection, care and support of orphans. We support the first of the strategies outlined in the framework. Strengthening the capacity of families to protect and care for orphans by improving the economic capacity of households is absolutely central. There are many different ways in which it can be done: cash transfers in the form of pensions; grants for children; in-kind transfers and so forth. The noble Baroness, Lady D'Souza, is surely right to say that we need to understand the most local and household economies if we are to have the right impact and provide tailor-made responses to poverty in general as well as the pandemic more specifically.

The UK is totally committed to tackling AIDS. Indeed, we are already the world's second biggest donor for AIDS and sexual and reproductive health assistance. The commitments signalled when the Prime Minister launched Taking Action, the UK's strategy for tackling HIV and AIDS in the developing world, underline still further this commitment.

My noble friend Lord Rea asked whether we evaluate what we have done in order to make sure that we are making progress. We certainly do, even quite early in these programmes. He is right to point out that each country must discuss factually and honestly the problems with their own peoples if we are to make any of these programmes work. The noble Baroness, Lady D'Souza, also helpfully reminded us what we can do through external work, in particular the quite exceptional work of the BBC World Service and the World Service Trust on AIDS awareness. I too congratulate both those bodies on their work.

The document Taking Action sets out how the UK will respond to the challenges by promoting a comprehensive response to tackle prevention, treatment and care as well as addressing the social impact of AIDS, prioritising the needs of women, young people including orphans, and other children made vulnerable by HIV and AIDS.

I hope in my next few comments to cover most of the questions put to me by the noble Baronesses, Lady Northover and Lady Neuberger. We have committed £1.5 billion of taxpayers' money to tackling HIV and AIDS over the next three years. This overall commitment includes a doubling of our support for the Global Fund to Fight AIDS, Tuberculosis and Malaria, bringing our total support to over £250 million through to 2008; additional funding, to £36 million over four years, to UNAIDS to support its global leadership; additional funding, to £80 million over four years, to UNFPA to support its HIV prevention and sexual and reproductive health work with women; increased support for research into microbicides and vaccines for HIV prevention; and at least £150 million on programmes to meet the needs of orphans and other children made vulnerable by HIV and AIDS. I have been asked if all this is new money. I can give the categorical assurance to noble Lords that it is all new money.

The UK became one of the first countries to endorse UNICEF's Strategic Framework for the Protection, Care and Support of Orphans and Children Made Vulnerable by HIV/AIDS. This provides guidelines for the global response to the issues.

We are committed to acting within the framework's five pillars—and, indeed, urging it on the United States and all other governments. These pillars are: strengthening families' ability to cope through financial credits, childcare and developing skills; starting and supporting community-based responses, largely through involving local leaders—as the noble Baroness, Lady Rawlings, pointed out, political leadership is needed locally as well as at national level; ensuring that vulnerable children have access to essential services, particularly education and healthcare; ensuring that governments protect the children who are the most vulnerable; and, finally, raising awareness to create an environment that understands and supports these children.

These pillars are strengthened by three of our own considerations: to support national development plans and not in any way to undermine them; to support parents at the same time as we address children by providing effective prevention, treatment and care services—keeping parents alive prevents and delays orphaning for obvious reasons; and to act with all of our partners, national and international, as we work at the global, regional and country levels.

I mentioned that we are committed to spending at least £150 million over the next three years on orphans and vulnerable children, and I should like to give a little more detail on those plans. First, we are committed to supporting UNICEF, which will lead the endeavour, with about £44 million over three years. Part of this funding will go towards assisting national governments to analyse the extent of their problem and to plan an adequate response.

Secondly, we will spend £85 million in Africa through DfID country programmes. Of the money we are spending, approximately 90 per cent will be spent in Africa and 10 per cent elsewhere. Thirdly, we will spend at least £5 million in Asia. Fourthly, we will spend £2 million on scientific research and, finally, a further £14 million will be programmed as the needs emerge from the other work I have described.

The noble Baroness, Lady Northover, asked a number of questions and I shall do my best to answer them as briefly as I can. She asked first about DfID's country assistance plans to countries with large numbers of orphans. Country assistance plans are reviewed annually by DfID in the country offices. The purpose of the plan is to report progress against public service agreement targets, which include tackling HIV/AIDS. This year the reviews will have a strong focus on assessing what progress has been made in each country on AIDS, what contribution the international community has specifically made and where further action will be required. I should say to my noble friend Lord Rea and to the noble Lord, Lord St John, that many of the strong links in doing this are with the voluntary organisations; they often know much more than anyone else. The role of civil society organisations is plainly vital and we accept it in all countries.

I was asked whether DfID's field offices will be producing detailed action plans in addition to the revised country assistance plans in those countries. It is important that affected countries have detailed action plans to address AIDS. DfID strongly supports the "three ones" approach—that is, one strategic framework, one AIDS authority, one monitoring system—with due regard to the civil society organisations. Thus DfID's own country plans are designed to support the implementation of "three ones" rather than to set out a separate or parallel plan.

I was asked what steps the Government are taking to ensure that DfID field offices help to increase the capacity of the most marginalised ministries in developing countries responsible for protecting the rights of orphans and children. Through its country programmes, DfID is supporting many governments to advance their national OVC plans through health and education sectors—those ministries—the social protection programmes and working with civil society. To date, 16 sub-Saharan African countries have drawn up national OVC action plans in that light.

I have been asked what steps the Government are taking to ensure that civil society organisations in the developing countries are able to access resources. I mention this a little in passing. We are fully committed to supporting the work of these organisations in addressing the AIDS pandemic. Much of the support funded by our OVC finance commitment will be implemented in partnership with local and international CSOs. It is plainly vital that it should work that way.

The noble Baroness, Lady Falkner, rightly made the point that the deliverers on occasion face a number of potential funders, and that can be quite a complex business. Co-ordination under the "three ones" approach will certainly help. However, I know that some civil society organisations are quite pleased on occasions when one funding application has not worked to find a niche in which another one does. We have probably all, in our time, relied on the degree of flexibility that that affords. I agree very strongly with the points that the noble Baroness made.

The noble Lord, Lord St John, made points about building civil society organisations in South Africa, as elsewhere. They are ultimately always about empowerment if they are to work. I strongly agree, and I also agree with him that sport and other social activities have a decisive influence.

We are trying to ensure that the input sector codes for social protection for orphans and vulnerable children will enable us to track properly and monitor the £150 million commitment to make sure that it does not go in the wrong direction, as several noble Lords have mentioned. Legislation, institution-building and making sure that we reach the organisations that work with street children are all vital if we are to succeed.

I am sorry if I am making these points at too great a length, but it is such a vital, heart-tearing issue that I want to ensure that the House is properly informed of the arrangements in which we are engaged.

The noble Baroness, Lady Northover, asked about the high-level conferences in which we should be involved. In March, UNAIDS and the UK will co-host a high-level meeting to agree an action plan within the "three ones" concept to underpin future co-operation between developing countries and their partners. We aim for a consensus, stepping up the response to AIDS in the most affected countries and making sure that national governments can drive forward the action plans.

The noble Baroness, Lady Rawlings, asked how we are seeking to influence the United States and others. I have made a point about that, but the conference I have just mentioned and the one I am about to mention will be vital in the preparation of precisely that endeavour.

We will be hosting the Global Fund to Fight AIDS, Tuberculosis and Malaria's second replenishment conference in September this year. The meeting will be held alongside a broader AIDS funding meeting, building on the March event that I have just mentioned, which aims to close the financial gap for AIDS.

Using generic drugs is one of the issues that the Chancellor mentioned specifically last week. The activities of companies which are not always seen as making the greatest contribution in this area come to mind. GlaxoSmithKline, for example, is offering its key drugs for the treatment of HIV/AIDS at zero profit prices. Boehringer Ingelheim is providing its drugs to developing countries for five years free of charge, in many cases. So there are some quite inspiring examples of people producing the non-generic varieties of drugs and doing some excellent work.

By the end of 2005, we want an agreement among donors and the international system on a well co-ordinated and funded plan to tackle this vast problem. I think that the noble Baroness, Lady Rawlings, asked perhaps the most critical question. Plans are plans—they are just words on paper if they are not put into action. The vital question is, of course, political leadership—the absolute determination to make the plans work. I believe—perhaps I would—that we are working extremely hard, with support on all sides of the House, to ensure that political leadership in countries affected by HIV and AIDS is improving and is focusing, and that Ministers in those departments understand what they need to do. A lot of the work is tailored to that.

We are working on other kinds of leadership in the developing countries; we are working with religious leaders and leaders in civil societies. We are offering a good deal of aid in that area, because that is so often exactly where it is needed to yield the right results. Successful politically supported AIDS strategies are beginning to emerge as a result—Thailand has been mentioned.

In conclusion, I believe that we have serious plans into which we have put very considerable amounts of funding. Political leadership and a steely determination to make the difference are what is required. I thank all noble Lords who have, to a person, arrived at precisely that conclusion.

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