Examination of Witnesses (Questions 1
THURSDAY 8 JUNE 2000
1. Order, order, May I thank you all for coming
this morning to discuss this very serious and difficult question.
We are all going to have to be very disciplined to get through
the gamut of your very extensive report which you have given us.
We want to explore a number of aspects with you. Since its inception
the Committee has been concerned about HIV/AIDS in all our visits
overseas to Uganda, Rwanda, Kenya, most recently to Mozambique,
South Africa, Zambia and Malawi but also to the sub-continent,
Bangladesh, Pakistan and India. We have gathered quite a lot of
evidence by visiting DFID projects there and the Committee has
found itself in unusual circumstances in large brothels in Bangladesh
and in West Calcutta and in other extraordinary situations in
order to examine how best to combat HIV/AIDS. We do have quite
a lot of evidence but we do need the expert evidence which you
have and we look forward to hearing from you on it. I understand
you have a short opening statement.
(Dr Lob-Levyt) Just briefly to say that
we have found it an extremely useful exercise being asked to produce
this brief, it has helped us advance some of our own thinking,
and to reinforce the message that over the past more than a year
now we have really been moving out of the narrow health view of
this issue and moving it out into the much broader development
agenda, beginning to mainstream it into our work, looking at the
multidisciplinary skills which need to be applied and working
across many different sectors. Lastly, HIV/AIDS is seen as very
much part of the development and poverty agenda and has to be
dealt with in that context. We do not want to take it as a separate
issue but mainstreamed into our work.
2. Obviously HIV/AIDS is impacting on every
aspect of life not just in the developing world, so we have to
extend it and look at its impact on developments. That is exactly
the area on which the Committee wants to concentrate. May I ask
what has been learned about the spread of HIV/AIDS? Will rates
of HIV infection in sub-Saharan Africa continue to rise dramatically
in your opinion or is it plateauing as some have expected? What
are the current predictions for the HIV epidemic in other parts
of the world, such as Asia or the former Soviet Union?
(Dr Lob-Levyt) One thing we have learned is that HIV/AIDS
has proven to be easily underestimated and that what is of vital
importance is getting as much data on a country by country basis
as well as regional aspects as to how epidemics evolve. It is
clear that it is going to vary across different regions and within
sub-regions and that in some areas we are seeing some possibilities
of plateauing, possibly for example in Uganda, but in other areas
we are just not quite sure how far it is going to go and we are
seeing a different pattern of spread of the epidemic in Asia from
Africa. At this stage it might be helpful to invite Mr Bob Grose
to comment on it in some more detail and maybe my other colleagues
want to come in specifically on Asian and African issues.
3. Bob Grose, you are the HIV/AIDS Adviser in
the Health and Population Department, so this is your specific
area, is it?
(Mr Grose) Yes, that is right. We heard just a couple
of weeks ago that the number of countries in sub-Saharan Africa
that have prevalence of over 10 per cent amongst adults has now
gone up to 15. There is no reason to expect that more countries
will not get over that threshold within the next few months. The
answer to your question is that some rates are still going up,
we will see some very high rates developing in some of the sub-Saharan
African countries but in others, perhaps where the epidemic is
more mature, combined with strong governmental responses, we shall
begin to see the epidemic curve levelling out and, as has happened
in Uganda, perhaps beginning to drop.
4. Could I just be clear? Over ten per cent
adult infection in 15 countries.
(Mr Grose) Yes, that is right; in 15 countries at
5. I think we should be quite clear where our
statistics are coming from. Could you say how those statistics
are gathered and what degree of extrapolation is involved?
(Mr Grose) Those figures come from UNAIDS. UNAIDS
derives them from sources in countries and the best data comes
from what are called sero-prevalence studies which from time to
time measure the amount of HIV in women attending ante-natal clinics
or sexually transmitted diseases clinics. Those are the two most
important and also in other locations as well.
6. Would we be right to say that they are likely
to be understated rather than overstated?
(Mr Grose) We think it is probably a mixed picture.
Some of the most recent research findings suggest that prevalence
levels in ante-natal clinic attenders are probably lower than
for women in the population at large and there are reasons for
that which include the fact that fertility drops in women who
have HIV infection so they are less likely to turn up at ante-natal
7. And with age.
(Mr Grose) And with age, but the age group we are
looking at is mostly where women would normally still be fertile,
in other words in their teens, twenties and thirties.
8. We do not know therefore what the prevalence
is amongst men, do we?
(Mr Grose) You are right, there are not sentinel surveillance
studies to the same level or the same extent amongst men, though
they would probably tend to be the main attenders at sexually
transmitted disease clinics. Sometimes studies are carried out
in the military or the police. They also come from blood transfusion
services. Data in general can be very patchy but it may be worth
adding at this stage that whenever we or UNAIDS speak about a
specific figure, in fact there is sometimes a very big range around
that figure and they are all estimates.
9. May I say that I do not underestimate either
the importance of the issue, in fact quite the opposite, nor the
difficulty of obtaining data? I am a trustee of an organisation
called the HALO Trust working in Somalia, Angola and Mozambique.
I do not know how accurate this information I was given is but
they say they test all people who work for them, and they have
labour forces of 300 or 400, and they have never had an HIV positive
case amongst the tests. I found that extraordinary. It may be
that they are just plain wrong or that the person I spoke to did
not know. Really what I am asking is how accurate you think the
(Mr Grose) First a comment on the report you had from
the HALO Trust. It is very unusual for employers to test all their
workers and there are some fairly serious ethical issues which
I hope they are dealing with in doing that.
10. I think they do it as good employment practice
(Mr Grose) Yes, it is very surprising that they are
not finding HIV positive cases and I obviously cannot comment
on that except to say that it is not the norm as we understand
it. On accuracy, I refer back to my earlier comment about these
being estimates. Let me take it out of the African context and
put it in the Indian context for a specific example. A colleague
who is a world renowned epidemiologist worked with the Indian
Government on existing data and came up with a relatively low
estimate for India because the sound evidence did not exist for
higher estimates. As a result of further discussion with colleagues
from UNAIDS and World Bank and the Indian Government, they came
up with a much higher range. The range they were talking about
in that case, which is possibly a bit extreme, was somewhere between
about 2.5 million and 6 million and they eventually agreed that
a reasonable estimate, because the government wanted one figure,
was approaching four. Within that range different specialists
will have their preference. Some will say they think the evidence
does not support the high estimates and others will say even if
the evidence is not there, they think that all the indications
are that it is at the higher end. That is one illustration of
how difficult it can be. We are all working on the sentinel sero-prevalence
data which is the best available. I should say that it is improving
all the time.
11. What is your opinion on the spread of HIV/AIDS
(Mr Grose) Recently a very helpful workshop was run
alongside the annual meeting of the Asia Development Bank. The
paper which was submitted to that has presented what we think
will be the best argued case, though it is somewhat controversial.
The argument there is that there is no evidence at the moment
to suggest that South and South East Asian countries will follow
the southern Africa example. However, we have to say that HIV
has taught us all to be very careful about predictions like this.
It has proven itself to be unpredictable.
(Dr Lob-Levyt) In South Asia, even when you might
have low levels of prevalence, because of the much larger populations
which live in India and China and other countries the absolute
numbers are going to be stupendously large. There are countries
within South Asia which are already demonstrating quite high rates,
like Cambodia for example. There are populations at risk who have
very high transmission rates, for example migrant workers from
Nepal to India and commercial sex workers in different parts and
military and police are showing high rates. It is again a complex
picture and one strong message we are taking as DFID is a need
to increase the amount of resources going to surveillance, to
get better data, not only to get the absolute figures but to map
out the patterns of the epidemic as they vary across countries,
the at risk groups, because that will profoundly affect the kind
of strategies which might be involved to respond to the epidemic
country by country.
12. More for the record than anything else,
but it would be true, would it not, that a normally useful source
of statistics is cause of death, but that in this case the cause
of death is nearly always given as the opportunistic infection
at the end rather than AIDS itself? Would you confirm that?
(Mr Grose) Yes, that is generally correct. May I just
finish off the previous question on Asia and complementing what
Dr Lob-Levyt was saying, there is much variation amongst Asian
countries. The Philippines and Indonesia for example have very
low rates, whereas Cambodia and Thailand have higher rates and
the infected populations tend to be concentrated populations of
migrant workers or sex workers or their clients or the military
rather than, so far, a widespread epidemic across the population
as it tends to be in southern Africa.
13. What is distinctive about HIV/AIDS when
compared to other components of the communicable disease burden?
(Dr Lob-Levyt) We are saying that as a global burden
HIV/AIDS is increasing rapidly and becoming as important as other
communicable disease burdens such as TB. Of course there is a
close link between TB and HIV. It comes back to a need to tackle
HIV in the context of poverty and development. HIV thrives in
the same communities as TB, malaria and other communicable diseases
thrive, that is the poor living in developing countries.
14. Although this disease is not confined to
the poor, is it?
(Dr Lob-Levyt) No; that is absolutely correct. It
is not confined to the poor but poverty is a great driver of HIV
and the poor appear to be disproportionately affected for a number
of reasons compared with the better off. It crosses all levels
of society, for example the medical profession, the teaching profession
is being decimated in many of these countries.
15. There has been a lot of discussion recently
about where HIV came from in the first place. Do you have any
view yourselves on where it might have come from?
(Mr Grose) You are right, there has been a lot of
speculation and the most recent has been this book by Ed Hooper
in which he tries to make a link with some of the early polio
vaccine research. There may be something in it. The version I
prefer myself, but it does often come back to personal preferences
for these stories, is that it has existed for many, many years
in the simian population, in monkeys, and that at some stage,
who knows when, last century, earlier this century, it transferred
to humans, possibly even longer ago and that the takeoff happened
largely as a result of social changes such as rapid urbanisation.
The soundbite which I like on this issue is that it does not matter.
The issue is that it is now a major epidemic and these controversies
will run in the background for a long time.
16. You say it does not matter, but is it not
true that if it had been a consequence of a failed vaccine development
experiment the obligation to pour more resources into the development
of an effective vaccine against it on the developed world who
would have created the problem in the first place would be absolutely
inescapable. How much is being spent on developing a vaccine at
(Dr Lob-Levyt) We do not have the total figures that
are being spent on vaccines. The UK Government is contributing
substantially to vaccine development: £14 million to the
international AIDS vaccine initiative, for example.
17. Does that come out of your budget?
(Dr Lob-Levyt) That comes out of our budget. We also
put money with the Medical Research Council as well. I think your
point that it does turn out to be related to polio would certainly
add a kind of moral weight to there being more resources. There
is an absolute need for more resources for vaccine research; that
is absolutely vital and critical and we should like to see more
money going in.
18. Could I pick up something you said a couple
of minutes ago which was that it affects the poor more than the
better off? I understand that the poor are less well able to cope
with it, both in terms of drugs to suppress it and also in terms
of treatment for opportunistic diseases. I rather understood,
however, that in fact those who travelled more in countries in
Africa, and those might be people such as students, students of
medicine, students of teaching, teaching whatever it might be,
the professional classes, in fact have the highest proportion
of AIDS because they have travelled more. Is that fair or not?
(Dr Lob-Levyt) I think you are right; there are certain
high risk groups and you point to students moving into urban areas
in, say, medicine or education. They are in some countries and
it varies enormously from country to country. We are seeing quite
high transmission rates amongst those groups. When we take the
issue of poverty, the drivers of poverty are very much the same
drivers of social change, mobility of poor people looking for
work, the exploitation of women in particular in commercial sex
work, the inability of women to negotiate their reproductive rights
puts them at greater risk in the poorer groups.
(Ms Graham) Particularly in Africa, where households
are struggling with such great livelihood issues, any burden of
ill health, whether it is HIV/AIDS or malaria or whatever is likely
to contribute to the cycle of poverty and push a family under
the poverty line.
19. I do not disagree but my point is that actually
the infection rate seems from the evidence we have heard in some
places to be higher amongst what we might term the professional
classes than in the poor people. Is that fair?
(Ms Graham) Yes, that is true in some instances, but
it varies from country to country.