Select Committee on International Development Minutes of Evidence

Examination of Witnesses (Questions 1 - 19)




  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.

Mr Robathan

  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 the moment.


  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 clinics.

  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.

Mr Robathan

  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 data is.
  (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 actually.
  (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 in Asia?
  (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.

Mr Rowe

  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.

Ann Clwyd

  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.

Mr Rowe

  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 this stage?
  (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.

Mr Robathan

  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.

previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries index

© Parliamentary copyright 2001
Prepared 29 March 2001