Examination of Witnesses (Questions 20
- 39)
THURSDAY 8 JUNE 2000
DR JULIAN
LOB-LEVYT,
MR BOB
GROSE, MR
PAUL ACKROYD
AND MS
JOANNA GRAHAM
Mr Rowe
20. One of the controversies about HIV/AIDS
at the moment is mother/child transmission. What effect is that
having on DFID's health policies in other ways? They have been
madly sponsoring breast feeding and so on and now they have this
slight horror facing them. I just wondered what effect this was
having as part of the communicable disease burden.
(Dr Lob-Levyt) On that particular issue we are working
closely with UNAIDS and UNICEF for example on developing the appropriate
strategies for dealing with mother/child transmission. Part of
those strategies is making anti-retroviral therapy available to
women and then counselling women if they turn out to be HIV positive
as a first step as to what their options might be on a country
by country basis, whether it should be breast feeding or not breast
feeding. It is a difficult issue because it is very complicated
both to administer the treatment and to follow women and counsel
them and provide alternatives to breast feeding. It is affecting
our policy and it varies from country to country and the capacity
of systems to deliver the appropriate responses. Overall breast
feeding remains very much a priority for us and it is saving many
children's lives.
Chairman
21. It is said that in Uganda, Senegal and Thailand,
the spread of HIV/AIDS has plateaued or been controlled. Do you
agree with that?
(Dr Lob-Levyt) Yes, I think so and they offer clear
messages of hope and a very positive message that with the political
commitment and the ability to mobilise resources, but more importantly
open and free discussion on the issues, led from the highest level
but coming down through society, you can make an impact. That
is the message for governments and for donors, that we can do
something. It is the open discussions in Uganda which have enabled
people to access technologies to protect themselves and to change
behaviours and that clearly has made a difference. In Thailand
it has again been government commitment and substantial resources
focused on particular at-risk groups that has made the difference.
There is recent data coming out of Thailand suggesting that though
they have had this enormous fantastic success, in younger age
groups we are beginning to see slightly higher transmission rates
and they are beginning to increase and the Thai Government is
beginning to respond to that. They had perhaps taken their eye
off the ball with that younger at risk group. My message again
is that you cannot be complacent about HIV.
22. To what extent should the international
response to HIV be part of an integrated approach to poverty and
communicable disease? To what extent does it demand a distinct
and different approach?
(Dr Lob-Levyt) It has to be part of the poverty and
development agenda. What is qualitatively different is the size
of the problem which requires that we have a particular attention
and focus to it within that context and that it does actually
need substantial resources to make a difference. We are going
to be looking for more resources and greater political commitment
within that poverty and development agenda to address the HIV
needs.
23. Is it not distinctive in that in order to
combat it, you have actually to change human sexual behaviour,
whereas with other communicable diseases you do not have to do
that?
(Dr Lob-Levyt) Broadly I would completely agree. In
the absence of a vaccine, in the absence of affordable and effective
drugs, it is about social change which is going to enable people
to protect themselves better.
(Mr Ackroyd) One distinctive factor is the one you
are alluding to here, that it does raise very sensitive and social
issues which make it very much more difficult to talk about than
it is to talk about malaria or TB or these diseases which do not
have that emphasis. This whole issue of how you raise the awareness
in culturally sensitive subjects like this is a very key part
of this whole attempt to deal with the epidemic.
Ms King
24. DFID has committed itself to the eradication
of poverty and to the international development targets as a measure
of success in poverty eradication. Could we look for a second
at the impact of HIV/AIDS on these targets? Several members of
the Committee heard the Secretary of State the day before yesterday
saying how HIV/AIDS was having a detrimental impact on that and
she quoted Zimbabwe as having lost 22 years of life expectancy
as a result. Does that mean some of the targets have now become
unachievable due to HIV/AIDS?
(Dr Lob-Levyt) Yes, you are absolutely right. In some
parts of sub-Saharan Africa those targets which were a challenge
already are very unlikely to be attained, particularly those for
child mortality. There we are seeing increasing child mortality,
we are seeing reductions in life expectancy and in sub-Saharan
Africa that is going to make a difference to the overall development
goal of reducing by half those living in poverty. Yes, we would
agree with that.
25. Would it make a difference in the sub-continent,
in India for example?
(Mr Ackroyd) My judgement would be, if you are talking
about the overall target of reducing poverty, that the overall
picture in East Asia is that we shall almost certainly achieve
the target; there is very little doubt about that on present trends.
In South Asia it is going to be pretty close as to whether we
halve poverty by 2015 but there is a reasonable prospect. My judgement
would be that on the rate of HIV infection at present it will
probably not make a significant difference. That is not to say
that if the epidemic starts to spread significantly out of the
high risk groups which have been discussed into the mainstream
population it will start to have an impact although we are talking
about a gestation period which may actually hit after 2015 in
fact. My view in Asia would be that probably HIV at present will
not make a tremendous difference to the achievement of the overall
poverty target. It may have more impact on some of the individual
targets, particularly the maternal mortality and the child mortality
targets.
26. Are there not lots of other targets like
this? I know some of my colleagues are going to be asking you
later about universal primary education for example, but I recently
returned from Zambia and more teachers died last year of AIDS
than completed the teaching course. I do not see how it is not
going to have an absolutely devastating impact.
(Dr Lob-Levyt) In Africa you are absolutely right;
it is going to have a devastating impact on teachers and other
groups as well, which is going to impact on other targets.
27. Looking at the most recent international
development target which was adopted in 1999, which was about
the aim of a 25 per cent reduction in HIV infection amongst 15
to 24-year-olds in the worst affected countries by 2005 and globally
by 2010, could you tell me whether a strategy was adopted to go
with this aim?
(Mr Grose) May I first comment on the target itself?
We think it is an extremely good thing that there is a target.
We think its applicability varies from country to country depending
on the nature of the epidemic and that it is going to be much
more achievable in some countries than in others. Whether or not
there was a strategy, UNAIDS is now leading a process to try to
formalise a new global AIDS strategic framework which will be
a relatively short, limited framework really showing the most
important things that all the different players can do from whichever
government or organisation they come. That will build on what
is known already about what is likely to have most impact on prevalence
levels, which will be working in as targeted a way as possible
on people who are taking the most sexual risks. In some places
that will be the kinds of groups we have talked about, in other
places it will be the general population and everywhere will focus
on young people.
28. I know this was a very recent target obviously,
but how has it affected DFID's policies?
(Dr Lob-Levyt) I would say that by having this international
target, DFID has become even more focused on the importance of
HIV and we really are driving to mainstream HIV into all our development
efforts. We really are taking an intersectoral multidisciplinary
approach to this and it is really out of the health box, which
I am absolutely delighted about because I think that is the way
forward.
Mr Colman
29. Taking HIV/AIDS out of the health box, the
Committee is looking at the impact of HIV/AIDS on developing countries'
social and economic development. The five-year follow up to Copenhagen
is taking place at the end of this month. Could I ask whether
DFID—and I am assuming that the Secretary of State will
in fact be representing us at Geneva at the five-year followup—will
be submitting any proposals to amend the 100-point plan which
came out of Copenhagen to take account of what has happened in
the intervening five years and particularly the impact of HIV/AIDS
on social and economic development?
(Dr Lob-Levyt) I do know that DFID is addressing HIV
and other issues as part of the Copenhagen meeting and we are
ensuring that it has been adequately addressed and has reflected
changes since the last meeting.
30. Would you be able to go into any details
of what you will be proposing in terms of any amendments of those
goals? I am assuming this has already gone through the prep con
for Geneva.
(Dr Lob-Levyt) I cannot actually give you that detailed
information. It is being led from a different part of our department.
I can certainly provide the Committee with that information.[2]
Chairman
31. Could you ask that department to send to
us what they have done in preparation for Copenhagen? I should
be very grateful.
(Dr Lob-Levyt) Yes.
Mr Khabra
32. Most DFID HIV-related projects have been
in prevention. What preventive strategies have been proven to
work? What evaluations has DFID undertaken of its own preventive
programmes? What strategies appear not only to disseminate information
but also affect behavioural change?
(Dr Lob-Levyt) On the prevention side, yes DFID has
put a lot of effort into the prevention side. We are increasingly
moving towards care and support and impact mitigation. Specifically
on the prevention side, we have focused on intervention and have
contributed to research to determine whether these interventions
are effective, such as the treatment of sexually transmitted disease,
the use of male and female condoms, as important technical ways
of prevention and a substantial input in all our HIV programmes
into working with communities to ensure that they are well informed
and knowledgeable about the issues and the broader social prevention
strategies rather than the technological side of it. On the evaluation
side, there has been good research work evaluating the impact
of different kinds of interventions, in particular treatment of
sexually transmitted diseases and measuring the impact of that.
We have funded work jointly with other donors with UK institutions
which have done trials and studies in Africa and in Asia. Of our
own programmes and evaluating the impact of our own programmes,
this is a highly complex area with many multiple interventions
and it is still fairly early days to determine whether the specific
interventions that DFID have made have made a difference. We can
point to countries like Uganda where there have been comprehensive
interventions in many different dimensions which have contributed
to a reduction of the epidemic. We played our full part in doing
that. On the question on dissemination, is that dissemination
within the country or internationally?
33. Within the country.
(Dr Lob-Levyt) Yes, we work in all the programmes
that we support very closely with governments and with members
of civil society and the lessons which are drawn from the programmes
which we support in partnership with these organisations are widely
disseminated within countries. Increasingly we are trying to work
at a much higher sectoral level rather than individual project
so these are national programmes, national interventions drawing
on best practice and best lessons.
Chairman
34. Has that information changed behaviour?
(Dr Lob-Levyt) At the individual level?
35. Yes.
(Dr Lob-Levyt) I think we would say that in countries
like Uganda there is evidence that there is behaviour change and
in other countries like Thailand. It is a complex area and an
area where more attention is needed to evaluate the impact.
(Mr Ackroyd) Dr Lob-Levyt is right that generally
speaking it is rather early but there is one project in Bangladesh
which we have been supporting for five years which may indeed
be the one the Chairman alluded to earlier, where we have done
an evaluation of the first phase experience and come up with some
very positive indications that we have had an impact on behaviour
and on rates of transmission in that area.
36. The evidence we got in the brothel in Bangladesh
was that the sex workers had increased the use of condoms for
example from close to zero to 50 per cent of their interactions.
Fifty per cent is not enough but I suppose you would say that
is evidence that you have changed behaviour at least to 50 per
cent.
(Mr Ackroyd) Indeed; that is right.
Mr Khabra
37. What sort of consideration did the department
give to the traditional sensitivities of a particular community?
(Dr Lob-Levyt) That is absolutely important and all
interventions we support are carefully tailored to meet the particular
cultural issues and sensitivities of where they work or they would
not work. We spend a lot of time listening to people consulting
with stakeholders and helping others to do that to make our interventions
as effective as possible. Clearly that is an important issue.
Mr Rowe
38. At long last it seems to me that a lot of
the international organisations and organisations like your own
are taking the influence of the faith communities in the different
countries seriously. In many countries they are merely, sadly,
used to reinforce the worst possible practices but clearly on
a matter of this kind where, for example, chastity is by far the
best defence, presumably a dialogue, first of all to get the faith
communities to admit that bad habits exist and then to use their
influence to improve them, is important. I just wondered whether
you would like to say something about that.
(Dr Lob-Levyt) That is absolutely right and we have
learned that from before HIV in reproductive and family planning
programmes. Bangladesh would be a good example. Intensive work
with mullahs at the village level enables us to bring them on
board into important programmes and they became strong champions.
It is exactly the same cultural approach which is needed in these
very delicate issues. Clearly these are important stakeholders
and important agents for change.
Chairman
39. Are you in a position to say therefore what
really works and what really does not work?
(Dr Lob-Levyt) Yes, we can say with quite strong confidence
that political commitment is the most important thing and that
is what is required to make the difference and that has to be
translated into societies' open and free dialogue of the issues
and the very sensitive issues around HIV and that is the prerequisite
for making a difference. Then it is the behaviour change which
follows from that which enables women in particular to negotiate
the sexual contacts and to access the technologies to protect
themselves. That makes a huge difference. The second thing which
makes a huge difference is that people living with AIDS can be
supported to have much better quality of life in a number of different
ways, both with medical treatment of opportunistic infection and
with the support of communities and the support of individuals
not to fall into poverty because of HIV. We can make a massive
difference. We must be selling a very positive message. It is
not doom and gloom, it is a desperate epidemic but with that kind
of commitment we can make a big difference and that is the important
message which DFID is sharing with others.
2 See Evidence p. 71. Back
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