Select Committee on International Development Minutes of Evidence

Examination of Witnesses (Questions 181 - 199)




  181. Ms Bellamy, Mr Mark Stirling, you are extremely welcome. We are very grateful to you for making the effort to come along and talk to us about HIV/AIDS which both you and we are deeply concerned about. We need very much to know in depth your knowledge and your views on how we should proceed in the future. We met you last, you will remember, Ms Bellamy, in New York when we were talking on other matters but I do thank you for coming this morning. It will help us a great deal in bringing together this report which we hope will make a difference as to how we deal with this horrifying epidemic. I understand that you would each like to make an opening statement.

  (Ms Bellamy) Thank you very much. I appreciate the opportunity to appear before this Committee and we appreciate the fact that this Committee is taking this issue on because it has, I think it is fair to say, affected our work very much because of the implications that it has generally for development. I would like to make a few opening remarks and then Mark Stirling, who has held a number of senior positions and is presently the UNICEF representative in Mozambique, will make a few comments. I am quite well aware that this Committee is familiar with the statistics associated with this pandemic so I will not dwell on them although I probably will mention a couple. I will just say that from UNICEF's point of view we believe that HIV/AIDS is virtually reversing the social and economic gains of past decades in many ways and particularly in the impact it is having on child survival. In our view HIV/AIDS currently represents the greatest threat to the wellbeing of children in the developing world and I would say particularly in Africa but I think it is important to recognise that while the greatest numbers of people affected and infected are in Africa this disease is not limited to one continent. In terms of sheer numbers affected HIV/AIDS has become a greater threat to children than the sum of armed conflict, malaria, floods and famine. Young child mortality rates are expected to more than double in the most severely affected countries of eastern and southern Africa just over the course of the next few years. Unfortunately, the first opportunity to address this unfolding tragedy has not been grasped. Therefore, we believe that if the international community does not take decisive action now we who are working to promote development as well as the children of the poorest countries in Africa, will not have a second chance. Let me touch briefly on what we see as the impact of HIV/AIDS on children in very simple terms. First, there is loss of family, love, protection and care. It is estimated that there are already upwards of 11 million AIDS orphans, that is up from about eight million about a year ago and it is expected to go to 13 million in the not too distant future. Ninety five per cent of these orphans are in Africa. They are subject to discrimination, stigma and abandonment. They live under psychological and psycho-social distress. They may be forced to separate from their siblings, to migrate far away with loss of inheritance. It is a very bad picture. It is assumed in many cases that these children themselves are not infected, and they largely are not, but because of that they are often rejected by their own communities. There is reduced opportunity for schooling and increased demand for child labour. There is loss of health care and deterioration in nutrition and diet due to a reduction in the household income and due to higher health costs. Increased sickness and malnutrition also occur. As a result of direct exposure to HIV infection, maternal to child transmission and exposure to HIV as a result of living on the streets, there is increased risk of exploitation and abuse and that is particularly so when it comes to girls. What is UNICEF's response? We have a five point strategy and I will just tick off the five points. One is mobilisation. We are trying to mobilise in each country that is affected by HIV/AIDS a commitment at the highest levels of government and throughout society. This is not just a government issue, this is not just an issue that should be parked off in the ministry of health. This really has to involve society broadly but certainly starting at the highest levels of government in order to break the conspiracy of silence and its associated stigma and discrimination. Number two is prevention; first, prevention of HIV infection among young people. They are at the centre of the pandemic. We also believe that is where the hope is, where the potential is, because young people, unlike we old fogeys (or me at least), young people are the most open to behaviour change. Involving young people as actors in the effort to reduce transmission is very important, not just involving them as subjects but also as actors. Young people are a force for change among their peers. We need to provide them with the knowledge that they need to protect themselves and to make sure that they have access to youth-friendly health services. We believe the key in this area is voluntary HIV testing and counselling. Third is prevention also but preventing mother to child transmission of HIV. Half a million children were infected this way in 1999 alone. UNICEF is involved in providing and supporting voluntary testing and counselling for pregnant women. Those who test positive we think should have access to anti-reproviral drugs and advice on infant feeding. Fourth is care for orphans. We support actions to strengthen community capacity to identify and respond to the needs of orphans. They need, as young children do, access to basic health education and welfare services. Our fifth point is a point that turns us inward because we also believe it is important to support our own staff. We as an international organisation, highly decentralised in the field, have had staff who have been infected themselves or affected, both by their families being affected or their friends, and so from internal programmes to trying to provide family support we believe that is a key component to what we are doing. We cannot ignore our own staff. I will conclude by making a brief comment on what we think needs to be done by your Government and others. The experience in Uganda, in Senegal and in Thailand as examples, shows that effective response to HIV/AIDS is possible. What is required is leadership, targeted programmes, resources and speed. No more studies are needed. Action is needed. We would urge this Government and other governments and other leaders to commit to specific goals on HIV/AIDS prevention and reduction, such as reduction of HIV infection rates among young people by 25 per cent in highly endemic countries by the year 2005. We would urge that all G8 leaders confirm their own Governments' commitment to fight AIDS. We would urge all developing leaders with whom this Government and others have interaction to adopt and sustain a commitment to respond to the pandemic of HIV/AIDS. We would urge that this Government uses its considerable influence amongst the Bretton Woods institutions and other multilateral institutions to make sure that HIV/AIDS is treated as a core concern. Thank you.

  182. You have covered many of the headings that we have in our own briefing, but we will go through them in greater depth. Mr Mark Stirling, you would like to say a few words.
  (Mr Stirling) I think the reason I am here is that I have spent the last 20 years in Eastern Southern Africa. The course of my own life, my family life, but also my professional life has been to accompany an unfolding tragedy which is taking place of unprecedented proportions within that region of the world. I started my career 20 years ago in Uganda and I have worked down through most parts of eastern and southern Africa and have quite a strong experience of working in this area. There is absolutely no doubt that the impact of HIV is having a devastating effect on the lives of everybody. It is devastating families and communities, it is overwhelming health and other care systems, it is robbing schools of teachers and denying children their education. Businesses have certainly lost. Their personnel have become sick, they have lost productivity, they have lost profits. Economic improvements and growth have also been undermined by the same dynamics. Clearly out of this development resources which could have been mobilised to support sustained human development within this region, to build peace and development, are being lost; they are being diverted. In Mozambique where I live and work now some 50 per cent of today's 15-year-olds in Maputo are expected to be dead because of AIDS by the age of 45. That is the reality not just of Maputo, of Mozambique, but also of most of Southern and East Africa. Death rates are extortionately high. In a country like Mozambique where we have less than 10,000 kids in secondary school we are talking about losing half of those young people. Is it possible for Mozambique to develop the leadership, the technical expertise, the professional capacities, the workers, required to sustain the leadership and the economic progress, the security and stability of that country? Clearly not. It is a tragedy and something which is having direct and very severe impacts on life and stability. The question that therefore arises is that if this pandemic is having such a huge and devastating effect, why has there not been a response? Why are we now, 20 years after the beginnings of this pandemic, having sessions like this to try and work out what more we can do to trigger a response which is adequate? Thinking in the future, I am sure historians will dwell on these years and will probably be probing why the human cost had to become so high before an adequate response was mounted. They are going to question very seriously what was done, what more could have been done, by local and national leaders, and by the international community. The international community does not have a passive role but what more could have been done by them to respond? These are the issues which now need to be faced by this group and by all of our governments. With over two decades of work involved with the pandemic people know what works and what needs to be done. Experience of a number of countries where there has been significant change, particularly in Uganda and other countries have shown that HIV infection rates can be reduced, they can be significantly affected through investing in information and life skills education for young people, by promoting abstinence, safe sex and the use of condoms, by ensuring early treatment of sexually transmitted diseases, by ensuring that young people have access to voluntary and counselling testing services to deal with HIV. We have also increasingly added the importance of addressing issues of stigma, discrimination, of creating empowering and enabling environment for people to address HIV in their own lives. The question therefore stands. If we know what works, why have we not done it? What have been the critical constraints to governments, to communities, to take exceptional action to address an exceptional threat? Perhaps part of the answer to this lies in the fact that HIV and AIDS is largely about sex, sometimes infidelity, unfaithfulness, and sometimes about sin. It is about issues which many of us have a great deal of difficulty with and have been conditioned not to talk about frankly, openly and publicly. The reluctance and the discomfort of leaderships are clear, but also those leaderships have clear responsibilities to provide counselling, confidence and strength in times of danger and need and this is in fact one of the greatest leadership challenges which this century and the end of the last were confronted with. In the early years of the epidemic very few leaders spoke out, particularly in Africa, about HIV. We had the comments of Kenneth Kaunda when he lost his son in the late 1980s, and Musebeni a bit later on, when he started to see the impacts on the security and development of Uganda, also became a strident strong leader. But very few others followed. It is only recently, this last year in fact, when we have seen much stronger signals from leaderships. It is increasingly becoming a public issue. Statements of declarations of states of emergency, wars of liberation against AIDS have now been declared. This year in Africa the OAU, SADC, have dedicated special sessions to talking about leadership and the Economic Commission for Africa is holding a very important meeting in October this year to talk about AIDS and the leadership challenge within Africa, not just in government but also in civil society and the private sector. There is a movement there amongst leaderships in Africa to act on HIV and AIDS. It is hesitant, stronger amongst some than others but there is a momentum developing. This is an essential recognition. Another reason why there has been a lack of action is that very often leaderships have lacked information about the epidemic, about its impacts and about its consequences. In the past there has been very little investment in surveillance systems to understand the epidemics, impact studies were few, and little attention has been devoted to monitoring and researching the dynamics of the epidemic, and even less to monitoring and understanding the effectiveness of responses. In recent years these information gaps have been addressed, so there is movement on this front. We now have more committed leaders, more aware leaders, within Africa. In many countries in Africa plans have been developed but their implementation has been extremely weak. In most cases they have been under-resourced and this is a major reason why the implementation has been weak. Very often, because of a lack of resources dedicated to these issues, HIV has been overshadowed by other, more pressing priorities, for example regional wars, which have much less general cost than AIDS. To illustrate this, during the 1990s there was a considerable reduction in the amount invested in HIV. As the epidemic went from around 10 million HIV positive people at the beginning of the 1990s to around 30 million HIV positive people at the end of the 1990s, investment per person dropped from around 17 dollars per HIV positive person at the beginning of the 1990s to about nine. Support within government and also the international community largely failed. It has only been this last year or two when there has been, through the international partnership against AIDS, a recognition of the immensity of the problem and the need to mobilise additional resources. I am sorry for taking a long time but please bear with me for some more minutes. The point I am trying to stress is that while national leaderships are ultimately responsible for leading the fight against AIDS, the experience of recent years has also shown that effective responses require a very clear committed and sustained partnership of national level leaders and international partners. They require this because of the size of the problem, because of the complexity of the problem and because of the importance of sustained solidarity in responding to this threat. Over this last decade within Africa we have seen a number of countries going through very difficult reforms, economic and political reforms, which are now proving to be successful. In a number of countries good progress has been made in bringing about macro-economic stability. There has been progress made in liberalising economies, in introducing Civil Service reforms, in bringing about improvements in governance. Whilst certainly these countries have been able to bring about these changes because of strong leadership, it is equally true that it was required because of strong international partnership, through particularly organisations like the International Monetary Fund, the World Bank, the G8 nations and donor supporters through consultative groups, to find with countries certain development priorities to address and then, often with some pressure and force, help those governments develop the necessary decisions and the political frameworks, the policy structures, required to address this work. We saw this kind of international solidarity work in the anti-colonial struggle. We saw it bring down apartheid. It is the same kind of relationship of national and international forces and solidarity which is required to address AIDS. If this is so then what I am really calling for is a much stronger role of international partners working with national authorities to bring about policy changes, to put much more resources behind those national governments, to work with civil society leaderships, the media, lobbying groups, particularly people living with HIV and AIDS, so that they become active pressure groups to ensure sustained priority on the issue of AIDS. We need to move beyond an emergency declared in rhetoric to an emergency declared in physical resources and I believe that the Government of the United Kingdom and its people have a very important role in not just stating this as an emergency but actively working alongside affected countries to mobilise the resources and decisions required to address it.

  183. Thank you very much. We will be looking at many of the issues you have raised in your opening statements in our questions. There are one or two points of clarification which we should start with. What are "children" in UNICEF's definition?
  (Ms Bellamy) We are guided by the Convention on the Rights of the Child, so we define the child as an individual up to the age of 18.

  184. And what is an orphan?
  (Ms Bellamy) We define an AIDS orphan as a child who has lost either the mother or both parents to HIV/AIDS.

  Chairman: That is interesting because in this country we normally mean the loss of both parents but that is a good point.

Mr Rowe

  185. Ms Bellamy said, I thought, that while the numbers of people infected in Africa were higher than in other continents, my understanding was that the actual numbers infected with HIV are higher in India than anywhere else.
  (Ms Bellamy) I do not think we have that kind of data.
  (Mr Stirling) The answer at the moment is no. The large proportion of HIV positive people live in Africa but because of the size of the population of India, once they have developed the momentum of HIV infection they will have the greatest problems.

  186. They will have? They have not got it now?
  (Mr Stirling) No, not yet.
  (Ms Bellamy) To the best of our knowledge. I would say both India and China as well because it is an issue in China.

  Mr Rowe: That is interesting. We have had some evidence which conflicts with that.


  187. Can I first of all engage you in some questions on the incidence and prevalence of HIV/AIDs amongst children? What is the rate of new infection of HIV/AIDS amongst children and how does it compare with the incidence amongst adults?
  (Mr Stirling) The prevalence amongst adults in Africa ranges very considerably, but within East and Southern Africa we are talking of prevalence as slightly under 20 per cent, one in five. This can range in some areas and some places, like northern Botswana and Francistown, up to a prevalence amongst antenatal attenders, pregnant women, of 60 per cent. Certain populations and certain groups have extremely high prevalence rates. Amongst adults generally it is around 20 per cent. As regards children and infants, through vertical transmission roughly one third of infants born to HIV positive mothers will acquire HIV, and of that one third, which is round about 500,000 to 600,000 in the world, roughly two-thirds will acquire it during pregnancy and delivery, and the other third will be exposed to HIV through breast feeding.
  (Ms Bellamy) There are really two peaks of infection of children. The first is children under the age of two years old and this is due to mother to child transmission. The second in children, which is particularly girls, is between the ages of 12 and 18 and this is generally due to sexual transmission.

  188. There is a difference between girls and boys and that takes place after the age of puberty?
  (Mr Stirling) There is HIV transferred through sex, not through vertical transmission.

  189. Is there a relationship to poverty? You say there are differences in regions which you cannot explain, I gather, but is it related to poverty?
  (Ms Bellamy) Yes, I would say it is related to poverty but there are a number of other factors. Poverty is going to create an environment where probably your services are lacking or your access to youth-friendly services are less, the potential for violence is greater, the information that a pregnant woman might have available to her, nothing exists in its entirety in those communities that are most poverty stricken, but also children who are affected by some other way, children who are internally displaced, there are a number of other kinds of factors that are also contributing to this.

  190. Is there a difference between urban and rural areas?
  (Mr Stirling) Like every question, it is yes and no. On the issue of poverty, it is about poverty but it is also about disparity. If we look at the infection trails of how the pandemics or the epidemics have grown in Africa, they are largely working down the major transport corridors and the economic routes of that continent. We are also seeing that the epicentre of the highest levels of infection are around some of the richest areas of Namibia, Botswana, South Africa, or some of the richer areas before, such as Zimbabwe. It has got a lot to do with the movement of people, of man mobility and money. It has also got to do with poverty in terms of disparity. Young people and particularly young girls are extremely vulnerable to HIV infection if they are poor because of transactional sex, because of the need to survive. There is a whole lot of things which relate to poverty within disparity which make people more vulnerable to HIV infection.
  (Ms Bellamy) I do not mean to drag this out but I want to add one other thing to that because it is very important to recognise that the impact in many countries is hitting very much at that middle income community in many cases, the loss of teachers, the loss of doctors, the loss of civil servants. That does take it in some cases beyond it just being a matter of poverty. With respect to the issue of urban and rural, I think the assumption has been to date that it is more likely to be found in urban settings but, as Mark says, it is yes and no. I believe that just this week, and I must say I have not read it myself, there has been a report issued that was co-authored with the UN AIDS Secretariat and the Food and Agriculture Organisation, which indicated we must not ignore the rural areas. I do not think they said it was only in rural areas but that more attention has been given to urban areas and that rural areas should not be ignored because the prevalence of HIV/AIDS is growing there as well.
  (Mr Stirling) There are different things also fuelling the epidemic. Although much of it has been certainly on urban transport corridors, civil conflict and displacement of populations have fuelled it in large rural areas. For example, in Mozambique during the war there was large scale displacement into Malawi, into Zambia, into Zimbabwe, people went into those congested refugee centres, and infection rates were extremely high. They returned to rural areas. In Tete province, for example, in Mozambique, 85 per cent of the rural population was displaced and they have gone back into rural areas. It is a similar dynamic that we have seen taking place now in the Democratic Republic of Congo, the consequences of war and how that fuels infiltration of the epidemic into rural areas.

  191. The sense of what you are both saying is that whilst it may be spread in urban sectors, it is transposed into rural areas by the people returning to their villages. As I understand you, it is not being generated in the villages but it is in the transmission to the villages.
  (Mr Stirling) Where there is concentration or movement of people is the one of the major exciters of HIV.

  192. Is there an estimate of how many children are dying each year from AIDS and how many adults are dying who were infected when children?
  (Ms Bellamy) I think we have the estimates. The latest estimates I believe are being issued today or tomorrow out of the Secretariat of UN AIDS. In terms of child deaths in children living with HIV/AIDs in terms of 1999 estimates, we were talking about 1.2 million; child deaths for HIV/AIDS in 1999, about half a million, the cumulative number of child deaths as at the end of 1999 was 3.6 million, and again it was estimated that in the course of 1999 you had almost 600,000 children infected. These were the estimates as of the most recent reporting. I think there will be some slight updating of those numbers with the new material that has come out from UN AIDS. We do not have it because it is embargoed but it will come out over the next couple of weeks because it is coming out in anticipation of the major conference in Durban on HIV/AIDS which will take place in a couple of weeks. That is giving you the trend. The likelihood is that there will be a slight upward reassessment of those numbers.

Mr Worthington

  193. Can I ask about the reliability of the figures? We were hearing last week from South African people who were giving evidence to us and they said that with regard to cause of death the cause of death for the patient might be pneumonia but there would be a tear-off slip which would be "HIV/AIDS-related". What is happening in terms of knowledge about why people are ill, because there has been a lot of concealing of HIV? Where do your figures come from? Have you got causes of death or incidence? In many cases you do not test for AIDS because that would keep mothers away from the clinic. How reliable are these figures and are we seeing something which is still under-reported rather than over-reported?
  (Mr Stirling) I think that is very much the case. Ten days ago I was in Chimoio Hospital which is on the border of Mozambique and Zimbabwe, and I was shocked to find that in the ward there AIDS deaths are a third of all children admitted to that hospital, but they were the only ones who were tested. The estimate of the nurse was that all of the malnutrition which that hospital is seeing, which is roughly another quarter of deaths, were also HIV-related. There is huge under-reporting of the specific cause of death because testing of HIV is so restricted. All of these estimates which we are working with from UN AIDs and from national systems are based on models, on surveillance systems established within those countries and also on the case reporting. Then a professional judgment is taken in trying to draw that picture. I think that for people to say therefore there is a tendency to be over-estimating the problem, and this is obviously an issue which is raised by many, I think very much underestimates the magnitude of the problem. The way forward on this must be strengthened surveillance, sentinel site surveillance of infection rates and amongst particular population groups. There must be also, probably equally importantly, increased access to counselling and testing services so that not only health providers but also individuals know their status.

  194. Is there not also a case, so that we know about the reliability of the figures, for UNICEF to be having a global policy about the recording of deaths and the way in which the disease is monitored? At the moment it would seem each country is going about it to some extent their own way because of the problems associate with stigma and backing away from the problem.
  (Mr Stirling) I am not sure what the answer to that question is, but certainly it is something which needs to be worked through.
  (Ms Bellamy) I am not sure what it is either but it might be something in the context of the UN AIDS collaborating agencies. It might be something that we ought to take into consideration.

  195. Can we move to preventive education and support issues? The message that comes across in terms of prevention is that there are two ways of prevention of disease. One is abstinence and the other is condoms. How safe are condoms?
  (Mr Stirling) I think you probably need to get this answer qualified by somebody who knows, but I think it is 99.6 per cent or something. They are basically safe. We need to get that checked.
  (Ms Bellamy) You said either abstinence or safe sex, but there is just a basic lack of knowledge and information in some ways that one has almost to deal with even before that. You talk to young girls and they say, "Can you get HIV/AIDS from this man who looks healthy?" "Well, no, not if he looks healthy, I cannot." This is a desperate lack of information and lack of knowledge that one has to get through in the first place, and in language and in ways that young people will understand.
  (Mr Stirling) There is also a third option which you did not raise which is abstinence, fidelity, and safe sex if you are having multiple relationships.

  196. There are many forms of sexual activity. Are we only concerned with penetrative sex and the use of condoms, or does the message need to be more complicated than it has been so far?
  (Mr Stirling) A number of more enlightened leaders have talked of other ways of sexual fulfilment which is not penetrative sex, yes, so that is something which has been talked about by people involved within the struggle against HIV. Certainly that is an alternative.

  197. I am also puzzled by the emphasis on the male condom and the lack of reference in the text to the female condom in terms of tackling the spread of HIV/AIDS. Am I wrong to be puzzled?
  (Mr Stirling) No, I do not think you are wrong to be puzzled. I think it has been easier and there has been more experience of working with the male condom. It has also been considerably cheaper. There has not been sufficient effort to expand the use and adoption of the female condom and I think there has been linked with that some concern over the higher cost, but again I think there are probably people who can deal with this directly.

  198. In terms of the vulnerability of women, it just seems very strange that there has been so little emphasis upon giving women power.
  (Mr Stirling) It is true in that the level of development in providing women with the tools to have control and safety in their sexual lives is much less. Certainly within UN AIDS in the work of the co-responses there is a specific programme of research and support to improve the use of spermicidals, of the female condom. You are correct in that there needs to be much more work done in this area, like in many other areas.

  199. Do you not feel that UNICEF should be leading the way on this?
  (Ms Bellamy) On the female condom are we talking about at this stage? I think of the agencies on the ground we are, if not the most, one of the most active agencies on the ground, but I think that we probably could be doing more in a whole range of areas. I look at the difference between what we are doing this year as contrasted with a year ago. I said to myself, maybe I should have done more, but I say why were we not doing more then? This pandemic is virtually changing our activities in countries around the world, obviously more so in Africa right now, but we are designing our programmes with the governments around this issue now. It has just become such an all-encompassing matter. Yes, probably there is more but there has been an enormous movement in the last year.

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