Examination of Witnesses (Questions 220
- 233)
TUESDAY 27 JUNE 2000
MS CAROL
BELLAMY AND
MR MARK
STIRLING
220. Who is doing that research? Are the baby
formula manufacturing companies involved?
(Mr Stirling) I am sure that they are also doing some
of this research. The stuff that we have been more aware, which
is coming through UN/AIDS, is being done by professionals working
within settings which are implementing, for example, programmes
of mother to child transmission. A number of research groups in
South Africa are not being supported by these companies. They
are independent researchers who are concerned about the impact
of HIV on children.
Ann Clwyd
221. Can you tell us how the partnership between
the Government and NGOs works? Who has responsibility for that?
Are there clearly defined responsibilities or is it a muddled
area?
(Ms Bellamy) I think this differs from country to
country.
(Mr Stirling) The issue is that it does differ very
much from country to country. In some countries, there is a reluctance
and even a resistance within government to working with non-governmental
organisations, which means that in national strategic plans there
is little mention of the role of civil society or non-governmental
organisations. In others which are more successful—I think
that probably includes Uganda and Zambia—the seeds are being
sown in Mozambique, certainly in South Africa and there has been
a very strong role of non-governmental organisations defined in
planning documents, an appreciation that NGOs do have the opportunities
of making contact with people outside of government sectors, reaching
communities, being in touch with youth organisations or particular
groups who might be extremely vulnerable to HIV infection, who
have contacts with child prostitutes, street children and domestic
workers, so that they have that capacity of contact. Those more
enlightened governments in response to HIV have embraced NGOs
as a part of the national strategy.
222. Can you tell me what progress UNICEF has
made in voluntary HIV testing and counselling for pregnant women,
particularly in the most severely affected parts of sub-Saharan
Africa?
(Mr Stirling) I personally feel that this is probably
the critical constraint to address, increasing people's understanding
of their own status and the ability to deal with it. Our appreciation
of the importance of counselling and testing is relatively short.
Much of the evidence has really only surfaced within the last
two to three years of how powerful a tool it is. Progress has
been painfully slow. In my experience in a number of countries,
there has been resistance to moving rapidly with counselling and
testing, basically saying the costs are high and we cannot afford
those additional costs. It is not sustainable. We do not have
the capacity to invest in counselling. It is time consuming and
too labour intensive. In the Gaborone meeting that I was referring
to, this was seen to be one of the critical constraints which
needs to be addressed, not only on mother to child transmission
but also in expanding work amongst young people. Within that,
a number of recommendations were made on improving use of rapid
tests which are low cost, about $1.20 for a rapid test with high
specificity. Secondly, trying to find different ways of providing
counselling and support to people who are going through the process
of testing without necessarily involving a health professional
all the time because these people are so scarce. Progress has
been strong in some countries. Uganda has made good progress.
There was some good progress in Zambia for a while. It came unstuck
but I think it is back on track. In South Africa, it is expanding
but across all countries it is not being done to scale and being
sustained at a level required to have the effect which it can
potentially have.
(Ms Bellamy) First and foremost, our agency is there
in partnership with the governments. As you might expect, those
governments where there is less movement, where the leadership
has not responded, where it has been reluctant to engage with
NGOs, it has taken longer, which is why our effort is both at
focusing very specifically on prevention and mobilisation. To
get our programmes directly front and centre focused on these
issues, we have to help move the governments along and that is
why in some cases it has been slower. We all wish it had moved
a little faster.
(Mr Stirling) What are the triggers that can make
a difference in responding to the epidemic? Goals and targets
are important. We have been suggesting that this be a target and
that there be strong lobbying at national, regional and international
level to have a target on expanding access to voluntary counselling
and testing, particularly for young people.
Chairman
223. Are AZT and nevirapine or other drugs currently
available to pregnant women and mothers in the worst affected
sub-Saharan countries?
(Mr Stirling) No. People who have access to cocktail
therapies are generally rich people who are gaining those services
through private providers, normally outside of government services
and regulations at the moment. Many people in many countries are
going to private clinics or even going out of their countries
to get treatment of their HIV infection. The purpose of this MTCT
work is precisely to expand access to anti retroviral treatment
for the prevention of vertical transmission. The purpose of those
12 projects is to see what needs to be done to achieve that.
(Ms Bellamy) We have entered into an agreement with
Glaxo Wellcome and they are providing AZT for these pilot projects.
In that instance, it is available on a limited basis but it is
not available to the general public. You also mentioned nevirapine.
There has been one study done in Uganda with very positive results
but it is only one study and we are still looking to our colleague
agency, WHO, to give more of a go ahead to see if there is a way
for this to be more widely distributed.
224. Has an estimate been made of the total
cost of providing nevirapine to HIV positive mothers and their
infants in sub-Saharan Africa, both the direct cost of the drug
and the associated cost of the necessary health service provision,
or is it too early?
(Mr Stirling) There has been some work done by UN/AIDS
and by UNICEF in the context of this pilot project to get those
costs. The costs as they now stand for nevirapine are about $4,
the price of one pint of beer, for the management of one case,
which is a dose for the mother in labour and immediately afterwards
for the child. We know the basic figures through those estimates.
The challenge at the moment is looking at what needs to be done
to scale up the use of these drugs. Here, the critical constraint
is testing and improving women's access to HIV testing.
(Ms Bellamy) Let me give you a contrast. The AZT regimen
cost is estimated at about $50, whereas it is $4 to $5 for nevirapine.
It is still too high, but we are getting closer.
225. This is what I was trying to assess, whether
it is capable of being accommodated in the normal health budgets
of these countries, because their health budgets per capita are
pretty small anyway, are they not?
(Mr Stirling) We are doing some work at the moment
in Mozambique looking into the costs of these therapies, tests
and drugs for averting HIV against the opportunity costs. If we
do not avert it, how much will it cost us to manage a sickly,
HIV positive child? I think this is probably a much more useful
form of inquiry because the costs in human terms are obviously
huge but the economic costs are many, many times more.
226. It is still a considerable increase in
cost, is it not, as a percentage of the health budgets?
(Mr Stirling) We need to do both.
227. Is it a 50 per cent increase in health
provision?
(Mr Stirling) It will depend on the country. In a
place like Mozambique, the per capita health expenditure is only
about $10. The cost here of managing one case would probably be
about $6-$7.
228. Even this provision is quite considerable.
(Mr Stirling) That is the public expenditure. The
private expenditure which that family is going through in the
management of that sickly child will be many times more.
229. What other interventions, other than drugs
and infant formula, have been shown to reduce the risk of mother
to child transmission?
(Mr Stirling) There are a number of things. Any actions
which improve the health and nutritional status of women in pregnancy,
particularly their micronutrient status—certainly there
has been a strong correlation seen between transmission risk and
vitamin A status. This is important. Similarly, there have been
strong correlations between the levels of anaemia amongst pregnant
women. Issues like malaria are important, and the rollback malaria
programme is important in this context of providing for safe motherhood
and reducing HIV transmission risk. During delivery, to reduce
the mixing of bloods, to reduce physiotomies, for example. There
are a number of things which can be done which, in small fashions,
can reduce the transmission risk. However, the bottom line is
that significant reduction will take place through the use of
anti retrovirals.
(Ms Bellamy) It is very important to prevention of
HIV/AIDS that young women be empowered through education. Their
ability to make choices about their lives plays a role here.
(Mr Stirling) Primary prevention is the first thing,
to prevent it in the first place so that mum does not have it.
Ms Kingham
230. In your written evidence you state, "UNICEF
estimates that an additional US$2-4 billion per year for 10-15
years will be needed to control the epidemic. Much of these resources
will come from within affected countries. However, as HIV/AIDS
is a global problem, its response demands global action."
How much is UNICEF now spending on HIV/AIDS related work? UNICEF
states that you are considering the reallocation of funds from
other aspects of its programmes. Which programmes would lose out?
(Ms Bellamy) I cannot give you an exact figure. I
always find these questions very difficult to respond to. I could
add up the amount of money we are spending very specifically on
HIV/AIDS[2].
We have now added staff very specifically in the HIV/AIDS area
but that does not take into account the Mozambique country programme,
which is now trying to build in HIV/AIDS on a more horizontal
level rather than just a vertical intervention. There has been
a dramatic increase in the resources that we are allocating to
activities that impact on both mobilisation and prevention of
HIV/AIDS in the last couple of years.
231. If you are thinking of reallocating funds
from other aspects of programmes, presumably you have budget lines
that you work to either within country programmes or thematically
across your activities. If you are considering reallocation of
funding, you must have an idea of roughly how much that reallocation
will be and what percentage of your budget in approximate terms
it makes up. I am sorry to come back on it, but I find that a
bit surprising considering that, when we have received direct
mailshots from UNICEF or appeals, they usually state very clearly
how much has been spent on—
(Ms Bellamy) We can say what it costs to immunise
a child and what the cost of a Vitamin A capsule is. We can say
what a particular project, let us say in Zambia, is going to focus
on. Let us say moving ahead youth friendly services. We could
put a price tag on that but the way we are trying to approach
HIV/AIDS is not to have separate immunisation programme, the girls'
education programme and the HIV/AIDS programme, but to try and
have it somewhat more horizontally. The region that is the most
focused on it and that has done the calculation about the kinds
of resources they think are necessary is eastern and southern
Africa.
(Mr Stirling) Within eastern and southern Africa,
there have been a number of decisions taken to ensure that every
programme opportunity, mid-term reviews, annual reviews, the preparation
of new country programmes, is an opportunity to make sure that
we triple check how we are doing everything which we could possibly
be doing to respond to the priority of HIV. That is translating
more specifically on those five priority areas which Carol went
through. This does not mean that other things we are doing are
not important in the context of AIDS. They are even more important.
In the societies and communities which are affected by HIV, it
is even more important to make sure that you have access to good
immunisation services; you deal with diarrhoea; the management
of common illnesses, dealing with access and quality of water
supply, ensuring that girls get into school and stay there. These
are the priorities of our regular, normal programmes. They need
to be reinforced, quality improved and adjusted in many ways to
be more HIV sensitive. That is the principal focus of our programming
exercises. Many countries within the region have gone through
expanded reprogramming for HIV. In the case of Mozambique, over
the last couple of years, we have gone from three years ago a
budget dedicated to those five core areas of $100,000 to, this
year, being close to $4 million. Next year, we have a target of
trying to be $6 million. We are trying to mobilise additional
resources for that. Part of that strategy is this resource mobilisation
programming exercise going on now within eastern and southern
Africa, where we seek to raise an extra 250 million to support
action on HIV within the region. The issue at the moment is to
seek additional funds, not to take away from other important programmes.
232. It is not reallocation?
(Mr Stirling) At the moment, the strategy is more
and the climate seems to be supportive of more on HIV.
(Ms Bellamy) Particularly in eastern, western and
central Africa, we have added very specific staff on HIV/AIDS.
We have added a senior adviser at headquarters on HIV/AIDS. We
have seconded some people from UNICEF to UN/AIDS itself. The board
of UNICEF gives the executive director a modest flexibility of
something over seven per cent set aside. I used it this year for
HIV/AIDS and polio. We are getting close to wiping out polio and
that is a high priority.
Mr Khabra
233. By the end of 1999, there were approximately
11.2 million children who lost one or both parents to HIV/AIDS.
In many cases, a remaining parent is found to be quite ill and
dependent on the child for assistance. Before AIDS, about two
per cent of all children in developing countries were orphans.
By 1997, the figure had jumped to seven per cent in many African
countries. In some countries, the figure ran as high as 11 per
cent. What is being done to ensure that orphans and children in
distress are being cared for within communities? What is being
done to remove stigma from children related to those with HIV
or who are living with HIV themselves? What issues are emerging
in terms of the legal and human rights of children affected by
HIV/AIDS?
(Ms Bellamy) The numbers are growing, as we indicated
before. The traditional coping mechanism, which was the extended
family, is being stretched beyond capacity now. You are increasingly
finding grandmothers who are taking care of nine, ten or eleven
kids. You are now having an increasing number of child headed
households. You cannot put a little spot on a child's head and
say, "You are an AIDS orphan" and, "You are a war
orphan" and, "You are a different kind of orphan."
We are approaching the issue of orphans more generally. There
are some things that you have to deal with specifically. I said
in my opening remarks that many of these AIDS orphan then become
outcasts in their own communities because it is assumed that they
are infected themselves, or for some other reason. One does have
to give some specific attention there, but we are looking to try
and provide, very often with NGOs, some kind of supportive activities
in communities so that children can be reintegrated into their
community and also so that they can become full participants in
education or some kind of training.
(Mr Stirling) It is a pity the question is towards
the end of this session because this is probably one of the greatest
challenge areas which we are confronted with. The problem is not
here yet; it is still another five or ten years down the track,
when this population of orphans is going to be doubled and may
be even higher than that. What is taking place? Many UNICEF programmes
are working with governments, particularly with non-governmental
organisations, on strategies to strengthen family and community
capacities, to identify and to care for families and children
in distress. There is a role for orphanages, for improving services,
health education, but the critical solution to this is that the
only capacity upon which we can rely in the long term is at the
level of family and community, so it is trying to strengthen those
capacities. What does that mean? It means providing families with
more information and education on children and child care, strengthening
community leaders' capacities to identify kids in need. Some of
the work which we are doing in Mozambique is trying to mobilise
people around some basic principles. All children must be healthy
and well nourished. All kids must be in school and education.
All kids should be clothed and living in safe shelter. All kids
must have the right to participate in the decisions affecting
their future and all kids must live under the protection and care
of an adult. For example, that is what we are doing. Part of the
community capacity building is to discuss with communities and
support and facilitate processes there so that they can check:
are our kids healthy? If not, why not? What are the threats to
children? Which kids are not healthy? What can we do about it?
Are our kids in school? If they are not in school, which kids
are not in school? What can we do about it? As much as possible,
we try and stimulate those kinds of processes at the community
level and then to link supports for the responses to non-governmental
organisations who might have additional resources for micro credit
or education or to link up with services to do deals with local
teachers and headmasters to try and change their hours or make
adjustments; to try and strengthen capacities of coming up with
local solutions to these problems. It is the greatest problem
area and the greatest challenge area we have, largely because
HIV is impoverishing the same families which are wanting to strengthen
their capacities to care.
Chairman: Thank you very much indeed.
There is a lot more we would like to discuss with you but time
will not permit it. We would like to thank you very much indeed
for deepening our understanding of this extraordinarily difficult
disease and the whole question of the total approach to the family
and the child and the mother and what is required. Let us hope
that together we can make an impact on it. Thank you very much
indeed.
2 Note by witness: However, this would not
represent the total UNICEF is devoting to this disease. Back
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