Examination of Witnesses (Questions 480
- 499)
TUESDAY 18 JULY 2000
DR PETER
PIOT AND
DR JULIA
CLEVES
480. Can I ask whether this information on an
individual country's screening of blood supplies is available
freely? I think it would be important to tourists who are visiting
these countries. It could be used by governments in the developing
world to pressure countries from the developed world—I was
thinking in terms of tour companies—to ensure that work
is done on the testing of blood supplies and, therefore, is included
within the AIDS policies that countries may wish to have. If you
have a tour company in the United Kingdom that is promoting holidays
in various countries, they might wish to ensure that information
is available and that pressure is brought to bear, perhaps in
this case on DFID, to ensure that clean blood supplies are available.
(Dr Cleves) If I might add on the international response,
it is the WHO that takes the lead on safe blood. Indeed, this
year their world health campaign was on safe blood, under the
slogan "Safe Blood Begins With Me". They have done an
enormous amount of work promoting safe blood and, indeed, providing
technical assistance to countries in pursuit of safe blood. There
is abundant evidence that can be provided to you on their response
and on the situation globally.
481. Is this information available to tour companies?
(Dr Piot) We will send you the information. We have
it in detail for most African countries, except a few that are
at war, where the situation is probably predictable.
Mr Worthington
482. Can I ask you to talk a little bit about
the places that are quoted as successes, Uganda, Senegal and Thailand.
How do you demonstrate their success? What is the statistical
basis for saying they are successes? What do you think have been
the causes of their success? How did they achieve it? Is that
in some way linked to the social and political structure of those
countries? Is it possible to duplicate them elsewhere?
(Dr Piot) Firstly, what is the evidence? The ultimate
indicator of success in terms of HIV prevention programmes is
you have fewer infections today than yesterday or five years ago.
It is not so easy to measure but there are techniques. Certainly
in Uganda, in Thailand and also in parts of Zambia we see a decline
in the percentage of infected individuals in certain age groups.
The basis for our statistics, for our estimates, is so-called
sentinel surveillance, which means that groups of individuals,
usually women, who come to ante-natal clinics are then sampled
according to a sample frame that takes into account their age
particularly. They are being followed all of the time, not the
same individuals, for the percentage of infected individuals.
It is young people who are the most important. Why is that so?
When you look at the infection rate among 16 or 18 year olds that
reflects fairly closely recent events. That is the situation today.
What we have seen consistently in several of the sites in Thailand,
and also in Uganda, since 1992/1993 is there has been a steady
decline every year, less infected individuals. The question one
has to ask is this, is it because everybody who was infected died?
The answer to that is that the strongest decline is seen among
young people. This is where prevention is the "best".
Secondly, in all of these countries it is associated with dramatic
sexual behaviour change. This is one of the things we are doing
with a number of our partners in the countries. Estimated sexual
behaviour, when young people first start to have sexual intercourse,
today in Uganda on average is two years later than it was in the
early 1990s, which is a dramatic change. It was not even an implicit
goal of the campaign but it was one of the main results of the
campaign for responsible sexual behaviour. Condom use is up. The
number of sex partners is down. Numbers of sex workers are also
down. That is a pattern we are seeing in Thailand, Uganda, Senegal,
Zambia and also Brazil now. In Thailand much publicity was given
to the One Hundred Per Cent Condom Use campaign, which was a massive
campaign, saying that in commercial sex you should always use
a condom. What people tend to ignore is that at the same time
there was a campaign called Respect For Women, which was equally
important, where the message was—now I translate—"To
be a real man you do not have to go to prostitutes every Friday
with your colleagues". That resulted in a major increase
in condom use and a decrease in commercial sex. Many brothels
had to close because of the lack of customers. It is very important
that one looks at both sides of the coin. In other words, what
was this campaign trying to do? A change in social norms, what
is cool, as my daughter would say, and what is not cool in terms
of sexual behaviour. The evidence we have is very strong. It is
being confirmed year after year. The trends continue. To answer
your question, why has it happened in these countries and not
in others? I think you have to ask that question at the same time.
We see commonalities in what is going on in countries that are
so different, such as Uganda, Senegal and Thailand. Frankly, they
do not have much in common in terms of social structure, and so
on; it was what Julia said, the leadership, in many different
ways. In 1991 Prime Minister Anand Panyarachun who had just come
into power, was briefed by a group of economists who estimated
how much it would cost the economy if AIDS was not brought under
control. The Thai people being very pragmatic, he said, "We
have to do something". He appointed a state secretary in
his office, Mr Mechai who was a very well known family planning
activist and also a senator, to take charge of setting up a multi-sectoral
AIDS programme. The first thing they did was to make it compulsory
that every day on prime time TV every station, public and privately
owned, needed to spend, five minutes (it could have been less
or more) of air time on AIDS messages — that was in prime
time, not after midnight. Secondly, every single ministry had
to create a budget line and develop a plan for what they will
contribute to the fight against AIDS and how they will implement
their plans. For example, most of the cases in Thailand of HIV
came from northern Thailand and the sex trade in Bangkok. What
they decided was to intensify education, particularly girls' education
programmes and rural development programmes. You need leadership
and a clear plan. It is not enough to talk about it, you need
to know what you want to do. Thirdly, a multi-sectoral approach,
forcing all of these departments to work on it. Openness, we have
already touched on that. Testing is available. People with HIV
can come out. There are events that one can point to, like in
Uganda when one of the most popular singers, Philly Lutaaya came
out as being HIV-positive. When he came out nobody believed it
because he was a strong man but when people saw how he became
thinner and thinner and thinner they said, "He has got it".
It is the "Magic Johnson effect". Community involvement
is very important. In all of these countries there is a very strong
community-based response. The Government is in charge of the policies,
making sure there is a supportive environment based also on a
rights based approach but then the resources go to community groups.
It is not only groups of people living with HIV, in Thailand the
Pagods, the Buddhist monks, are very much involved. Museveni did
a very good thing in a sense in that the first chairman of the
Ugandan AIDS Commission was an Anglican Bishop. The current chairman
is a Roman Catholic Bishop. Bring them on board. In Senegal the
Marabouts, very powerful Islamic leaders, have really been at
the forefront of the fight against AIDS. The rest, of course,
involves condom promotion, messages for young people, that is
the easier part. How do you do it? Can that be transposed to other
societies? It requires leadership, it is a matter of governance.
There is a real link between good governance, democracy, empowering
communities and being able to fight AIDS. It came in Uganda after
years and years of dictatorship and war. The whole country was
there with hope and then there was AIDS.
Ms Kingham
483. You mentioned about a multi-sectoral approach.
I am interested in the pieces which are picked up, aspects of
work you touched on, such as brothels closing down. What happens
to the sex workers in those circumstances? What kind of redeployment
programme is there? Is that a fundamental part of the activities
or are you looking at it with tunnel vision in dealing with HIV/AIDS?
(Dr Piot) That is a good question because in this
case I have a positive answer to it. Because it was really a comprehensive
programme in Thailand. They did take that into account. Thailand
has a ministry for industrial investment in rural areas. They
linked it to that so there were more job opportunities in the
north of Thailand for women.
484. What about the people who were in the urban
areas? A lot of those sex workers move to urban areas, brothels
close down and then you have the problem of total destitution
and poverty and sex workers are out of jobs.
(Dr Piot) I fully agree, however they had planned
for this but then something that was not planned for happened
and there was a sudden economic and financial crisis in Thailand,
which led to urban/rural migration back. I think the test will
be, now that the economy is starting to pick up again, what will
happen there? The approach that we are taking now has been tested
out in the Piaro district in Thailand. It is a really integrated
approach, where you need a community response, a local response.
This is how you have to deal with orphans, instead of going into
the sex trade there are job opportunities for women. This is why
education is important. It sounds wishy-washy when I say it but
in the end this is where it has to come together. That is why
the AIDS programmes cannot work in isolation from the major development
policy. That is why we need the multi-sectoral approach, while
at the same time, with AIDS intervention, knowing exactly where
we can get the best for our money. We have documented that in
Thailand. I am very interested in that question because I often
see by "solving" one problem we create another one in
development. That has unfortunately been inconsistent in our work.
How do we avoid that? That is a model that we are trying to introduce
in a number of countries now, Tanzania, Burkina Faso, Zambia,
Ethiopia. It is what we call local response. That has to be brought
together.
(Dr Cleves) We have documented a great deal of what
accounts for success and makes for success. Peer pressure and
why it is that young people change their behaviour, is something
that we can probably do well to investigate a little further.
When you were asking about statistics and evidence for success,
in Lusaka, for example, the rate of HIV among pregnant teenagers
has fallen by half in the last six years. When you look at the
behaviourial evidence it shows that sexual activity amongst unmarried
girls has fallen from 52 per cent to 35 per cent in the same period.
We can point to the fact that communities have been involved and
religious leaders are involved. Undoubtedly, there is a tremendous
amount of peer pressure and peer education going on at the same
time.
(Dr Piot) The biggest problem are the men. The driving
force in this epidemic is male sexual behaviour. As long as that
does not change we can empower these fifteen year old girls but
when they are raped that approach is not very useful. It is the
sexual behaviour of men that is really fundamental to understand
this epidemic. Even for injecting drug users, the overwhelming
majority of drug users are also men. We are trying to translate
that concept, that knowledge, into something operational. That
is why I think changing the norms is so important and also working
with businesses. Reaching men is difficult. You can do that with
sports events, in the work place, we have not really exploited
these ports of entry enough. For the future that should be one
of our major emphases. That is also why our World AIDS campaign
over the next few years is focusing on men. It is not always easy
or well understood.
Mr Worthington
485. There is a tendency to say, "Here
is a huge problem, we have to experiment and find out what works".
The message we have been receiving overwhelmingly, is there is
not much more to find out. We basically have to do the best everywhere
now, instead of a small-scale project, we have to scale that up.
Is that the message you would give or is there still a lot of
scope for innovation or finding new methods?
(Dr Piot) This is exactly my message. If we apply
what we know works then we could save millions and millions of
lives every single year. In terms of new developments we need
two things, at least, a vaccine and a microbicide, a product that
women can use, it is a chemical condom, that would also make a
difference. If all countries could be as successful or effective
as Thailand or Uganda, who are cutting the number of new infections
by half, that is what we need.
486. One of the things which has puzzled me,
you referred to the behaviour of men, which is appalling probably
everywhere all of the time, but we put all of the focus on condoms.
We know what is wrong with condoms as a method and there seems
to be extremely little attention paid to the female condom and
microbicides. Am I right in that?
(Dr Piot) What you are saying is music to my ears.
The messages are a bit more complicated. As I said before, I think
changing the norms, what is okay in terms of sexual behaviour,
is also important. It is not only a matter of condoms but condoms
must be used in all cases, which means that today woman depend
entirely on the goodwill, and skills, and so on, of the men. That
is why we feel that the female condom should be an integral part
of any programme. The price is high and up to recently, with the
exception of DFID, there was no donor who was really interested
in supporting the female condom programme. As Julia said, at the
moment we have countries where the demand for condoms, certainly
for female condoms, exceeds the supply of affordable condoms.
That is a good sign. Ten years ago that was not the case. That
is an indicator that the messages are being taken. The female
condom has been part of that. Our strategy has been, again based
on the judo strategy, to create small projects to create a demand.
In many countries people have not heard of the female condom.
If they know it exists we can push and create a demand, but without
subsidising, what is after all a social good, it will not happen.
Ann Clwyd
487. Do you think that the balance of funding
is right between vaccine and microbicide development?
(Dr Piot) Between these two?
488. Yes.
(Dr Piot) There is hardly any funding going to microbicide
development. There is probably a much higher probability of coming
in with a product within the next five years.
Mr Worthington
489. Why is that?
(Dr Piot) From a commercial perspective what you need
is an over-the-counter product which is very cheap and which does
not have side effects, because women have to use it as many times
as it is needed and it would have to be distributed everywhere.
That does not make it very appealing for any company to invest
in because you need to invest a large amount of money. Clinical
trials demonstrating that it works are basically as complicated
as for demonstrating that a vaccine would protect, they could
be even more difficult, I think. With a vaccine you know when
you give a shot in the arm, but with a microbicide you do not
know exactly. The balance is not right. I think there is a case
for more investment in the future.
(Dr Cleves) Having said that, there are twenty microbicide
compounds that are ready for safety trials in human volunteers
at the moment and three other compounds being considered for large
scale trials and thirty-six at a pre-clinical stage. There is
a certain pipeline of microbicides that are ready to move forward,
however that does definitely need a push.
490. Being cynical about it, the pay-off from
preventing it happening is less than the pay-off for treating
the disease when you have it.
(Dr Cleves) There is always this debate about push
and pull factors. There are not very many strong forces pulling
a microbicide on to the market at present, that is absolutely
correct.
Ms Kingham
491. You mentioned previously having a minimum
standard of care. Presumably any minimum standard of care would
provide assistance to the whole health structure of the country,
a sectoral approach to the Health Service. You also mentioned
a figure of 1.5 billion, is that 1.5 billion realistic? Are you
envisaging that 1.5 billion to be the cost for helping to give
assistance to the whole sectoral approach of health care for the
country?
(Dr Piot) This is a most complicated question.
492. I thought it might be.
(Dr Piot) We are really faced with an enormous complexity.
We are trying to dissect the complexity and see where we can make
a difference. We should be realistic, it is not because there
is an AIDS epidemic that suddenly we collectively, those dealing
with AIDS or the international communities, would solve problems
which have been there for many years in terms of health care,
access to drugs and to treatment. That has been a problem before
AIDS was discovered. Today if you need renal dialysis or you have
breast cancer in these poor countries, it is the same problem.
That is one point. Secondly, what we have based our estimates
on, as Julia mentioned before, was palliative care, treatment,
the cost of treating opportunistic infections, HIV testing and
treatment science, preventing opportunistic infections, particularly
tuberculosis, which also has some benefits outside AIDS. It is
the service delivery cost where the big problem lies. As much
as I do not think that AIDS will result in beefing-up health systems
I think it should provide a major incentive to invest more in
health care services and to speed up what we are doing with these
health sector-wide approaches. I must say that the whole approach
that DFID has taken there is the model to follow. With AIDS it
has to accelerate because otherwise I think we are in a situation
where either we go for the full package or we can throw the money
out of the window. If you do not beef-up the services that can
respond to the enormous demand of people living with HIV, which
is going to increase, people will vote with their feet, it is
not whether we should deal with them or not, they become ill and
they go to hospitals and health centres. If we continue business
as usual, with health care infrastructure building or revamping,
that will bring the system even more in this area than before.
We need to keep pace and intensify the supply in terms of services.
Can that be done? That is an answer that I do not have at the
moment. This is why it is so important that the WHO and the Bank
are coming in in a major way on things which are not necessarily
AIDS-specific. I am not sure my answer is clear enough.
Ann Clwyd
493. Are you saying that $1.5 billion does not
include service delivery?
(Dr Piot) It does, to a certain extent. About half
of that would be service delivery. That is before we talk about
antiretroviral therapy, that is not included.
(Dr Cleves) We are not envisaging some three-layered
super highway for developing HIV/AIDS care. We have the systems
and we have to use the systems. As everybody knows, at the moment
those systems find it very difficult to deliver treatment for
TB, which is only a tiny bit as complex as other things. Nonetheless,
some of the systems there are competent and can deliver much more
than they are able to at the moment, with more injection of resources,
both financial and human. It is also important to recognise that
we have to think outside the box and think outside public sector
systems. We have to find ways of engaging the private sector,
the community sector and the civil society more generally. There
is a great deal of interest in the WHO at the moment. We are working
with them actively on thinking about how to innovate and how we
can use the epidemic to really push the capacity of all sectors
to deliver these basic services.
Ms Kingham
494. In terms of funding, has there been any
agreement internationally as to where funds come from, the burden
sharing of funds between multilateral donors and bilateral donors
and the developing countries themselves?
(Dr Piot) No, there is no agreement in terms of percentages.
What we are trying to do now is to collect figures, who is contributing
what, so we have a base line. That base line tells us that, for
example, at the moment in sub-Saharan Africa we estimate that
about $300 million in 2000 will go to AIDS prevention programmes
and about 100 million will come from national resources, domestic
resources, and 200 million from international resources, half
of those from the United States. Our point is that countries really
need to increase their investments, the developing countries themselves.
We are working out potential sources of money for each country
as part of national strategic planning, with costing potential
sources of money. I think the experience from ICPD Plus five was
targets were set. Deciding who should contribute how much was
perhaps a bit naive. What we are trying to do now is try to see
what is the base line and then target who does not pay enough.
495. Will you have some common reporting mechanisms
to be able to ascertain who is paying what and how they are paying?
In reality, how is it getting off the ground? We have been picking
that up from numerous witnesses. Some organisations might find
it impossible to say how much they are actually spending on projects
that are HIV/AIDS-specific. If you are not careful it can disappear
into a big pot somewhere.
(Dr Piot) When our board was in the United Kingdom
two years ago it asked that question, a very simple question,
and I thought we would have the answer in a few months' time.
It is very difficult. I think we have already done two rounds
of it and we are getting close to, at least, an estimate of what
is being spent. That is why I can give you these figures.[5]
We spelt it out by donor, by country and that report will come
out very soon. This is something that I feel is a service that
we can provide. What we are doing is, and it is quite interesting,
having a double approach. We approach it from the capitals, from
the donors and also from within the country. You will see that
it does not match, even for the same donor.
496. That does not surprise me dramatically.
(Dr Piot) I am not singling out any donor. We have
major discrepancies. Then we sit down and we say, "What is
it?" We can monitor the trends and what we are trying to
do now, and this makes it even more complicated, is to build foundations
for that. There is big foundation money coming in—Bill Gates
particularly, also the Turner Fund and some of the pharmaceutical
companies. I think we will be able to monitor it. It is true as
you say, on the one hand we are pushing for an integrated approach
or integration of HIV activities in rural development programmes,
micro credit schemes and reproductive health and that makes it
more difficult to track it - that is where we also have a very
conflicting message. On the other hand, we are asking for more
precise reporting on every single sub-item you can think of. For
me the key is to collect the information, particularly at the
country level.
(Dr Cleves) It is very complex.
Mr Rowe
497. What are the implications of HIV/AIDS for
structural adjustment programmes? We have heard that you should
cut back on your civil servants, and so on, and then you find
that the cost of HIV/AIDS is cutting back on the Civil Service
faster than anybody would have done. Are there implications in
cost, recovery, health and education services and scaling down
public services?
(Dr Cleves) I think we should put the question the
other way around as well, have we also been very concerned about
the effect of structural adjustment on the AIDS epidemic. There
was quite a lot of discussion recently at the Durban Conference
on trying to track precisely what the relationship has been between
the epidemic and the structural adjustment. There are some reasonably
positive examples where a country like Brazil in recent years
has obviously undergone a structural adjustment process but has
managed to retain its investment in AIDS and, indeed, has a very
successful programme, both in terms of prevention and, increasingly,
in terms of the resources it is able to put into care. In other
countries, and elsewhere, the picture is, perhaps, less rosy,
not least because with structural adjustment programmes there
tends to be this terrific urbanisation, an increase in the export
market, an increase of roads and road traffic in terms of long
distance lorry hauliers, which we see in sub-Saharan Africa and
India as well. This always bring with it the spread of the HIV
epidemic. Structural adjustment raises particular problems for
governments because most of the factors which fuel the AIDS epidemic
are also those factors that seem to come into play in structural
adjustment programmes.
498. That is very useful and it is interesting,
because it comes from a slightly different angle than I was coming
at it from. The World Bank tend to say to countries, "You
have too much fat in your bureaucracy". Is there not a real
danger in trying to adjust to that in a country like Malawi, where
1,000 teachers died last year? The idea that there are too many
people in your education service strikes one as a bit chilling.
(Dr Piot) I agree with that. It is crystal clear to
me that the AIDS epidemic has not been integrated into longer
term planning, for the public sector or the whole structural adjustment
issues. When I was at the World Education Forum in Dakar in April,
I was really shocked by the fact that in many countries planning
for education, for expanding education in school systems, and
so on, continued as if there was no AIDS epidemic, as if this
was not affecting, in economic terms, the supply and demand and
the quality of education. This is why it is so important that
we go beyond this health sector and that we come up with credible
alternatives. It is so important that AIDS is integrated in the
poverty reduction strategies. That is a point of entry to counterbalance
this. I would say that is a very strong recommendation. I bring
that message everywhere.
499. Given that developing countries' health
budgets are so stretched, what do you think is the best strategy
for such governance in terms of effective expenditure? Should
they concentrate on HIV/AIDS specific programmes or on establishing
sexual and reproduction health services or provide safe drinking
water? If you were the chief minister where would you put your
money?
(Dr Piot) If I was the chief minister and twenty-five
per cent of my adult population were HIV positive—according
to UNAIDS fifty per cent or more of my fifteen year olds will
die from AIDS—there is nothing more important, in terms
of ensuring the continuity of the nation and also of ensuring
that other development investments will pay off, than that AIDS
it brought under control, it is contained. I think we need to
approach AIDS more and more in a war-type fashion. We are not
going to make a significant impact on AIDS if we are not really
putting in all of the resources as we would in a war-type effort.
You need alliances. You work with people you hate, but you go
for it. You really have to take the resources where they are and
we need to expand the resource base. That is one of the reasons
for a multi-sectoral approach. To answer your question directly,
the cost of dealing with this epidemic, in terms of government
resources, can be distributed. It can be shared over several departments.
One does not have to cut on clean water, one should not cut on
programmes for education. We know that with education, in general,
in the long-term it is one of the best things we can do to contain
this epidemic. At the moment the redistribution has to come from
sectors that are looking into some of the structural adjustment
programmes, making sure that money that comes in is freed by debt
relief operations and that would go to AIDS in the first place.
(Dr Cleves) I think it is important not to see these
sectors as competitive. You cannot look after people who have
HIV/AIDS if there is no clean water for them to wash their wounds
with. One of the issues that emerged strongly at Durban was military
expenditure, the inordinate billions that go into military expenditure
in heavily indebted countries and very poor countries. That is
definitely one area where a few judicious cuts would make resources
available.
Ann Clwyd: This Committee has continually
made that point.
5 See Evidence pp. 249-50. Back
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