House of Commons - International Development

Select Committee on International Development Third Report

Section 3 — Prevention and Care

129. The most effective action to reduce the impact of HIV/AIDS on a country or region is to reduce the number of transmissions of HIV through effective prevention. Professor Roy Anderson's paper to the International AIDS Conference in Durban pointed out that, in order for an epidemic not to expand, the number of secondary infections resulting from one primary infection should be one or lower. If higher, the multiplication of infections will eventually result in a mainstream epidemic with high prevalence.[168] Many witnesses and publications emphasise that the means of preventing or reducing transmission of the HIV virus are already known; what is lacking is the will to make this happen on the necessary scale.

130. The following section is not a comprehensive summary of prevention activities but highlights some of the areas which the inquiry touched on and for which the Committee felt further or different work could be undertaken. It was also emphasised that these activities need to be simultaneous and complementary, carried out on many fronts. There is no one simple answer to reducing transmission of HIV. Social change, changes to sexual behaviour and relationships, use of available barriers such as condoms, and research to try to discover new technologies are all needed.

131. UNAIDS state that "two decades of experience show that behavioural prevention can make a serious dent in the rate of new infections and change the course of the epidemic".[169] UNAIDS goes on to list the options traditionally promoted in prevention campaigns, "One is to abstain altogether from sex — or, for young people who have not yet become sexually active, to postpone the start of their sex life. Another is to engage in sex that involves no penetration. As a further option, people are encouraged to have sex with only one other person — someone who will never have sex with anyone else. Mutual fidelity is protective, of course, only if both partners stick to the rules and were uninfected to begin with. Finally, the consistent and correct use of condoms (both the traditional kind and the female condom ...) for every act of sexual intercourse protects both partners from HIV and other sexually transmitted infections".[170]

132. Uganda is frequently cited as an example of successful prevention. It was once the country with the highest prevalence rate in the world. Now it is fourteenth. Since 1993, it has seen declining prevalence rates in the ante-natal screening programmes. In addition, surveys show corresponding changes to sexual patterns. The age of first intercourse increased by two years, condom use increased from 15.4 per cent in 1989 to 55.2 per cent among men in 1995. There was also a drop of 50 per cent in the proportion of men and women exchanging sex for money .[171] In "Open Secret", published by ActionAid, the authors identify a combination of factors which have led to this relative success, "By restoring the rule of law, freeing the mass media from official interference, and reviving democratic participation in national and community affairs, the government created a social climate in which community initiative could flourish".[172]

133. An AIDS Control Programme was set up by the Ugandan Government in 1986 and instituted a wide range of actions which have all contributed to the relative success story of Uganda. With political leadership and community participation, there was increasing openness and challenging of stigma against people with HIV. A health programme combined health education, treatment of sexually-transmitted diseases, voluntary counselling and testing and widespread distribution of free condoms. Speaking about Uganda, Jeff O'Malley pointed out that political action had followed on from community action.

134. Since the fall in prevalence of HIV has become known, Uganda has become a beacon of hope for Southern Africa, evidence that the right combination of actions combined with political leadership, social change and community participation may offer a solution. The prevalence rate among pregnant women attending surveillance ante-natal clinics appears to be stabilising around 10% (from 25-30% in the early 1990s), however there is no evidence of it continuing to fall below this rate.

135. In a Report such as this it is important to maintain a balance to our analysis. On the one hand it is important to stress the cataclysm of the epidemic, the need for urgent and concerted action to decrease rates of infection and mitigate the impact of the disease. On the other we must emphasise that the fight against HIV/AIDS is not a hopeless one. Even in the absence of a vaccine, and with limited resources, successful prevention is possible.

136. Evidence raised a number of aspects of prevention which required support and further work. One important area is work amongst young people both within the school curriculum and through peer education. Many witnesses stressed the need to establish effective primary health care, sexually transmitted disease services and testing and counselling facilities. It is also vital at early stages of an epidemic to take prompt action amongst high-risk groups. We do not intend to expand on these points in this Report. We stress that this is not because they are unimportant — on the contrary they form the bedrock of any effective and meaningful prevention. As such, there is already a significant amount of literature and experience on which donors can draw. We certainly expect DFID to be advocating and supporting such interventions as a central part of its HIV/AIDS strategy and welcome the prevention work DFID has engaged in to date.

137. We have discussed the loss and developmental harm caused by HIV/AIDS in sub-Saharan Africa. Even though we do not concentrate on prevention in this Report it remains the priority, and of particular importance in Asia. There even low prevalence rates translate into appalling absolute numbers of HIV-positive people because of the size of populations. Were the sub-Saharan Africa prevalence rate to be replicated in Asia, there would be a further 285 million HIV-positive people in the world. The consequences for the global economy and security, as well as the scale of the resulting humanitarian disaster, are unimaginable. The prevention of a high-prevalence HIV/AIDS epidemic in Asia must be a priority for the international community. There is debate as to the likelihood of such a scenario. What is certain is that complacency and inaction only make the worst-case scenario more likely. The appalling consequences of failing to implement an effective prevention programme at an early stage can be seen in South Africa where prevalence rose from 12.9 per cent two years ago to 19.9 per cent today.[173]

138. In this section we consider two aspects of prevention. The first is the medical and material aspects of prevention and protection — the availability of male and female condoms, research into microbicides and vaccines, harm reduction amongst injecting drug users, the prevention of mother-to-child transmission. The second is the behavioural side to prevention, where we consider prevention and human rights, prevention and the media, prevention in the workplace.

139. There were a number of other issues raised by witnesses which are relevant to discussion of prevention such as safe blood supply and the possible effect of male circumcision in reducing the risk of HIV transmission. We refer readers to the evidence should they wish to explore these matters further.

Material interventions

MALE CONDOMS

140. Condoms remain the only proven effective means of preventing and reducing the transmission of HIV through sexual intercourse. Throughout the world, prevention has focussed on encouraging the use and acceptability of the condom. This has had to contend with religious objections, especially from the Catholic church and from leaders who believe that promoting condoms encourages sexual behaviour, particularly outside marriage. President Museveni of Uganda, at the 1991 International AIDS Conference, denounced condoms as an HIV prevention strategy. His change of heart was as a result of evidence from WHO and USAID, and was followed by a reversal of policy from church leaders. By the mid-1990s, active condom promotion was a regular feature of Ugandan society.[174]

141. Dr Julia Cleves of UNAIDS told us that there is a shortage of male condoms in a number of African countries. She said,"in this day and age and with the epidemic at this stage, this is quite extraordinary".[175] We are appalled that at such late and grave stage of the epidemic there remain condom shortages in sub-Saharan Africa. One aspect of this shortage could well be cost. There is also, however, a question of effective logistical planning by government health departments. DFID has recently given £25 million to UNFPA for the purchase of condoms for developing countries. We welcome this intervention and believe bilateral and multilateral donors have a vital role in this area. We would also encourage the provision of technical assistance to developing countries in the purchase both of condoms and of drugs and other medical supplies to ensure consistent and sustainable supply over time.

142. The colour of condoms made available in the developing world has been raised as a subject of concern.[176] In general, condoms available in the UK are the natural colour of latex which is similar to Caucasian skin colour, although coloured condoms have been produced by London Rubber Company targeted at British black and Asian communities. The WHO Specification & Guidelines for Condom Procurement say that there is no reason why a colour should not be added to the latex and that this may be useful to "segment a market, such as condoms used in free clinic programmes from those used in social marketing programmes".[177] When in South Africa we came across the view that the promotion of condoms was a "white man's conspiracy" to reduce the African population. Inappropriate colouring of condoms can do little to dispel such beliefs. Conversely, appropriate colouring might well enhance acceptability. We recommend that DFID take colour into account when considering the provision of condoms to the developing world and that market testing should identify whether colour could make any difference to the acceptability and use of condoms.

FEMALE-CONTROLLED PROTECTION

143. We have previously mentioned the fact that central to any HIV/AIDS strategy must be the promotion and protection of women's rights. We are convinced that were countries to implement effectively the various conventions and protocols on women's equality and sexual and reproductive rights there would be considerable progress made against the epidemic. In the following paragraphs we consider some forms of protection against HIV/AIDS which empower women rather than leave them dependent on the cooperation of men. The promotion of such forms of protection is an important aspect of the recognition of a woman's right to control her own sexual and reproductive health.

Female condoms

144. Even where condoms are available and culturally-appropriate, it is frequently reported that men are reluctant to wear them despite the fact that the female partner would prefer it. HIV/AIDS programmes should certainly include training for women in assertiveness in relation to the use of condoms by male partners during sex. The male condom, however, leaves with the man a significant degree of control and power in such sexual encounters. We heard from a variety of witnesses that the female condom may have advantages in some situations, notably with commercial sex workers. A joint UNAIDS and WHO publication"The Female Condom — an Information Pack" concluded that "The female condom has been shown to contribute to women's sense of empowerment, especially if supported by education and informational activities".[178] More recently, research has shown that it may be cost-effective in reducing HIV infections, particularly if targeted at women involved in "high-risk behaviours" and if it is offered as an alternative, rather than a replacement for, the male condom. In particular, research with sex workers in Thailand showed that where the female condoms was provided as an alternative, the incidence of sexually-transmitted infections was a third lower than when only the male condom was provided.[179] During our visit to commercial sex workers in Carltoneville, South Africa, they complained about their lack of access to female condoms, which would have clearly been a popular alternative to the male condom.

145. During evidence, Dr Julian Lob-Levyt of DFID was asked about the female condom. He said, "it will probably never be as important as the male condom for a number of reasons, partly price, sometimes preference. What we are seeing in a number of countries where DFID has been one of the lead donors in supporting this particular condom is an increasing usage amongst women...It will have its niche and be an important one."[180] Dr Peter Piot also paid tribute to DFID's involvement, "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...at the moment we have countries where the demand for condoms, certainly for female condoms, exceeds the supply of affordable condoms".[181]

146. One factor which could dramatically improve the cost of the female condom is if it is able to be used more than once. Washing and re-use of the condom, which is made of more durable polyurethane and not latex, has been reported by agencies in developing countries. UNAIDS convened a roundtable discussion in June 2000 to consider available evidence about the safety of this practice. They were unable to conclude from available evidence that washing and re-use could be safely recommended. WHO is funding further research to try to reach a conclusive position.[182]

147. Alongside moves to develop other female-controlled prevention tools such as microbicides, the female condom clearly has an important role to play and DFID is to be congratulated for its early support. The female condom is not invisible or inconspicuous; women who currently find it impossible to get a male partner to wear a condom will not be spared the need to negotiate. However, there are situations where it will have an advantage, especially for sex workers. We recommend that DFID continue to support the promotion of the female condom.

Microbicides

148. A potential tool to reduce transmission of HIV would be a microbicide, a substance introduced into the woman's body which would protect by inhibiting transmission of the virus during intercourse. As a method controlled by women, it could have distinct benefits over condoms by reducing the necessity for negotiation with a male partner.[183] A microbicide which was not also a contraceptive would be welcomed by populations where having children remains a priority and it may also prevent other sexually-transmitted infections. Unlike a vaccination, a microbicide would not need to be administered by medical personnel. There are approximately 60 compounds under investigation as potential microbicides, some of which are currently in trials.[184] It would be unlikely that a substance would be completely invisible and the cultural preference for "dry sex" (sex with herbs or scouring agents introduced into the vagina) in some parts of Africa is a potential drawback.[185]

149. Giving evidence to the Committee, Dr Peter Piot was asked whether the balance of funding between microbicides and vaccines was correct. He explained that there is hardly any funding going into microbicide development at the moment despite the fact that there is a much higher probability of a product being found within the next five years than there is of finding a vaccine.[186] Dr Julia Cleves of UNAIDS said that there was definitely a need for a push to get various microbicide candidates into trials. The Alliance for Microbicide Development and the Global Campaign for STI/HIV Prevention Alternatives are at the forefront of this work.

150. The Department of International Development has previously directed some funds to research into microbicide development.[187] As the area has been relatively neglected internationally, there is clearly potential for greater investment. Investment by the UK Government would could play an important part in developing a product with the potential to reduce dramatically incidence of HIV infection. In its HIV/AIDS strategy, the Department for International Development should prioritise microbicide research alongside research for a vaccine and act as an advocate internationally to encourage other donors to give microbicides a higher priority.

VACCINES AGAINST HIV

151. Evidence presented to the Committee demonstrated that great hopes are being placed in the future discovery of a vaccine that will be effective at preventing the transmission of the virus or mitigating its effects. Financial investment and scientific attention devoted to this area of research have increased significantly recently, with several encouraging multi-national partnerships bringing together private and public sectors. Work is concentrated on investigating potential vaccines, testing their safety and efficacy and considering how such a vaccine could be made available to the developing world. We heard evidence that most current research is focussed on sub-types of the HIV virus found in the developed world. We believe that vaccine development partnerships and investors should take steps to ensure that research prioritises sub-types of the HIV virus found in developing and worst-affected countries as least as highly as those more commonly found in the developed world.

152. The UK Government was the first national contributor to the International AIDS Vaccine Initiative with an initial donation of £200,000, followed by £14 million in 1999. This was an important step towards encouraging other countries to invest and other countries such as the United States, Canada, Ireland and the Netherlands have followed the United Kingdom lead. There was a consensus among witnesses that the most optimistic timescale for the discovery of a safe and effective vaccine is between seven and ten years. This timescale has been postulated for some considerable time. We were in agreement with Dr Peter Piot when he said, "I am very clear that we cannot rely on technology. I deeply, deeply hope that we will have a vaccine, the sooner the better. We are not going to make it with technology, it is with people".[188] Jeff O'Malley said, "In the past few years I have welcomed the increased attention to the development of an HIV preventative vaccine, but I fear that the sexiness of a magic bullet is such that perhaps there has been inadequate attention paid to funding what can make a difference today and tomorrow".[189]

153. We believe that the Department for International Development should continue to support the search for a vaccine. We believe that all spending on HIV prevention should be carefully monitored to ensure that there is a balance between searching for prevention technologies such as vaccines and microbicides and work aiming to achieve behavioural and social change and to promote the use of condoms. The latter will clearly remain the only proven effective means of prevention for the foreseeable future and therefore a careful balance of priorities needs to be maintained so that this work does not get neglected.

154. An important factor in the development of a vaccine is its availability in resource-poor countries. The experience of access to treatments for HIV infection demonstrates that the private sector alone is unlikely to market a vaccine that is affordable to developing countries' budgets. We congratulate those international partnerships which are grappling with this problem in advance and attempting to ensure that use of the vaccine in the developing world will be its first priority. We heard evidence from the National Aids Trust that the European Commission is funding a research programme, EUROVAC, through the private sector. We hope that the EUROVAC programme, and other similar initiatives, will take steps to ensure that public money is only used to fund the development of products which will be affordable in developing countries.[190]

155. In November 2000, the Prime Minister requested the cross-departmental Performance and Innovation Unit to examine how to achieve better availability of drugs to prevent and treat HIV/AIDS, tuberculosis and malaria in developing countries. An interim report identified a number of both 'push' and 'pull' instruments aimed at stimulating greater research and development activity and strengthening incentives by improving the prospective value of the market. In the 2001 Budget, the Chancellor of the Exchequer announced a package of measures aimed at encouraging pharmaceutical and other companies to commit resources to the prevention and treatment of such diseases. Measures included:

consultation on a new vaccines tax credit;
additional tax relief for research into such diseases;
consultation on new measures to facilitate the donation of drugs and vaccines to international aid organisations and public health authorities.

DFID's Globalisation White Paper also made a number of proposals to encourage pro-poor research on diseases such as HIV/AIDS including the use of public purchase funds whereby governments would undertake to buy vaccines for developed country markets at a fixed price, providing the private sector with the financial incentive that is now missing. Further suggestions included differential pricing and extending the period of intellectual property protection and the use of tax credits. We welcome the initiatives of the United Kingdom Government in attempting to secure better availability of drugs to prevent and treat HIV/AIDS, malaria and TB in the developing world.

168 Roy M Anderson, Nick Grassley and Geoff Garnett, "Success in HIV control: fact or fiction?", Wellcome Trust for the Epidemiology of Infectious Disease, University of Oxford. Back

169 UNAIDS June 2000 Report p.55 Back

170 UNAIDS June 2000 Report p.55 Back

171 Open Secret, Strategies for Hope No.15, 2000, p.5 Back

172 Open Secret, Strategies for Hope No.15, 2000, p.6 Back

173 UNAIDS June 2000 Report p.9 Back

174 Open Secret, Strategies for Hope No.15, p.18 Back

175 Q.471 Back

176 Q.50 Back

177 Specification & Guidelines for Condom Procurement, Family and Reproductive Health, World Health Organization, 1998, p.37 Back

178 UNAIDS and WHO "The Female Condom - an Information Pack" April 1997 Back

179 UNAIDS/WHO "The Female Condom - a Guide to Planning and Programming". 2000, p.21 Back