Select Committee on International Development Third Report

Section 3 — Prevention and Care


180. As previously noted, prevention of future infections offers the best hope that the impact of HIV/AIDS on developing countries will be reduced in the long-term and this is a clear priority for donor countries and international organisations. However, there are compelling reasons to consider the care and treatment needs of people already infected. As DFID noted in its submission, "While the epidemiological arguments might be to use scarce resources almost entirely for prevention, humanitarian realities dictate that the swelling numbers of people with HIV-related illnesses have a major claim on governments, civil society and international agencies".[214]

181. Furthermore, there is not as clear a divide as is sometimes assumed between interventions categorised as prevention and those seen as care, particularly in countries with high prevalence. As has been noted, with mother-to-child transmission above, some treatments have a role in preventing infections. Moreover, the absence of any form of treatment is a disincentive for voluntary testing — a key part of prevention strategies. As Dr Peter Piot said: "You cannot deal with prevention without care...What is the incentive [to test] when there is no care at the end of the bad news?"[215] Care and support for people with HIV infection is also an important element of a prevention strategy as only those already infected can pass the virus on; the provision of support and counselling is an opportunity to discuss protecting future sexual partners from infection. Clare Short told us that DFID was "widening and deepening" its efforts and thinking, and that this included an acknowledgment of the need "to put more effort into care", whilst continuing to support prevention.[216] All HIV/AIDS strategies must include an emphasis on the care of HIV-infected persons. This is not only a humanitarian imperative but also an indispensable component in any effective reduction in infection rates. We welcome the recent acceptance by DFID of the need to put more resources into care.


182. Too often, the debate about access to treatments for HIV/AIDS has been reduced to a debate about access to anti-retroviral drugs. VSO warns, "AIDS treatment in the North now includes anti-retroviral drugs (ARVs) which slow the course of the whole disease. But discussions of treatment must not be limited to these drugs. VSO partners have identified accessibility to treatments for opportunistic infections and symptoms as a key issue".[217] They point out, "According to WHO, one third of the world's population lacks access to essential drugs, this figure rises to over half in the most impoverished parts of Africa and Asia. Not having access to these drugs is undermining development: If an HIV-positive person's life is lengthened by five years through access to treatments, and during that time they are relatively well, that is five more years during which they can be breadwinners, parents and maybe skilled teachers, health workers and business people".[218] As we noted earlier, the rate of HIV-related deaths in the UK had begun to fall prior to the introduction of anti-retrovirals, as a result of better treatment and prophylaxis for opportunistic infections.

183. Other witnesses also stressed that in the developing world access to all forms of treatment is often severely restricted. Julia Cleves of UNAIDS said, "There is a shortage of basic drugs for palliative care. Many people die in Africa without so much as paracetamol, or calamine lotion for a skin rash."[219] A UNAIDS study of 22 teaching hospitals in Africa and Asia found that only two-fifths had strong painkillers available.[220] Inexpensive drugs to treat opportunistic infections are rarely available to poor people living with HIV. VSO make the point that "even though some of the medicines are cheap, budgets do not stretch to buying adequate quantities".[221]

184. Dr Peter Piot told the inquiry that HIV/AIDS has come "at a time when the health infrastructure in many countries has basically collapsed and is much worse off than five years ago, ten years ago, even twenty years ago.."[222] The Committee asked the Secretary of State what her spending priorities for health services in high prevalence countries. "I believe that all poor countries need a universal primary health care system, and for something like as little as US$12 a head a year you can get a basic primary health care system reaching all, then you have a mechanism for immunising children, giving people access to reproductive health care, proper supervision of TB treatments and malaria advice...That is our passion and our work".[223] Similarly, the BMA Foundation for AIDS said that "There are difficult choices to be made, but strengthening primary health care and improving access to clean water, sanitation and basic services may be a more appropriate strategy for benefiting people affected by HIV/AIDS and other diseases" than broadening access to complex medicines.[224]

185. The Committee agrees that basic healthcare is a necessary pre-requisite for the medical care and treatment of people with HIV. DFID's identification of this as a priority is clearly appropriate. Primary healthcare for all would immediately and markedly improve the health of people living with HIV through access to basic palliative and other essential medicines, effective treatment of tuberculosis and STDs, and would offer the potential for expanding access to drugs to treat common opportunistic infections.

186. Dr Peter Piot explained that UNAIDS is "working with countries to establish standards of care. We need to rationalise the agenda because if we do not do that it is as if pure market forces take over, meaning that only the rich who have access to anti-retroviral therapy will have access to care, and the poor with HIV will not have access to simple treatment".[225] UNAIDS has published a draft document entitled "Key Elements in HIV/AIDS Care and Support". It divides possible interventions for the care of people with HIV/AIDS into three levels, identifying Essential, Intermediate and High levels of care (see below). We strongly endorse the approach of UNAIDS in producing a clear set of priorities to inform multilateral agencies, bilateral donors and governments of developing countries. We believe that this model should determine the priorities of DFID and other agencies and that action should concentrate first on provision of essential care interventions before consideration of access to anti-retroviral drugs.

Essential activities

  • HIV Voluntary counselling and testing
  • Psychosocial support for people living with HIV and their families
  • Palliative care and treatment of common opportunistic infection (pneumonia, oral thrush, vaginal candidiasis, pulmonary TB — with DOTS)
  • Nutritional care
  • Treatment for sexually-transmitted infections and contraception
  • Cotrimoxazole prophylaxis among HIV-infected people
  • Community activities to mitigate impact of HIV (including legal protection against discrimination)

Care and support of intermediate complexity and/or cost

  • Active case-finding and treatment for TB for HIV+ve people
  • Antifungals for mycosis (such as cryptococcosis)
  • Treatment of Kaposi's sarcoma, lymphoma and cervical cancer
  • Treatment of extensive herpes
  • Prevention of mother to child transmission of HIV
  • Post exposure prophylaxis of occupational exposure to HIV and for rape
  • Funding of community efforts that reduce the impact of HIV infection

care and support activities of high complexity and/or cost

  • Triple antiretroviral therapy
  • Diagnosis and treatment of opportunistic infections that are difficult to diagnose and/or expensive to treat, such as atypical mycobacterial infections, cytomegalovirus infection, multiresistant TB, toxoplasmosis, etc
  • Advanced treatment of HIV related malignancies
  • Specific public services that reduce the economic and social impacts of HIV infection

Community involvement

187. The International HIV/AIDS Alliance in its submission argued that "Successful responses to HIV/AIDS require community involvement and commitment, especially from people living with HIV".[226] Indeed, in resource poor countries where the health sector could be completely overwhelmed by trying to meet the needs of people with HIV, home-based care, voluntary support and self-help offer potential solutions to the high levels of need. Furthermore, this community involvement has the potential to reduce the stigma and silence surrounding HIV. The South African Government's HIV/AIDS Strategic Plan 2000-2005 promotes community and home-based care with intersectoral task teams on an area basis and a priority to reduce stigma associated with HIV and with home-based care. Jeff O'Malley pointed out the way that TASO, The AIDS Service Organisation of Uganda, adapted a model of "buddying" — itself developed as part of the early crisis response by gay men in the United States — from experience of the Terrence Higgins Trust's services in London.[227] When in Uganda, the Committee saw an impressive example of community work on HIV/AIDS — young people banding together and agreeing voluntarily to be tested, promising to support each other whatever the results.

188. The involvement of people living with HIV in the planning of services has been a key principle for HIV/AIDS work, although with many difficulties in countries where stigma attached to HIV has remained high. In 1994, the Paris Declaration declared that the greater involvement of people living with HIV/AIDS was "critical to an appropriate, ethical and effective national response to the epidemic" and agreed to support this by "an initiative to strengthen the capacity and coordination of networks of people living with HIV/AIDS and community-based organisations."[228] The UNAIDS June 2000 Report said that "Although the [involvement of people with HIV] mandate has been generally accepted by all countries, there are still very few successful initiatives under way". It said that "in many sub-Saharan African countries, an environment characterised by high levels of denial, fear and stigmatisation has undermined" this initiative. It is hoped that DFID considers the way in which people living with HIV have been involved in the planning and consultation of programmes, and the ways in which they will be involved in overseeing the delivery and monitoring of all programmes it is funding. This principle needs to be constantly re-affirmed and would go a long way to change the invisibility of people with HIV in developing countries, to challenge the silence and stigma attached to HIV infection and to affirm a rights-based approach that does not simply consider people with HIV to be passive recipients of care.

Access to anti-retroviral drugs

189. In industrialised countries, the introduction of Highly Active Anti-Retroviral Therapy (HAART) has caused the numbers of people dying as a result of HIV infection to fall by two-thirds since 1995.[229] Both length of life and quality of life of infected people has improved dramatically in Northern countries. Since HAART is widely available to all people with HIV, if these improvements continue, HIV may come to be seen as a long-term chronic condition.

190. Where anti-retrovirals are available in a developing country, it is only to a few wealthy individuals who can pay for treatments or senior staff in private or government corporations who have comprehensive health insurance. In their evidence to the Committee, Standard Charter Bank and Anglo American plc discussed levels of healthcare available to their employees. Dr Brian Brink of Anglo American said that there is a health insurance scheme which staff can join and which provides anti-retrovirals. However, this is "an example which is at the top end of our health insurance arrangements. The health care plans for the biggest section of our workforce, which is the less-skilled section on our mines generally, is through company-owned medical facilities and services which are provided free of charge to the employees....I would say at this stage as things currently are to offer anti-retroviral therapy to the entire workforce would cost too much and would not be affordable".[230] During the inquiry, newspapers reported that Members of the South African Parliament who have HIV are receiving anti-retrovirals through their parliamentary medical insurance system.[231]

191. The issue of access to anti-retroviral drugs for developing countries has become a major international political issue and was discussed frequently during the inquiry. The current case in South Africa where 39 pharmaceutical companies are taking the South African Government to court over the provisions of the Medicines and Related Substances Control Amendment Act 1997, which they claim contravenes WTO rules, has added to the controversy. We certainly do not intend to come to a view on the merits of that case nor how in detail to interpret the TRIPs agreement of the WTO (Trade Related Aspects of Intellectual Property Rights). The question of concessional drugs pricing for the developing world is a vast and extremely complex subject which could well be considered by itself. We content ourselves with mapping out some of the key issues of principle. It should be clear from the rest of this Report that whilst we consider cheaper drugs to be an important issue we do not believe that drugs pricing is the only obstacle to an effective response to HIV/AIDS in the developing world. Some of the recent media coverage of the issue has failed to make this clear. It is too easy, faced with a multifaceted and devastating phenomenon such as HIV/AIDS, to create a single identifiable enemy (the pharmaceutical companies) and a single identifiable solution (cheaper drugs). While we discuss below the important issues of patents and pricing, it is important to point out that no evidence to the inquiry called for the purchase and donation of anti-retroviral drugs to be a priority for donor funds. It was pointed out that the healthcare infrastructure to deliver and monitor these complicated drug regimes does not exist in most of the worst affected countries. The BMA Foundation for AIDS state, "The issue is not solely one of cost. Anti-retroviral therapy is complex and requires specialist monitoring. Health service infrastructures in developing countries are inadequate to deliver these treatments safely to large numbers of people".[232]

192. Clare Short pointed out, "These drugs are extremely expensive even after the drug companies have said they will supply them at cost. They are something like three dollars a day. There are a lot of countries in Africa that spend less than ten dollars a head a year on health care. That is my biggest worry, that the fashion will be access to anti-retrovirals. We have not got primary health care, we are not even reaching people. They have not got enough food, soap, water, very, very fundamental care. Budgets could be sucked into a kind of fashionable campaign to make anti-retrovirals available which again would necessarily be in the cities and would not reach all the people".[233] We pointed out earlier that HIV/AIDS cannot be considered outside the context of the larger disease burden of the developing world and the epidemic is already affecting the quality of care available to those not suffering from HIV/AIDS. It would be quite wrong to spend what amounts to the greater part of health service budgets on HIV/AIDS to the detriment of care for other illnesses. The provision of anti-retroviral treatments to people with HIV in the poorest developing world is clearly not a practical or sustainable development intervention. Donor funds and activities should concentrate on prevention of further infections, development of basic healthcare systems, provision of palliative drugs and basic treatments of opportunistic infections.

193. There is, however, a wider issue of the pricing of drugs in developing countries. Even if for many countries anti-retrovirals appear at the moment to be out of the question, it is important at least to have essential drugs at affordable prices and reliably supplied. The TRIPs agreement, whilst protecting patent and intellectual property regimes, does allow compulsory licensing and parallel importing in certain circumstances. This would significantly reduce the price of drugs still under patent, including certain antifungal drugs and antibiotics which are crucial in the treatment of opportunistic infections but which are at the moment beyond the reach of most developing country budgets. Even putting aside the question of anti-retrovirals, the debate over drugs pricing and the TRIPs agreement remains a very relevant one.

194. We heard many criticisms of the pharmaceutical industry for only making their products — both anti-retrovirals and other drugs which treat opportunistic infections — available at Western price levels. An article in "The Lancet" points out that many anti-retrovirals were developed and tested in public laboratories with public funding but have been given to private companies for exclusive marketing. "Nothing explains why companies charge so much except that they were initially put on the market in the USA, a rich country without price controls".[234] James Cochrane said that Glaxo Wellcome "would be seeking to recover the investment in research and development through our sales in the United States, through our sales in Europe, and through our sales in sophisticated markets."[235] Given that Glaxo Wellcome said that current sales in sub-Saharan Africa are "extremely low; very, very low indeed", the failure to establish preferential pricing systems in any significant scale is difficult to understand. Pharmaceuticals are no doubt fearful that cheaper versions may make their way back onto Northern markets. We were told in evidence, however, of the Accelerated Access Initiative, established between five UN agencies and five pharmaceutical companies under the auspices of the International Partnership Against AIDS in Africa "to find practical and specific ways of working together more closely to make HIV/AIDS care and treatment available and affordable to significantly greater numbers of people in need in developing countries".[236]

195. Countries which have signed the World Trade Organisation's TRIPs Agreement are committed to respect medical patents. However, as the patents are not retroactive, generic versions of anti-retrovirals are produced in India, Thailand and Brazil — countries which only signed the agreement after production had begun. In Brazil, 90,000 people with HIV are receiving HAART . Furthermore, the TRIPs agreement allows that a national emergency entitles a country to issue compulsory licences for local production or to import generic products. South Africa is unusual, in that it believes it could produce generic versions and make them available to many more of its population than can currently have them.

196. Giving evidence to the Committee, Dr Peter Piot said, "I think the contracts that have existed between the pharmaceutical industry and western nations and now reaching its limits when it comes to access to these goods in medicines for the poor. The contract is based on the fact that through patent protection and giving a monopoly of certain products for x period of time, the efficiency of that has been very high, high for shareholders and high for western society, because new products were developed. The poor countries have really not benefited from that, that is not new. With AIDS that has become and overwhelmingly publicised, moral issue."[237] Referring to the fact that the full TRIPs provisions are due to be in place in 2006, Dr Piot said, "We need to look into that because if the full TRIPs agreements are going to be put into practice this is going to restrict even further what developing countries will benefit from in terms of innovation."[238]

197. In its Globalisation White Paper, DFID announced that it will set up a Commission on Intellectual Property Rights to look at how rules can be designed to benefit developing countries and in particular access to generic resources.[239] We welcome this important step in the consideration of how both to ensure appropriate respect for patents and the encouragement of further research and development, whilst also aiming to maximise the access of the developing world to affordable drugs. It has been striking how the pharmaceutical companies, faced with mounting discontent at their pricing policies in poorer countries, have begun at last to offer significantly discounted prices for their products. Preferential pricing agreements, particularly for drugs to treat opportunistic infections, need to be agreed and implemented without delay. We criticise the slow progress being made under the Accelerated Access Initiative.

198. The UK-based Action for Southern Africa submitted evidence critical of the use of TRIPs to prevent South Africa from producing generic versions of anti-retrovirals or importing cheaper or generic versions.[240] They claimed that the United States Government, the European Union and the UK Government intervened to try to persuade South Africa to drop its challenge to TRIPs. As we mentioned earlier, the court case brought by local offices of international pharmaceuticals against the South African government is now being heard. The provisions of TRIPs under which a country can use parallel importing or compulsory licensing in a national emergency were put in for a purpose. Progress in agreeing concessional prices with the pharmaceutical companies is to be encouraged. This should not be at the expense of developing countries also pursuing alternative solutions permissible under WTO rules. We do not believe the United Kingdom Government, the European Union or any other developed country should put pressure on developing countries not to make use of available TRIPs provisions. Technical assistance should rather be given both to identify what can be done within the WTO agreement, how affordable any cheaper drugs are to the health department budget, and whether they will genuinely reach the poor, rather than an elite.

214   Evidence, p.25 Back

215   Q.466 Back

216   Q.517 Back

217   Evidence, p.273 Back

218   Evidence, p.273 Back

219   Q.471 Back

220   UNAIDS June 2000 Report, p.89 Back

221   Evidence, p.273 Back

222   Q.466 Back

223   Q.566 Back

224   Evidence, p.283 Back

225   Q.466 Back

226   Evidence, p.86 Back

227   Q.157 Back

228   "Enhancing the Greater Involvement of People living with or affected by HIV/AIDS in sub-Saharan Africa", UNAIDS Best Practice Collection, 2000, pp.4-5 Back

229   Communicable Disease Report Vol.10, No.30 28 July 2000, p.274 Back

230   Q.322 Back

231   Sunday Times, UK, 8 October 2000. Back

232   Evidence, p.288 Back

233   Q.560 Back

234   Lancet [05.08.00] 2000; 356: pp.502-503 Back

235   Q.384 Back

236   Evidence p.163 Back

237   Q.501 Back

238   Q.501 Back

239  Eliminating World Poverty: Making Globalisation Work for the Poor, DFID, December 2000, p.46 Back

240   "Exploding the Myth: The WTO, drug companies and AIDS in Southern Africa", ACTSA, October 2000. Back

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