APPENDIX 6
Memorandum submitted by Voluntary Service
Overseas (VSO)
VSO supports nearly 2,000 volunteers in 74 of
the world's poorest countries. HIV/AIDS affects them all. In response
to the International Development Committee's Inquiry on HIV/AIDS
and Social and Economic Development, VSO would like to respond
to points 1d, 2c and 2d.
1. The impact of HIV/AIDS on developing countries
d. the impact of HIV/AIDS on the budgets of
developing country governments, including a consideration of the
cost of drugs and therapies
Access to Treatment for HIV/AIDS
VSO partners identify access to drugs and therapies
as a key issue in the HIV/AIDS jigsaw. According to WHO, one third
of the world's population lacks access to essential drugs, this
figure rising to over half in the most impoverished parts of Africa
and Asia.[5]
Not having access to these medicines 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.
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
in Southern Africa have identified accessibility to treatments
for opportunistic infections and symptoms as a key issue.
Treatments for symptoms and infections
"I need medicines for my TB (tuberculosis)
but the pharmacy doesn't have them every day".
Jeremiah Mulumba, Zambian living with HIV.
Many medicines for treating opportunistic infections
and symptoms are relatively cheap, because they have passed their
patent period and thus are subject to competition between "generics"
companies. This process drives prices dramatically downwards once
drugs come off patent. Nonetheless, these drugs are not available
to those most in need. For example, a recently returned VSO pharmacist
who had been working in Namibia pointed to the cost of basic drugs
as the single largest barrier to treatment access. She was working
at a regional hospital—a tertiary-level referral centre
which was well resourced in comparison with smaller hospitals
or local clinics in the country.
"The financial year begins in April, and
the medicines are beginning to run out by September . . . it depends
what you mean by expensive. For example drugs to stop diarrhoea
are cheap, but we still only had enough for me to give 10 to each
patient. They could get through those in a day".
In other words, even though some of the medicines
are cheap, budgets do not stretch to buying adequate quantities.
Not surprisingly in the above example, more expensive medicines
were unavailable or in extremely limited supply.
The figures for health service spending in some
countries also indicate that health budgets are simply not adequate.
The World Bank has calculated that a "minimum package"
of health care (including immunisation, tuberculosis treatment,
treatment for children, family planning and some health education)
costs (at today's prices) US$14 per year.[6]
This figure was reported in 1993, and did not allow for the massively
increased demands placed on health services by HIV/AIDS. Yet,
the amount available for spending on health per capita in Zambia,
for example, was on average US$5.3 between 1990 and 1996. Given
current health expenditure needs, this deficit means that the
public health sector cannot consistently provide even the most
basic treatment.
TRIPS, patents and essential drugs
Another limiting factor to the accessibility
of drugs for treating HIV/AIDS-related illnesses is the complex
relationship between patented drugs, intellectual property rights
and generic drugs production. The coming into force of the TRIPs
(Trade Related Intellectual Property) agreement as part of WTO
rules has shed light on the potential health implications of international
trade rules.
Most of the types of drugs mentioned above are
not patented. But some drugs relevant to HIV/AIDS are still under
patent, including for example, some antifungal drugs, some newer
antibiotics (including some of those used for resistant TB) and
ARVs.[7]
Patented drugs are generally much more expensive than generic
drugs, almost by definition, and therefore completely out of reach
of most people in poor countries most of the time.
TRIPs has the potential to undermine generic
drugs production so crucial for addressing the HIV/AIDS crisis
in Africa. The WHO says "the emergence of a generic drug
sector in a number of developing countries represents a set of
successful social policies that may be harder to duplicate under
TRIPs.[8]
The recent public-private initiative announced
between UNAIDS and five pharmaceutical companies to make a limited
number of HIV/AIDS-related drugs available at reduced prices demonstrates
that greater price flexibility is possible under current market
conditions. Certain organisations, such as Medécins Sans
Frontie"res, Health Action International and the Consumer
Project on Technology suggest that keeping the market open to
competition from generics drugs manufacturing companies would
make radical reductions in the pricing of these substances possible.
Under current TRIPs and WTO rules, such competition
should be possible through compulsory licensing and parallel importing.
Reports from around the world though, indicate there are potential
problems with the way in which TRIPs is being put into practice
on national and regional levels. For example, the West African
Bangui agreement, which implements TRIPs for 15 countries in the
region, is more restrictive than necessary under TRIPs rules.[9]
Until recently, the United States was guilty
of applying bi-lateral pressure on developing countries to draft
legislation that undermines the health-related clauses embodied
in TRIPs. By executive order of the US President, this should
no longer take place in southern Africa. To our knowledge, similar
promises have not yet been forthcoming from the European Union.
2. THE RESPONSE
TO THE
EFFECTS OF
HIV/AIDS ON DEVELOPING
COUNTRIES
c. The human and legal rights of those living
with HIV/AIDS in developing countries
One basic and crucial right of people suffering
from HIV/AIDS is the right to be HIV-positive publicly in a safe
and supporting environment. The stigma attached to having HIV
is undermining communities and setting back development. This
is best illustrated by the experience of VSO's programme office
in Zambia.
The primary effect of stigma on VSO's work in
Zambia is what is referred to as "the denial factor".
People are generally unwilling to speak openly about HIV/AIDS,
and to disclose one's HIV status is still almost unheard of. AIDS
is widely understood to be a disease of promiscuity and people
are ashamed to "admit" that they (or their family members)
have contracted it. AIDS-related illnesses are identified only
by the name of the actual infection (ie TB, pneumonia) and never
as secondary to HIV. AIDS-related deaths are much the same—obituaries
describe "death following an illness", and the death
certificate purposely omits any references to AIDS. There have
been no disclosures from high-ranking government or church leaders
or well known sports or entertainment personalities, even through
deaths "following an illness" are frequent and widely
understood to be AIDS-related.
In VSO's work in Zambia, we meet people daily
whose lives are touched by AIDS: they are caring for sick relatives,
they are supporting orphaned children whose parents have died
of AIDS, they are attending funerals of friends who have passed
away . . . But rarely is AIDS identified as the culprit. Disclosure
can bring serious repercussions: people are fired from their jobs
or are denied employment, they are evicted from their rented accommodation,
they are shunned by their families and communities for bringing
shame and dishonour.
Denial thus becomes a coping mechanism. People
who suspect themselves to be HIV+ rarely choose to be tested so
do not have access to counselling and support. And the consequences
are serious:
— they continue to infect others;
— they lose the opportunity to re-plan
their lives, failing to make provision for the care of their children
or the distribution of their property;
— they may be off work on several months
sick leave which is never acknowledged as terminal, thus neglecting
to handover of work-related responsibilities, this affects the
general level of service provision across the board—in government,
manufacturing, industry, service, education, agriculture, etc
leading to loss of productivity and revenue as well as frustration;
— employers condone denial by allowing
extended sick leave, placing colleague in "acting" or
"temporary" positions without the training, handover
or authority to plan or make decisions. This reduce efficiency,
continuity and morale in workplaces across the country, and affects
most VSO Zambia volunteers in their placements;
— children are exposed to the painful
deaths of other family members at an early age, often as caregivers
themselves, yet education curricula and teacher training do not
include strategies for dealing with traumatised children;
— AIDS is thought to be the underlying
cause of hospitalisation for 70 per cent of all in-patients, yet
health care workers have no special training or equipment to implement
universal precautions. They are more likely, out of fear and disrespect,
to discharge these individuals or ignore their basic care needs.
Patients are then left to their own devices, and suffer needlessly
before dying a premature death.
Thus the denial factor affects everyday life:
at home, at work, in the community. People have a right to a secure
social, political and economic environment that enables them to
live positively with HIV and continue to make valuable contributions
to the broader society.
d. The response of the international community,
and in particular DFID
One important component of DFID's strategy for
tackling the HIV/AIDS crisis in southern Africa is the VSO Regional
AIDS Initiative of Southern Africa (RAISA). Through this project,
VSO and the UK government are taking a two-strand approach focusing
on both prevention and care. The four year initiative which began
in January 2000 will place over 40 volunteers in HIV/AIDS-related
posts with both government and NGOs in six countries (Malawi,
Mozambique, Namibia, South Africa, Zambia and Zimbabwe). A further
700 VSO volunteers will receive specific training to enable them
to address HIV/AIDS through their diverse cross-sectoral work
placements. Finally, the project will develop and strengthen learning
and networking at both national and regional levels. RAISA illustrates
how creative approaches can be found to help governments and communities
in developing countries overcome the HIV/AIDS crisis.
VSO would recommend that governments and international
agencies consider taking the following actions:
— encourage the use and production
of generic versions of existing drugs for treating HIV/AIDS-related
illnesses (in compliance with WTO rules);
— clarify UK and EU positions on health-related
clauses and exceptions embodied in TRIPs and ensure they are not
undermined by more restrictive intellectual property rights measures;
— provide greater technical support
and advice to developing country governments to strengthen their
ability to strategically plan their drugs purchasing and delivery
and enable them to buy drugs at lower cost;
— show solidarity with HIV positive
people in developing countries by pushing for greater international
commitment to the rights of HIV positive people; and
— ensure that an HIV/AIDS strategy
is integrated into projects in countries where AIDS is a priority.
Ken Bluestone
Advocacy Programme Manager
Anna Thomas
Senior Advocacy Officer
Voluntary Service Overseas
17 May 2000
5 WHO Medicines Strategy 2000-03, Framework for Action
in Essential Drugs and Medicines Policy, WHO. Back
6
World Development Report, World Bank, 1993. Back
7
Patent Situation of HIV/AIDS Drugs in 80 Countries, UNAIDS, January
2000. Back
8
Globalisation and Access to Drugs, Perspectives on the WTO/TRIPS
Agreement-WHO Action Programme on Essential Drugs, 1999. Back
9
Joint Mission MSF-WHO-UNAIDS, Review of Pharmaceutical Policy
in Cameroon-Medicine Patents in Francophone Africa. Back
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