Memorandum submitted by the BMA Foundation
We greatly welcome the Select Committee's inquiry
into HIV/AIDS and development and would like to thank the Committee
for extending its timescale to enable us to submit evidence.
The HIV/AIDS epidemic clearly represents the
most devastating challenge to global development in recent history,
as is illustrated by the graph showing how it has led to falling
life expectancy in African countries. We therefore applaud the
Committee's decision to examine the broader implications of HIV/AIDS
for economic, political and social stability in developing regions.
As a medical organisation, we have chosen to concentrate on providing
the Committee with background information on some specific medical
issues, but we would not wish this to be perceived as detracting
from the wider impact of the epidemic.
Specific points which we would like to draw
to the Committee's attention are described below. We would be
happy to supply further information on these points, including
references, if requested.
HIV/AIDS ON THE
Although we have no good data, we would like
to point out that developing country health services are doubly
affected by HIV/AIDS. The epidemic leads to growing needs for
health care, while simultaneously undermining health sector capacity
through illness, mortality and loss of morale among health workers.
As the Committee is doubtless aware, HIV/AIDS has a particularly
serious impact on all economic sectors because it primarily affects
young adults in the most productive age groups. It is also associated
with prolonged or intermittent illness prior to death, leading
to a substantial burden of need for formal and informal care.
The development of effective vaccines holds
out the best hope for long term control of the HIV/AIDS epidemic.
We welcome the UK Government's support for research directed towards
vaccines specifically suited to the needs of developing countries.
However, a number of issues remain:
vaccine development is a slow process.
We anticipate that it will be at least five years, and more realistically
10, before an effective vaccine can be available for widespread
although some work has been done
in preparing for trials of vaccine efficacy, some ethical and
methodological difficulties remain.
a preventive vaccine will not help
the many millions of people who will already be infected with
HIV at the time when the vaccine becomes available. These people
will continue to develop AIDS and need care over ensuing years.
most vaccines currently in use in
developing countries are given to infants or young children and
are intended primarily for prevention of childhood diseases:
if an HIV vaccine is given to
children, there will be a long lead time before the vaccinated
generation grows up and becomes sexually active. Hence any impact
of the vaccine on the epidemic will be delayed.
an alternative strategy, of vaccinating
adolescents and young adults, would have a more immediate effect
on the epidemic. However, getting the vaccine to these age groups
would present a greater logistical challenge for developing countries,
since adolescents and young adults do not already access other
We welcome the recent announcement of dialogue
between UNAIDS programme and five major pharmaceutical companies
on how to broaden access to HIV-related drugs in developing countries.
However, even with massive price discounts (eg 95 per cent or
more), the vast majority of people living with HIV/AIDS in developing
countries will not be able to benefit from antiretroviral therapies:
the issue is not solely one of cost.
Antiretroviral therapy is complex and requires specialist monitoring.
Health service infrastructures in developing countries are inadequate
to deliver these treatments safely to large numbers of affected
it is not obvious that broadening
access to complex medicine represents the best health investment
for developing countries. 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. Clearly, any improvement in health service provision
is difficult in the face of the overall social and economic impact
of the epidemic.
improved primary health care could
usefully include much better access to cheap, generic palliative
drugs such as painkillers and antidiarrhoeals. These would benefit
people with a variety of diseases, and in the case of HIV/AIDS
could lead to significant improvements in quality of life and
there is a particular problem in
access to opiates in many developing countries. Some controls
are necessary to prevent abuse of these drugs, but over-regulation
and lack of understanding among health professionals lead to many
people suffering severe pain unnecessarily. New regulations and
guidelines and training for health professionals are needed to
promote appropriate use of these cheap effective drugs.
since the presence of other sexually
transmitted infections (STIs) increases the risk of HIV transmission,
cost-effective, evidence-based STI treatment and control programmes
are particularly valuable. Also important are the promotion and
distribution of condoms to prevent transmission of HIV and other
STIs. There is the potential for public/private partnership in
the promotion and delivery of both condoms and STI services. Some
businesses are already subsidising condom provision for employees.
Drugs for the prevention and treatment
of opportunistic infections associated with HIV/AIDS are another
important issue. The UNAIDS programme recently recommended that
adults with symptomatic HIV/AIDS and children with symptomatic
or asymptomatic HIV/AIDS throughout Africa should receive routine
daily treatment with cotrimoxazole, a cheap antibiotic which can
prevent some serious opportunistic illnesses. However, even this
relatively simple treatment can have serious adverse effects and
requires the advice of a trained health worker. Hence implementation
of the UNAIDS recommendation will pose challenges for developing
country health services.
The one purpose for which widespread use of
antiretroviral drugs may be feasible in developing countries is
in preventing HIV-positive women from transmitting the virus to
their babies around the time of birth. It has been known for some
time that giving a course or a drug called zidovudine
(also called AZT) to the mother before birth and then to the baby
can reduce the risk of the baby becoming infected with HIV. In
some counties (especially South Africa) there has been controversy
about whether this treatment should be implemented widely. Although
there is some evidence suggesting it can be cost-effective compared
to other health interventions, in counties where the prevalence
of HIV infection is high the total cost of implementation could
be prohibitive. Moreover, there are logistical difficulties in
delivering this treatment in developing countries where pregnant
women may not be in contact with health services before the onset
Last year, however, a ground-breaking paper
showed that a different drug, nevirapine, can also reduce the
risk of mother-child transmission of HIV. This is much easier
to deliver since it involves only two doses, one given to the
mother during labour and one to the baby, and the cost of the
drugs is only US$4 per mother-baby pair. Hence nevirapine for
prevention of mother-baby transmission of HIV may be a genuinely
feasible and affordable intervention for developing countries.
A number of issues remain, however:
there is evidence that the most cost-effective
way of using nevirapine in many African countries would be to
give it to all women and babies, without first testing for HIV.
There are potentially ethical difficulties, however, in giving
medication to healthy people who do not need it, as there could
be as yet unrecognised long-term adverse effects.
the alternative of offering women
HIV tests and giving nevirapine only to those who test positive
and their babies, can also be problematic. There are good reasons
for broadening access to HIV testing in developing countries,
to enable people to find out their status and plan better for
the future. However, targeting testing specifically towards pregnant
women potentially exposes them to a risk of stigma and discrimination
including rejection by their husbands/partners (who will, in many
cases, have been the source of the infection). Community education
measures to combat stigma and discrimination are urgently needed
in many developing countries.
although nevirapine is a simple oral
treatment, its administration still requires women to have access
to at least basic health care around the time of labour. Fortunately,
this fits well with recent thinking among international development
agencies on the importance of increasing access to obstetric services
in order to reduce maternal mortality from causes unrelated to
neither nevirapine nor zidovudine
treatment schedules prevent transmission of HIV from the mother
to the baby via breast-feeding. Where formula feed is affordable
and can be used safely, it is a valuable means of preventing transmission.
However, in developing countries formula feed may cost more than
the annual family income, water supplies may be inadequate and
are often contaminated, and other diseases are common. In such
circumstances, the protection of clean, balanced, antibody-rich
and nutritionally appropriate breast milk makes breast-feeding
the best option, even though the risk of HIV transmission is significantly
preventing mother-child transmission
of HIV does not protect these children from the risk of later
orphanhood. Death rates are likely to be higher among the uninfected
children of HIV positive compared with HIV-negative mothers, because
of the impact of maternal illness and death on the care they receive.
In conclusion, although the recent research
on nevirapine offers real hope for the future, HIV/AIDS will continue
to have a devastating impact on child mortality. We welcome the
development of trials such as PETRA looking at alternative treatment
programmes to prevent mother-child transmission which are affordable
and achievable in developing countries.
Meanwhile, the international development target
for a two-thirds reduction in infant and child mortality by 2015
appears severely threatened by the HIV/AIDS epidemic. Such mortality
is rising in much of sub-Saharan Africa.
HIV AND TUBERCULOSIS
The HIV epidemic is intricately linked with
tuberculosis. In developing countries a high proportion of people
are infected with the tubercle bacillus, but usually this remains
latent and does not cause disease. Concomitant infection with
HIV dramatically increases the risk of tubercule infection leading
to active tuberculosis disease, which is the most common HIV-associated
opportunistic illness in many developing countries. Hence the
HIV/AIDS epidemic has led to a major increase in tuberculosis
Tuberculosis is also interesting for another
reason. Even when the person is co-infected with HIV, tuberculosis
is curable. The WHO Directly Observed Treatment/Short Course (DOTS)
approach involves taking a combination of drugs regularly for
a few months. Failure to take the treatment correctly not only
leads to resurgence of tuberculosis disease, it can also cause
the tubercle bacillus to become drug resistant and prevent future
treatment from working. The same can happen if antiretroviral
treatment for HIV is not taken correctlythe virus can become
resistant to the drugs. Despite the fact that tuberculosis treatment
is fairly cheap, and much less complex than antiretroviral therapy
for HIV, many developing countries have experienced difficulties
in implementing tuberculosis treatment programmes. Although the
DOTS approach helps ensure drugs are correctly taken, effectiveness
is bedevilled by poor management of drug supplies, incorrect prescribing
specially in the private sector, and lack of public and patient
education about the need for correct and complete treatment. A
country's success in implementing tuberculosis control can therefore
be perceived as a barometer of the quality of its health sector
management. It is hard to see how districts or countries which
are failing to manage tuberculosis effectively could be ready
for the much greater challenge of antiretroviral treatment for
HIV (other than for prevention of mother-child transmission).
Strengthening tuberculosis programmes will, however, benefit people
with HIV as these are the group at greatest risk of developing
BMA Foundation for AIDS
We have not attempted to reference this memorandum
fully, but suggest that the following source materials may be
of particular interest:
World Bank presentation on the development impact
of HIV/AIDS (source of graph on life expectancy) http://www.worldbank.org/aids-econ/board/index.htm.
Joint United Nations Programme on AIDS (UNAIDS).
AIDS epidemic update; December 1999. http://www.unaids.org.
UK NGO AIDS Consortium Working Party on Access
to Treatment for HIV in Developing Countries. Access to treatment
for HIV in developing countries; statement from international
seminar on access to treatment for HIV in developing countries,
London, 5-6 June 1998, The Lancet 1998; 352; 1379-80.
Guay L A, Musoke P, Fleming T et al. Intrapartum
and neonatal single-dose nevirapine compared with zidovudine for
prevention of mother-to-child transmission of HIV-1 in Kampala,
Uganda; HIVNET 012 randomised trial. Lancet 1999; 354;
Marseille E, Kahn J G, Mmiro F, Guay L, Musoke
P, Fowler M G, Jackson J B. Cost effectiveness of single-dose
nevirapine regimen for mothers and babies to decrease vertical
HIV-1 transmission in sub-Saharan Africa. The Lancet 1999;
11 Antiretroviral drugs act directly on HIV to suppress
viral action and prevent development of AIDS. They have led to
major improvements in health and survival for people with HIV
in the UK and other developed countries. To ensure effectiveness
and prevent the virus from becoming drug resistant, treatment
must be monitored and a person must use more than one such drug
(UK guidelines recommend at least three). Treatment should be
given continuously on a long-term basis-ideally for life. Back
Prevention of mother-child transmission is the one circumstance
in which it is acceptable to use only one antiretroviral drug
at a time. Back