Select Committee on International Development Written Evidence


Supplementary memorandum submitted by the BMA Foundation for AIDS


  We would like to thank the Committee for inviting the BMA Foundation for AIDS to join the panel for its session on drugs and HIV/AIDS. We regret we were unable to accept the invitation, but we are grateful to be given the opportunity to comment on the transcript of that session, including the verbal evidence from Mr James Cochrane (Glaxo Wellcome plc) and Mr Saul Walker (National AIDS Trust), and to offer additional thoughts.


  In this memorandum, the numbers refer to question numbers in the transcript of the Committee session, and the evidence given in response to these.

    380  The drug to reduce mother-to-child transmission of HIV, referred to in the last paragraph of this answer, is nevirapine, which we discussed in our first memorandum to the Committee. Following the release of research on this drug at the 13th International AIDS Conference in Durban (9-14 July 2000), nevirapine's manufacturer Boehringer Ingelheim announced its intention to provide nevirapine free of charge for the prevention of mother to baby transmission in developing countries to all who cannot afford to pay for it.

    381  South Africa is in some respects a special case. It has a higher per capita GDP and better infrastructure than many other African countries badly affected by HIV/AIDS. On the other hand, the present Government has shown particular reluctance in relation to AZT and there has recently been international criticism of the president's priorities in relation to AIDS. It is arguable that in South Africa, although unaffordability is certainly an issue, there have been other factors at play as well.

    382  While broadly agreeing with the emphasis on partnership, we have some concerns about what forms such partnership might take. For example, there have been proposals in the USA for a loan fund to enable developing countries to buy HIV drugs. However, many of the countries which most need these drugs are already struggling under a heavy burden of debt. There is a risk that such a loan fund might be set up to prevent developing countries from buying cheaper versions of the drugs from manufacturers based in countries which do not respect international patent law or are able to produce cheaper generic versions of some drugs. This might benefit the pharmaceutical companies more than the people of developing countries.

  In assessing affordability, attention needs to be paid to more than just the price of the drugs themselves. Hospital and laboratory facilities are required, as are trained staff who understand the treatments and, if current guidelines are followed as in developed countries, three-monthly tests to monitor each patient's viral load and CD4 counts. These tests alone can be prohibitively expensive. (The Panos Institute quotes a cost of $70 and $20 respectively per test in Zambia, where the government is unable to meet the basic annual health budget of $14 per capita.) While access to anteretroviral (ARV) drugs may be the ultimate goal for all and the short-term option for a small number of wealthy individuals, greater benefit is likely to accrue in most developing countries, especially the poorest, from investment in adequate nutrition, clean water and sanitation, as well as in primary health care, with access to cheaper drugs for the prevention and treatment of opportunistic infections and for palliative care.

  For countries which are able to afford limited provision of ARVs, there may be some hope for new, cheaper treatment regimes in the future. For example, evidence was presented at the 13th International AIDS Conference in Durban (July 2000) from research into structured intermittent therapy, which would reduce the quantity of drugs needed for each individual, offering the possibility of expanding the numbers able to access treatment somewhat. However, despite a few early cases which appeared to show success, more time is needed before the effectiveness of this therapy can be demonstrated (or not).

    386  It is true that the infrastructure is not in place in many developing countries to provide treatment with ARV drugs. However, the sweeping statement that "there are no committed governments in place who really want to do something about it" should be challenged. Firstly, providing ARVs may not be the most effective way to "do something" (see above). Secondly, some governments have taken steps to introduce ARVs, even if limited. Many have failed to show adequate leadership and commitment to tackling HIV/AIDS, but where they have (eg Thailand, Senegal, and some countries in Latin America), this should be recognised and applauded, and the learning disseminated.

    390  It is not true that ARVs should be taken as soon as a person is known to be infected with HIV, and this is not what UK treatment guidelines recommend. However, it is true that these treatments are more effective if started before severe damage to the immune system.

    394+  We agree there should be more investment in female-controlled methods of HIV prevention.

  The female condom is on the market but its use is still on a very small scale compared to the male condom and it is much more expensive. The 13th International AIDS Conference in Durban gave evidence of its acceptability among women in a number of countries, although it has not always been found popular with users. It is more controllable by women than the male condom, although this control is limited because it cannot usually be used without the man's knowledge. For some women, whose main risk of HIV comes from sex with a husband or regular partner with whom they want to have children, it may be no more acceptable than the male condom because of its contraceptive effect. But if there is a proportion of the population at risk who would use the female condom and not the male condom, it could still prove a cost-effective part of the prevention toolkit. Sex workers have had particular attention in this regard, as the female condom can be an option when male clients are unwilling to use the male condom.

  Re-use of the female condom by women who are unable to access or pay for a new one on each occasion of sexual intercourse has been reported in a number of countries, and this is often likely to occur where the risk of infection is higher (eg among sex workers). Because of its potential to make the female condom more affordable, re-use offers interesting possibilities for prevention, but there is a lack of data on the risk of infection to the woman and her new partner(s) from this practice. The WHO and UNAIDS convened a consultation on the safety and feasibility of re-use, with a view to issuing guidance on risk-reduction strategies (eg washing). The consultation concluded that currently available evidence was not conclusive and that therefore re-use of the female condom was not recommended at present. A draft protocol for disinfection, washing, drying, storage and relubrication is currently being tested and the results from this could have a significant impact on the potential future role of the female condom in prevention strategies.

  Although microbicides to date have been disappointing, including the recently reported unsuccessful trial of nonxynol 9 (not monoxalmine as in answer to question 534), other products are undergoing clinical trials, using a number of approaches. There are several potential advantages of microbicides, including female control and the possibility of preventing infection without preventing pregnancy. Their likely effectiveness in comparison with the condom is as yet uncertain, but if found to be less effective, they would still provide some protection for those unable to negotiate the use of condoms as well as perhaps providing additional protection if used with the condom. However, because of the questions about relative levels of protection, there may be ethical and practical difficulties in conducting clinical trials (and eventually in promoting a new product).

  The investment to date in microbicide research has been relatively small, and perhaps one of the strongest arguments for scaling this up is the potential for getting a usable product onto the market more quickly than can be hoped for with vaccines. On the other hand, the technical complexities should not be underestimated and it is still far from certain that they can be overcome (for example, ensuring adequate contact in the vagina for the product to work, or eliminating the risk of inflammation which increases susceptibility to HIV).

  Research on female-controlled technologies is needed to complement vaccine research. Vaccine development is a slow process and even once an effective vaccine is found, there are likely to be significant challenges in implementing an effective vaccination programme.

  The focus on development of new preventive technologies should not obscure the value of existing prevention approaches which have been shown to work and could be further developed. Although not 100 per cent conclusive, research has indicated that treatment of other sexually transmitted infections (STIs) in a population can significantly reduce rates of HIV infection, and because of this, UNAIDS and WHO have designated the control of STIs as one of the priority interventions for the prevention of HIV transmission. Integration of STI services into primary health care and the use of the "syndromic approach" (which reduces the need for expensive laboratory tests) should be key elements of effective STI control in developing countries. Primary prevention is essential for avoiding the acquisition of viral STIs as well as HIV, and prevention interventions will be essentially the same. At national policy level, HIV and STI programmes should be integrated, or at least coordinated.

  To meet the overwhelming challenge of HIV prevention, no one type of intervention is adequate on its own and a combination of approaches is essential, including:

    —  continued promotion of condoms;

    —  improved STI treatment services;

    —  vaccine research;

    —  research on female-controlled methods;

    —  education and empowerment to give girls and women greater control over their own sexual lives;

    —  HIV information and education for both sexes to enable informed choices;

    —  better provision and promotion of voluntary HIV testing with advice and counselling especially for couples—there is good evidence that couples who have tested serodiscordant (ie one positive, one negative) are much more likely to use condoms than untested couples; and

    —  strategies to increase openness, and to decrease the denial, stigma and discrimination associated with HIV and AIDS—it is important to counter the belief of some governments that the principles of confidentiality and informed consent contribute to the spread of HIV (the opposite is the case).

    398  We agree that support, and access to care and treatment, for people with HIV is essential for effective prevention. However, this does not necessarily mean access to ARVs. The concept of "continuum of care" described in answer to question 400 is helpful.

    401  The task of costing the provision of ARV and other interventions in developing countries, in order to provide a cost benefit analysis, is daunting. The drug-only cost could be estimated based on estimated numbers of people with HIV (itself a very inaccurate figure), but the colossal improvements in infrastructure required to deliver the drugs would also need to be costed. In order to provide a baseline measure, it would be necessary to audit the whole current level of health infrastructure. The improvements to infrastructure built on top of that baseline, however, would give much wider health benefits than just providing HIV-specific therapies. Looked at even more broadly, the health benefits would in turn provide economic benefits to society (reduced loss of trained professionals in the workforce, for example). Thus quantifying both the "cost" and the "benefit" for a cost benefit analysis would be extremely complex.

  Perhaps it is more helpful to say that the question is misleading in implying an either/or choice between providing basic health care and providing HIV-specific care. Basic interventions such as clean water and primary health care will benefit people with HIV along with the rest of the population, while expensive medical interventions specific to HIV cannot be delivered until clean water and primary care infrastructure is already in place. (However, the potential for significant reduction of mother-to-baby transmission through the relatively affordable and potentially feasible use of an ARV should not be overlooked—see our original memorandum to the Committee.)

    409-410  It cannot be assumed that universal HIV vaccination programmes in developed countries would be introduced, or effectively implemented, immediately, thus creating a massive instant market for a new product. It may be worth noting the rather slow uptake of vaccines for hepatitis B. For example, the Department of Health in this country has not introduced a programme of universal hepatitis B vaccination, preferring instead an approach targetting groups at higher risk (including health care workers). Even with such a policy in place, implementation of the targeted approach is patchy, with far from universal vaccination of health care workers or other groups at risk, such as injecting drug users. Levels of uptake of an HIV vaccine by individuals could be affected by perception of personal risk, which among the majority of the population in this country is low in relation to HIV, though this might be offset by the degree of fear, which is higher for HIV than other infections. In addition, proposals for universal vaccination programmes could face some political reluctance because of opposition from sections of society arguing that they would encourage behaviours seen as morally wrong. So despite the evidence given in response to question 547, there is a possibility that a vaccine developer might not recoup its costs within the lifespan of the product's patent. This may partly explain the apparently limited commercial interest in vaccine research to date.

    411  The inventor of the smallpox vaccine, Edward Jenner (1749-1823), was voted £30,000 by Parliament in recognition of the value of his services and the sacrifices they had entailed.

  We have not provided references for this memorandum but would be happy to on request.

  Since our original memorandum to the Committee, two reports have appeared which may be of interest, both launched at the 13th International AIDS Conference in Durban (July 2000), and on which we have drawn in producing this memorandum.

  The Panos Institute. Beyond Our Means? The cost of treating HIV/AIDS in the developing world. (Available to download from

  The Population Council and International Family Health. The Case for Microbicides. A Global Priority. (Available on request from International Family Health, Cityside House, First Floor, 40 Adler Street, London E1 1EE. Tel: 020-7247 9944. Fax: 020-7247 9224.

BMA Foundation for AIDS

September 2000

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