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Westminster Hall

Thursday 11 December 2003

[Sir Nicholas Winterton in the Chair]


Motion made, and Question proposed, That the sitting be now adjourned.—[Joan Ryan.]

2.30 pm

The Parliamentary Under-Secretary of State for International Development (Mr. Gareth Thomas) : Thank you, Sir Nicholas, for finding time for what the whole House will agree is an important debate. I thank the hon. Member for Carshalton and Wallington (Tom Brake) for taking the initiative and seeking an Adjournment debate about world AIDS day. I hope that today's three-hour debate will enable Government and Opposition Members to reflect on the Government's "UK's Call for Action on HIV/AIDS", which we published on 1 December, and to consider what is needed for us to get our response right to the horrifying HIV/AIDS epidemic.

"Call for Action" makes it clear that we are thinking seriously about the next steps. We want to hear the views of hon. Members and their constituents, non-governmental organisations, partner Governments and partners in the donor community. A series of significant recent developments in the UK and overseas has signalled an increased focus on the epidemic.

The UK media were helpful with regard to 1 December. The Guardian and The Observer both printed thoughtful supplements. I also congratulate The Sun on its thoughtful and helpful analysis of the importance of the HIV/AIDS epidemic. World AIDS day marked a significant point in the UK's political approach to HIV/AIDS, and we are beginning to scale up our response in terms of both policy and finance.

All Members will know that the epidemic's scale is staggering. Some 60 million people have been infected since the late 1970s. There have already been 20 million deaths, and 40 million people currently live with the virus. By the end of this year, there will have been an estimated 5 million new infections—nine a minute. Sadly, we expect 3 million people to die of AIDS this year—five a minute. More than half the new infections are among 15 to 24-year-olds, and we know that women and girls have a heightened risk of infection.

HIV/AIDS has had its greatest impact on sub-Saharan Africa. Southern Africa has 30 per cent. of HIV/AIDS infections, but only 2 per cent. of the global population. Although much of the attention on world AIDS day was on sub-Saharan Africa, it is important to note the seriousness of the epidemic in other parts of the world. In Asia and the Pacific regions, 7.4 million people are infected, 4.5 million of whom are in India. In eastern Europe and central Asia, 1.5 million people are infected, which is a relatively low number in comparison with both Asia and sub-Saharan Africa, but HIV/AIDS is growing faster there than anywhere else in the world.

In the worst affected countries, HIV/AIDS has reversed 50 years of development gains. By 2010, life expectancy in many African countries will fall to around

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30 years of age. Botswana is probably the worst affected country. It is currently an upper-middle income country, but it faces a decline in life expectancy from 65 between 1990 and 1995 to 40 now and, we think, to 27 by 2010. The epidemic's impact on the whole country might mean that it drops from being a middle-income country to a low-income country.

In the face of the greater demands, public services across Africa have to cope with significantly depleted resources. Education and health services are hardest hit and teacher absenteeism has dramatically cut the number of teaching hours across southern Africa. As we debated on 1 December, in Malawi, the number of teachers dying is outstripping the number of new graduate teachers. Inevitably, in such circumstances, morale is evaporating too, and that adds to the pressures.

In Botswana, evidence suggests that up to one third of health workers may have been infected with HIV/AIDS in 1999, and up to 40 per cent. could be infected by 2005. That will place massive pressure on its health care system.

HIV/AIDS also has a significant impact on economic growth and on the engine of economic growth, the private business sector. In terms of countries' labour forces, the International Labour Organisation estimates that nine out of 10 people infected with HIV/AIDS worldwide are adults in their productive and reproductive prime. Inevitably, AIDS leads to increasing costs for businesses because of reduced productivity as employees become sick or have to care for family members. It also leads to lower morale and to the loss of skills and knowledge.

In Chennai in India, a study revealed that absenteeism in large industries is expected to double in the next two years, mainly because of AIDS-related illnesses and sexually transmitted diseases. At a micro-level, one agro-estate in Kenya has seen its medical costs soar by 600 per cent. over six years because of HIV/AIDS.

It is not surprising therefore that HIV/AIDS has had such a significant impact in slowing down economic growth. In sub-Saharan Africa, we think that growth rates will have been cut by at best 0.3 percentage points, and at worst, by two percentage points per year by 2015—a massive impact considering the numbers that will continue to live in poverty. As adults become sick and are unable to work and money has to be spent on medical care and funerals, there is a considerable impact on household incomes.

The coping strategies that families use when one of their members has HIV/AIDS sadly, too often, gradually exacerbate the problems for household incomes. For example, they may stop producing high-value crops such as coffee and start producing lower-value root crops such as cassava, which are easier to grow but are of poor nutritional value. We know from the work of the Select Committee on International Development, among others, that the impact of HIV/AIDS on food security was demonstrated all too clearly during the recent food crisis in southern Africa.

Parents are unable to transfer skills to their children before they die; some households are forced to sell assets and take children out of school in order for them to provide care and a living for the family. Perhaps the

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most shocking impact of the epidemic is the creation of many orphans. Many children are much more vulnerable because of it.

There are currently about 14 million AIDS orphans, and we think that that figure will rise to about 25 million by 2010. Such statistics can never do justice to the trauma and misery that many young people will experience because of HIV/AIDS. Orphans are less likely to attend school; they are more likely to suffer poor health and malnutrition; and they are more vulnerable to physical and sexual abuse. As I mentioned, the impact is felt long before their parents die. Children, especially girls, have to drop out of school to become carers and to take responsibility for the farm and household chores.

The social consequences of HIV/AIDS could be enormous. Children who have suffered profound distress with little adult guidance and support face very uncertain futures, often in the wake of widespread stigma and discrimination. Such discrimination may inhibit them from accessing the care and treatment to which they are entitled. A survey conducted in 2002 among 1,000 medical staff in four Nigerian states found that 10 per cent. of doctors and nurses admitted having refused to care for an HIV/AIDS patient or having denied HIV/AIDS patients admission to hospital.

We know, too, that people with HIV/AIDS suffer discrimination in the workplace. They may be removed from their jobs, or have to experience the withdrawal of health and insurance benefits.

HIV/AIDS reinforces inequality and poverty. Women, for example, shoulder the burden of caring and are less likely to be cared for themselves. They suffer greater discrimination and poverty. Equal inheritance and land rights laws fuel poverty and the risk of HIV/AIDS in many countries.

There are clear links between conflict and the spread of HIV/AIDS. HIV rates are estimated to be rising in Angola, Burundi, the Democratic Republic of the Congo, Liberia, Sierra Leone and Sudan. Lack of access to information and the breakdown of services in those conflict zones create an environment in which HIV/AIDS is only too easily spread. Sexual relations and behaviour can change as a result of conflict. In many countries affected by armed conflict, there are even fewer sexual and reproductive health services and that seriously undermines the prevention and care efforts that we would otherwise wish to see.

The scale and the breadth—the severity—of the HIV/AIDS epidemic demand a more powerful response from the Government and the international community. The UK is increasing the priority given to tackling HIV/AIDS in the developing world. The "Call for Action" that my right hon. Friend the Secretary of State for International Development published on 1 December calls on the international community to intensify its efforts to tackle HIV/AIDS, and to achieve progress towards some of the key international targets for HIV/AIDS that the special session of the UN General Assembly in 2001 set out.

That special session stipulated that the international community should work towards ensuring that 25 per cent. fewer young people are infected with HIV/AIDS

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by 2005, and some 3 million people—2 million of whom are in Africa—should be receiving treatment by the end of 2005. We need one national strategy, one national AIDS commission and one way of monitoring and reporting on progress in every country affected by HIV in order to be on track to slow the progress of HIV/AIDS by 2015, the key millennium development goal in this area.

There are four key elements to the response that the UK wants to generate within the international community. First, we want much stronger political direction in the fight against HIV/AIDS. We will make AIDS and Africa a centrepiece of our presidencies in 2005 of the G8 and the European Union. We will work with the New Partnership for Africa's Development and the Africa partners forum to focus on HIV/AIDS. We shall push for a special session on HIV/AIDS at the UN Security Council in early 2004.

The second element of the strategy is to recognise that we need to make HIV/AIDS a priority for extra funding. The Secretary of State has made it clear that we remain committed to ensuring that £1 billion of development assistance goes to Africa by 2006. We will make HIV/AIDS a priority for the extra £320 million of the figure that we shall be devoting to Africa by that point. We shall also press for support for the international finance facility to help meet the funding gap for HIV/AIDS that we all know exists, as well as for the other millennium development goals. We shall continue to work with the global fund to enable it to disburse funds quickly and effectively.

The third element of the strategy is to achieve better donor co-ordination. We shall start by stepping up our co-ordination with the Americans and other donors in Ethiopia, Kenya, Nigeria, Uganda and Zambia—a taskforce was announced during the visit of President Bush two or three weeks ago. As I confirmed in a response to the hon. Member for Carshalton and Wallington, we are doubling our core funding of the Joint UN Programme on HIV/AIDS—UNAIDS—to help it to strengthen its co-ordination role in countries and also to establish an annual forum on donor co-ordination.

The fourth element that was highlighted by the call for action was the need to see better HIV/AIDS programmes in country. We shall work with developing countries and other partners to strengthen their generic health systems. We will produce a new UK Government strategy on AIDS next year, which will define how the whole Government, not just the Department for International Development, will work with countries to establish a stronger response in country. We shall issue policy guidance on the role of HIV treatment and care, and we intend significantly to increase our funding to developing countries through working with non-governmental, private and multilateral partners to improve prevention, as well as treatment and care programmes.

UNAIDS says that the UK is the world's second largest bilateral donor when it comes to HIV/AIDS. It is certainly true that our funding has increased sevenfold over the past six years from £38 million in 1997–98 to more than £270 million over the past financial year. We are working on HIV/AIDS in some 40 countries. Bilateral funding supports the national HIV/AIDS strategies of developing country partners such as

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Kenya, where the main focus has been working with non-governmental organisations to provide services to marginal groups, such as commercial sex workers and users who inject drugs. In Kenya, we are funding an 18-month impact study of an existing programme that teaches teachers to teach HIV prevention in primary schools with a view to rolling out a more effective national prevention campaign; and, through a joint programme with the United States Agency for International Development, we have increased our support for the social marketing of condoms, using a distribution system that currently exists for insecticide-treated nets to expand the distribution of condoms in rural areas.

In recent months, partly because of the increasing affordability of treatment, growing attention has been paid to its importance as an essential part of a revised stepping-up of our response to the epidemic. The UK's early efforts were concentrated primarily on prevention, but in the past two years there has been an increasing focus on treatment, care and impact mitigation. Treatment needs to be delivered as part of a comprehensive approach to care that would include services such as voluntary counselling and testing, prevention of mother-to-child transmission, diagnosis and treatment of opportunist infections, psychosocial support, proper nutrition advice, proper palliative care, social support and a whole range of other services relating to community mobilisation.

Treatment needs to be recognised as part of a continuum with impact mitigation and prevention. Those things need to form a virtuous circle; they cannot be considered in isolation. There is evidence from a number of small-scale pilots that treatment can be administered effectively in poorer countries if it is integrated into a strong programme incorporating prevention, counselling, training and community mobilisation. For example, in Brazil, universal access to treatment has reduced HIV-related mortality by 50 per cent. since 1996.

Coverage of treatment is currently low in low-income countries. In Africa, only 1 per cent. of the people with HIV/AIDS who are in need receive anti-retroviral drugs. Sadly, it is predominantly the better-off who receive the drugs. We know that treatment is becoming more affordable as the price of anti-retroviral drugs continues to drop. In some cases, the price has dropped by up to 95 per cent. in the past three years. That has been helped by various initiatives by the UN and the Clinton Foundation, and by the efforts of the drug industry. There is no reason to think that further reductions in the price of drugs cannot be achieved, and we should certainly work for reductions by seeking further production efficiencies from companies, through economies of scale and through competition from generic producers.

We work extensively through multilateral organisations, including UNAIDS, the World Health Organisation and the World Bank. We also support worldwide research initiatives on HIV, sexually transmitted infections, vaccines and microbicides. We were a prime mover in setting up the global fund to fight AIDS, tuberculosis and malaria, and we have committed some $280 million over seven years to contribute to the long-term stability of its funding. We also contribute to the global fund through the European

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Commission and, together with EU member states, the European Commission has provided more than 50 per cent. of the funding for the global fund. That is in line with the call from our Prime Minister and President Chirac for Europe to play its part in making the global fund effective.

Countering the devastating impact of HIV/AIDS on developing countries also requires improved access to affordable medicines and good health care services. That has been a priority for the United Kingdom since we came to power in 1997 and we have provided £1.5 billion, which is significant and substantial support, since 1997 to strengthen the health systems of developing countries. We shall try to do more in the coming years.

Given the scale of the epidemic and the sense of gloom that too often descends on people who study the problem, it is important to note that a number of countries have been successful in reducing significantly the prevalence of HIV/AIDS. Uganda, Senegal, Thailand and Brazil are cited as the countries that have made most progress and it is important to mention the reasons for their success. Strong political commitment and leadership is fundamental, as we recognised in our call for action. President Museveni played a key role in leading the Ugandan effort in Kenya. Early and decisive action is crucial to getting the right response. Countries that in 1990 were in a similar position as Uganda, such as Thailand and South Africa, are in a very different position now compared with Uganda. It is also crucial that those countries have engaged a broad range of stakeholders in mounting an effective response to HIV/AIDS, including civil society, local leaders, religious groups, and people living with HIV/AIDS, as well as the public and private sectors. Those countries have often involved people who are affected by HIV/AIDS in the design of their programmes, in their response to the epidemic and in achieving effective support from international donors for support of national efforts. That is another key part of the effective response.

The "Call for Action" published on 1 December is the start of a process that will take us beyond our presidency of the European Union in 2005. We want to produce a revised strategy for our work on HIV/AIDS in developing countries at some point next year and we want to engage in consultations not only with parliamentarians, but with constituents and NGOs.

I welcome the opportunity in this debate to hear the initial response of parliamentarians with expertise in the matter to the call for action and I look forward to meeting the challenge of HIV/AIDS in the coming months and years.

Several hon. Members rose—

Sir Nicholas Winterton (in the Chair): Order. The House is grateful to the Minister for his opening comments. I want to be helpful, so I shall not counsel brevity today. All those who wish to speak should be able to do so. I shall call the spokesman for the Opposition, and then I shall return to the Government Benches before calling the hon. Member for Carshalton and Wallington (Tom Brake). Other hon. Members can be confident that they will catch my eye.

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2.52 pm

Mr. Julian Brazier (Canterbury) (Con): I welcome the opportunity to speak in this debate and many of the Minister's comments. As this is the first time that I have had the opportunity to speak in my new capacity as shadow Minister for International Development, Sir Nicholas, I hope that it is in order to say that I feel particularly strongly about the matter. My father-in-law worked with the United Nations, as did one of my cousins, and their work often took them to sub-Saharan Africa, which, as the Minister said, is the worst focus of HIV/AIDS. Many members of earlier generations of my mother's family worked in civil administration there and I still have relatives and friends in a number of sub-Saharan countries who report back to me the sheer horror of the problem.

Much of the Minister's speech concentrated, inevitably, on the sheer magnitude of the horror that AIDS represents in many parts of the world, not just in sub-Saharan Africa. I shall repeat some of the statistics. We believe that 42 million people in the world today have HIV/AIDS and that it kills about 6,000 people each day. There are an estimated 13 million AIDS orphans in Africa alone—the Minister's figure is 14 million—and it is expected that by 2010 the total number will have almost doubled.

Many people in the prosperous west think of HIV/AIDS as someone else's problem, affecting those who are nameless, faceless and far away. That simply is not true. It was estimated that 50,000 people in this country were living with HIV by the end of 2002. Last year alone, 6,600 new cases were diagnosed. Nine out of 10 of the heterosexual cases of HIV/AIDS diagnosed last year were acquired overseas. The problem is very real, but it is our problem, too—it is coming here.

Another common misconception is that AIDS is merely a health issue. However, it affects not only the individuals concerned but, as the Minister said, it shatters families, whole communities and even in one or two cases entire countries' infrastructure. Beyond the great personal loss of losing a loved one to AIDS is the huge economic loss to the country of the growing problem. In some parts of the world, HIV/AIDS wipes out complete sectors of the work force, and not only in the health care set-up. Whole societies are affected and undermined as key groups—the Minister mentioned health care workers and teachers. I understand that in Ivory Coast 70 per cent. of deaths in service of teachers is due to AIDS. Whole generations who could be fuelling the development that, after all, the Minister's Department exists to promote are simply lost to the epidemic. UNICEF has stated:

So whose responsibility is it to tackle the global spread of HIV/AIDS? If we are to make any concrete headway in the fight, there must be serious political will in developed and developing nations. The Government are to be commended for the extra money that they have committed and for shifting overseas development funding towards AIDS. However, I suggest to the Minister that, as well as extra money, we must think a little harder about the strategy.

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What would Conservatives in office do to tackle the problem? We believe that the focus must be where the need is greatest: in the developing world. We have set out five key, practical proposals for tackling the AIDS epidemic.

First, we must have a more integrated approach. We need a strong partnership between non-governmental organisations and pharmaceutical companies, as well as the World Health Organisation and other international institutions. There must be a more co-ordinated response that combines the scientific expertise in pharmaceutical companies with the practical experience of NGOs, which work on the ground. The global health fund must adopt a co-ordinated strategy when disbursing funds rather than simply funding large numbers of ad hoc projects. All sides must work with the Governments of developing countries to produce an effective strategy. I wish to focus briefly on one of the Minister's examples. The Minister was right to pick Uganda from the list of the relatively few success stories. I shall be slightly more specific about the campaign there. The Ugandan Government took the lead and, as the Minister said, did so early on. They went for what one might call a blunt HIV prevention campaign. As early as 1987, they recognised the magnitude and impact of the disease and by 1992 had established the Uganda Aids Commission.

They adopted the A, B, C approach. A stands for abstinence, which is not a popular word today. B stands for being faithful to one's partner, and C for the use of condoms—an interesting hierarchy. The national strategic planning exercise mobilised Government Ministries, NGOs, faith-based organisations, the business sector, the media and cultural institutions, as well as all available assistance from the UN. The impressive result was a reduction by more than half in HIV seroprevalence in just four years. Surely, we should encourage other countries with AIDS problems, not just in sub-Saharan Africa but throughout the world, to look at that model. It is particularly impressive because Uganda is a very poor country.

Secondly, we believe that it is vital to build up the infrastructure necessary to administer medical care. Most countries in the developing world do not have the infrastructure to deal with the HIV/AIDS crisis. If people do not have the benefit of anti-retroviral treatment for HIV/AIDS, they must have access to proper medical care. For that, we need to strengthen primary health care systems and take really basic action such as improving access to clean water, sanitation and basic services. Coming from a long line of engineers, I always like to trumpet the great claim of the engineering community: that the Victorian introduction of drainage did more for health care in this country than the entire medical profession. Tackling HIV/AIDS also requires more education in developing countries to enable people to understand how AIDS is spread and treated.

Thirdly, we would like to ensure that a significant proportion of the UN global health fund is spent on purchasing the anti-retroviral drugs needed to treat people with HIV/AIDS. I welcome the Minister's

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comments on providing more on that. Bernard Pecoul, director of Médecins sans Frontières, has expressed concern in the British Medical Journal that

That is a chilling thought.

Many countries cannot afford the necessary drugs to treat their populations. The global health fund should help poor countries to purchase those drugs. Already pharmaceutical companies are selling their drugs far more cheaply in Africa than in Europe. For example, all six of GlaxoSmithKline's HIV and AIDS medicines are available in certain poor countries at discounts of up to 90 per cent. compared with the amounts charged in rich countries—less than one tenth of the price. I hope that the Minister will take the opportunity in his winding-up speech to congratulate that company on setting a remarkable example in corporate social responsibility. It is not alone, but it has set a remarkable example.

Fourthly, we believe that the global health fund should purchase anti-retroviral drugs to be administered to pregnant women. More than 600,000 infants worldwide are infected with HIV from their mothers each year. Transmission rates are as high as 35 per cent. when there is no intervention but below 5 per cent. when anti-retroviral treatment and appropriate care are available. According to the World Bank, the cost of drugs to prevent maternal transmission of the virus could be as little as 8 cents per capita for drugs and replacement feeds, which is a tiny, tiny fraction of the cost of trying to do something for that baby after it is born.

Fifthly, we propose that the global health fund encourage research and development by pharmaceutical companies into diseases in the third world. The Minister mentioned that. The global health fund must pledge to respect the intellectual property rights of manufacturers. Pharmaceutical companies invest hundreds of millions of pounds in drugs. One of the world's largest is Fisons, just outside my constituency. Many hundreds of my constituents work there. It is an excellent company, which also has a very good record of corporate responsibility in our own local community, not least in the local health care and education systems.

Most drugs produce no return, and most projects that start in a pharmaceutical company—often expensive ones—do not produce any payback at all. Those least likely to make a return on their investment are those in developing countries. Unless the global health fund is willing to guarantee that it will uphold intellectual property rights—we can discuss afterwards how to make the drugs affordable for the people who most need them—the required investment simply will not happen in many cases. If the global health fund pledged to buy effective vaccines, that would encourage companies to invest in vital research programmes. The fact is that most of the research and development that needs to be done will be done in the private sector if it is done at all. Thinking that through—having joined-up government, to borrow the phrase—is important.

Investment in effective drugs and vaccines is the only long-term solution to the diseases of the developing world. An affordable and effective HIV vaccine could be

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developed within seven to 10 years if rich and poor countries co-operated on research and development. Improvements in drugs to treat influenza, which killed about 20 million people in the winter following the first world war—some countries lost more people in the epidemic than they did in the war itself—have ensured that the number of fatalities from influenza is now very small, except among the most vulnerable people, despite NHS overstrain most winters. Other diseases, such as measles, whooping cough, rubella, diphtheria, tetanus and tuberculosis, have been curbed by vaccines and in some instances have virtually disappeared in the developed world and even parts of the undeveloped world.

To conclude, if we are to reverse the spread of HIV, there must be serious political will in both developed and developing nations. We must break down the stigma and discrimination that is fuelling the global HIV epidemic. All Governments must use their voices to educate and enlighten people about the realities, dangers and consequences of AIDS.

3.6 pm

Tony Worthington (Clydebank and Milngavie) (Lab): I welcome the hon. Member for Canterbury (Mr. Brazier) to his post and thank him for what he said.

I welcome this debate in Government time. When I look back, I find that one of the great weaknesses of this place is how little we discuss big events in world; somehow, we do not find time. I welcome the Government's new document on AIDS and the declaration that we have become the second largest bilateral donor in the world. The world seems gradually to be ratcheting up its response to AIDS. That has taken a long time, but it is important.

I want to devote my remarks to the policy aspects of our approach to AIDS. The document is not really about what we do; rather, it states what the problem is and how much money we give. I am pleased to hear that another document on how we tackle the problem is on the way, which is crucial. If the Minister cannot respond to my points at the end of the debate, perhaps he could do so by letter.

Sir Nicholas Winterton (in the Chair): Order. If there is sufficient time, with the permission of the House, I shall certainly call the Minister to wind up the debate.

Tony Worthington : There can be no doubt that the world community's policy to date on Africa has been a dismal failure. One cannot look at the figures and disagree with that. Unless we make policy changes, we will be incapable of facing what is on the way in China, India, Russia and eastern Europe. It is said that within two to three years there may be tens of millions of sufferers in India alone. We will not stop that with what we have done so far. We must remember that Africa is a sparsely populated continent and the numbers are relatively small compared with Asia.

In some respects, we have been unbelievably amateurish and even malign. Unprotected sex has had a serious impact, yet the only protection against the virus is the condom. I have no quarrel with what the hon. Member for Canterbury said about ABC—abstinence, being faithful and the condom—but we must remember

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that the condom is essential. However, the supply of condoms is not mentioned in the report, and I was disappointed that the Minister did not go into the subject. He talked about social marketing, but not about the supply of condoms to the developing world. Surely the first action should be to ensure a plentiful supply of condoms. After all, the price of a condom supplied by the United Nations Population Fund is a mere 2p, which is what we spend each year on condoms for each man in Botswana, the most infected country in the world. The average man in Botswana is supplied with one condom a year, yet an estimated 40 per cent. of the country is infected. That is shattering and must be put right. We spend billions of dollars on the valuable pursuit of developing anti-retroviral drugs, but we are not willing to spend a pittance on the only proven protection for people who would otherwise have unprotected sex.

The refusal to supply condoms kills thousands of people through both AIDS-related deaths and pregnancy-related deaths. The US has stopped providing condoms to 29 countries since 2000. The refusal to supply condoms is, in some cases, not just stupid and mean in the fight against AIDS, but malign as well. The first President Bush supplied 800 million condoms a year to Africa. The second President Bush is supplying 300 million condoms a year to Africa despite the explosion of AIDS throughout that continent. That is a result of him withdrawing funding from the UNFPA on the spurious ground that it is involved in enforced birth control in China, despite the fact that countless investigators, including representatives from this House, have gone there and have found no evidence of that practice whatsoever. However, although he has withdrawn about £28 million a year from the UNFPA, that does not relieve the rest of the world of the obligation to ensure that all poor people have access to condoms to protect them from HIV/AIDS.

I take my spiritual advice from the bishops of Mozambique. I have quoted this before, but it is a splendid statement, so I shall quote it again. They said:

That is my kind of pro-life bishop, and I wish that there were more of them.

President Bush, in his proposed anti-AIDS programme, is obsessively funding programmes that emphasise abstinence and exclude contraception. I do not disagree that abstinence and behaviour change are crucial, but we should remember what the hon. Member for Canterbury told us about Uganda, where a Government-backed information campaign promoting condom use saw the incidence of HIV among 15 to 49-year-olds drop from 21 to 10 per cent. in just four years.

Given the dire situation with regard to condom supply, it is strange that the document does not mention how important it is. I hope that that will be put right. It beggars belief that Africa, with such a high percentage of AIDS victims, is being supplied with fewer condoms than it was at the beginning of the 1990s. That one condom in Botswana is nearly worn out.

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I congratulate the Department for International Development on its contribution to microbicide research. Like the condom, microbicides act as a barrier to stop infection. Crucially, however, that barrier method is under the control of women. One of the wretched features of the AIDS pandemic is that it has made clear the extent to which women in Africa are not in control of their destinies in sexual matters and how they are so often the victims of the power relationships between men and women. Most women are infected by their husbands.

It is an interesting reflection of our values that, faced with this crisis, the major pharmaceutical companies invested huge sums in finding drugs to manage the disease in the prosperous world, which is where the profit lies. Huge congratulations must go to countries such as Brazil and South Africa for cracking the power of the big pharmaceutical companies. They did not give up their power voluntarily. They would have clung to their profits while millions died if they had not faced the new power of the poorer countries and worldwide condemnation had their control of the drugs not been broken. It is astonishing how prices have tumbled since the power of those companies was cracked in the weeks leading up to Cancun. The pharmaceutical companies invested much less in the search for a vaccine to cure the disease. Next to nothing has been invested in finding a barrier method for women. That is where DFID, the Rockefeller Foundation and the Bill and Melinda Gates Foundation have stepped in, and all credit to them.

I would welcome the Minister's comments, either now or in writing, on a Financial Times article of 28 November entitled, "Microbicides: Big advances in low-tech treatments", on the progress that is being made in microbicide research. Is that claim true? The article did not back up the headline with much substance. If progress is being made, it will be enormously important.

There must be a co-ordinated effort between donors. How will that be achieved? The document says that DFID will step up its co-ordination with the United States and other donors, starting with Ethiopia, Kenya, Nigeria, Uganda and Zambia. The United States programme has promised an extra $10 billion dollars to twelve sub-Saharan African countries and two countries in the Caribbean. When that money eventually turns up, those countries will receive a large sum. The five countries that DFID lists are also on the United States list. Co-ordination is good, but about 40 other sub-Saharan African countries are not mentioned by either the United States or us. How will they be dealt with?

Another strange aspect of the document is the lack of a complete commitment to the global health fund, which was founded just two years ago with our enthusiastic support. It was to have a major catalytic and co-ordinating role in tackling AIDS, tuberculosis and malaria, as the hon. Member for Canterbury wants it to. It is difficult to understand DFID's reticence on that issue. I expected the global health fund to be right at the centre of the document.

Through the auspices of the all-party group on AIDS, and my hon. Friend the Member for Walthamstow (Mr. Gerrard), I have met the head of the global health fund, Dr. Richard Feachem, several times, and I find him very

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impressive. The global health fund's performance is getting better, but it desperately needs funding for the next round. The document's statement,

is ambiguous. I would have thought that more could be said about the role of the global health fund.

On other policy areas, such as working with young people, the international community has been relatively slow to recognise the scale of the problem. The hon. Member for Canterbury mentioned the devastating number of orphans, many of whom members of the Select Committee on International Development see when we go about our work.

We have the largest generation of young people in history. All over the world—the problem is not confined to this country—people are squeamish about talking to the young about sex. We have an extraordinary belief in education, education, education, except when it comes to sex, for which we hold the strange belief that ignorance is bliss. That ignorance is killing thousands and thousands of people. We must find different ways of working with young people. We must focus on the young, however young they might be—they almost cannot be young enough. A few weeks ago, a South African group gave a presentation. When one considers the age at which people are being infected, information about altering behaviour must get to them when they are very young.

We also hope that the extended families of orphans can be helped to cope, but we need bold new programmes that make older children leaders in self-run communities. The Secretary of State and I were privileged recently to meet a group of young people from all over the world. The event was organised by Plan International, a non-governmental organisation, which urged us to stop considering children and young people simply as recipients of development aid. In some circumstances, older children must be seen as leaders. They will have to run their own businesses, farms and activities, and should be assisted in doing so. We have not focused enough on that. I want NGOs, such as Plan International, to advance such proposals.

The Minister mentioned palliative care. Many of us, including my hon. Friends the Members for Putney (Mr. Colman) and for the City of York (Hugh Bayley), have had the dismal experience of visiting African hospitals that are overrun with AIDS victims. The wards are dingy and dirty, with several people to a bed and relatives all around trying to give what support they can. Those hospitals have nothing to give to those people. They do not have the drugs or the expertise. Palliative care is needed.

I have also seen work carried out in the back streets of Nairobi by a group of volunteers, led by an inspirational nun from the west country in Britain, which was achieving miracles in supporting people in their homes. The other side of the problem is, of course, that the hospitals cannot get on with the rest of their work because of the presence of AIDS victims. They are unable to help the people whom they could otherwise have assisted.

My final point is my main one: we continue to make a great mistake in our approach to the prevention and treatment of AIDS. When AIDS first appeared, the

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stereotype of the AIDS sufferer was of a reasonably well off, white, gay male or an intravenous drug user. Now, the stereotypical AIDS sufferer is a desperately poor black, heterosexual woman. Our approach to AIDS has not changed to reflect that. If the disease had been seen as starting with poor, black, heterosexual women, we would have seen AIDS as it is—a reproductive health issue. Overwhelmingly, AIDS is a heterosexual sexually transmitted disease. That was recognised at the 1994 Cairo conference on reproductive health, at a conference that I attended in Ottawa last year, and by the World Bank, which says:

If we had conceptualised HIV as something to which women in poor countries were particularly vulnerable, we would have taken a dramatically different approach to AIDS. We would not have been so obsessed with anti-retroviral drugs. At whatever price, anti-retroviral drugs will not be sufficiently cheap or sustainable in many African situations. We should put far more resources into reproductive health and preventive work because behaviour change is required, and clinics would be better equipped to cope with the huge problem of mother-child transmission. There are no symptoms to indicate that a person is HIV-positive. That can only be found out by testing. In many cases, people find out too late that they are HIV-positive, and, as the hon. Member for Canterbury said, that is disastrous for a child on the way.

We could have ensured that enough condoms were available, the drug companies could have shown more interest in vaccines and microbicides, and we could certainly have concentrated on women's gender empowerment. However, we initially saw AIDS as affecting mainly affluent gay males in the developed world, which distorted our approach to the problem. I hope that the forthcoming DFID paper addresses that and considers how changing the AIDS paradigm could introduce new and helpful approaches.

3.25 pm

Tom Brake (Carshalton and Wallington) (LD): I congratulate the hon. Member for Canterbury (Mr. Brazier) on his maiden speech in his new role. I also congratulate the hon. Member for Clydebank and Milngavie (Tony Worthington) on raising the important issue of condoms and the position adopted by the US. I find its attitude less than helpful. He could have mentioned also the position that the Vatican has adopted, which is equally unconstructive, if not destructive.

I thank the Minister for referring to the debate that took place on 1 December; I will try not to go over too much of the same ground. A half-hour Adjournment debate is not sufficient to discuss the matter, and it is therefore entirely appropriate that the Government have made more time available. I hope that we will return to the matter on a regular basis.

I will touch on five or six key areas: funding, to which the hon. Member for Clydebank and Milngavie referred in relation to the global fund; the issue of overlapping initiatives that I raised in the debate 10 days ago, which concerns Government policy in the Department for

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International Development that is undermined by policy in other Departments; orphans, to which several Members have referred; questions that were still up in the air after the Adjournment debate on 1 December; and the critical issue of the leadership that the Government and others will provide.

On funding, many Members are members of the all-party group on AIDS, or receive its excellent briefings. One briefing confirmed that, if one were to consider UK wealth, the contribution that the UK would be expected to make to the global fund in 2004 is about £107 million. It would be interesting to know whether the Minister agrees with that figure and whether there are any negotiations within the Government about the level of funding for the global fund. Clearly, there was an opportunity yesterday in the pre-Budget statement to make an announcement, but I am not aware of any having been made.

The overstating of funding is another issue, particularly in relation to condoms. Depending on the circumstances, the spending on condoms is accounted for in relation to initiatives related to birth spacing and as funding in relation to HIV/AIDS. There may be some double counting on which the Minister could comment; or he could guarantee that it is not taking place and that the funds are clearly allocated to one fund or to the other. It may be that he would like to state the circumstances where it is appropriate for the condom to be used in both cases. I cannot foresee circumstances in which it would be appropriate for it to be used in both cases. Perhaps the Minister could comment on that.

As for solutions, it is one thing to identify a funding issue, but hon. Members will have followed yesterday's Prime Minister's questions in relation to the Liberal Democrats' funding pledges. My role in the party is to fight for additional AIDS funding, and the global fund is a priority. I hope to bring forward good news on that front. However, one source of funding is already available, and I would like the Minister to say what the Government are doing about funds from the European Union. I understand that about $2 billion of unspent funds are available from the EU. The problem is that the developing countries have to apply for those funds. Will the Minister confirm that the Government are working with developing nations to help them gain access to that money, which could increase the funding for HIV/AIDS initiatives?

The Government see the international finance facility as a mechanism for bringing forward investment to tackle HIV/AIDS. We support that concept, but can the Minister tell us something about the reality of it? Is there a target for the funding that is to be raised through that mechanism? What has been the response from other countries to the initiative? Have any of them signed up to it? Is there a deadline by which contributions have to be made for that facility?

I spoke about overlapping initiatives at some length in the Adjournment debate on 1 December and I do not intend to dwell on the issue to the same degree today. Suffice it to say that the Government support the idea of the "three ones"—one commission, one strategy and one method of reporting. I wonder whether that is sufficient, and whether we need an individual organisation to take the lead within a country. Clearly,

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having one commission and one strategy is good, but if two major organisations are active in a country, the risk is that initiatives will overlap. I hope that the Minister can say more about that.

I wonder whether the Minister believes that the "three ones" will be able to resolve some of the problems that I understand from today's Financial Times have been experienced in Nigeria. They seem to have the funding, but there has been a problem in the supply chain. As a result, people have started anti-retroviral treatment but the supply of drugs has been held up somewhere, thereby putting the programme at risk.

On the question of initiatives being undermined by activities of other Government Departments, it is worth dwelling briefly on the situation in Ethiopia. Ethiopia's epidemic started in the early 1980s; it now has the 16th highest prevalence rate globally, with an estimated 5,000 people being infected every week. Nearly 3 million people are infected, and nearly 1 million children have been orphaned. However, one should look at the activities of the Department of Trade and Industry in relation to Ethiopia.

Notwithstanding the Prime Minister's comment on 9 December that we already prevent the sale of small arms in Africa, the arms export licences that have been granted by the Government to Ethiopia include licences for chemicals that could be used as precursors for toxic chemical agents, for aircraft and air equipment, for imaging equipment such as radar and infrared, and perhaps more alarmingly, for production equipment to manufacture arms. The Minister said in the debate on 1 December that he would talk to other Government Departments as part of the consultation process, which was very welcome. He should be discussing quickly and seriously with the DTI whether providing arms export licences to Ethiopia, a country where there is a conflict with Eritrea, is appropriate. I hope that he will report back on those discussions in the near future so that hon. Members can be reassured that the discussions between the Department for International Development and other Government Departments such as the DTI are meaningful.

The Minister will no doubt be aware that Save the Children issued a statement after the call for action on HIV/AIDS was published, which said:

It went on to congratulate the US Administration as

I invite the Minister to comment on that. Does he believe that there is an issue there and that it would be appropriate to identify separate funding for children and orphans, specifically for priorities such as education, food and protection? I would welcome his comments on that.

In the Adjournment debate on 1 December, I mentioned Canada's patent laws. The Minister did not respond to that, but he is going to today. He had an opportunity to do that on 1 December in that the Government had already written to me confirming that they were actively pursuing that idea, but the letter was

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unfortunately lost in the mail. I hope that the Minister will set out how he sees the idea being taken forward. Is there a need for primary or secondary legislation?

Mr. Gareth Thomas : Let me try to put the hon. Gentleman out of his misery now. I apologise for not having covered the point in my response to him on 1 December. Our colleagues in the Department of Health are examining that system and the legislative change needed to effect it in the UK at the moment. It is an issue of shared competence, so we are also discussing with the European Commission what changes are necessary in European directives. Work is under way to sort out the issue

Tom Brake : I thank the Minister for his extremely useful clarification. That is good news, although anything involving the European Commission may take rather a long time to get resolved, and clearly we do not have time. I am sure that the Minister will throw his weight around as much as he can to try to get that sorted out as quickly as possible.

On leadership, there is an issue on which the Minister might not be able to comment unless he does so with help from his officials, discreetly or through thought transfer. Has the internal reorganisation in the Department for International Development helped to provide leadership on HIV/AIDS or has it in some respects made that harder to tackle? I understand that a small core of people have taken over all responsibility for the issue and are now examining it. It may be that other people who previously had some involvement now do not see it as their role to be involved. Perhaps the Minister could comment on that, or if anyone wants to write to me anonymously, that is fine.

Mr. Thomas : Ultimately, it is the responsibility of Ministers to make decisions on how one responds to particular development challenges. I know that there has been concern about reproductive health. One of the groups of officials in the Department is tasked to work on the millennium development goals and on reproductive health. Our internal reorganisation is helping us to generate a more effective response, and I hope that hon. Members will accept that in the light of the call for action that we have published and in the light of the recognition that we need to do more work to get our strategy right. Ultimately, however, that is the responsibility of Ministers, not officials.

Tom Brake : Clearly, I understand that, but it would be useful for hon. Members if stated objectives for that reorganisation were placed in the public domain so that we could assess whether they had been met.

Returning to the issue of leadership, the call for action document says:

I hope that the Minister will be able to set out exactly what—apart from the Mugabe incident—happened in relation to HIV/AIDS at the Commonwealth Heads of Government meeting. Was it discussed, and if so, what was the outcome of the discussions?

The document also refers to the annual forum on donor co-ordination, as have other hon. Members and the Minister. The first meeting is planned for early 2004,

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and I wonder whether the Minister will tell us when the meeting will take place, who is likely to attend, and what sort of items will be on the agenda. In the debate on 1 December, I referred to the priority that the Government have stated will be given to HIV/AIDS when they take over the G8 and the European Union presidencies. That is something I welcome. However, at the time I said that the Government had also decided that trade was to be a priority of the G8 and EU presidencies, and a couple of days ago, the Prime Minister said that climate change was going to be a priority of the G8 and EU presidencies. There is a point where everything cannot be a priority. I do not know whether there is a hierarchy of priorities that will be discussed under those presidencies, but I hope that the Minister will do all he can to ensure that the issue of HIV/AIDS is not lost because of the other priorities that will be discussed while the UK holds the presidency of those two groupings.

There is clearly a crisis in Africa with HIV/AIDS. The infection trend in the UK is worrying. There is the threat of a pandemic in Asia, which has not really kicked off yet. The Government's call for action is a strong start to the process, but there is still more room for consistency in relation to interdepartmental Government policy. We shall need to return to this subject again and again, because if we allow our attention to be diverted, millions more will die and millions more will be orphaned.

3.43 pm

Hugh Bayley (City of York) (Lab): I congratulate the hon. Member for Carshalton and Wallington (Tom Brake) on proposing and securing the debate.

HIV/AIDS is clearly the greatest humanitarian challenge facing the world today. It is killing more people than wars or famine, and many, many more people than terrorism. In the west, because of medication, it is mainly now a chronic illness. In developing countries, HIV is a death sentence. In developing countries, its victims are so weakened by the disease, so poor, so often stigmatised, ostracised and isolated, and so widely dispersed around the world that they have not attracted the attention of television cameras in the same way as wars or famines. As a result, their plight has been overlooked for far too long.

I warmly welcome the Government's publication of their "Call for Action" on HIV/AIDS. It sets out important objectives, reminds us that the UK is the second biggest bilateral donor—after the United States of America—and it commits the UK to formulate a new Government HIV/AIDS strategy in 2004. I know that many Members, including those here today, will want to make a contribution to that strategy.

In the new year, the Africa all-party parliamentary group will hold an inquiry into HIV/AIDS. It will examine the social, economic and political consequences of this unprecedented epidemic, which in some countries is likely to kill at least a quarter of the adult population. It will address the actions that could mitigate those dire consequences and the preparations that need to be made now to deal with the social and economic consequences in 10 years.

The group has already put out a call for written evidence, and I hope that the Government will submit a draft of evidence. It intends to hold oral hearings in the

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spring, and we have invited the Secretary of State for International Development to appear before our group. We intend to produce a report and conclusions, which we will forward to the Government, and which we hope will contribute to the policy development process for their new strategy. We also hope that the report will provoke questions and debate in both Houses of Parliament. As the chair of the all-party group, I should declare an interest. The group receives from the Royal African Society the benefit of the work of a part-time researcher.

I will now offer my initial comments on the Government's work on their new strategy: I should emphasise that they are my comments, not those of the group. The strategy must relate the initiatives funded by the Department for International Development and the multilateral agencies that we support more closely to the outcomes that the Government wish to achieve than does the "Call for Action" document. We need to estimate the impact that each initiative is likely to have on those outcomes and regularly to audit the progress towards them.

The global fund annual report for 2002–03 projects that its current funded programmes will increase over the next five years the number of Africans receiving anti-retroviral drugs from 50,000 at present to 400,000, and the number of people in the world receiving voluntary counselling and testing will rise from 3 million to 31 million. The United States also sets out explicit goals in its strategy: its funding is intended to prevent 7 million new infections and to care for 10 million HIV-affected persons and orphans.

The biggest change in UK policy, which is highlighted in the excellent "Call for Action" document, is the Government's decision to commit resources to treatment. I welcome that. I used to be a sceptic: I thought that the cost of anti-retroviral treatment in developing countries was too high and that the same amount of money spent on prevention would save more lives. I changed my mind at about this time last year when, as a member of the International Development Committee, I visited Malawi during the famine that that country was experiencing. That famine was greatly intensified by the HIV/AIDS epidemic. We discovered that drugs that cost £10,000 per person per year in Europe were available to a very small number of people in Lilongwe for £360 per person per year.

In the 12 months since that visit, the cost of anti-retroviral drugs has fallen further. The Clinton Foundation has negotiated contracts with suppliers to produce anti-retroviral drugs for 38 cents per day, or something like $140 a year. That is still an enormously high sum for most developing countries—the average health spend in sub-Saharan African countries is $20 per person per year—but it is not the unimaginable figure that $10,000 per person per year, the western cost of those medicines, would be. When one considers that $140 per year is less than the cost of providing insulin for a diabetic in Africa, the figure becomes affordable and feasible. One would not suggest that diabetics in Africa should receive no treatment and be allowed to die.

In Malawi too, members of the International Development Committee saw the devastating effect of AIDS on the number of teachers, nurses and civil

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servants. We were told that 6 to 8 per cent. of all the teachers in Malawi die each year, and that the cost of returning their bodies to their home villages and of their funerals absorbs a major slice of the education budget. One third of the top officials whom we met at the Ministry of Agriculture and Irrigation—the people responsible for leading the country's response to the famine—were HIV-positive. Some will have died in the past year. The rest, without treatment, will die in the next two or three years.

That raises a question; what will Malawi do if it faces another famine in two or three years' time but has lost a third—maybe more—of its top agricultural experts? If some of those people could be kept alive to use their expertise and knowledge and to pass that knowledge on to other people, that would be worth $140 per year. Although this should not be merely an economic matter, that is also far less than the cost of retraining other people to take their place.

I warmly support the Government's decision to spend money on anti-retroviral drugs in Africa. The "Call for Action" document envisages that, by 2005, some 2 million out of the 29 million people who are HIV-positive in sub-Saharan Africa will be receiving anti-retroviral drugs, which raises a difficult ethical question. How does one choose whom to treat? I urge the Government—better still donors and recipient countries working together—to establish and take advice from a medical ethics committee that consists of doctors who specialise in the disease, ethicists and health economists.

A number of criteria need to be assessed to ensure that the allocation of anti-retroviral treatment is not arbitrary and does not merely favour the richer urban elites. The committee should examine the clinical impact—for instance, it might make a decision to treat people at a later stage of HIV, when their immune system is depleted and when people are at the greatest risk of opportunistic infection, and to set that as a criterion. It should also consider the social impact. Perhaps it might decide to protect carers—for instance, a surviving parent of dependent children after the other parent dies. It would need to consider the economic impact, and the argument for preserving key workers such as teachers, nurses and agricultural specialists. The committee might also consider the epidemiological impact. For example, it could intervene in areas of highest prevalence, if it can be shown that treatment encourages others to come forward for voluntary testing and counselling, and if that voluntary testing and counselling changes behaviour about safe sex.

Finally, the committee could possibly look at the risk and danger of creating a drug-resistant strain of HIV/AIDS. That could occur if people who were allocated drugs did not stick rigidly to their drug-taking programme. There are many reasons why people might not do so. Their supply of drugs could be disrupted. The side effects might influence their decision. They are not pleasant drugs to take, and the temptation if one feels that one's HIV status is under control is to miss some of the drugs. They might not take them because of generosity to friends, giving the drugs to those who were not chosen to receive drugs, or possibly because they were so poor that they were selling their drugs on the street corner. If such things were to occur, that could lead to the development of drug-resistant strains of HIV

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infection, so it might make sense to limit the provision of the drugs to areas with health infrastructures that are adequate to supervise the drug regime.

Médecins sans Frontières is currently testing that theory in rural parts of the Democratic Republic of the Congo. It is seeing whether effective anti-retroviral treatment can be provided in areas without that health infrastructure. If Médecins sans Frontières proves that such treatment can be provided, my worries would be unfounded. These are not issues for politicians to determine; it is for a medical ethical committee to draw up clear guidelines so that the allocation of drugs is rational and fair, and not arbitrary and skewed towards those who are more powerful.

The new emphasis on anti-retroviral treatment should not divert attention or resources from less heroic, lower-tech, but possibly more effective, medical therapies such as vitamin A supplements. When the Select Committee visited the Kintampo health research centre in Ghana, we learned about work supported by the Department for International Development and carried out in partnership with the London School of Hygiene and Tropical Medicine, the John Hopkins university in the United States and other clinical centres. It had been discovered that six-monthly supplements of vitamin A given to infants between the age of six months and five years reduced child mortality by 23 per cent. If we are concerned about saving lives, that is a highly effective intervention that costs about 1 cent per dose—1 cent every six months. The same centre is carrying out randomised controlled trials with pregnant women following a study in 1999 in Nepal that showed that a slightly different regime of vitamin A supplements produced a 43 per cent. reduction in maternal mortality.

We need to continue research to find a safe and effective microbicide, as my hon. Friend the Member for Clydebank and Milngavie (Tony Worthington) suggested. It was reported in the Financial Times last week that even a partially effective microbicide could prevent 2.5 million infections over three years. DFID is funding microbicides and the Bill and Melinda Gates Foundation has made an extremely generous $60 million donation to the International Partnership for Microbicides. As my hon. Friend so rightly said, that sort of intervention would bring particular benefits to women, who often find it difficult to negotiate safe sex in Africa. We should remember that 60 per cent. of all new infections in Africa are among women.

We need to consider the benefits of using anti-retroviral drugs not to control HIV infection, but to reduce mother-to-child transmission, as the hon. Member for Canterbury (Mr. Brazier) pointed out. Some 600,000 African children each year are infected with the HIV virus by their mothers. They have a very short life expectancy—on average less than two years. The South African Treatment and Action Campaign believes that the use of anti-retroviral drugs to control mother-to-child transmission could save 20,000 South African children a year from acquiring HIV-positive status.

We also need to increase funding for the supply of simpler drugs, including antibiotics, to deal with the opportunist infections that those with HIV/AIDS face. When the Select Committee was in Malawi a year ago, we saw that Lilongwe Central hospital was under acute stress. It had fewer staff, because so many had died from

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the epidemic, and many more patients to care for. The hospital estimated that a vulnerable person who in the past might have been admitted once a year with pneumonia could be admitted six or seven times if they were HIV-positive. That has had a devastating effect on the hospital's drug budget and the availability of drugs for treatment. We need to focus on the need to treat sexually transmitted diseases other than HIV, because of the increased risk of HIV transmission from unprotected sex to those who suffer from such diseases. Possibly most important, we need to look at the availability of food, because a healthy diet is the first line of defence against HIV infection.

I have an administrative point for the Minister. The United States has appointed a top executive to lead its programmes to combat AIDS globally, Randall Tobias, who is a former chief executive of the pharmaceutical company, Eli Lilly. The UK is the second biggest bilateral donor. According to "Call for Action", we provided 28 per cent. of world bilateral aid to fight HIV/AIDS globally this year, compared with the 35 per cent. that the United States provided. Although we provide a little less than the USA, our expenditure is in the same league. Perhaps we also need to appoint a high-powered executive to carry forward our programmes.

In the debate on Africa in the House a month or so ago, I said that even if we had a magic wand and could tomorrow prevent all further HIV infection, the death toll among those already infected would continue to rise, at least until the end of this decade, with enormous social, political, economic and security consequences for Africa. That is the issue that we in the all-party Africa group wish to address in our report. If we—the donor countries and Governments in Africa—do not address those consequences now, how will we care for the millions of orphans in 10 years' time? How will we educate them? How will we create a viable economy and an effective public sector? How will we stop failed states that become refuges for terrorists? How will we address all those problems? The simple answer is that unless we address them now, by 2010 it will be too late.

4.2 pm

Mr. Neil Gerrard (Walthamstow) (Lab): I am pleased that we are having this debate, and I welcome the Government's document, "Call for Action". I do not propose to repeat all that has been said about that already, but I am sure that we would all support the points that the Minister highlighted about funding, better co-ordination and better programmes. Having read the document and listened to the Minister and the Secretary of State, I am also glad that we are not going to promote the simplistic message that abstinence is the only way of tackling HIV. Given what my hon. Friend the Member for City of York (Hugh Bayley) said about the American attitude, that is important.

It is pleasing to see that over the last two or three years, HIV/AIDS has moved up the international development agenda not just in the UK, but across the world. Five or six years ago it was not there, and was not given the priority that attaches to it now. That is essential, because we know—we do not have to guess—that political leadership is necessary to intervene and make a difference. We know from Uganda, Senegal and other countries that have been successful, that political leadership at the country level is important. We know

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that it made a difference here too, and we should give credit to the Ministers who were responsible for health in the UK in the 1980s. They responded quickly to an emerging epidemic and made a big difference. It is important that that happens internationally as well. Although, as will always be the case in such debates, much has been said about the massive scale of the problem, and the fact that we have never seen an epidemic on this scale before, some current developments can give us encouragement and provide real opportunities.

My hon. Friend the Member for City of York has referred to changes in treatment, and it is true that two, three or four years ago many people were saying that drugs could not be delivered in poor countries. Things have changed—and it is not only people's attitudes that have changed; there have been important changes on the ground, for example in the price and in the sort of drug regime available. There are simpler drugs and treatments, perhaps requiring just one or two tablets a day, rather than some of the complicated regimes that we are more familiar with. The pharmaceutical companies, perhaps because of some of the pressures that they have been under, are seeing the need to do something to change their policies. I agree with what my hon. Friend said towards the end of his remarks: this is not just about drugs and treatment, and there is no one simple answer telling us what we have to do.

The main issue that I want to concentrate on is resources and the mobilisation of resources. "Call for Action" refers to the United Nations General Assembly special session. I was privileged to be a member of the UK delegation to UNGASS, and before this debate I looked back at the UNGASS declaration. It was there that the vital decision to establish the global fund was taken. We can discuss what ought to be done on treatment, what ought to be done on care and what ought to be done on the provision of drugs, but the root of all those is the provision of resources. It does not matter what policies there are; if there are not the resources to implement them, action will not be taken.

We know a great deal about what needs to be done. We know that we do not have a cure, that we are some way off a working vaccine and that a lot more needs to be done on protection methods such as microbicides, but we also know much that will work, both in treatment and prevention. It is not difficult to find projects to put money into that we know will make a difference. We have seen such things and we know that they can work.

I shall quote what my right hon. Friend the Chancellor had to say about resources, which related to the international finance facility and went a little wider than just HIV. In evidence to the Select Committee on International Development, he said that

He went on to say that

Those comments in themselves demonstrate what needs to be done on resources.

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I have heard what hon. Members have said about the global fund, but I am not sure whether the hon. Member for Canterbury (Mr. Brazier) was quite clear about what it does and why. He mentioned the need for it to purchase drugs, but the global fund does not purchase drugs; it does not purchase anything. It is a financing mechanism, as it was set up to be. It does not take action itself, but finances other people to do so. The key feature of the global fund is that it does not try to dictate to people in individual countries what they should do. It looks at projects and programmes that are put forward, carries out assessments to see whether those programmes look as if they will succeed technically, and then decides whether to finance them.

When we consider all that has happened, we must remember that the global fund came into existence only in January 2002, since when we have had three rounds of grant approvals, with £2 billion approved for 224 programmes in 121 countries. The money is now being distributed: £155 million has been disbursed so far, and the speed of disbursal is increasing.

When I compare that rate of progress in less than two years with the normal rate of progress of Governments and large institutions, it strikes me as pretty good that things are happening at that speed. The resources are being disbursed to the right places: so far 60 per cent. of the approvals have gone to Africa, 20 per cent. to Asia, the middle east and north Africa, and 20 per cent. to Latin America. HIV/AIDS has received 20 per cent., 23 per cent. has gone to malaria and 17 per cent. to tuberculosis.

We could argue about the exact balance and whether a particular initiative should or should not have been funded, but I would not argue with the fact that the fund is making real progress and starting to target money in the right areas. My hon. Friend the Member for City of York pointed out some of what is expected from those first three rounds after five years.

The pledges that have been put in place for the global fund since 2002 include $1.6 billion from the US, $627 million from France, $428 million from Italy and $340 million from Germany. For 2004, just over $1 billion has been pledged so far; the fund needs $3.3 billion to do what it would really like, and it would like two rounds of funding in 2004. It is $300 million short for the first round, although it will almost certainly obtain that. The question is: will it get the extra money to meet the $3.3 billion that it would like to spend in 2004? In 2005 the fund will certainly need $3 billion, because by then, as well as there being new projects to fund, some of the first grants will be up for renewal. What will we do to ensure that it hits that target?

It is important to remember how the fund obtains its money. The US is obviously the biggest donor, but the US Congress has required that contributions be no more than 33 per cent. of the total global fund. The US is putting in money but it is asking others to put in money as well. There is a danger that if we do not obtain matching funding from the rest of the world, the global fund will not get all that the US has been prepared to put in. Given the points that my hon. Friend the Member for City of York made about the attitude of the US to some bilateral funding, and the fact that it may withhold funding from a particular country because it does not

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like its birth control policy, for example, the more we encourage the US into adopting multilateral funding, the better.

I hope that we shall consider the contributions that we, too, make multilaterally as well as as an individual country. The point has been made about the European Union and our presidency in 2005, and we know that there is money sitting in the European development fund that is not being spent. We should consider whether we could get our hands on that and disburse it to the global fund or other initiatives.

On the question of the international finance facility, the Chancellor said that, as we would all accept, there was a need to obtain more money to meet the internationally agreed millennium development goals. The aim of the international finance facility is to increase the amount of development aid from $50 billion to $100 billion over 10 years, to double the amount of international finance aid. The money will be raised not only by countries donating money, but through the international capital markets. The intention is that 80 per cent. of the IFF will be raised through market borrowing. That is a shift in the way in which money is raised, which means that significant amounts of debt will be incurred. That raises several questions about how the IFF is intended to operate, to which I hope that the Minister will provide answers. If he believes that it is the Treasury's responsibility, perhaps he will draw it to the attention of Treasury Ministers. If large amounts of debt will be incurred over the next 10 years through the international capital markets, how will that debt be repaid after 2015?

I am still unclear about other aspects of the IFF. The other significant issue is how the money will be disbursed. Who will decide where the money raised through the IFF will go, and what the systems of accountability will be? We more or less know what is happening with the global fund and the systems of accountability and monitoring that are being set up. We will be able to see the effects of those, and obviously we want to see the effects of our own bilateral aid. If, however, the IFF raises a great deal of money, how will it be disbursed and who will monitor the process? Who will be accountable? Will the money be distributed only through the Government, or will it be distributed to non-governmental organisations or to civil societies?

Many questions remain that are still unclear. A question that has been asked several times is how the distribution of the money will be co-ordinated. How does the IFF fit in and co-ordinate with other significant initiatives such as the global fund and multilateral initiatives organised by the World Health Organisation and UNAIDS? We want more money, but we also want to ensure that we know how and where it will be spent.

There are many other initiatives, but I will not dwell on them as they are not the direct responsibility of the Department for International Development. We should support the WHO's initiative to improve access to treatment, to establish drugs and diagnostic facilities and to advocate funding. We should also support the work done by the Clinton Foundation, and support the bilateral aid donated under the US emergency fund and the World Bank. Many initiatives make me optimistic that we are starting to push HIV/AIDS further up the international agenda, which we have not managed to do before.

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Since DFID produced "Call for Action", many more people are taking an interest in the issue and are seeing the importance of it, which is to be welcomed. DFID produced a strategy some three or four years ago, but we should see its new updated strategy early next year, which is also very welcome.

I want to make two final points. First, this is not a short-term problem. My hon. Friend the Member for City of York made that point, as have other hon. Members. There is no quick fix for HIV/AIDS. Politicians are pretty useless at long-term commitments. We tend to look for quick fixes and quick answers, but there is no quick fix or easy answer for this problem. When we commit resources, we need to commit them not only for 2004 or 2005, but for years and years to come. Long-term commitment is necessary. Now there is increased interest and HIV/AIDS is further up the international agenda, we must ensure that in two or three years' time it does not slip back to where it used to be.

Then there is the question of what we can afford, both as individual countries and through the international institutions. My hon. Friend the Member for City of York said that in the UK, HIV/AIDS had become a chronic illness. I am a little wary of being that confident. People are still dying of AIDS in the UK; somebody with whom I worked through the all-party group died of an AIDS-related illness just a few weeks ago. We have only had anti-retrovirals for a few years. Although we can be hopeful, none of us can be sure that in 20 years' time the drugs will still work for the people who are taking them now. The drugs do not work for everybody, either, and we know that drug resistance can occur—there have been examples of that in the UK. Therefore, we should be cautious about assuming that we have cracked AIDS in the UK, and we no longer have a problem.

On the subject of resources, I looked at some of the figures in the Chancellor's pre-Budget report yesterday. It says that by 2006, the UK alone will be spending £15 billion a year more than we do now on education, and by 2008 we shall be spending £41 billion more on health. Yet we are arguing about whether we should put £40 million or £107 million a year into the global fund. When we think about international development issues, we should put things in perspective. This Government have done more than any Government have done for many years in increasing our contributions to international development. We can be proud that we have increased the aid budget significantly. However, when we compare £40 million or £107 million with an extra £41 billion for health in the UK alone by 2008, can we really say that we cannot afford more resources? The truth is that we cannot afford not to find more resources, because if we do not, the impact will not be just in Africa or Asia, but here, too.

4.22 pm

Mr. David Borrow (South Ribble) (Lab): I am pleased that the debate is taking place this afternoon. Four years ago, I made my first visit to sub-Saharan Africa, when I was part of a delegation that visited Botswana. I remember meeting its then Minister of Health and raising the question of HIV/AIDS. I was told that it was not a major problem, and that people who became ill were looked after at home. Several days later, we visited

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a diamond mine and the company township. I asked the general manager about HIV/AIDS. The company had just completed an anonymous survey of its work force, which had revealed an infection rate of some 30 per cent. That led the company to review its entire recruitment and staffing policy and the resources that would have to be put into health care for the work force. Twelve months later, some colleagues from this House went to Botswana, and found that the whole approach had changed. The Government had become very proactive, and that has been the case ever since.

In 2000, I visited Uganda, the country that had been affected first and had taken a proactive approach. Even so, the infection rate was nearly 20 per cent. Lots of people were dying and ill, a lot of foreign and non-governmental organisation money was going in, and many workers from outside Uganda assisted in dealing with the epidemic. However, despite all that good work, the epidemic was still progressing—although the infection rates were beginning to fall.

If I were asked then, or even 12 months ago, what our priority should be I would have said that we should do what we could to assist with the basic health care. I agree with what my hon. Friend the Member for City of York (Hugh Bayley) said about that. However, our priority now should be the development of a vaccine. Two or three years ago, we were told that vaccine development was about five or 10 years away. It is still five or 10 years away—and in another five or 10 years it will probably still be the same. At that point, it seemed that the key priority in the international response was putting money into the development of a vaccine. The pharmaceutical companies had developed anti-retrovirals, which were generally available in the developing world, and also in Uganda, if people were prepared to pay for them. There was a weekly clinic at the Mildmay hospital in Kampala, which shows that those were available to people who could afford to pay. At that time, however, they were not regarded as something that should be made generally available throughout sub-Saharan Africa.

My view changed after a meeting towards the end of last year, at which Botswana was discussed. Botswana is a country of just over 1.5 million people, but it has a 39 to 40 per cent. infection rate and within the next few years it faces the prospect of the whole of its middle-range population being wiped out and a whole generation of children being left without parents. There is no way that a society facing that can survive, because there will be no role models, no parents, and the whole family structure will fall apart. Even if drug therapy can keep parents alive for only 10 or 20 years to allow those children to be brought up to adulthood in a different environment, that is a price worth paying. The alternative is too horrible to think about. However, that is not the long-term answer. I shall return to that later on.

Two or three years ago I was invited to a UNAIDS and Inter-Parliamentary Union meeting in Geneva, where a handbook on the human rights approach to HIV/AIDS was developed for parliamentarians. I had many discussions with parliamentarians from the developing world. It came home to me that we will tackle HIV/AIDS only if we face up to what is happening in our societies. HIV strips away the pretence

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in societies. We pretend that we are living smug, 2.2-children family lives, but the reality of relationships is different. Unless people face up to those differences, there will be no chance of dealing with HIV/AIDS.

Earlier this year I was invited on a study tour. I visited Peru, New Zealand and Ethiopia—three very different countries—to study HIV/AIDS. I had an interesting meeting with the New Zealand human rights commission and the New Zealand AIDS Foundation in Auckland. We discussed how New Zealand had tackled its HIV problem in the 1980s. The country realised that the groups most at risk were gay men, intravenous drug users and sex workers and it had to do something to enable proper prevention work with all those groups. Gay sex had to be decriminalised and equal rights had to be brought in for gay men in New Zealand. New Zealand had to allow needle exchanges and recognise all the political and legal difficulties of such a measure and tackle them. Earlier this year, as part of a human rights approach that recognised the reality of what was going on in society, it passed legislation to make prostitution legal.

It was interesting that in New Zealand the prevention budgets went to organisations set up to work with client groups. The New Zealand Aids Foundation is run by and for gay men in New Zealand and is the delivery arm of the prevention services in New Zealand. Similar organisations operate for drug users and prostitutes. New Zealand may be atypical, but that was its approach.

We also visited Peru where the infection pattern is very similar to that in most western countries and arises among men who have sex with men. The approach of the Peruvian Government during the 1980s and 1990s was progressive. They worked with a gay rights group based in Lima to implement much of their prevention work, involving the use of condoms and recognition of the problem. The legal issues concerning the age of consent and criminality had already been removed. Two and a half years ago, the Government appointed a new Health Minister who was a member of Opus Dei. He reversed the prevention approach involving condoms and so on and advocated abstinence instead of providing the tools to deal with prevention in the real world. HIV prevention took a big step backwards. However, a few weeks before I visited Peru, a new Health Minister, who was a health professional, was appointed. I met him and he was in the process of changing and reviewing that policy because he recognised the difficulties and what had gone wrong. The human rights approach, which recognises the realities of what happens in the community, is essential, but that is sometimes uncomfortable and in parts of Africa it is often uncomfortable.

I was in Ethiopia in December last year and spoke to a number of people there about marriage, how women and men meet and the age difference. Women in Ethiopia are married very young, but if a woman says no and does not want to marry a man, it is not uncommon for that woman to be raped because the man knows that no other man would marry her after that. The law in Ethiopia is progressive and there has been a lot of good work. My hon. and learned Friend the Member for Redcar (Vera Baird) visited Ethiopia twice doing human rights and women's issues work with the judicial

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police there. The legal framework is progressive, but the reality on the ground is that its society is regressive, anti-women and male-dominated.

I have some figures from a survey by Voluntary Service Overseas in South Africa in 2000. It covered 37,000 young men and found that one in four had had forced sex with a woman by the age of 18. Such gender issues are uncomfortable for society, but their role in the way which the disease is transmitted is central to tackling the spread of the disease.

Mention was made of the fact that most women who become infected are infected by their husbands. A survey by the Positive Women's Network in India estimated that 75 per cent. of women in India with HIV/AIDS were infected by their husbands, who were their only sexual partner. We must recognise the reality of what happens and the difficulties that must be faced. Drugs are important, but it is also important that, under the Government's initiative, we work with our partner Governments in the developing world to face up to some of the issues concerning the spread of the epidemic which are uncomfortable and worry me.

In western Europe, north America, Australia and New Zealand we think of men who have sex with men as being the main group at risk, and most—if not all—of those men would consider themselves to be gay. I asked questions about transmission in Peru, and was told that 30 per cent. of young men under 25 in Peru had a bisexual lifestyle. In India, despite the denial that men have sex with men, it is not uncommon, but those men do not regard themselves as being gay. They are married and have children, but have relationships with other men. In India, a lot of the work being done on prevention is done with female sex workers. It is not uncommon for those in India to believe that one can get HIV from a female sex worker, but not from a man.

Those are uncomfortable issues that have to be faced. In India, out of 1,000 million people, a million people are already infected. In cultures in south America, there is much more ambiguity concerning sexuality. However uncomfortable those issues are, AIDS strips things down and reveals the reality of the relationship. What we think is happening is not necessarily what is happening. Societies have to go through some trauma in introducing legislation and practice that recognises the reality of sexual relationships in their communities. That will be the challenge in much of the developing world if the disease is to be beaten.

I want to touch on one or two other issues briefly. One issue raised in the last year is the question of transmission through medical procedures. There was some controversy about the suggestion that a large part of the HIV infection in sub-Saharan Africa resulted from hospital treatment. When in Ethiopia, I examined some of the figures on infection rates. In the figures relating to children aged from one to four, up to the age of 14 or 15, there is no point in the middle age range where there is no infection rate. Therefore, there are youngsters too old to have got the disease from their mothers and too young to have got it through sexual activity, who are still picking up the infection. Having visited some of the hospitals, I recognise some of the risks surrounding the use of syringes and various other instruments—or their improper use. I think that there is a problem of transmission taking place between patients

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in medical facilities. If we can help to improve the cleanliness and proper procedures of medical facilities, that will have some effect.

I visited the Mother Teresa AIDS orphanage in Ethiopia. There were 250 youngsters in that orphanage up to the age of 11 or 12. Every child was infected. When we went round the facility, I saw many who were quite seriously ill. That brought home to me the fact that those youngsters did not all get the disease from their mothers—they must have picked it up somewhere else. That is a real issue.

Mr. Brazier : I have been listening very carefully to everything that the hon. Gentleman has said, and he has made some telling points. However, the point that he makes about recognising the world as it is somehow carries an implication that he does not want to see a change in behaviour. If there is a country where a quarter of the young men committed rape, there has to be a change in behaviour. He gave the example of children getting infected. In many of those countries, child prostitution is the reality, and it is a reality that we have to work to change, not just accept.

Mr. Borrow : I hope that the hon. Gentleman has not misinterpreted the gist of what I am trying to say. There is evidence that transmission can take place without sexual activity. Obviously, child rape and child prostitution is a significant matter. Sex at a very young age is not common, but where it is we must get society to recognise it and do something about it.

My last point may tie in with what was said by my hon. Friend the Member for Walthamstow (Mr. Gerrard). Anti-retrovirals are not the solution. Most western societies are now on the sixth, seventh or even eighth drug to be used in the cocktail. After a time, the drug cocktail becomes less and less effective, and other drugs have to be developed to add to the cocktail. Only 80 per cent. of those who are HIV positive respond to the drug treatment, which means that 20 per cent. do not respond. Resistance to the drug therapy is inevitable, and we continually depend upon more drugs being developed. However, we cannot assume that the new drugs will be as effective.

I saw some interesting statistics when I was in New Zealand, which reflect what is beginning to happen in many western societies. Effective prevention programmes—condom use, safe sex and so on—can bring down the rate of new infection within at-risk groups. However, over the past four or five years, even with ARVs being available, the group of people who are infected is growing because, every year, more people become infected. Whereas five or six years ago, a certain number would die, the cohort of infected people in the community continues to expand. The time will come when the prevention work that reduces the number of deaths will be defeated by the fact that we have a bigger pool of infected people.

Infection rates here, in the United States and in western Europe—and in Africa once ARVs are used more often—will dip and then go up again. Not only we but millions of people throughout the world will then be dependent upon an expensive drug treatment that needs to be changed regularly to respond to the changes in the disease. The only long-term solution is to invest in the

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development of vaccines. The drug treatments merely give us breathing space. In Africa, it is crucial to help keep those societies together.

Mr. Kerry Pollard (St. Albans) (Lab): I entirely agree with my hon. Friend. However, we should accept that some simple things can be done. I was recently in Zambia, and went to Chirundu on the border between Zambia and Zimbabwe, where there is much cross-border traffic. Lorries can take three days to get across the Zambezi river, because they are held up by bureaucracy. During that time, lorry drivers indulge in sex day after day. We should speed the process up by getting them across in five minutes; it could be done if the drivers and lorries were registered on a computer. That would make a singular difference, and it would cost absolutely nothing. It is nothing to do with anti-retroviral drugs; it is a simple matter of bureaucracy.

Mr. Borrow : My hon. Friend is right in recognising that although treatments and drugs are essential, the way in which the disease is spread is important. In eastern and southern Africa, the disease has been spread along the lorry route and, in the early stages, by sex workers at lorry stations on the way. That pattern needs to be recognised, which is uncomfortable for those societies to do, but they have largely done so, and action must be taken to avoid some of those pitfalls.

If the world community got its act together, ARVs could enable Africa to avoid complete disaster. However, a long-term solution to the problem can be achieved only if the rich developed world does something that the pharmaceuticals would be reluctant to do on a profit-and-loss basis: put investment, year after year, into the development of vaccines to deal with the various strains of the disease.

Several hon. Members rose—

Sir Nicholas Winterton (in the Chair): Order. We still have plenty of time. Two further hon. Members seek to catch my eye, but we should give the Minister 10 minutes or so to reply to the important points that have been raised in this interesting and important debate.

4.45 pm

Ms Sally Keeble (Northampton, North) (Lab): Thank you, Sir Nicholas.

I am grateful to have the opportunity to take part in this debate. I agree with everything said by previous speakers, particularly my hon. Friends the Members for Clydebank and Milngavie (Tony Worthington) and for City of York (Hugh Bayley) on the gender issue, which we perhaps had not recognised. It was interesting and inspiring to hear my hon. Friend the Member for South Ribble (Mr. Borrow) talk about human rights, which we may also overlook somewhat.

I will deal with two particular issues: HIV/AIDS in orphans, and anti-retrovirals, which colleagues have also spoken about. First, I welcome the Government's call to action, the announcement of extra money and the support for the provision of ARVs. It is an enormously

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welcome injection of funds and an important recognition of the need for strategies of treatment as well as prevention and education.

However, I am concerned about the lack of attention given to HIV/AIDS orphans. They are one of the biggest challenges of the AIDS epidemic. If we in this country had the equivalent of a city the size of Birmingham consisting entirely of orphans, what would the Government do? How would we ensure that those children were fed, clothed, educated and, perhaps more importantly, socialised and turned into functioning adults—or prevented from becoming dysfunctional adults? That is the challenge facing Zimbabwe, which has up to 1 million AIDS orphans. We all know the difficulties that that country has in a whole range of areas, which are overlaid by that particular social dimension.

In other southern African countries, one in five children have been orphaned by AIDS. That figure is due to almost double as the AIDS death toll unfolds. Previous speakers have talked of the profile of the deaths as a result of AIDS. Whatever happens in the future, a generation of orphans already exists. As the founder of a home for orphans in Zimbabwe said to me, "These children are literally a time bomb."

Last month, I went to three of the worst-affected countries—to Lesotho and South Africa with World Vision, and also to Zimbabwe. Both World Vision and UNICEF produced excellent reports on the position of AIDS orphans, which I recommend to colleagues.

I found the visit traumatic. People in those countries know what is needed, they have policy frameworks and there are some inspirational examples of child care—I met outstanding and dedicated professionals—but there is a complete lack of money for any rolling out of services. Of course, there is also a lack of food, which is critical.

The situation is heartbreaking. I spoke to a family of six orphaned boys, who had managed to live together in extraordinary circumstances for several years since their parents' death. The eldest was only in his teens. I met a 68-year-old widow, who was caring for her 15 orphaned grandchildren in a hut in a remote part of Lesotho. I also met a young girl who was living with her baby sister and recently widowed mother. Her mother was still traumatised by her husband's death a week earlier. The mother and baby were both HIV-positive and unwell so the little girl was going to be completely orphaned and lose her sister. There was no money, and they had few possessions: just a tiny stone hut in the middle of nowhere in Lesotho.

I met children who had lived on the streets before being taken into a children's home. Those children came with all the problems associated with the street: glue sniffing, child prostitution and a tendency to antisocial behaviour. The home that they were living in was run by an elderly vicar and it was trashed by some of the boys. Former street children are not dear little orphans but some of the most difficult children that one could find. There was a shortage of money to put right what had happened, quite apart from all the difficulties in feeding and clothing the children.

I gave a detailed report of my visit to my right hon. Friend the Secretary of State, so I shall just a pick out a few points. First, there is a big difference between

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announcing headline spending and providing front-line services. What the children need are front-line services, and they need them quickly as they will soon be grown up. There is an issue about the length of time that it takes for funding to go through the international system, and we must ensure that money is spent effectively and quickly. The focus needs to be on service delivery and community-based services, which often come in below the radar of the international system. I hope that that will be looked at in developing strategy. From what I saw, there are many ideas at local level about how to achieve that. There is, however, a shortage of money.

Secondly, the services needed are not just health services; indeed, they are mostly not health services. I went to speak to the Zimbabwe National Council for the Welfare of Children, which is a non-governmental organisation that pulls together other NGOs—I must add that it did not realise that it was talking to a British MP. It said that the priorities for the children are: protection of property rights; access to certificates and legal guardianship because if children cannot prove when they were born, they cannot get access to all kinds of things; protection from abuse, including abuse in care; housing; payment of school fees; purchase of school uniforms; access to food and medicine; and, something that is often neglected by us, counselling and psychological services.

Thirdly, any strategies for orphans must also deal with carers. I met a 68-year-old widow who was a stroke victim and was caring for her orphaned grandchild. When she went out to forage for wild vegetables to supplement their mealie meal, she had to carry the little orphan boy on her back because she could not leave him. One has to ask oneself what the prospects are for that child, the woman and the three other grandchildren that were about to be orphaned by AIDS and who would end up living with her. We should be familiar with that syndrome from our experiences in this country. Vulnerable people—usually women—end up being carers for even more vulnerable people.

That brings me to my second point, which relates to any anti-retrovirals. I take on board the point raised by my hon. Friend the Member for South Ribble that those are not cures and should not be seen as any kind of panacea, and that there is still the need to look for vaccines. I welcome the initiative to get 3 million people on to anti-retrovirals by 2005, but I think that that is doing too little and it will not keep pace with what is already unfolding in southern Africa in terms of the scale of the epidemic and, importantly, people's aspiration to live. The professionals whom I met said that anti-retrovirals should be part of any strategy for dealing with AIDs. They also said that any strategy would have to recognise the survival needs of carers, especially of mothers, because, as they put it, the death of the mother predicts the failure of the child.

The specialists at the Baragwanath hospital in Soweto expected the availability of anti-retrovirals to drive improvements in primary health services, not the other way round. Much more is needed, and I echo the comments that have been made about the cost of it all. It does not all have to be desperately expensive. I saw the programme for treating pregnant women in Baragwanath. I was given one of the pills that is provided. I thought that I would bring it back as a souvenir of my visit, and I am holding it up now. When

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I said that I did not want to take away an expensive pill, I was told that the plastic bag that it had been put in was probably more expensive. After a woman has been to the clinic, she takes the pill with her—it is put in a bag and clipped to her notes. She takes it when she goes into labour, and she gets a second pill when she delivers a baby. That simple programme can, of itself, roughly halve the number of babies who are born HIV-positive, which represents great progress in tackling the epidemic. Although the drugs are cheap, there are issues about delivery: there is not enough money to roll this out nationally, let alone regionally.

We also need to face up to the public response to these drugs. Although anti-retrovirals are not cures, many people regard them as the new miracle drugs. They want them. If we in the affluent part of the world do not fund proper strategies for provision of these drugs, people will find ways to get them by hook or by crook, and then, at some stage in the future, we may have to deal with the consequences of their interrupted use, which some doctors consider to be misuse. My hon. Friend the Member for City of York raised this issue: I do not know whether interrupted treatment will be a great problem in the future, but it certainly can be in the short term for individuals.

Maluti hospital is one of the leading hospitals in Lesotho for dealing with HIV/AIDS. In conjunction with a pharmaceutical company, it was providing six-month courses of anti-retrovirals, because it could provide people with only six months of treatment, which is just enough to stabilise them.

In Lesotho, I met a young girl called Mamphaso who had had one of those six-month courses of anti-retrovirals. She and her mother were HIV-positive, and they had been taken into hospital earlier this year. One morning, she woke up to find that her mother's bed was empty. The community nurse, who is very fond of her, got her a six-month course of anti-retrovirals, which pulled her back literally from the brink of death. When I met her, she was living again in a hut in a remote area with her grandmother. When that course is finished, Mamphaso's health will deteriorate again. There might be some more money in the future for anti-retrovirals, until—the nurse expects—at some stage she will have a reaction against them, which I am told is one of the risks of interrupted courses of treatment, and she will die. Of course, without the drugs she will die, too—and probably quite quickly.

I have a daughter of about the same age as this little girl, and I have worked out that the cost of her anti-retrovirals is about the same as the cost to the NHS of treating my child for a simple complaint that she will outgrow. Therefore, I challenge what is said about the cost of the drugs. There are enormous pressures on us to ensure that we can provide these treatments on a proper and consistent basis.

One of the saddest moments on my visit was when I asked the little girl what she thought Governments should do for HIV/AIDS orphans. She was a mature little girl, and she had talked me through all the problems that she had faced with that wisdom that some small children have, so I expected her to say something about money or medicine. However, she spent a little time thinking, and then she said, "I think that the Government should give toys to the children."

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That is a reminder that we are talking about children. If we are going to do justice by them, we need to fund policies and strategies that will meet the developmental needs of children. We are not very good at that in this country. We have just got a Green Paper on children, but that is the first one that we have had since 1997.

The last time that we faced a big challenge of dealing with orphans, we sent some of them off to what is now Zimbabwe. There is an issue about sowing the wind and reaping the whirlwind: with the HIV/AIDS orphans, the legacy will be ferocious if we do not get the strategies in place to meet all the needs of this generation. I urge my hon. Friend to put more emphasis on the strategy that has developed on the needs of orphans, in line with the proposals that have come from UNICEF and World Vision, and to push the international community, because we cannot do everything ourselves. We must push our international partners to ensure that they massively increase the funds for antiretrovirals.

Several hon. Members rose—

Sir Nicholas Winterton (in the Chair): I call Tony Colman, and congratulate him on his patience and equanimity in waiting so long.

5 pm

Mr. Tony Colman (Putney) (Lab): It is a privilege and an honour to take part in this debate, to follow so many of my esteemed colleagues and to have heard their words of wisdom. I hope that I will be able to rise to the excellent standard of the debate so far. The debate is supposed to be about accelerating the UK's response to the HIV/AIDS epidemic, and I always believe that before one looks abroad one should perhaps address the situation in one's own country, albeit briefly. In the excellent information pack that we received from the House of Commons Library is an article from The Independent on Sunday, dated 30 November. It says:

Clearly, those figures are extremely low compared with those in many countries that we have spoken about today, but it is important that we take on board the need to deal effectively with the situation in our country. I have six children aged between 22 and 37, and I would want them all to use condoms when they have sex. It is extremely important that we do not shy away from that topic with our own children. We must accept that this is a problem not only abroad but here. Great praise is due to the Methodist Church and the United Reformed Church in the United Kingdom for publishing on world AIDS day, for UK consumption, a booklet called "Speaking out about HIV/AIDS". It is important to see what is happening in the UK.

Like other hon. Members, I welcome the hon. Member for Canterbury (Mr. Brazier) to his role. When I was doing some research for this debate, I looked up

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the very good article that his colleague the hon. Member for Buckingham (Mr. Bercow), the shadow Secretary of State for International Development, wrote for The House Magazine. Like the hon. Member for Canterbury, I shall follow the structure of that article, which is headed, "Escalating the war on AIDS".

The first point raised by both hon. Gentlemen is the need for a strong partnership between NGOs, pharmaceutical companies, the World Health Organisation and national Governments. We have heard from my hon. Friend the Member for St. Albans (Mr. Pollard) about the amazing work that World Vision does in Zambia and elsewhere in southern Africa. I, too, on a separate occasion, visited the Chirundu lorry stop and was appalled to hear that so many of the sex workers there, who were in their early teens, would be infected within two weeks. It is appalling to see that situation. One of the Health Ministers, who is working on the simple idea of speeding up the lorries, accompanied me there.

I have to say that the problem lies more on the Zimbabwean than the Zambian side, but World Vision is doing excellent work on its cross-border initiative and I strongly request the Department for International Development to get involved in funding World Vision to help to open up lorry routes into Angola from the south. Angola is currently largely free of HIV/AIDS compared with other countries in the region, and it is important that that work be done now, rather than our having to pick up the pieces subsequently. There are many other NGOs in this area, but I pay tribute to World Vision in particular.

Secondly, it is important for Governments to deal with the issue. It concerns me that in many countries the campaign to deal with HIV/AIDS has stayed within the president's area, largely, perhaps—I hope—because of the importance of the issue, but perhaps also because of the large amounts of funds that are available. The work should go to the Health Ministries, if possible. I pay particular tribute to Charity Ngilu, who is the Health Minister of Kenya. I know that he finds it difficult to get joined-up government between the President's office and the Health Ministry.

Mr. Pollard : Does my hon. Friend accept that as well as presidents taking an interest in such matters, countries themselves must acknowledge that HIV/AIDS exists? I visited Iraq about 18 months ago and spoke to the Health Minister. I asked him how many HIV/AIDS sufferers there were in Iraq, and he said that there were none. I cannot believe that that is true. Governments themselves must recognise the problem before any progress can be made.

Mr. Colman : I entirely agree with my hon. Friend.

As I said, I was pleased that the Minister was able to accompany me and see with his own eyes what was happening. In opening the debate, he spoke about the shortage of doctors, nurses and teachers caused by HIV/AIDS. I am proud to have the organisation Voluntary Service Overseas in my constituency, and it supplies just those workers on an entirely voluntary basis. It is amazing that in many countries of the world there is a problem in getting work permits for people to go in and do that work. I would be happy to give the Minister

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chapter and verse on that. It seems slightly bizarre that there are shortages, and there are people willing to volunteer and devote one, two, three or four years of their life to countries where there is a great crisis, but they are unable to do so. Work is being done under mode 4 of the general agreement on trade in services of the World Trade Organisation that may help move that situation forward.

The third area of partnerships is the private sector. I worked in the private sector before entering the House, and it is good to see the work being done by companies such as Anglo American and many others, which are committing themselves to providing anti-retroviral treatments not only for their staff and the families of their staff but for the countries in which they work. I strongly applaud that.

My wife raised her eyebrows when she found a condom in my toilet-bag after I returned from Cameroon, but I told her that I had picked it up in the hotel in which I was staying, because I thought that it was such a good example of the private sector coming up with practical ways forward. In this case, a major hotel chain was providing condoms along with the shampoo and the shower caps. I hope that my wife believed me. [Interruption.] In response to that comment from a sedentary position, yes, there was just the one. I asked and was told that it was replaced every day. One can jest about such issues, but that is a good example of real partnership and looking for ways to deal with the epidemic.

The next point in the list is the need to ensure that there is infrastructure for administering medical care. My hon. Friend the Member for Clydebank and Milngavie (Tony Worthington) rightly said that we have seen many dirty, dingy wards on our journeys as members of the International Development Committee. I was particularly pleased that my hon. Friend the Member for South Ribble (Mr. Borrow) mentioned dirty needles, which is something that people find difficult to discuss.

I take the New Scientist, and I was astonished to find in that esteemed periodical on 6 December an interesting article, headlined, "WHO accused of huge HIV blunder". The following edition on 13 December contained no letters correcting the article, and I have not seen it corrected elsewhere. It follows up the points raised by my hon. Friend the Member for South Ribble. Apparently, last week

It is said that

The article continues:

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It is said that

That backs up what my hon. Friend the Member for South Ribble said.

The issue is important and difficult, but at the end the article says, again quoting Physicians for Human Rights, that,

If those are the facts, that issue must be dealt with and not swept under the carpet. Dealing with it should be a major call on the money available from the UN global health fund.

The third point is that a significant proportion of the UN global health fund's money should be spend on anti-retroviral drugs. As my hon. Friend the Member for Walthamstow (Mr. Gerrard) said, the choice on how to spend the money lies with Governments—the global health fund does not spend it on their behalf. However, it is good that the money is becoming available, and I agree with my hon. Friend the Member for Clydebank and Milngavie that it is impressive to see the commitment of the senior management of the fund to following the initiative through. I am also pleased to hear that we are a prime mover in the fund.

That brings me on to the fourth point, which is the difficult issue of mother-to-baby transmission of HIV/AIDS. For the last two years I have said a lot about the free availability of the Boehringer Ingelheim drug Nevirapine, to which my hon. Friend the Member for Northampton, North (Ms Keeble) referred. Interestingly, the Financial Times surveyed a large number of countries, including the whole of Africa, and found that the only two countries using the drug systemically were Ethiopia and Botswana. I repeat that Nevirapine is free and that there is no reaction to it, so mothers who are HIV-negative as well those who are positive could take it, and it could be administered to all the babies. I understand that the drug has an 85 per cent. efficacy rate, so huge numbers of children without HIV could be born to HIV-infected parents.

We face an extraordinary state of affairs. My hon. Friend the Member for City of York (Hugh Bayley) is due to lead hearings as the chair of the excellent all-party group on Africa. When he does so, I hope that he will ask Governments across the world why they are not taking advantage of Nevirapine, which has been made available free and could stop mother-to-baby transmission. I have attempted to talk about the issue again and again. I hope that the reason is not to do with replacement feeds. That can be a factor, because an HIV-infected mother cannot breastfeed her non-infected child; otherwise the child would be infected. I look forward to the Minister's response on that subject.

We are approaching the moment when the Minister must be allowed time to respond, so I shall make my last few points. The hon. Member for Carshalton and Wallington (Tom Brake) mentioned intellectual

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property rights, and it is extremely important that they are supported. If anything, I would like there to be longer licence periods for IPR. The hon. Member for Canterbury touched on that matter. I do not understand why there is as yet no legislation before the House dealing with the agreement of 30 August. Three and a half months have passed, but nothing has happened.

The International Development Committee's very good report was published today, and in it, we back Oxfam's call for action now. I understand the fact that we must work with the European Commission because this is an area of so-called mixed competence. The Department's response, which has already made its way to me, and to the hon. Member for Carshalton and Wallington, states:

All I would say is that three and a half months is not as rapidly as possible.

Canada has passed the legislation, but the United States and Switzerland have not—I am talking only about the countries with major pharmaceutical companies. It is extremely important that we be seen to take a lead; those who are suffering this epidemic demand no less.

Sir Nicholas Winterton (in the Chair): With the permission of the House, I call the Minister to reply.

5.16 pm

Mr. Gareth Thomas : I will try to do justice to the interesting and thoughtful contributions of all those who have participated in the debate. I will certainly need to reflect further on them as we work up our strategy for next year. I was particularly interested to hear from my hon. Friend the Member for City of York (Hugh Bayley) that his all-party group will conduct an inquiry into this issue, and I will look with interest at what it has to say.

I, too, congratulate the hon. Member for Canterbury (Mr. Brazier) on his new post. He made a very interesting speech, and I will pick up on three of his points. Perhaps the most important related to the need for an integrated approach to treating HIV/AIDS. Hon. Members have touched on a whole series of different aspects of the HIV/AIDS crisis. The point of an integrated approach is to emphasise that every sector of Government and society must play its part in finding solutions to the problem. That is why, as part of our call for action, we re-emphasise the need for one strategy, which NGOs, civil society, Governments, donor communities and others can take part in formulating—one AIDS commission to deliver that strategy and, crucially, one monitoring and evaluation framework. That integrated framework is central to the response to HIV/AIDS, and it has been at the heart of the strategy in countries where we have been successful in reducing prevalence rates.

The hon. Gentleman asked me for more detail about the vaccine and the wider research effort. My hon. Friend the Member for Clydebank and Milngavie (Tony Worthington) also raised the issue. We are working through the International Aids Vaccine Initiative, which is a global non-profit making

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organisation that is working to speed the development and distribution of preventative vaccines. We have funded a five-year programme of support for IAVI. It began in January 2000 and is worth £40 million. IAVI has eight vaccines under development for use in the developing world. The candidate vaccines are being developed by the Medical Research Council and by the universities of Oxford and Nairobi. They are aimed at combating the HIV strain that is most common in east Africa. The most significant progress seems to have been made in the Oxford and Nairobi trial. We will all continue to support that work and hope that it leads to a successful vaccine.

My hon. Friend the Member for Clydebank and Milngavie also talked about microbicides and asked how the research effort was progressing. The products that have been developed are entering phase 3 trials, but there has been no breakthrough yet. There will be a bi-annual conference in London on microbicides in March 2004. I hope that researchers on those programmes will be able to give us some good news.

I join the hon. Member for Canterbury in congratulating GlaxoSmithKline on its sense of corporate responsibility. I also congratulate other members of the accelerated access initiative—Merck, Boehringer Ingelheim, Bristol-Myers Squibb, Hoffman-LaRoche and Abbott Laboratories. However, I re-emphasise that we need to work with them further to see whether we can continue to push down the price of drugs and consider other aspects of the pressures such as the inability to secure proper access to medicines for people in rural and urban areas.

I agree with my hon. Friend the Member for Clydebank and Milngavie that providing access to condoms must be a fundamental part of our response. The UK already devotes considerable resources to bilateral funding programmes to support the provision of condoms. For example, we give £2 million to Ethiopia and £8.6 million to Kenya. My hon. Friend touched on the work of UNFPA, which estimates that there will be a 50 per cent. increase in demand for condoms. The UK clearly needs to do further work on funding such programmes and convincing the wider international community to get behind the need for greater access to medicines.

My hon. Friend also touched on the issue of co-ordination, to which several hon. Members have referred. The five countries with which—during the visit of President Bush—we and the Americans agreed to work closely on donor co-ordination are just the beginning. We need to learn the lessons of that process and roll them out in order to improve donor co-ordination across the rest of sub-Saharan Africa and the other countries where HIV/AIDS is a particular problem.

I was interested in the idea of a drugs tsar proposed by my hon. Friend the Member for City of York, although the role is best left to UNAIDS. Indeed, one reason why we have extended our funding of UNAIDS is to help it improve donor co-ordination. Every country needs to make its own decisions about how to organise its response. I think that the Department for International Development taking the lead is the right response; we do not need a drugs tsar. However, it is crystal clear that donor co-ordination is nothing like as effective as it needs to be. We will work with UNAIDS to develop that

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further. We are also working with our European partners and have just begun discussions with France. We want to continue to make HIV/AIDS a priority in European Union discussions. It is interesting that each of the next four like-minded presidencies of the European Union—that includes our own—wants to make HIV/AIDS a priority. I hope that that engenders confidence in the hon. Member for Carshalton and Wallington (Tom Brake) that there will be a sustained EU focus on HIV/AIDS.

My hon. Friends the Members for Clydebank and Milngavie, for Walthamstow (Mr. Gerrard) and for Putney (Mr. Colman) touched on the issue of the global fund and the UK's attitude to it. Uncharacteristically, my hon. Friend the Member for Clydebank and Milngavie suggested that we are more sceptical about the global fund than is fair. We were a leading supporter of its establishment. Along with President Chirac, the Prime Minister has campaigned for further funding from the European Commission and EU member states. At the moment, Europe provides the majority of funding for the global fund.

However, we have been cautious partly as a result of reports from staff of in- country offices in Africa about the additional bureaucracy generated by the global health fund and increased transaction costs for partner Governments. Those reports have been echoed in our discussions with Government officials in those countries. There have also been problems with consistency and transparency of some of the global fund processes, and with how some of the mechanisms can be harmonised effectively with country procedures.

We have been working closely with the global fund to try to resolve those issues. I share the views of its director, Richard Feachem, who is a very impressive person, as hon. Members will be aware. We have good relations with him and his team. It is the UK Government's responsibility to work closely with the global fund to resolve problems when they are pointed out to us. I alluded to the fact that part of our strategy will involve examining the issue of financing, and the global fund will be considered as part of that. Several funding instruments can be used in our response to AIDS: not only the global fund but bilateral country programmes. HIV/AIDS will be a priority for the further funding that we are committed to spending in Africa, for example, in the run up to 2005–06, as it will in our generic funding of the development of health systems.

The last point that my hon. Friend the Member for Clydebank and Milngavie raised was the importance of involving young people in organising responses to the HIV/AIDS epidemic. The crucial point is that we must ensure that young people are involved at an early stage in the development of a strategy, that they have an input

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into the work of national AIDS commissions and that they are consulted on the effectiveness of in-country responses to HIV/AIDS.

The hon. Member for Carshalton and Wallington asked whether I agreed that there is a funding problem in the international response to HIV/AIDS—I do. Some $4.7 billion is being generated internationally, but UNAIDS estimates that $10.5 billion is needed by 2005 and $15 billion by 2007. Therefore, the international community needs dramatically to scale up its financial and policy response. I should add one note of caution: as a result of a reduction in drug prices, UNAIDS is re-examining its figures and will be publishing its conclusions in early 2004.

My hon. Friend the Member for City of York also touched on the possibility of a medical ethics committee. That is an interesting idea, but it is a matter for individual countries to address as part of their thinking on how strategies and AIDS commissions will work. Clearly, it is important for countries to examine how they ensure in the fairest way that treatment reaches those who most need it.

Importantly, my hon. Friend the Member for South Ribble (Mr. Borrow) highlighted the need for a human rights response to HIV/AIDS. He usefully drew attention to the importance of tackling stigma as well as discrimination and the gender dimension to it. That needs to be a fundamental part of countries' responses. If a series of other issues is not tackled, HIV/AIDS will just get worse. That must be at the heart of countries' responses and explains why political leadership is so important. We should examine not just the necessary headline issues and strategic responses, but the wider responses to discrimination, which often prevent people from gaining access to medicine.

My hon. Friend the Member for Northampton, North (Ms Keeble) discussed the detailed report on her visit, which I have had a chance to glance through but will read a little more thoroughly. She is right that we must do further work on the problem of orphans. Free primary education and strengthening our support to community-based care for orphans and vulnerable children as part of a broad multi-structural response to HIV/AIDS are fundamental. We have worked with UNICEF and UNAIDS to examine that in more detail.

My hon. Friend the Member for Putney highlighted the issue of Nevirapine and mother-to-child transmission. In the past, he has referred to Botswana, where only 15,000—

Sir Nicholas Winterton (in the Chair): Order. I am afraid that time is up. I am sure that the Minister will reply by letter or by other forms of communication in response to the questions with which he has been unable to deal.

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