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11 May 2006 : Column 167WH—continued
The emphasis on that idea has been the subject of considerable discussion, particularly with regard to the effectiveness of such an approach at the apparent expense of other initiatives, such as the distribution of
condoms. PEPFAR’s five-year strategy document mentions condom provision and promotion only for those who practise high-risk behaviour; condoms are not mentioned as a strategy to help young people in general. Clearly, that approach differs significantly from previous US policy and the policies of other donors, including the UK. The European Union and the Global Fund to Fight AIDS, Tuberculosis and Malaria have a similar view to that of the UK. Often, the ABC approach—abstinence, being faithful and condoms—is advocated by the US, but sometimes it is over-weighted in favour of the A and the B. Hon. Members will know that there have been reports of organisations refusing US funding because they believe that condoms should be promoted beyond high-risk groups. There is a fear that the approach will lead to the restigmatisation of condoms and promote the notion that they do not work as a form of HIV prevention. Such stigmatisation is a side effect that we can ill afford.
The medical journal The Lancet has published an editorial calling PEPFAR’s approach to preventing sexual HIV transmission “ill-informed and ideologically driven”, and calling for a complete reversal of the policy. The editorial concludes:
“Many more lives will be saved if condom use is heavily promoted alongside messages to abstain and be faithful”.
I could not agree more. The essential problem is that PEPFAR sets other funding restrictions that are not necessarily based on evidence of what is most effective in combating HIV and AIDS. Thankfully, DFID’s approach has been quite the reverse. It is crucial that we use what leverage we have to steer US policy towards what works and away from what will satisfy the conscience of the American Christian lobby.
One further issue that warrants serious discussion—it has been mentioned—is the potential use of HIV testing as a medical routine for any patient whose symptoms may be due to HIV and as routine for all individuals with tuberculosis. There is a growing feeling that that could be justified, not only in the interests of the patient but in the broader interest of HIV prevention. As hon. Members will know, HIV has a long incubation period; many years can pass with no symptoms apparent. As a result, individuals can unwittingly pass on the disease to many people. Clearly, one major challenge is identifying those individuals at an early stage.
Sir John Crofton, a distinguished Edinburgh scientist and the pioneer of the DOTS—directly observed treatment short course—programme for TB, is one of the growing number of cheerleaders for routine testing. Sir John recently pointed out to me that many years ago, when syphilis was a major health problem, it was routine to test for syphilis all patients complaining of almost anything, as syphilis has such a wide variety of symptoms. Similarly, if we are to treat HIV as a public health emergency, which it undoubtedly is, routine testing could make a major difference in preventing the spread of the disease and improving early diagnosis and treatment. Having to ask every patient for permission to test for HIV can give rise to much unnecessary anxiety, as many patients will undoubtedly be negative. There is also the danger that the practice only reinforces the stigmatisation of HIV that has been such an obstacle to progress.
The contrast between the treatment of tuberculosis and the treatment of HIV is also worthy of some consideration. TB prevention and control programmes have epitomised the public health approach, where controlling transmission of the disease has been a paramount aim, with less focus on patient-centred goals. In contrast, HIV programmes have tended to focus on an individual approach to HIV testing that is private, confidential and voluntary, but which has placed little emphasis on interrupting chains of transmission.
We have to ask ourselves whether that approach is sustainable. In a region where such a large proportion of the population is living with HIV, public health must be the priority. Fewer than 10 per cent. of African patients with TB are tested for HIV. I would be interested to hear the Minister’s thoughts on the introduction of universal HIV testing for patients with confirmed or suspected tuberculosis. TB and HIV go hand in hand so often that it would make sense for treatment and prevention to do likewise.
We should also be sensitive to the relationships among TB, malaria and HIV. In the countries with the highest HIV prevalence, more than 75 per cent. of TB cases are HIV-associated. Those three diseases are interconnected and it is important that responses are tailored to reflect that. I am pleased that a truly co-ordinated approach towards TB and HIV is now recognised at the highest levels. Many members of the Committee and other hon. Members have met too many people who have suffered from HIV and AIDS. One is one too many, but fortunately the provision of antiretrovirals provides a light at the end of the tunnel. We must ensure that, through the report and this debate, we continue to tackle the problem and keep it at the top of our agenda.
3.47 pm
Ms Sally Keeble (Northampton, North) (Lab): I shall keep my remarks brief, because I appreciate that other hon. Members want to participate. I should also like to say what a pleasure it is to follow the excellent speech made by the hon. Member for Edinburgh, West (John Barrett).
I shall focus on two points. The first is the report’s recommendations on children and the second is delivery on the ground. In commending the report, which above all is focused and concise—that strengthens its recommendations—I am pleased to see its recommendations on the need for more attention to be paid to children with HIV and AIDS, particularly in connection with the research on new paediatric formulae and diagnostics. I shall not repeat the remarks that the hon. Member for South-West Surrey (Mr. Hunt) made in his excellent speech, but I should say that he set out clearly the problems faced as a result of the lack of paediatric formulae; indeed, I understand that only one combination of drugs is prepared specifically for children.
The issue of diagnostics is desperately important. Anyone who goes to homes and street shelters in sub-Saharan Africa will find children who have been abandoned at the steps for other people to bring up. The carers have no idea of the status of the children or sometimes of the background of the parents. There is
no way in which the carers can establish such status because of the lack of research on effective diagnostics for children. I have seen children who were clearly ill, but whose illness it was impossible for the carers exactly to determine.
UNICEF gave evidence to the Committee—it made an excellent submission—and at one stage it was proposing to establish a special fund to look at the development of paediatric formulae and of diagnostics. I would be interested to hear from my hon. Friend the Minister whether UNICEF is still pressing for that fund and if so, whether the Government will contribute to it, as it would seem an important way to plug one of the gaps in HIV/AIDS provision.
I also want to deal with the effectiveness of aid and access to antiretrovirals, because there are two sides to treatment: the roll-out of antiretrovirals, and ensuring that people can access drugs and take advantage of them. We must focus on both aspects. I commend the work of Save the Children in this regard. In an excellent report on blockages in the international aid system, it identified such blockages and, in particular, identified money that goes into national Governments and does not come out again. It was a real credit to Save the Children that it also found that money goes into large NGOs and stays there without reaching the community organisations.
I should also like to draw attention to the work emerging from the technical consultation in London organised by the consortiums working group on orphans and vulnerable children. My hon. Friend the Minister knows about that work, which specifically considered such issues, and about the research that World Vision has just set up to analyse in practical terms in the field the way in which funding gets through. I hope that DFID will take on board all that work to ensure that aid is more effective.
I have recently returned from Nairobi in Kenya, where I spent two days at a conference that the Department for Education and Skills sponsored to consider children’s issues and, in particular, young carers in relation to AIDS. It was an excellent and well-organised conference. I encourage DFID to liaise with DFES and to pick up the recommendations from the conference and find some way to carry them forward. They focus largely on the details of child care using a child-centred approach, and they do so from the perspective of child policy, which sits within DFES but has profound implications for international development policy.
I also took the chance to visit Kibera and speak to the Kenyan Network of Women with AIDS, with which I work, as my hon. Friend knows. The network still has financial problems. It is grateful to DFID for the funds that have been provided, which amount to about £10,000, but it needs a budget of $300,000 to run a total of eight centres, so there is still a substantial shortfall.
Having spoken to the network in some detail, I understand that the World Bank and the Global Fund to Fight AIDS, Tuberculosis and Malaria are not funding the Kenyan Government, because of the problems in that Government. One can say that we should not put funds through a government with traceability and accountability problems, but in practice it means that in Kenya, which has one of the
highest prevalence of HIV/AIDS, either 300 or 3,000—I cannot remember how many noughts were on the figure—community-based organisations are without money. Some have shut down, while others such as KENWA have been able to beg, borrow and cadge to get enough funds to keep on going. However, they have had to retrench people, reduce payments and refuse to take on new cases, and in the Kenyan context, that is desperate.
Cynics might ask what the funding of community-based organisations has to do with the roll-out of antiretrovirals. The answer is simple: those organisations work in the slums where the high incidence rates are. Kibera has an infection rate of about 40 to 50 per cent., according to Médecins Sans Frontières. The organisations have credibility in the community, and they can deal with the problems of stigma and provide an holistic approach for people. They will provide people with food and ensure that their rent is paid and that they are strong enough to withstand the rigours of antiretroviral treatment, which, as the hon. Member for South-West Surrey said, is a major issue.
Funds and treatment need to be provided, and everyone recognises that there has been enormous progress in that area, thanks in particular to the UK Government, who have played an influential role. At the same time, however, the pull of demand is required at the other end. We need people to come forward and access counselling and treatment in the most disadvantaged areas where infection rates are highest. I understand that at the UNGASS meeting next month, the community-based organisations are going to bring up the fact that funding at community level is not there.
Mr. Hunt: Does the hon. Lady agree that one problem for community organisations is the fact that DFID is reluctant to fund small organisations in countries such as Kenya, because it prefers to fund big programmes? Often, some of those important community organisations, which can be very effective on the ground, find that they cannot get the support that they need.
Ms Keeble: I am grateful to the hon. Gentleman for making that point. This is a complex issue. It is understandable that a large, bilateral programme is not well placed to fund an individual, small-scale community-based organisation. There is a need to have local ownership. UNICEF also provides funding: it provides some of the £150 million earmarked for orphans and vulnerable children. There is an issue regarding how the consultation methods are set up; it is about people knowing how to get access to those funds when they are provided through other organisations.
There is a major issue with situations in which there is a corrupt or problematic Government through whom funding is supposed to be going, and we should probably consider whether there is some arms-length way of dealing with that problem. I completely understand that the global fund and the World Bank do not want to put enormous amounts of our constituents’ money through corrupt Governments, but it is unacceptable for our constituents to think that
money has been earmarked and then find out that there are 300 or 3,000 organisations at grass-roots level that are desperate to help some of the poorest and most vulnerable people, but simply cannot get access to the money. It is not surprising when such organisations say, “Excuse us for being just a tiny bit cynical; we hear about the money being spent but we simply don’t know how to get hold of it. In the meantime, we are laying people off, the kids are going hungry, we can’t get people on to treatment and people are dying.” That is a serious issue.
Dr. Strang: I think that hon. Members are impressed by my hon. Friend’s involvement in the situation and her knowledge. She is clearly making a distinction between bilateral support from the UK Government and the global fund. I am sure that she will agree that it is important to maintain the credibility of the global fund. Does she agree that there is a danger that if projects are not properly tested and people are not confident that the Government are delivering, the global fund will begin to lose credibility?
Ms Keeble: I take that point. The funding issue is too complex to go into within the confines of this debate. My hon. Friend the Minister has been helpful by listening to me moaning at him about this matter for quite some time. I appreciate his patience in that, and the detail of his responses. I assume that he is going to the meeting that I mentioned, and I ask him to take time to meet the organisations, listen to what they say, take it seriously, and find a way to deal with the red tape that prevents people from getting the money that everyone wants them to have to produce the results that everyone agrees are a desirable goal. If he can do that, there will be real progress on the ground and, given that the UK Government have been so good about giving out all the money, the roll-out of the antiretrovirals will be effective and will reach some of the most vulnerable people, whom we see when we visit those communities, and ensure that they and their children have the benefit of these miracle drugs—longer life and better health.
I apologise, Sir Nicholas, that because some constituents have been waiting to see me for rather a long time to talk about health issues, I shall have to duck out of the debate for a while. I apologise also to whichever hon. Member speaks after me, but I shall return.
4 pm
Alistair Burt (North-East Bedfordshire) (Con): It is a pleasure to take part in the debate and to be reacquainted with friends on a Committee that I still miss very much. The work of Her Majesty’s Opposition has taken me in a different direction for the past couple of years.
It is also a pleasure to listen to a series of speeches that would, if they were more widely available, do much to combat the rather smart cynicism about modern politics and our commitment to people. The compassion and knowledge shown by members of the Committee and hon. Members who speak about the topic never ceases to amaze me, not least the contribution of my new colleague, my hon. Friend the Member for South-West Surrey (Mr. Hunt). Every now
and again, contributions come along that make one appreciate politics in general and the fact that one’s own party is in good hands for the future, and do much to contribute to such a belief.
What personal and slight knowledge I have of the topic tends to come from my work with World Vision, a visit to Mozambique last year and the challenging and interesting contributions from my hon. Friend the Member for Buckingham (John Bercow). World Vision took us to see children orphaned by AIDS and I want to base my brief contribution on the part of the report that covered that.
I am sure that we have all experienced the same feeling on such visits: a mixture of a distressing and an uplifting experience. What one sees is distressing, as is one’s feeling of inadequacy at walking away from almost unbearable life situations which the throw of the dice has given to others. Yet, it can be uplifting because of the extraordinary commitment of those who work with such families and the spirit of those who are infected but find a way to live which would challenge the presumptions of most of us.
I, too, found the difficulties relating to diet that my hon. Friend the Member for South-West Surrey mentioned distressing. In the small district that we visited, 80 people had been diagnosed with HIV/AIDS, none of whom was receiving treatment because the available diet would not have sustained the treatment that could have been had at some of the local clinics.
Children who are orphaned by AIDS present a series of problems. Food and care must be found for the family and the children must do that, so their education suffers. The number of children in families with HIV/AIDS who are dropping out of the education that is available on a greater scale than ever before is a worry for us all.
World Vision has long had a focus on children orphaned by AIDS and I pay tribute to the work of that Christian-based organisation. Some of the issues surrounding HIV/AIDS are tricky, but I want the compassionate voice of Christians who work in the area to be heard. There are some difficult mindsets to be thought through, not particularly in Africa but certainly in the United States. Plenty of Christian believers can cut through those and work with compassion. If we want to see Jesus in our world today, we should expect to find him not in the harsh words and angry controversies of men dancing about on pinheads of doctrine, but rather in the sweet voices and kind hands of those who touch the broken and the hurt.
To give an example of that and to reflect on something said by the hon. Member for Gordon (Malcolm Bruce) in his opening comments, I draw hon. Members’ attention to the “Hope” initiative that World Vision has been running for some years. It is deliberately targeted at some of the most vulnerable people and those whose behaviour is on the margins to which the hon. Gentleman referred. The “Hope” initiative in Mozambique concentrates particularly on drivers who take goods from the centre of the country to the ports. They follow particular routes and are away from home for great lengths of time. Their vulnerability to HIV/AIDS and the danger that they pose to others through their conduct can, of course, lead to them being at the very edge of society. They are
perhaps not on everybody’s first list of those who need care and support, but World Vision is providing that care, and it thinks it very important to work with sex workers, truck drivers, miners and those in particularly high-risk situations. It works through prevention, through offering care and, increasingly, through advocacy. World Vision sees that as not only a social and health issue, but a human rights issue, too, as the hon. Member for South Ribble (Mr. Borrow) mentioned.
I wish to make two brief points on our concerns about children, an issue highlighted yesterday in the House, and today in this debate. I welcome the attention that the Committee paid to the needs of children, and to making sure that children are not missed out from efforts made to increase provision of, and access to, treatment for HIV/AIDS. In particular, I draw the Minister’s attention to targets; I hope that we will firmly press for country plans to include targets. If money has been ring-fenced to deal with children with AIDS and those orphaned by it, it is essential that it actually gets through. Plenty of countries have made commitments in the past, but things have not always worked out, because it is easy for those without voices—children orphaned by AIDS are often precisely those with the smallest voice—to be missed in a rough-and-tumble situation where there is much demand for scarce resources. I would appreciate it if we looked hard at the issue of appropriate, measurable, transparent and achievable targets, and if that could be covered in the reporting-back process that the right hon. Member for Edinburgh, East (Dr. Strang) mentioned.
Secondly, when considering affordable medicines, one should please take note of the need for affordable diagnostics, too. The most commonly available, easy-to-use diagnostic test is inaccurate for children under 18 months. Infants must be diagnosed through a more complicated test that measures the HIV virus instead of antibodies. Unfortunately, current tests require technical expertise as well as costly equipment. As it stands, many multinational diagnostic companies have shown little interest in developing accurate, simple, fast and affordable tests for diagnosing children. There are similar arguments on the production of necessary vaccines, tablets and other medicines. In much the same way, colleagues refer, in the report, to the very amateurish attempts to break down adult doses into something apparently more compatible with children.
Again, proper diagnostic testing needs to be done—not in an ad hoc way, but in a proper, scientific manner. We should get those who can provide such tests to engage in the subject, and to realise the importance of their products to the most vulnerable. It would be most welcome to have a commitment to ensuring that when treatment is considered, diagnostics will be considered, too.
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