Examination of Witnesses (Questions 1
- 19)
TUESDAY 22 NOVEMBER 2005
MS SANDRA
BLACK, DR
MANDEEP DHALIWAL,
DR TOM
ELLMAN AND
MR BEN
PLUMLEY
Q1 Hugh Bayley: May I thank the witnesses
for attending. We have an hour with you before we move on to talk
to some DFID officials. I will ask my colleagues to pose their
questions briefly and you to answer succinctly. We do not necessarily
want an answer from each of you. You may want to confer amongst
yourselves as to who would best answer each question but of course
if more than one of you wishes to answer, you are welcome to do
so. Perhaps I can set the ball rolling with a broad question?
We know that Senegal and Uganda have better prevalence rates than
many other parts of Africa, but it is not clear why that is. Have
global efforts to control the epidemic yet identified what actually
works and what implications does this have for our prospects of
achieving the Millennium Development Goals?
Mr Plumley: Perhaps it would be
appropriate for UNAIDS[1]
to start with that. We have looked very closely at the very limited
success stories that we have around the world. Senegal and Uganda
are interesting, Senegal because it has managed to maintain rates
of infection extremely low in a region in western Africa that
is not seeing the same kind of rates of infection as one sees
perhaps in eastern and southern Africa. Its political leadership
combined with a real commitment to community mobilisation and,
even in countries with low infection rates, a commitment to provide
treatment at an early stage is crucial because that encourages
people to come in and access services, either for prevention or
indeed, if they are positive, for treatment. With Uganda, again
there has been a political commitment over the long term, a real
commitment to prevention in the late Eighties and early Nineties,
using the ABC approach—abstinence, behaviour change and
condoms—and that is important, a comprehensive prevention
approach. I would just add that we are seeing some more success
stories coming through. I would like to draw your attention to
Kenya, just next door to Uganda, where the figures that we released
yesterday are showing that, despite perhaps the attrition of people
unfortunately infected some five to 10 years ago now dying, we
are nonetheless seeing rates of infection going down in sexually
active young adults and clearly the behaviour change message is
having an impact there.
Ms Black: In adding to what Ben
has already said, it is important to recognise that there is a
growing body of empirical evidence on what works. WHO[2]
very much tries to support public policy related to the evidence,
especially on the prevention side because prevention strategies
have been in place for a number of years now. It is very important
to recognise that that evidence exists and also to advocate for
member states and countries that have various types of epidemics
that they use the evidence that has been developed to inform their
national response. On the treatment side, I think what we are
beginning to learn is that there are particular approaches that
work better than other approaches, but I would also indicate that
we are very much in a learning by doing phase. That is appropriate
at this stage of the epidemic when we look at treatment in particular.
I will not respond expressly to that now but I think that there
are optimum models for scaling up access to prevention and treatment
that can be promoted with member states, and it is important that
we encourage them to do that.
Q2 Hugh Bayley: Is there any evidence
that there is inadequate resource for prevention campaigns because
it is being sucked out into either treating opportunistic infections,
treating the virus itself or going into counselling and testing
programmes? Is sufficient money available for prevention?
Ms Black: You have a number of
questions there, Chairman. You are asking if the human resources
are available and is there money available? The two are contingent
on each other but not necessarily dependent on each other. Human
resources to respond to the epidemic are different in various
developing countries. What we are trying to promote at WHO is
to look at models that respond to the human resource capacity
in that country, especially models that look at engaging the community
as much as possible. That is about having a decentralised approach
to service delivery and looking at task shifting amongst health
cadres. I have to indicate that even though the body of evidence
for those types of interventions for HIV and AIDS are relatively
new, there is a large body of empirical evidence that demonstrates
close to client care is the most efficient and effective way to
provide sustained health services. I would suggest that what we
are promoting for HIV already builds on an existing body of evidence.
What we are trying to do is promote service delivery models that
provide equality of care that we can guarantee to communities
and to member states that is going to be sustained in the long
term.
Mr Plumley: I would endorse that
but add that far from diverting funding from prevention, treatment
has an incredible power to galvanise an increase in funding across
the board and, of course, prevention and treatment work together.
It is often posed as a risk. As far as I am aware, there is no
evidence that it has happened, and it is much more an argument
for nay-sayers on treatment than it is a reality. Certainly, the
interest that has developed around HIV in the last few years has
been very much driven by the treatment agenda. We have to make
sure that that treatment agenda in no way diverts funding from
prevention but rather increases interest around prevention as
well.
Hugh Bayley: We may return to the dichotomy
between prevention and treatment later, but let us stay with treatment
at present.
Q3 John Battle: In September 2003,
the WHO launched the "3 by 5" initiative, three million
people to get onto anti-retroviral treatment by 2005. In that
time, only 600,000 have been added into the treatment. That leaves
a gap of two million. The latest estimate shows 6.5 million in
need of treatment. I wonder what we have learnt from that target
that was set. From the experience of our visits, sometimes the
argument a few years ago was about the cost of anti-retrovirals,
but what happens if there are no clinics to deliver them, so we
are getting the drugs there but without the back-up? I wonder
what we have learnt from that whole experience of setting the
target, getting the drugs but not being able to deliver them?
Ms Black: That is a great question.
The "3 by 5" strategy was initiated by UNAIDS and WHO
and it was really to mobilise a movement around treatment, and
there was the acknowledgment that there was a public health emergency,
that many people required treatment and had no access to treatment.
This was an initiative to encourage member states to launch national
treatment programmes in particular. When "3 by 5" was
started, three member states in the highly endemic and highly
burdened countries had treatment plans. Today over 40 countries
have plans. There were four countries that had treatment targets.
Today over 40 countries have treatment targets; 14 of those countries
have indeed met their targets. It is really important to recognise
two things: these are not WHO or UNAIDS gains but rather you have
to applaud what those member states have done to be able to put
programmes into place. These are countries with profound human
capacity issues, health systems issues, drug procurement and supply
chain management issues, all of these are huge issues. They have
been able to demonstrate that it is possible, with the support
of the donor community, technical agencies and the UN community,
but also having utilised their resources in the country, to put
these plans in place. We have learnt a lot of lessons from "3
by 5". We have also learnt where the huge bottlenecks are.
I think, as we move forward after "3 by 5", those are
the lessons that we are going to have to really review and decide
on the best way to give advice and guidance to member countries.
Dr Dhaliwal: One of the most important
things that we have seen in the programmes in the 20 developing
countries where we work is the value of the tremendous global
leadership demonstrated by UNAIDS, WHO and other stakeholders
accompanied by in-country technical support which really mobilised
action at community level. The importance of sustained global
leadership is about inspiring and mobilising countries to set
their targets a little more ambitiously than perhaps they would
have done. I would like to offer the example of India, which has
a domestic ARV[3]
production industry which supplies a lot of Africa, which had
no national treatment programme until the "3 by 5" initiative,
and the leadership that it provided in helping them set a treatment
target, which was not initially very ambitious but they are revising
these targets upwards in the next phase of their national AIDS
control programme. Focusing on implementation is very important
but global leadership, predictable, sustained resources and technical
assistance to support in country initiatives are also critical.
Mr Plumley: From our perspective,
the big success of "3 by 5", the really important thing
about it, was proof of concept, proving that you could bring combination
therapy that had been proven in rich industrialised countries
and make it work in resource-poor settings. A lot of lessons were
learnt and there are a lot of gaps we have to face, not least
the question, moving forward, of ensuring we have the manufacturing
capacity, which will mean a mobilisation perhaps of both generics
and brand names in a way that has not been done before. It also
means that we have to deal with the kind of health system problems
that have been encountered. As you rightly said, Mr Battle, it
is a question of when you do not have clinics, how do you provide
therapy in these settings. As we move into the next stage, we
are looking at working with countries to find really ambitious
country-led targets that provide broad coverage for their citizens
who need treatment.
Q4 John Battle: I am encouraged to
hear about the country-led targets, but I am not convinced that,
whatever "global leadership" might mean, they have got
the message. At the G8 they reiterated a "3 by 5" to
the power of 10 by saying that all those who needed access would
have it by the year 2010, I think it was, which would effectively
mean 10 times as many people getting the treatment in four years.
So the global target is there but do they understand the country-by-country
approach in detail? Is that message getting through, so that there
is more focus perhaps on a county-by-country approach rather than
just setting these numerous global targets that are never going
to be reached?
Mr Plumley: This is precisely
what we are working on at the moment. Following on from the G8,
the members of the General Assembly at the World Summit endorsed
a commitment to provide universal access for prevention, care
and treatment close to 2010. But the whole point here is not to
set global targets now but to work with countries on really building
their commitment and leadership. It does come back to the resources
as well. As much as the donor community needs to sustain, and
indeed expand, its commitment, we must be looking at countries
themselves making significant commitments.
Dr Dhaliwal: There is evidence
of these commitments being taken up in some of the hardest hit
countries. At a recent meeting of the African Union Health Ministers
in Botswana in October, the health ministers themselves endorsed
the call for universal access to treatment, prevention and care.
I think the time line might have been slightly different but there
is a clear commitment. I think there is a call from countries
with a need for technical and financial support. What we have
to provide at this level is sustained, predictable funding along
with technical and policy support. We applaud the leadership of
the British Government but the work is not over; it has just begun.
I think we have to use our special relationship with the United
States Government and the Canadian Government and those of the
other countries of the G8 and ask them to increase their development
financing.
Q5 Mr Hunt: May I echo the comments
of my colleague, John Battle? The concern about the "3 by
5" target is that although we have made significant progress,
still two million people who should have been on ARVs are not
on ARVs or will not be by the end of this year. We now have a
new, even more ambitious target. In order to give that target
credibility, do you not think, Ms Black and Mr Plumley, that WHO
and UNAIDS need to commit to intermediate targets so that we do
not just have as close as possible to universal access by 2010
but we actually have a fixed, agreed target for the number of
people who will be on ARVs by the end of 2006/07/08/09 so that
then the world community can scrutinise whether or not we are
making progress towards this target?
Ms Black: As Mr Plumley has indicated,
the intent, as we move forward to achieving universal access,
is to encourage countries to set their own targets. Those may
be progressive targets, as you have indicated. It will be important
that they have guiding principles for setting those targets, guiding
principles that guarantee equity and principles that look to see
that the targets are responsive to the epidemiological situation
in their country. If you look at the trajectory for scaling up
services, what we have seen under "3 by 5" is not unusual.
You tend to get a curve that goes very much like this and
then it goes like this. We are still at the lower end of
this trajectory. I do not think any of us who have worked in this
business for a long time are surprised that that is where we are.
We need to work with countries to provide them with the technical
support and the funding capacity that they need to continue on
that trajectory. Countries may decide to meet progressive targets
and if they do, we will try to promote the essential services
that you need to have in place. You need to have prevention and
mother-to-child programmes in place. It is unconscionable that
while in the developed world you have virtually no transmission
from positive mothers to their children, that is far from the
case in the developing world. There are realistic, progressive
targets that we can put in place but there are some things that
are not negotiable. If we want to ensure equity and human rights,
as we scale up universal access, then the global community has
an imperative, regardless of whether you are a donor, a technical
agency or a UN agency, to promote this type of target setting
with the countries.
Q6 Mr Hunt: Just cutting through
that, I think what you are really saying is: no, you do not think
that WHO should be setting intermediate targets. You think it
may be up to countries to set intermediate targets, but you do
not think that WHO should. Is that what you are saying?
Ms Black: That is exactly what
I am saying. The global community has set targets. Before, we
had the Millennium Development Goals by 2010. There have been
so many global targets. The ownership and the accountability for
what a country does, needs to reside at the country level. That
is not to say that they do not need the support of the global
community to enable that to happen, but they need to be able to
be responsive to the situation that they have at hand.
Q7 Mr Hunt: What was the point of
setting a target at the G8 summit in Gleneagles for 2010 if you
are not prepared to commit to intermediate targets to achieve
that target for 2010?
Mr Plumley: I think the point
with universal access is that we are explicitly moving away from
setting a global target and what we are looking at now is really
strengthening capacity in countries. I am being explicit that
universal access will not globally say: it is aimed that X million
people will be in treatment by 2010 or take a step-wise approach.
What we are looking at with the universal access work is to put
in dedicated resources to help countries strengthen their own
programmes on prevention, treatment and care, and that they themselves
will set ambitious coverage targets, and that then the international
community should, as it were, rally behind those. I am quite certain
that at country level that there will be some interim targets
that they will set. All of this work is going on right now. We
will report back at the time of the UN General Assembly high level
session on AIDS in June next year, when we will be in a position
to see how these country plans have been developed and what kind
of support is needed to do them. As Sandra says, we are being
very explicit that this is not the time for global targets; it
is really time to support the scaling up.
Dr Ellman: May I add that it may
not be a question of defining targets year-on-year but it is certainly
a question of a transparent monitoring of the process so that
year-on-year we are aware of how many people are being treated
and whether they are getting access to quality treatment. There
is a very heavy emphasis in the discussion, around getting many
people on treatment. Many of our field programmes are in weak
states where they do not necessarily have governments that are
going to have the capacity to build the programmes without external
support, particularly technical support and civil society. The
feeling is that in many of these it is one step forward and almost
one step back. There is plenty of evidence that there is a global
commitment to putting treatment forward and to putting prevention
back on the map, but so much is going on in terms of access to
medicines since 2005. The TRIPS[4]
safeguards are no longer there to ensure that the cheap drugs
that most people in developing countries currently have will still
be available. There is a huge question mark around second-line
drugs. There is evidence of a lack of commitment around some of
the key prevention messages, particularly from the United States
who are rarely mentioned in official documents, from DFID and
others, as the culprit that they are in these things. One of the
key questions that was mentioned earlier was around bringing care
to the level of the community: we need radical measures to ensure
that treatment is scaled up around Africa. Doctors are not going
to be at the heart of prescribing anti-retroviral drugs. So far,
there is very little evidence of leadership on really pushing
forward an agenda that is not going to rely on the current status
quo around delivery of care, which is based around the Western
medicalised model. That is not to say that we should downgrade
doctors and nurses. We need more and they need to be better paid,
but we need new systems.
Q8 Mr Singh: I was very interested
in your responses to targets. I would like to ask you, in this
approach that you have been outlining to us, whether you are not
in conflict with the American position, with the US President's
Emergency Plan for AIDS Relief (PEPFAR), which is entirely reliant
on targets and delivery at that level? How can we have a co-ordinated
international approach to these issues if the US is left out of
that, or if the US does not participate?
Dr Dhaliwal: I think targets are
essential. What has been really important about the targets around
"3 by 5" and the universal access target is the sense
of urgency and accountability that it brings at the global and
at the country level. I think there absolutely needs to be a harmonised
response from donors and other actors to this. Targets at the
country level and at the global level are of two types: you have
the political, aspirational targets; but then you also have the
operational, implementation-level targets, which will be month-by-month
roll out of X number of people on treatment, X clinics strengthened,
X health workers trained and then X medicines, diagnostics, prevention
and support services delivered. I think it is important that we
do not step away from these targets and the political pressure
that they bring at the global and at the country level. The measure
of urgency and accountability that these bring is critical.
Mr Plumley: To answer your question
explicitly, the US are part of the universal access work.
Q9 John Barrett: One of the submissions
we received was from Professor Alan Whiteside[5],
Director of Health Economics in the Research Division of the University
of KwaZulu-Natal. While he agreed that prevention must remain
a priority, he said that he was troubled by the global emphasis
on ARVs and, "While I believe providing therapy is crucial,
it seems the response is becoming too simple . . . ." The
basis of his concern is this: he is saying that concentrating
on the ARVs is "at best naïve and at worst damaging"
because he is arguing that there has been too much emphasis on
anti-retrovirals and not enough emphasis on prevention. Each of
you has mentioned prevention as being the other side of the coin
to treatment. Do you think there has been too much emphasis on
treatment and not enough emphasis on prevention as a target?
Dr Dhaliwal: Having worked on
the epidemic for 20 years now, I think what we see now is a real
paradigm shift. You have heard us all talk about treatment and
prevention today for a particular reason. I think "3 by 5"
in particular and the universal access commitment at Gleneagles
and then at the UN World Summit in New York have resulted a real
shift in our thinking. Professor Whiteside probably would agree
that we now must be talking, as we move ahead, about treatment,
prevention and strengthening of health systems as a virtuous cycle.
That is the only way we will really move ahead to ensure universal
access. One really important piece of that is free access to treatment
at the point of service delivery and stigma reduction because
those are two big barriers that need to be addressed if we are
going to move forward to universal access.
Ms Black: What you hear from Professor
Whiteside is not new, and I have read the body of the literature
that was presented to this panel. This is a common theme that
emerges. The global community was lagging very far behind in responding
to treatment needs generally. In some ways, what we have witnessed
is a large upsurge and response to providing treatment when, quite
frankly, it should have been initiated much sooner in the epidemic.
Did we see a disproportionate response to treatment? Yes, we did,
but we should have because we were really far behind where we
should have been at that point in the epidemic. However, I do
think what has happened is that the focus on treatment and the
number of dollars of funding not only for treatment but for the
epidemic now provide wonderful opportunities to do both prevention
and treatment. I agree with Mandeep's comments: it is not one
or the other; it is all of it. We do not have any choice but to
do all of it. Many of you will have seen the epidemic report that
was launched yesterday.[6]
That will continue to get worse if we do not do both.
Q10 Hugh Bayley: To follow up John's
question, I think what I am hearing is a medicalisation of the
epidemic. If I was a cynic, I would say that the drug companies,
the pharmaceutical companies, make big money out of the treatment
programmes and, yes, you keep paying lip service to prevention,
but each new infection is somebody who is going to die from this
disease. I have not heard one of you talking about scaling up
new initiatives on prevention programmes and research to find
out what prevention strategies work. You do preface all your comments
by saying, "Well, these are two sides of the same coin but
let us talk about treatment, about meeting targets, and getting
medication to people". I am not against medication but I
would be horrified if, for each death, prevention programmes are
not absolutely fully funded. If you had to make a choice between
fully-funded prevention and fully-funded treatment, surely you
must fully fund prevention, even though you would still be using
80% of the money on treatment?
Mr Plumley: It really will depend
where your priorities are. I want to be quite clear that from
UNAIDS' perspective, prevention most certainly is a priority.
At our board this year, we got through, and I have to thank the
support of the UK for this, a really ground-breaking prevention
policy. That is why since then we have really been pushing prevention
as the central response. I would also say that universal access
work is very explicitly focused on scaling up prevention. We have
the body of evidence of what works on prevention. There is no
question about that. There can be no debate about the effectiveness
of ABC plus, if you like. The question is about scaling up. That
is why the universal access work is so critical and I really want
to stand behind it, because it is now the time really to put prevention
to the fore. That is why in the report yesterday there was a whole
section on prevention and what needs to be done. The other point
is that in mobilising communities that are heavily hit by HIV,
you have got to have both: you have got to have things to offer
people that are living with HIV to encourage communities to come
forward.
Dr Ellman: I find it difficult
to understand how we can cost prevention without including the
costs of treatment. It is very easy to say that we could save
far more lives by spending this amount of money on awareness-raising,
education and condoms. I think the figure of £4.5 billion
is quoted as an amount that could save X number of lives. Without
the pull of treatment, as you were saying, particularly in the
heavily affected settings, to engage people, to offer people who
test something, there is really not much evidence that prevention
on its own will work. It is pointless to describe a prevention
target and a prevention agenda without engaging treatment with
it. Therefore, I accept that we have been focusing our discussion
on treatment, but from my side that is firmly with an understanding
and a genuine belief that treatment is part of prevention.
Q11 Hugh Bayley: Is that so even
though Uganda reduced prevalence rates from 20 something per cent
to 8% before anti-retrovirals were available?
Dr Ellman: There are many discussions,
reasons and arguments about the Uganda experience, and also about
the fragility of the gains that have been made in these countries.
There is an opportunity now to consolidate and ensure that these
gains were not flashes in the pan that disappear over the next
10 years. There is very real reason to worry about the next 10
years, even in Uganda.
Dr Dhaliwal: The UNAIDS' epidemiology
report cites very clearly that in countries with mature, generalised
epidemics of a certain age where prevalence data goes down, often
that can be due to an equal number of new infections and large
numbers of people dying. I think we need to scrutinise drops in
prevalence and gains very carefully.
Q12 Hugh Bayley: Prevalence, by definition,
must be people dying because they are no longer there to be prevalent.
Dr Dhaliwal: Absolutely.
Q13 Richard Burden: In relation to
prevention, obviously I am pleased that in response to questions
you have said that you see that as a priority alongside treatment,
but in terms of delivery of prevention programmes, and particularly
the ABC plus approach, how far do you see that being affected
or skewed by emphasis from some quarters on one of those letters
to the exclusion of the other two letters? I am thinking in terms
of PEPFAR; 7% of total PEPFAR funding is for abstinence-only prevention
messages.
Dr Dhaliwal: One of the biggest
challenges we have seen in our prevention programmes has been
the retreat from evidence-based prevention by the United States,
and I think we have to name it, (we always say "some donors"
but it is the United States) that is pushing back on evidence-based
prevention. We heard from Mr Plumley that we have solid evidence
on what works in prevention. An over-emphasis on one of the letters
of ABC is not evidence-based prevention. I think we need to do
much more, given our Government's special relationship with the
United States, to ensure that major donors, such as PEPFAR, are
supporting evidence-based prevention.
Mr Plumley: I would like to be
clear that the United States signed off on this HIV prevention
policy. We will share it with the Committee afterwards.[7]
It was clear that the US signed off on it.
Dr Dhaliwal: Translating policy
into action at global, national and community levels is a big
challenge. That is also one of the challenges that we see with
the fantastic HIV treatment and HIV policies of the British Government.
What their global policies translate to at country and community
levels is often something very different. I think it is the same
with PEPFAR. They may at the global level sign a fantastically
progressive UNAIDS prevention policy statement but how that translates
into country level programming is often a very different story.
At the global level, we have to be much more proactive and not
complacent about our wonderful global political successes around
HIV, by ensuring that they translate into similar successes at
the country and community levels.
Q14 Mr Singh: Professor Tony Barnett[8]
says about the successes in Uganda and Senegal that we do not
really understand what has happened there. You seem to be agreeing
with him. He made a very bold statement that by and large prevention
has failed. How do you react to that statement?
Mr Plumley: I have reacted to
say that prevention has not failed. Again, Tony Barnett's work
with Alan Whiteside is very well known. We have done reviews of
the experience of Uganda and Senegal, and not restricted to them,
in terms of behaviour change programmes. We believe there is solid
evidence to show that sustained programmes that are constantly
renewed, that meet the needs of the targets of the groups that
they are working with, do have an effect. We are also seeing that
in countries like Kenya, as I mentioned. I come back to it: I
think there is a very solid body of evidence in favour of prevention.
It is not about medicalising the response to the epidemic; it
is about mobilising all sections. One of the really key and exciting
things that has happened in a number of countries has been the
mobilisation not only of different government ministries—education
is one that immediately comes to mind—but the mobilisation
of other sectors, whether it be faith-based communities or the
business sector. We see education awareness programmes happening
in all sorts of innovative places. This is the central way in
which we move the prevention agenda.
Ms Black: We have been very much
focusing on prevention as the African issue, but if you look at
yesterday's report, many of the new and emerging epidemics are
related to injection drug use. The prevention strategies are very
well documented. We know what works, but it is more than having
available treatment programmes in place; it is having legislative
and regulatory capacity at the country level to respond to those
types of epidemic. Of course, the concern is that there are a
number of countries that do not have legislative and regulatory
practices in place that enable a robust response to an injection
epidemic. They tend to be punitive and they tend to be very focused
on the crime rather than trying to put responsive strategies in
place to be able to reduce the harm related to those types of
epidemics. I think that is where organisations such as DFID have
a wonderful opportunity to be able to leverage, encourage and
promote what you have domestically here in order to promote the
same thing happening in those countries also.
Q15 John Bercow: The Committee has
received a number of written submissions which have emphasised
the vulnerability of children and their relative neglect in relation
to HIV/AIDS treatment. Given that AIDS has already caused infant
mortality in Africa to rise by 19%, that under 5% of HIV positive
children are receiving the treatment that they desperately need
and that every minute one AIDS-afflicted child or child with an
AIDS-driven disease is dying, how do you think that phenomenon
is to be addressed in relation to the 2010 target?
Dr Dhaliwal: There are five clear
strategies which you also see in the UNICEF evidence. Some of
these are also alluded to in the OVC working group evidence presented
to the Committee.[9]
These are: the importance of cotrimoxazole prophylaxis; having
solid prevention mother-to-child transmission programmes; ensuring
community-based support for orphans and vulnerable children; ensuring
that there is development of appropriate paediatric formulations
of ARV treatment; and all the work that needs to happen around
TRIPS to ensure that when those paediatric formulations are developed
they are available to those most in need. For example, Cipla is
launching fixed-dose combination in March, "Pedimune",
which will be like the adult "Triomune" combination
but will that really be available and accessible, given the TRIPS-plus
provisions in the Indian legislation now? Are we going to be able
to make these paediatric formulations available to children in
sub-Saharan Africa who will need the treatment? I think these
five different strategies need to be pursued together if we are
really going to make a difference to ensure that children are
a meaningful part of the universal access target.
Q16 John Bercow: What is your assessment
of the quality of the data on the children who could benefit from
ARVs, given that resources are finite and presumably you want
to target them as effectively as possible? Could you add something
in your list of present obstacles to be overcome, hopefully in
the near future, some commentary on the number and adequacy of
pharmaceutical companies to supply the drugs and invest in the
research required?
Mr Plumley: There has been a reluctance,
it is certainly true, by pharmaceutical companies to do research
into paediatric formulations. That always comes second. I think
we very much welcome the leadership being shown by UNICEF now
under Ann Veneman to push the children and AIDS response to the
fore of UNICEF's work. Certainly, one of the areas that we are
looking at is to encourage both generic and brand name pharmaceutical
companies to prioritise the production of paediatric formulations.
Dr Ellman: One other real gap
at the moment is the tools to diagnose HIV in young children.
Half affected children die before the age of two, and they are
effectively excluded. If you look at children who are currently
on treatment, there are incredibly few, in fact almost none certainly
amongst the 10% or so that MSF has on treatment, under the age
of two, simply because we do not have the means to diagnose them.
There are currently initiatives looking at cheap, affordable ways
to get viral load, which is what would be needed for children,
PCR[10]
techniques. We need to find ways to get those funded. We know
of at least one example in this country that has so far been coming
to MSF for funding because it is unable to find research funding
from the UK.
Q17 John Bercow: Just to take this
forward a little, with what speed, if any, can one expect progress
on this front? Although I do not want to harp back on it, and
will get into great trouble with the Chairman if I seek to harp
back to the earlier questions being put by my colleague Jeremy
Hunt, I am conscious, as I think we all are, of the immediacy
of the crisis and the need for progress. You make a very important
point about work that is being done. Is it centre-stage? What
level of publicity is attached to it? To what extent is it recognised
by decision-makers as being a priority for extra resources? Where
does the United States stand on the matter? Do you see what I
am getting at? I am impatient, as I am sure we all are.
Mr Plumley: UNICEF with UNAIDS
and WHO, our other co-sponsor, launched a new campaign for children
with AIDS in October this year. It is a key priority for them.
We can probably find you the details of how long it takes to provide
paediatric formulations. They tend to follow after the main ones,
and undoubtedly that has to be addressed. This really is a priority
for the international organisations, whether it be on the medical
front or on the community-based front.
Dr Ellman: Our experience is that
there is a lack of interest in countries to find children with
HIV because of the difficulties of getting treatment, and also
a reticence due to lack of experience in treatment. For example,
for every HIV positive woman we should be trying to find out whether
they have children who are affected, offering testing for the
children, offering treatment for the children. That simply is
not happening at the moment because countries do not have access
to affordable medicines to provide to those children. As Mandeep
was saying, there are very serious concerns about lack of availability
in future because of the TRIPS effects in India, China, Brazil,
Thailand, the countries that up to now have been the great hope
of cheap drugs and have been the reason we are currently treating
anybody at all in Africa.
Dr Dhaliwal: We have an interesting
experience in the Ukraine treatment programme where we provide
the national treatment services. When we started the programme,
actually more children were registered than we had seen in other
countries. It was quite interesting because in many countries
they would rather treat the children than treat the sex workers
or the injecting drug users or the men who have sex with men,
because children are innocent and we would all like to provide
treatment to children. While we are focusing on children, we should
also make sure that the focus also remains on those populations
that are key to the dynamics of the epidemic, who are vulnerable
and marginalised and exist on the fringes of society, in government
programmes and government priorities, and that these key populations
must be provided with treatment and prevention services.
Ms Black: This is one area that
the normative work is going to change very rapidly. For example,
it has to be progressive. Until we have new diagnostic measures
in place, if you think a child under 18 months has been exposed
to HIV, you consider giving them prophylaxis medicine, cotrimoxazole.
Therefore the normative work will continue to change as more technological
advances are made.
Q18 Joan Ruddock: Mandeep Dhaliwal
said earlier in passing that she thought that drugs needed to
be free at the point of access. I wonder if you could take us
through this and if the other members of the panel could do the
same. There have been arguments put that if people have to pay
something, then it makes for a better commitment to the treatment
programme and they value it more, that there is an aspect of sustainability
in programmes where money is being received. The question really
is why HIV/AIDS should be treated differently from other diseases
where in many countries people have to make some payment?
Dr Dhaliwal: I will start with
evidence that we have seen from the "3 by 5" experience
where one of the biggest barriers to people accessing treatment
is the cost of treatment. There is a lot of evidence that providing
treatment free at the point of service delivery improves the sustainability
of and adherence to the treatment. There is no evidence that I
know of that user fees end up back in the system and supporting
and strengthening the health system. There is quite a bit of evidence
to the contrary. There is a policy statement, which Sandra Black
can tell you about, that is being issued by WHO. Unfortunately,
there is no co-sponsor agreement on that. There was a meeting
with UNAIDS and World Bank and all the sponsors of UNAIDS on the
free treatment issue. In spite of a lot of evidence, I believe
the World Bank and other co-sponsors are reticent to sign off
on this policy, but we know that in the case of anti-retroviral
treatment there is strong evidence. Countries like Senegal, which
initially had some form of user fee, have now, on the basis of
that evidence, changed their policy to provide free access to
treatment. Senegal, Zambia, Tanzania and Ethiopia are all now
providing free access to anti-retroviral treatment at the point
of service delivery. I think some of these hypotheses about people
valuing something more because they pay for it are just that and
the evidence is quite to the contrary in the case of life-long
treatments, such as anti-retroviral treatment.
Ms Black: To respond to your point
about why would we do this for HIV and we do not do it for other
diseases, it happens for other diseases in different manners and
different ways. The reality is that we are in an exceptional public
health emergency here. The developments of aid that have been
made over the last 40 years have been lost and eroded in many
countries. We know that we have to have an exceptional response
to an exceptional situation. You look at a number of elements
that need to be put in place. That is why we support free access
at point of service delivery. How a member state in that country
decides they are going to fund that is an issue. We had a long
discussion about this at a three-day meeting in Geneva. Essentially,
what the member states said to us, especially from the African
developing countries, was that if we promote a free access policy,
then we need to put a structure in place to support it. It might
be financing schemes, public insurance schemes, requesting more
money from the global fund. There was the acknowledgment that
they needed to have a sustained response that that was one of
the elements that they needed to have in their national strategies.
Q19 Joan Ruddock: May I just check
something with you? People are not paying the full costs of the
ARVs, are they, in any of these circumstances, or are they?
Ms Black: That certainly was a
point of a lot of discussion. What does free access mean? Does
it mean to the drug itself, to the anti-retroviral drugs, to the
drugs for opportunistic infections, to transportation to the service
delivery site? Those are issues that a country needs to define.
The policy statement that WHO will issue on free access will have
these elements discussed in it. This issue is very important as
countries put a responsive plan in place to look at those particular
issues, recognising that they want a sustained response because
that is an important element?
Dr Ellman: I say clearly that
universal access will be impossible without free treatment. Cost-recovery
systems exclude the poorest members of society and HIV affects
disproportionately the poorest members of society. We would certainly
go further with regard to the exceptionalism around HIV to say
that in communities where most people are poor, which is most
of sub-Saharan Africa, all treatment should be free at the point
of delivery. We should also be very clear that, regardless of
whether the rest of the health system is free or not, it must
not just be anti-retrovirals; it must be all opportunistic infection
treatments. I have seen people excluded from follow-up and therefore
excluding themselves from anti-retroviral treatment simply because
they cannot afford the few pence that cotrimoxazole costs. That
was what would have kept them in follow-up. It is very clear,
and for TB as well, it has to be free; it is free in principle
but in many countries there are payments in practice. This is
about more than anti-retrovirals.
Dr Dhaliwal: Going back to the
global financing issues, I think financing is the key question
when we are talking about delivering free anti-retroviral treatment
at the point of service delivery—financing and ensuring
that countries are enabled to use the flexibilities that are allowed
in TRIPS. We have not even had any discussion here about second
line treatments and some of the first line treatments that are
still under patent, and the paediatric formulations, which are
certainly going to be under patent. We would like the British
Government to support countries basically to help them stand up
to the United States if the US does, through other trade negotiations,
apply pressure on countries to enact TRIPS Plus legislation. If
we have TRIPS Plus legislation in all of these countries, it means
that we will never have universal access to treatment, that they
will not be able to have access to the cheapest drugs possible.
Dr Ellman: I would add that we
have had an indication from Pascal Lamy, the Head of WTO,[11]
that there is interest within WTO to review whether or not the
spirit of the Doha declaration (which was that public health should
override profit, that people should have access to affordable
medicines for HIV and other diseases) is actually being implemented
and not to amend things, which is currently what is being put
on the table, to institutionalise systems which we see as very
unwieldy and not likely to lead to drugs being available for poor
people. We have heard that EU Members need to lobby the EU Commission
to put this to WTO. We would ask the UK with the Presidency of
the EU to take that forward and see whether or not the current
implementation of TRIPS is leading to any good at all for people
getting hold of cheap drugs.
1 Joint United Nations programme on HIV/AIDS Back
2
World Health Organization Back
3
Anti-Retrovirals Back
4
Trade-Related aspects of Intellectual Property Rights Back
5
Ev 59 Back
6
UNAIDS/WHO, Aids epidemic update, December 2005: http://www.unaids.org/Epi2005/doc/EPIupdate2005_pdf_en/Epi0_00_en.pdf Back
7
UNAIDS, Intensifying HIV Prevention: a UNAIDS policy position
paper (August 2005) Back
8
Ev 39 Back
9
Orphans and Vulnerable Children Working Group of the UK Consortium
of AIDS and International Development. See Ev 60 Back
10
Polymerase Chain Reaction Back
11
World Trade Organisation Back
|
