Select Committee on International Development First Report

1  Delivering the goods: HIV/AIDS and the provision of anti-retrovirals


1. The HIV/AIDS pandemic is a global health emergency. Coordinated international action is imperative, both to prevent further transmission of HIV, and to provide care and treatment for those living with AIDS. Without such comprehensive action, progress towards meeting at least 6 of the 8 Millennium Development Goals (MDGs) by 2015, will be significantly retarded.

2. Establishing clear global agreement on the goal of universal HIV/AIDS treatment for all those who need it by 2010 has, therefore, been one of the key achievements of the UK government's focus on development during its European Union (EU) and G8 presidencies in 2005. We commend DFID for the important role which it played in securing the G8 commitment to universal anti-retroviral treatment provision by 2010.

Global targets for HIV/AIDS treatment

3. The last global HIV/AIDS treatment target was WHO's '3 by 5' campaign, which aimed to get 3 million people in developing countries onto ARVs by 2005. Although it is unlikely that this target will be met,[2] the initiative has been significant in providing: "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."[3] In their memorandum to the Committee, DFID told us "The target has served as an effective advocacy tool for increased political commitment to treatment, and mobilising countries and communities to respond", but that "There have been criticisms of the '3 by 5' initiative that it has been highly 'vertical' — imposing new targets on countries that may not accord with existing planning processes."[4] Mr Ben Plumley from UNAIDS told us that the strategy which UNAIDS and WHO are developing to achieve the new 2010 universal treatment goal aims to avoid this pitfall by using a 'bottom up' approach based on individual country plans for increasing ARV provision.[5]

4. It is right for UNAIDS and WHO to emphasise the importance of country ownership in the design of their strategy to achieve the 2010 universal treatment goal. But this approach should not allow an abdication of responsibility for meeting the goal at a global level. G8 governments must acknowledge that in making their commitment to universal treatment, they also took on responsibility for ensuring their commitment is realised.

5. We intend to scrutinise the contribution which DFID makes to realising this global goal over the next five years. This will be difficult unless DFID undertakes to publish data on progress towards the goal between now and 2010. We accept that simple numerical targets for the number of people on treatment may not be the most appropriate measure of success, and that progress towards the target may be initially slow, as healthcare systems and other infrastructure are established. We recommend that DFID establishes a transparent monitoring system which will allow year-on-year external evaluation of how many people are being treated and whether they are getting access to quality treatment. In addition, we recommend that DFID considers the inclusion of a target on access to HIV/AIDS treatment when it formulates its Public Service Agreement for the next comprehensive spending review period, 2007 to 2010.

Gaps in existing HIV/AIDS treatment provision

6. Much of the evidence given to the Committee identified gaps in existing provision of ARVs, including access to drugs for nomadic groups,[6] intravenous drug users,[7] men who have sex with men,[8] and children. Many of the written memoranda we received focused on issues which hamper the provision of drugs to children, including:

  • a lack of investment in the development of paediatric ARVs by pharmaceutical companies,[9] for whom research into paediatric formulations: "always comes second";[10]
  • paediatric formulations of ARVs currently available are up to 6 times more expensive than equivalent adult treatments,[11] and Polymerase Chain Reaction (PCR) tests for diagnosing HIV in infants under 18 months are not affordable;[12]
  • ARVs are not packaged in child-friendly doses (adult pills must be crushed, or children persuaded to swallow unpleasant tasting syrups);[13]
  • limited availability of antibiotics (particularly cotrimoxazole) to treat opportunistic infections in children;[14] and,
  • a lack of age-specific data on children who could benefit from ARVs,[15] and of research on the distribution, metabolism and efficacy of ARVs in young children.[16]

7. We commend both the decision of the United Nations Children's Fund (UNICEF), under the leadership of Ann Veneman, to launch its global campaign 'Unite for Children, Unite Against AIDS', and the support which DFID has given to this campaign. We encourage DFID to continue to raise the profile of children's access to HIV/AIDS care and treatment in its interactions with national governments, UN agencies and other donors. We recommend that DFID also makes an effort to ensure that the HIV treatment needs of other vulnerable groups, including nomadic groups, intravenous drug users and men who have sex with men, are not neglected in the international push to expand access to ARVs.

User fees and access to ARVs

8. We heard evidence from Dr Mandeep Dhaliwal of the International HIV/AIDS Alliance, and Ms Sandra Black of the WHO, that user fees are an additional and unnecessary obstacle to treatment access, and to the efficiency and equity of treatment programmes.[17] As Ben Plumley pointed out, there is some evidence that users are more likely to use condoms when they are required to pay a small charge to obtain them,[18] but the Committee heard no evidence that adherence to ARV drug regimens is improved by user fees. User fees do not contribute significantly to the cost of ARV programmes, and therefore do not improve the long-term sustainability of ARV programmes.[19] We were surprised to discover that UNAIDS' position is not in line with the emerging global consensus on removing user fees for HIV/AIDS-related treatment. We are aware that international statements are in no way binding on national and international bodies. However, we believe that an international policy statement supporting the principle of free access to HIV treatment at the point of service, would be influential in the global debate. We therefore recommend that DFID works with WHO and UNAIDS to issue such a statement, and more importantly, to translate this into practice.

Policy coherence on HIV/AIDS

9. In 'Taking Action: the UK Government's strategy for tackling HIV and AIDS in the developing world', published in July 2004, DFID emphasised the importance of 'comprehensive HIV programming'; that is, coherence between HIV/AIDS policies and wider poverty reduction and governance strategies. In its memorandum to the Committee, the Stop AIDS Campaign[20] expressed its concern:

    "…about the translation of [DFID's] commitments at a country-level. Many of our partners are experiencing problems with DFID's in-country delivery, finding DFID offices are not yet oriented towards comprehensive HIV programming, let alone a concern to reach universal access to treatment by 2010."[21]

Ms Robin Gorna, from DFID, reminded us that priorities for HIV/AIDS programming are determined at a country level by in-country DFID teams, rather than dictated from London. She added that the Department is planning to undertake an interim evaluation of the implementation of 'Taking Action' at the end of 2006, which will examine the degree of coherence between DFID's HIV programming and its poverty reduction and governance work. It is essential that the progressive policies set out in 'Taking Action', DFID's strategy on tackling HIV and AIDS in the developing world, are reflected in the HIV/AIDS policies and programmes which in-country DFID teams implement. We await the outcome of DFID's interim review of 'Taking Action'. In the meantime, we urge DFID to address any possible disparities between their policy and practice on comprehensive HIV programming.

10. Although DFID is the lead Department on HIV/AIDS in Whitehall, the issue cuts across the work of several other Departments. We were encouraged to hear about the examples of cross-Whitehall working on HIV/AIDS undertaken by the 'Cross-Whitehall Coherence Group on Tackling HIV and AIDS in the Developing World' and the 'Cross-Whitehall Group on Access to Medicines.'[22] We were told, however, of a lack of coherence between the Home Office, the Foreign and Commonwealth Office (FCO) and DFID in relation to the provision of free ARV treatment to individuals who have failed in their asylum applications, and the deportation of those living with HIV who have no right to reside in the UK.[23] We were concerned to hear that the Home Office only "occasionally" consults DFID and the FCO regarding the availability of ARVs in countries to which they propose to deport individuals living with HIV.[24] Robin Gorna told the Committee that this subject would be addressed at the next meeting of the cross-Whitehall group on HIV in developing countries. We accept that cross-Whitehall working on HIV/AIDS is in its early days, and commend the progress which has been made thus far. We request that DFID informs us of the outcome of the discussion in the cross-Whitehall group on HIV in developing countries, regarding the coherence of HMG policy on individuals with no right to reside in the UK and HIV/AIDS treatment.

Intellectual Property Rights and access to ARVs

11. The agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS), introduced in 1995, requires countries to grant patent protection to pharmaceutical products for a minimum period of 20 years. In November 2001, the WTO agreed that TRIPS: "…does not and should not prevent Members from taking measures to protect public health", implying that poor countries should be able to manufacture, buy and import cheap generic copies of more expensive, patented drugs if they perceive a threat to public health. In August 2003, the WTO announced a new temporary agreement, intended to allow generic copies made under compulsory licences to be exported to countries that lacked production capacity, provided certain conditions and procedures were followed. In their submission to the Committee, DFID described the August 2003 agreement as: "a balanced framework that respects the importance of intellectual property rights and the need for countries to have the flexibility to import generic medicines where needed."[25] Others, including Médecins Sans Frontières, have argued that the August 2003 solution is too complex to be used by developing countries.[26] Mr Daniel Graymore, from DFID, admitted that:

    "…following the agreement in Cancún to waive the clause that made it difficult for countries which do not have their own industry to import copies, that the process has been fraught on occasions. It is a very complicated agreement and there are lots of different levels that need to be addressed."[27]

Mr Graymore went on to explain that the TRIPS-waiver had deliberately been agreed in advance of generic-producing countries, such as India, beginning to implement TRIPS after becoming fully compliant with the agreement on 1 January 2005. He suggested that it is therefore too early, as yet, to judge the real impact of the waiver.[28]

12. We strongly encourage HMG to lobby the European Commission, to make representations in the WTO, that the WTO should undertake a review of the implementation of TRIPS, to assess whether the agreement has compromised public health to any degree. We further recommend that DFID continues to work with other donors to build the capacity of low- and middle-income countries routinely to use TRIPS safeguards, such as compulsory licences and government use provisions, to facilitate the production and export of affordable medicines, particularly second-line ARVs.

IMF influence on public health investment

13. According to ActionAid, fiscal constraints imposed by the IMF are discouraging government spending on public health in low- and middle-income countries.[29] This issue was raised in oral evidence by Dr Tom Ellman, Medical Adviser to Médecins Sans Frontières (UK).[30] Mr Hans-Martin Boehmer, from DFID, explained that the IMF may advise countries against planning to pay for long-term commitments, such as recruiting more health workers, using unpredictable sources of funding, such as donor financing (as opposed to more predictable flows, such as domestic tax revenues).[31] Mr Boehmer went on to say, that if a country went against IMF advice and decided to finance the recruitment of health workers using what the IMF judged to be an unpredictable source of financing,[32] the Fund could withdraw its support for a country's fiscal framework. This, Mr Boehmer admitted, could have very serious consequences for a country's receipt of funds from other donors:

    "Donors do not have the fiscal capacity to assess: "Is this a sound fiscal framework or not?" But they do provide budget support or other support through the national budget. If the IMF says, "We do not advise that this is a sound fiscal framework," many donors would shy away from putting their money into the budget."[33]

14. The Committee understands the IMF's rationale for encouraging countries to minimise risks when designing their fiscal framework. We are, however, concerned to hear that IMF fiscal advice may dissuade countries from investing in their public health infrastructure, particularly since this is key to the expansion of ARV programmes. We encourage DFID to continue working with the IMF and other donors to increase the coordination and long-term predictability of donor funding for HIV/AIDS, in order to enable countries to use donor finance to fund long-term health infrastructure commitments.

The significance of prevention

15. We hope that the G8 commitment to universal ARV provision by 2010 will add valuable impetus to the case for rolling out ARV treatment in the global South. But the relatively new focus on treatment should not be allowed to displace the important work which has been done on HIV prevention. We were surprised to hear, for example, that only 20% of the US$15 billion committed by President Bush for the President's Emergency Plan for AIDS Relief (PEPFAR) will be spent on HIV prevention, while a total of 70% will be spent on HIV treatment and palliative care.[34] Many of the witnesses who gave oral evidence to the Committee stressed that HIV prevention and treatment are 'two sides of the same coin',[35] and that in a best-case scenario, treatment, prevention and strengthening health systems should work together in a virtuous cycle.[36] Expanding access to HIV treatment should not be seen as a simple, technical fix to the pandemic. We believe that a scaling-up of HIV prevention must form an integral part of all programmes to expand access to treatment. We commend DFID for the important role it played in securing international agreement on UNAIDS' new prevention policy 'Intensifying HIV prevention',[37] and urge the Department to continue to balance its work on HIV treatment with sustained attention to HIV prevention.

16. Sandra Black, Ben Plumley and Mandeep Dhaliwal told the Committee that there is a strong body of research supporting the 'ABC' approach to prevention.[38] The 'ABC' approach refers to comprehensive HIV prevention programmes which promote Abstinence, Being faithful to one partner and using Condoms. However, written memoranda received by the Committee emphasised the continuing need for research into the complex range of factors which affect HIV transmission and determine the efficacy of HIV prevention strategies.[39] The Committee is convinced that it is essential for all HIV prevention programmes to be firmly evidence-based, and encourages DFID consistently to analyse the HIV prevention work it undertakes, in order to determine what works.

17. We were concerned to hear that the United States' emphasis on abstinence within its HIV prevention work[40] risks undermining a comprehensive response to HIV transmission,[41] particularly given that the US is the largest donor on HIV/AIDS. As Mandeep Dhaliwal told us: "An over-emphasis on one of the letters of ABC is not evidence-based prevention".[42] The current US preference for building bilateral donor relations also risks undermining the coordinated approach promoted by multilateral agencies and instruments, such as UNAIDS and the Global Fund to fight AIDS, TB and Malaria. The Committee recommends that DFID maintains its "very lively dialogue with the US"[43] on the issue of HIV/AIDS, and does all it can to support national governments to maintain ownership of their individual country plans to tackle HIV/AIDS. In any situation where evidence-based policy is not being implemented, we expect DFID firmly to express their concern.

2   The WHO '3by5' initiative was launched in September 2003, at which point there were 400,000 people living in low- and middle-income countries who had access to ARVs. By the end of June 2005, this figure had been increased to 1 million (UNAIDS and WHO, Progress on Global Access to HIV Antiretroviral Therapy, an update on '3 by 5', June 2005). Back

3   Q 3 [Mr Ben Plumley, UNAIDS] Back

4   Memorandum submitted by DFID, paragraph 29 Back

5   Q 4 [Ben Plumley]; see also Q 5 [Ms Sandra Black, WHO] Back

6   Memorandum submitted by ACORD, paragraph 2 Back

7   Q 14 [Sandra Black] Back

8   Q 17 [Dr Mandeep Dhaliwal, International HIV/AIDS Alliance and Stop AIDS Campaign] Back

9   Memorandum submitted by UNICEF, paragraph 9 Back

10   Q 16 [Ben Plumley] Back

11   Memorandum submitted by UNICEF, paragraph 9 Back

12   ibid, paragraph 7 Back

13   ibid Back

14   Memorandum submitted by Working Group on Orphans and Vulnerable Children, of the UK Consortium on AIDS and International Development, paragraph 4 Back

15   Memorandum submitted by UNICEF, paragraph 6 Back

16   Memorandum submitted by Nyumbani, paragraph 5 Back

17   Q 18 [Mandeep Dhaliwal, Sandra Black]; see also Q 19 [Dr Tom Ellman, MSF (UK)] Back

18   Q 10 [Ben Plumley] Back

19   Alan Whiteside and Sabrina Lee, The "Free by 5" campaign for universal, free antiretroviral therapy, PLoS Medicine, 2 (8), August 2005. Back

20   The Stop AIDS Campaign is an initiative of the UK Consortium on AIDS and International Development, consisting of more than 70 UK development and HIV/AIDS groups. Back

21   Memorandum submitted by the Stop AIDS Campaign, paragraph 2.4 Back

22   Q 29 [Ms Robin Gorna, DFID]; Q 30 [Mr Daniel Graymore, DFID]; memorandum submitted by DFID, paragraph 78 Back

23   Memorandum submitted by Professor Tony Barnett; memorandum submitted by National AIDS Trust Back

24   Q 31, Q 32 [Robin Gorna] Back

25   Memorandum submitted by DFID, paragraph 81 Back

26   Médecins Sans Frontières, MSF to WTO: re-think access to life-saving drugs now, 25 October 2005. Back

27   Q 39 [Daniel Graymore] Back

28   Q 40 [Daniel Graymore] Back

29   Rick Rowden, Changing Course: Alternative approaches to achieve the Millennium Development Goals and fight AIDS, ActionAid, September 2005; Rick Rowden, Blocking Progress: How the fight against HIV/AIDS is being undermined by the World Bank and the International Monetary Fund, ActionAid, September 2004. Back

30   Q 23 [Tom Ellman] Back

31   This raises the issue for donors of how to increase the predictability of their funding, an issue that DFID is working on in response to the work of the High Level Forum on Health MDGs (see Back

32   Whether this was domestic tax revenue or a predictable supply of donor financing, such as that which DFID has undertaken to provide to the Government of Malawi over the next ten years; Q 34 [Mr Hans-Martin Boehmer, DFID].  Back

33   Q 46 [Hans-Martin Boehmer] Back

34   See Back

35   Q 2 [Sandra Black, Ben Plumley]; Q 9 [Sandra Black]; Q 43 [Robin Gorna] Back

36   Q 9 [Mandeep Dhaliwal] Back

37   UNAIDS, Intensifying HIV Prevention: policy position paper, August 2005, UNAIDS Back

38   Q 9 [Mandeep Dhaliwal], Q 10 [Ben Plumley] Back

39   Memorandum submitted by Professor Tony Barnett; memorandum submitted by Professor Alan Whiteside Back

40   One third of total PEPFAR funding for HIV prevention is earmarked for abstinence-only prevention messages (see Harinder Janjua, Act Now; access to care and treatment, meeting the AIDS challenge, October 2005, Stop AIDS Campaign). Back

41   Q 7 [Tom Ellman]; Q 13 [Mandeep Dhaliwal] Back

42   Q 13 [Mandeep Dhaliwal] Back

43   Q 55 [Robin Gorna] Back

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Prepared 1 December 2005