Select Committee on International Development Written Evidence


Memorandum submitted by the Department for International Development

SUMMARY

  The global response to AIDS—and the UK's role in supporting this—has developed rapidly over the last five years moving from global advocacy to building strong political commitment and securing substantial financing, including new instruments like GFATM (the Global Fund to fight AIDS, TB and Malaria). In the past two years, energy has turned to addressing the impact of these enhanced efforts, agreeing the "Three Ones" principles to enhance greater donor harmonisation and alignment with country priorities to make the money work more effectively. The UK has made AIDS a centrepiece of the 2005 G8 and EU Presidencies, emphasising the importance of securing "more aid and better aid" for AIDS, combined with strong policies on scaling up towards universal access to AIDS treatment, and maintaining momentum on HIV prevention. As we move into 2006, there is a clear global priority to move from commitment, targets and money to a strong emphasis on delivering better AIDS services to poor people. Accountability for action will be highlighted in June 2006 when the High Level UNGASS meeting reviews achievements against the targets set in the 2001 Declaration of Commitment on AIDS, and the new goals set at this year's G8 summit in Gleneagles and the subsequent Millennium Review Summit.

Until recently ARV provision for poor people was seen as largely unworkable. Prohibitively expensive medicines, weak health services, and limited resources and attention for AIDS meant that the 2001 UNGASS Declaration of Commitment on HIV/AIDS gave a very basic indication of intent, " . . . in an urgent manner make every effort to provide progressively and in a sustainable manner, the highest attainable standard of treatment for HIV/AIDS . . . ". Less than five years on, global commitments have shifted dramatically. Following substantial reductions in the cost of ARVs, significantly increased financing, evidence on the effectiveness of treatment for poor people, and the role of treatment in supporting prevention, UNAIDS and WHO launched the "3 by 5" initiative in September 2003. The then Minister of State for International Development, immediately pledged the UK's support to meet this goal. Building on this commitment, in 2005 the UK government mobilised international attention and secured global agreement (through the G8 summit at Gleneagles and the UN Millennium Review Summit) to work towards as close as possible to universal access to treatment by 2010. The UK has accepted UNAIDS' invitation to co-chair the Global Steering Committee on Scaling Up Towards Universal Access, and will use this opportunity to ensure that real action follows this ambitious agreement.

  The UK now plays a substantial role in global efforts to tackle AIDS. As the second largest bilateral donor on AIDS (and providing one of the highest proportions of GNI to AIDS) the UK is committed both to securing greater financing for AIDS, and to ensuring that the money is used efficiently to secure high quality AIDS programmes benefiting as many poor people as possible. The UK's approach to AIDS in general—and ARV provision in particular—has a number of strands. The UK engages in policy dialogue at global and country levels to promote effective action. UK finances are directed both through multilateral channels (GFATM, World Bank, the UN family) and through direct bilateral assistance. Much of the UK's bilateral assistance—especially in Africa—is provided through Poverty Reduction Budget Support (PRBS) and Sector Wide Approaches (SWAps). Some AIDS-specific programming is also supported, and the UK is making some strategic long-term investments (eg in research and development). This means that in terms of ARV provision, the UK's action cannot be wholly disaggregated from broader global efforts which the UK supports and influences. By placing AIDS at the centre of the 2005 G8 and EU Presidencies, the UK has helped achieve new international commitments, focused on AIDS treatment (G8/MRS Commitments), and improved the broader environment within which AIDS services are provided (the GTT, the wider commitments to increase aid flows to Africa). Balancing action on specific AIDS issues with action to tackle poverty is fundamental to the UK's approach.

ADDRESSING THE HIV/AIDS PANDEMIC: WHAT ARE THE PRIORITIES IN 2006?

1.  The global response to AIDS—and the UK's role in supporting this—has developed rapidly over the last five years moving from global advocacy to building strong political commitment and securing substantial financing, including new instruments like GFATM (the Global Fund to fight AIDS, TB and Malaria). In the past two years, energy has turned to addressing the impact of these enhanced efforts, agreeing the "Three Ones" principles to enhance greater donor harmonisation and alignment with country priorities to make the money work more effectively. The UK has made AIDS a centrepiece of the 2005 G8 and EU Presidencies, emphasising the importance of securing "more aid and better aid" for AIDS, combined with strong policies on scaling up towards universal access to AIDS treatment, and maintaining HIV prevention momentum. As we move into 2006, there is a clear global priority to move from commitment, targets and money to a strong emphasis on delivering AIDS effective services to poor people. Accountability for action will be highlighted in June 2006 when the High Level UNGASS meeting reviews achievements against the targets set in the 2001 Declaration of Commitment on AIDS, and the new goals set at this year's G8 summit in Gleneagles and the subsequent Millennium Review Summit.

Progress on Achieving Target 7 within the Sixth MDG

2.  Assessing progress on the Sixth MDG on AIDS is hampered by the fact that the MDG target to halt and reverse the spread of HIV and AIDS is rather broad, and there is insufficient data. In line with the commitments in Taking Action, to play an active role in the monitoring and evaluation activities of the international community to measure the impact of our combined response to AIDS, the UK is participating in the UNAIDS-convened "Monitoring and Evaluation Reference Group" (MERG) which seeks to develop multilateral solutions to address problems related to inadequate data.

3.  The steps needed to reach this MDG are elucidated in the UNGASS (UN General Assembly Special Session) Declaration of Commitment on AIDS, agreed in 2001. Achievements against this road map will be reviewed at the High Level meeting in June 2006. An interim review was held in 2003, and at this time the UN Secretary General noted that the world appears to be off-track.

4.  According to UNAIDS, every day an estimated 14,000 people are newly infected with HIV. The total number of people living with HIV is estimated at 39.4 million, with an estimated 4.9 million people newly infected with HIV in 2004. The total number of AIDS deaths in 2004 was an estimated 3.1 million. Women and young people are disproportionately affected—76% of young people with HIV are female.

5.  In sub-Saharan Africa women and girls make up 60% of all people infected. And in 2004, there were 3.1 million new infections across sub Saharan Africa with 2.3 million deaths. Yet while the picture across Africa is sobering, there are pockets of hope. In some parts of East Africa there are suggestions of modest declines in prevalence among pregnant women in urban areas. In West and Central Africa there is little evidence of changes in prevalence levels, which have stayed steady at 5% or lower. National prevalence statistics, though, can hide much higher levels of infection in particular provinces, states or districts. While HIV prevalence measured at antenatal clinics has edged lower in parts of some countries and in specific age groups, there is no sign yet of an overall, national decline in Southern Africa. In South Africa, HIV prevalence rates continue to rise.

6.  DFID has identified 16 countries in Africa within its Public Service Agreement (PSA). All have generalised epidemics—ie HIV prevalence greater than 1%—ranging from 2.1% in Sudan through to 21.5% in South Africa and 28% in Lesotho. In Mozambique, current projections indicate that by 2010 almost one fifth of adults will be infected with HIV, and if current trends continue, AIDS will cause a drop in life expectancy to 36.5 years by 2010 (from a previously anticipated "high" of 50.3 years).

7.  In Asia the only PSA country with falling rates of both new infections and overall numbers of people infected with HIV is Cambodia. Prevalence rates confirm a generalised epidemic. Six states in India have official prevalence rates over 1%, and the number of high prevalence districts within states doubled between 2003 and 2004. The overall prevalence rate in India is 0.9%. Elsewhere in Asia national HIV prevalence rates remain below 1%, but there are increasing rates of infection in vulnerable groups and/or geographic spread of HIV in Pakistan, Nepal, Bangladesh and Indonesia and Vietnam. New data from China will be available in December 2005.

8.  After Africa, the Caribbean is the most affected region, where five countries have national HIV prevalence rates exceeding 2%. In many places the epidemic is concentrated among sex workers. Yet there is also an increasing impact on the general population, especially in Haiti, where prevalence is around 5.6%. Cuba has been an exception in this region, with very low HIV prevalence. Universal free access to AIDS treatment has kept the number of cases and deaths very low.

9.  In Latin America Brazil accounts for more than one third of people with HIV. HIV in Argentina remains concentrated largely in urban areas. 65% of HIV infections are estimated to occur in Buenos Aires and its surrounding areas. In the Andean region HIV has been concentrated among sex workers, their clients and men who have sex with men. In Central America among those with HIV men outnumber women by roughly 3:1 in most countries. Mexico's prevalence in the adult population has remained under 1%, but overall heterosexual transmission of HIV has increased in recent years.

10.  In Eastern Europe and Central Asia the Russian Federation is home to the largest epidemic, and the Ukraine is experiencing a surge of reported infections. Several Central Asian and Caucasian republics have entered the early stages of the epidemic. In most of the countries HIV is spreading rapidly among injecting drug users.

The Delivery of ARVs in Resource Poor Settings

11.  With the current global push to secure as close as possible to universal access to AIDS treatment in poor countries, it is easy to lose sight of the fact that it is just two years since the ambitious "3 by 5" target—to get 50% of poor people on treatment—was proposed by WHO and UNAIDS. Prior to that, the very real challenges and costs of delivering Antiretrovirals (ARVs) to people in resource poor settings were seen as substantially outweighing the arguments, from a human rights perspective, of scaling up access to treatment.

12.  Provision of ARVs is highly complex in resource poor settings. Without broader attention to the wider context, including strengthening weak health care systems, ARV provision is not feasible. There are very real fears that ARV programmes will not be sustainable (yet sustainability is essential if people are to benefit from life-long treatment for a chronic condition) and parallel concerns that a firm emphasis on AIDS treatments could detract from other essential services (eg maternal health).

13.  DFID published its Treatment and Care Policy in 2004 (at the time of "Taking Action", the UK Government Strategy on tackling HIV and AIDS in Developing Countries). The Policy identifies a broad range of interventions required to provide AIDS treatment and care services, including education and awareness campaigns; community mobilisation and treatment literacy; greater access to testing services, in particular voluntary counselling and testing (VCT); support for people with HIV; campaigns to tackle stigma and discrimination; prevention and treatment of opportunistic and sexually transmitted infections; strengthening human resources and wider systems issues; securing high quality, affordable ARVs, and essential laboratory and clinical backup; systems of drug management and procurement; palliative and home-based care.

14.  The UK approach recognises that treatment and care services cannot be divorced from comprehensive multi-sectoral AIDS programmes, embedded in poverty-reduction strategies and wider development processes. Harmonisation among donors, and efforts to ensure that programmes are fully aligned with country ownership and priorities (in line with the Three Ones principles)[1] are essential. Once implemented, the recommendations of the Global Task Team on Improving AIDS Coordination Among Multilateral Institutions and International Donors should secure long-term sustainable country-led programmes, properly supported by the international system. These concerns are reflected in the G8 and MRS statements which recognise that efforts to get as close as possible to universal access to AIDS treatment will only be feasible if embedded in the Three Ones principles, and if countries develop and implement a comprehensive package of care, treatment and prevention initiatives. Delivering all of this in resource poor settings is extremely difficult.

Gaps in Treatment: Children and Other Vulnerable Groups

15.  The UK's approach to AIDS is founded in DFID's overarching commitment to poverty eradication—an ambition which the AIDS pandemic endangers. In this context the UK has consistently pushed to ensure that the needs of the poor, vulnerable groups, women and children are prioritised in respect of service provision. Yet there is very limited data on equity in ARV provision and few countries have disaggregated systems for tracking ARV provision in rural settings, among sub-populations, women, children etc.

16.  Ensuring ARV provision for the most vulnerable is a substantial challenge. AIDS treatment scale up has been slowest in countries where there is major conflict or political instability, and where HIV is concentrated among injecting drug users and sex workers. There are substantial problems with securing continuity of treatment for prisoners, refugees and internally displaced people.

17.  There has been widespread concern that women will not have equitable access to treatment due to cultural attitudes giving men priority over women despite the greater impact of HIV on women. Of the limited disaggregated data available, evidence suggests that there are not wide disparities. In sub-Saharan Africa, almost 60% of adults on treatment are women, reflecting an equitable distribution in line with known epidemiology. It is thought that women may in fact be over-represented as maternal health clinics may be a convenient venue for ARV provision. However, there are concerns about the ability to stay on treatment—and therefore to realise the consequent real benefit—as compared to enrolment (eg women and girls may enrol on treatment during pregnancy, but ongoing adherence rates, eg post-partum, are rarely monitored).

18.  Globally, access to treatment for children is low, despite the fact that—in the absence of treatment—50% of children with HIV will die before their second birthday. In Mozambique and Malawi, for example, 5% and 7% of those on treatment are children, whereas equitable access would require coverage of approximately 13%. Effective AIDS treatment is more than just ARVs. A DFID-supported trial in Zambia found that providing the cheap antibiotic cotrimoxazole to children with HIV reduced mortality by as much as 43%. Yet there is no adequate data on current provision, and certainly no evidence to suggest that the four million children currently in need of cotrimoxazole prophylaxis, and the 660,000 in need of ARVs have access.

Prevention and Treatment: Achieving a Balance

19.  Globally, less than one person in five has access to basic HIV prevention services. This "prevention gap" is fuelling the spread of HIV. Access to evidence based, effective HIV prevention information services and supplies has never been more important. This is why one of the key themes DFID has adopted for 2005 is "Maintaining HIV Prevention Momentum". This approach reflects the fact that as global attention shines a spotlight on efforts to increase ARV provision, it is vital to support countries in maintaining properly balanced, comprehensive AIDS programming, not distorted by false dichotomies, or simplistic cost-benefit analyses between "treatment" and "prevention". Countries, communities and individuals demand a more nuanced approach which recognises the inter-connectedness of services.

20.  "Taking Action" emphasises the need for comprehensive evidence based prevention strategies, embedded in broader social, education and health systems, integrated with sexual and reproductive health services and grounded in rights-based approaches which confront gender inequality, stigma and discrimination. Effective HIV prevention cannot be reduced to simple public health interventions. Rather it must take account of economic and socially entrenched gender and other inequalities that shape people's behaviours and limit their choices. It is vital that those who are most vulnerable, and often marginalised, including sex workers, men who have sex with men, drug users, prisoners, migrants have access to prevention services.

21.  Virtually every region, including sub-Saharan Africa, has several countries where the epidemic is still at a low level or at an early enough stage to be held in check by effective action. Studies suggest that AIDS treatment can support HIV prevention and that HIV prevention is essential to make AIDS treatment affordable. It is estimated that a comprehensive HIV prevention package could avert 29 million (63%) of the 45 million new infections expected to occur by 2010. The cost of these prevention measures is estimated at US $4.2 billion annually by 2007.

22.  Significant challenges remain to providing comprehensive and evidence based HIV prevention. Governments are often reluctant to tackle taboo subjects such as sex, sexuality and drug use. Yet tackling stigma and discrimination—and the underlying structures and societal attitudes which fuel them—is fundamental to effective responses. Evidence based HIV prevention requires steps to confront ideological approaches and gender power dynamics that may not recognise women and girls' vulnerability to abuse and violence, or simple lack of social and economic power to abstain from sex or control mutual fidelity. In addition, services need to be aligned with need. Improving health systems performance is also key, including in terms of addressing the lack of access to vital supplies such as condoms and kits for the diagnosis and treatment of sexually transmitted diseases—improved systems that assure sustained commodity security are also critical.

23.  The UK played an important role in supporting UNAIDS finalise a new comprehensive prevention policy "Intensifying HIV Prevention", and continues to play a key role in increasing political support for attention to sexual and reproductive health and rights, and for support to evidence based HIV prevention efforts. We helped to ensure greater attention to reproductive health in the Millennium Summit Outcome and are now working to ensure that this is translated into the revised Millennium Development Goals (MDG) monitoring framework. Under the EU Presidency DFID is working with the EC and EU Member States to prepare a European Statement of support for comprehensive and evidence based HIV prevention. A UK policy position on Harm Reduction for Injecting Drug Users will be published later this year.

INTERNATIONAL TARGETS FOR ARV PROVISION

24.   Until recently ARV provision in resource poor settings was seen as largely unworkable. Prohibitively expensive medicines, weak health services, and limited resources and attention for AIDS meant that the 2001 UNGASS Declaration of Commitment on HIV/AIDS gave a very basic indication of intent, " . . . in an urgent manner make every effort to provide progressively and in a sustainable manner, the highest attainable standard of treatment for HIV/AIDS . . . ". Less than five years on, global commitments have shifted dramatically. Following substantial reductions in the cost of ARVs, significantly increased financing, evidence on the effectiveness of treatment in resource poor settings, and the role of treatment in supporting prevention, UNAIDS and WHO launched the "3 by 5" initiative in September 2003. The Right Hon Hilary Benn MP, the Minister of State for International Development immediately pledged the UK's support to meet this goal. Building on this commitment, in 2005 the UK government mobilised international attention and secured global agreement (through the G8 summit at Gleneagles and the UN Millennium Review Summit) to work towards as close as possible to universal access to treatment by 2010. The UK has accepted UNAIDS' invitation to co-chair the Global Steering Committee on Scaling Up Towards Universal Access, and will use this opportunity to ensure that real action follows this ambitious agreement.

Lessons Learnt from the WHO 3 by 5 Initiative

25.  3 by 5 was launched in September 2003 with the aim of getting three million people—50% of those in poor countries in need of treatment—on antiretroviral therapy (ART) by the end of 2005. In addition to the substantial contributions the UK makes to WHO's core budget, the UK was the first government to provide a specific contribution to 3 by 5—earmarking an extra £3 million contribution to 3 by 5 for 2004-05. DFID also placed a leading technical expert in WHO Geneva to drive forward efforts in the 3 by 5 initiative.

26.  In June 2005 WHO estimated that whilst the target of three million was not going to be met, one million people were now on treatment in low and middle income countries, a substantial increase from 400,000 people when the initiative was launched. Of 49 "focus countries", 40 had declared national treatment targets and 34 had completed, or were developing, national treatment scale up plans. Funding for ART has risen sharply during this time from international and domestic sources.

27.  It is clear that substantial challenges remain for countries to expand access to treatment, including in terms of ensuring continued equitable access as treatment widens and promoting the integration of prevention and treatment programmes. Expanded treatment relies on broader health systems, yet these are often weakened by critical problems with human resources, procurement and supply management systems and appropriate, accessible health care infrastructure. These challenges are often exacerbated by AIDS—death and disease may deplete health cadres further.

28.  During 2005, the Global Task Team on Improving AIDS Coordination among Multilateral Institutions and International Donors (the GTT) identified further challenges to improving the performance of the multilateral system on AIDS, of which the 3 by 5 initiative is an important element. These include challenges to:

    —    secure inclusive national leadership and ownership;

    —    harmonisation and alignment of multilateral institutions and international partners;

    —    the effectiveness of the multilateral response; and

    —    accountability and oversight.


29.  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. Certainly there have been tensions between the 3 by 5 advocacy role, and the complexities of implementation. The target has served as an effective advocacy tool for increased political commitment to treatment, and mobilising countries and communities to respond. Yet some have made vocal accusations of heavy-handedness and top-down approaches, believing that the approach is distorting country-driven priorities. An evaluation of 3 by 5 is underway, and DFID sits on the Steering Committee. The purpose of the evaluation is to review the accomplishments and lessons learnt by WHO during the implementation of 3 by 5. It will examine WHO activities at global and national levels and will report in March 2006.

The G8 Commitment to Universal ARV Provision by 2010

30.  The G8, at the Gleneagles Summit in July 2005, made a commitment to "working with WHO, UNAIDS and other international bodies to develop and implement a package of HIV prevention, treatment and care, with the aim of as close to possible to universal access to treatment for those who need it, by 2010". The UN Millennium Review Summit in September reaffirmed this commitment, and as such there is a clear global agreement to pursue this goal.

UNAIDS strategy to achieve the 2010 goal, including DFID's role

31.  UNAIDS—the secretariat and its ten co-sponsors—has been coordinating efforts on how to take the 2010 target forward. It is generally agreed that the target can only be achieved if it is country-owned and based in specific country approaches, integrated with broader development processes. The Global Task Team's recommendations have created the groundwork for increased action by countries to scale up comprehensive responses, with the support of the international community, and to use donor and domestic resource flows to maximum effect. Efforts to expand services and aim for as close as possible to universal access to treatment by 2010 will rely on these agreements and the Three Ones principles. Significantly the G8/Millennium Review Summit texts emphasise that this goal depends upon developing and implementing a comprehensive response—prevention, treatment and care—not simply the provision of ARVs. As a co-sponsor of UNAIDS, WHO are playing a key role in developing the health systems components of the essential package of prevention, treatment, care and support.

32.  UNAIDS is in the process of establishing a Global Steering Committee, which the UK will co-chair. It will be based on the principle of country ownership—recognising the need to work through existing national structures and processes—and focus on mobilising countries to scale up ambitious national action plans in line with the 2010 target. In addition the Global Steering Committee will encourage countries to identify key obstacles—and develop solutions—to scaling up towards universal access. UNAIDS will provide a small secretariat for the Global Steering Committee, and assist at the regional and country level through existing Regional Support Teams, UN Theme Groups on AIDS and UNAIDS Country Coordinators.

33.  Efforts to scale up towards universal access will build on existing processes, including the implementation of GTT recommendations, planned Regional meetings and consultations to secure country ownership, and provide regional peer review of proposals. In early 2006, it is expected that there will be a meeting to review progress, and in particular to consider how to align donor commitments behind local plans. A likely blockage to progress will be a lack of predictable and sustainable financing to give countries confidence in committing to long-term plans, including for life-long treatment. A Roadmap or Global Action Plan, which will include steps to be taken to find solutions to common obstacles (eg procurement), will be tabled at the UN Heads of State conference in June 2006 to review progress on the UNGASS Declaration of Commitment on AIDS.

34.  DFID has accepted UNAIDS invitation to co-chair this process. In this role DFID will continue to work closely with the broad range of stakeholders, including bilateral donors (including G8), UNAIDS, WHO, World Bank and other members of the international community. DFID's country offices will be encouraged to work with national authorities, through existing country dialogue. DFID will continue to support multilaterals to engage in this process in line with GTT recommendations, and programme assistance that is consistent with the GTT and Universal Access goals.

THE UK CONTRIBUTION

35.  The UK now plays a substantial role in global efforts to tackle AIDS. As the second largest bilateral donor on AIDS (and providing one of the highest proportions of GNI to AIDS) the UK is committed both to securing greater financing for AIDS, and to ensuring that the money is used efficiently to secure high quality AIDS programmes benefiting as many poor people as possible. The UK's approach to AIDS in general—and ARV provision in particular—is multi-faceted. The UK engages in policy dialogue at global and country levels to increase the political space for effective action. UK finances are directed both through multilateral channels (GFATM, World Bank, the UN family) and through direct bilateral assistance. Much of the UK's bilateral assistance—especially in strong policy environments in Africa—is provided through Poverty Related Budget Support (PRBS) and Sector Wide Approaches (SWAps). Some AIDS-specific programming is also supported, and the UK is making some strategic long-term investments (eg in research and development). This means that in terms of ARV provision, the UK's action cannot be wholly disaggregated from broader global efforts which the UK supports and influences. By placing AIDS at the centre of the 2005 G8 and EU Presidencies, the UK has advanced new international commitments, focused on AIDS treatment (G8/Millennium Review Summit Commitments), but also to improve the broader environment within which AIDS services are provided (the GTT, the wider commitments to increase aid flows to Africa). Balancing action on specific AIDS issues with action to enhance the broader environment, within a clear poverty focus, is fundamental to the UK's approach.

DFID policy and practice on HIV/AIDS: the implementation of Taking Action

36.  In 2004 the UK published "Taking Action, the UK's strategy for tackling HIV and AIDS in the developing world", alongside new DFID policies on Treatment and Care and Sexual and Reproductive Health, and UK government policy and plans on increasing access to medicines in developing countries. At this time the UK pledged to spend at least £1.5 billion on AIDS-related activities over the three year period 2005-06—2007-08.

37.  The UK's strategy outlines action to:

—    close the funding gap;

—    strengthen political leadership, internationally and nationally;

—    improve the international response, including in terms of greater harmonisation between international initiatives and multilateral organisations, and ensuring a better fit between these responses and national approaches in developing countries;

—    support better national programmes, including through our bilateral assistance to country responses; and

—    our work to improve the long term response, including through support for research into new medicines, preventative technologies and AIDS programmes.

Taking action to close the funding gap

38.  A revised estimate of the resource needs for an expanded response to AIDS in low and middle-income countries, was prepared by UNAIDS in response to calls from the Making the Money Work meeting. It showed that there were annual needs of US$15 billion in 2006, US$18 billion in 2007 and US$22 billion in 2008 (with at least an additional $18 billion required over the next three years) to achieve universal AIDS programmes including steps towards universal access to treatment by 2010, comprehensive HIV prevention services, and to deliver care for 12 million orphans and vulnerable children in Africa by giving them better access to education, health care, home support and cash transfers. The UK has taken active steps not just to increase its own contributions to AIDS, but also to encourage a broad range of other donors—and countries themselves—to increase resources for AIDS.

39.  The Global Fund to fight AIDS TB and Malaria (GFATM) is one of the most important multilateral instruments to support a scaled up AIDS response. The UK hosted the GFATM Replenishment Conference in London (5-6 September). This was largely successful with donors pledging a total of US$ 3.7 billion, just over half the US$ 7.0 billion required for 2006 and 2007. Progress was also made on embedding the GFATM within the wider architecture for AIDS financing, supporting GFATM to be even more effective, especially harmonising and aligning to strengthen engagement at the country level. The UK has pledged £359 million (US$ 640 million) to the GFATM over seven years (2002-2008), which includes £100 million for 2006 and £100 million for 2007. Over half of this can be attributed to AIDS. The UK is now the fourth largest donor for the period 2006-07 and the second largest in the EU. The EU provides over 50% of the Fund's finance. Through GFATM, the UK contributes to substantial scale up of ARV provision—with GFATM's latest update showing 200,000 people on ARVs through their finance.

40.  The World Bank is an important source of financing for AIDS, with financing dramatically increasing over the last four years to $250-300 million annually in Sub Saharan Africa, and having provided some $2.5 billion cumulative global lending to date. The UK's IDA 14 contribution is £1.43 billion, making us the second largest donor. The UK as such plays an important role in directly scaling up ARV provision, as well as building the broader environment.

Taking action to strengthen political leadership

41.  Taking Action committed the UK to make AIDS a centrepiece of our Presidencies of the G8 and EU. This has clearly been achieved. HIV and AIDS has had a high profile throughout both Presidencies, and in terms of the G8, this led directly to an international commitment to universal access to treatment.

42.  The UK played an active role at the UN Millennium Review Summit in September to ensure AIDS and sexual and reproductive health had a high profile, working with other UN members to secure the international mandate for Universal Access in the Millennium Review Summit outcome document, which reflects the G8 language.

43.  The Commission for Africa (CfA) achieved much in challenging the international community on those factors affecting Africa's development, including AIDS. The CfA recommendations in this area were widely welcomed and provided a foundation for the subsequent G8 and UN Millennium Review Summit commitments. The CfA also provided an additional way in which the UK Government worked closed with the Africa Union and NEPAD to encourage scaled up responses to AIDS.

44.  The "Three Ones in Action: Making the Money Work" meeting in London in March was the beginning of a process both to deliver more aid and better aid to tackle HIV and AIDS. The meeting identified four key problems:

(a)  AIDS money is spread unevenly including high prevalence countries lacking support;

(b)  The huge administrative burden placed on governments by AIDS donors

(c)  Overlap among international AIDS agencies

(d)  More investments needed in people and systems to deliver prevention, care and treatment.

The meeting also set up the Global Task Team on Improving AIDS Coordination Among Multilateral Institutions and International Donors (GTT) to develop solutions to these problems. Progress has been substantial and has been achieved through a constructive and inclusive process that was very outcome orientated.

Taking action to improve the international response

45.  In 2003-04, the UK worked closely with UNAIDS and the US to secure global agreement to progress the set of principles known as the "Three Ones": one HIV and AIDS strategy; one national AIDS coordination authority; and one monitoring and evaluation system. The Three Ones translates broader agreements made on harmonisation and alignment, (particularly OECD/DAC on aid effectiveness) into the AIDS context. However, change is slow, and whilst many countries established coordinating bodies and strategies, many are still struggling to use the increasing levels of financing available effectively. Also, donors remain insufficiently harmonised.

46.  On 9 March 2005 the UK hosted a meeting of leaders from donor and developing country governments, civil society, UN and other multi-national agencies to review the global response to AIDS with the theme: "Making the Money Work". Participants called for urgent measures to improve the impact of global AIDS action and to make the system more coherent. The GTT was established at the meeting to make specific time bound recommendations to improve coordination and enhance the quality of national responses.

47.  GTT recommendations were released in June and build strongly on the commitment made by the UN and others to the Three Ones and the Paris DAC Aid Effectiveness agenda, including measures to: improve the effectiveness of national responses, drawing on country leadership; reduce unnecessary management and technical burden on governments and to reduce competition and duplication in the provision of technical support; and, streamline and improve accountability in the UN and the GFATM. UNAIDS has developed and costed a Consolidated UN Technical Support Plan, for 47 high priority countries to ensure the GTT recommendations are implemented within timeframes provided.

48.  The UK government has also worked to improve the international response in terms of its impact on poor people's access to medicines, including for HIV and AIDS.

49.  The UK has worked with EU partners to shape a new EU Programme for Action on HIV/AIDS, TB and Malaria, with proposals to support improved access to preventive and therapeutic treatment and increased R&D for new medicines, diagnostics and vaccines.

50.  The UK has continued to take a lead role in efforts to secure agreement on an EU Regulation on the Trade Related aspects of Intellectual Property rights (TRIPS) agreement and Public Health, to implement in EU domestic legislation the TRIPS waiver agreed on 30 August 2003. This allows countries with no domestic pharmaceutical capacity to import copies of patents from third party countries, in accordance with the provisions of the decision. Under the EU Presidency the UK has also continued efforts to secure international agreement on the amendment of the TRIPS agreement at the WTO to incorporate the 30 August Decision.

51.  In March 2005 DFID with the Department of Health and the Department of Trade and Industry launched Increasing People's Access to Medicines in Developing Countries: A Framework for Good Practice in the Pharmaceutical Industry, which was developed in consultation with the pharmaceutical industry and its stakeholders and which brings together good practice in the industry to encourage pharmaceutical companies to go further in making their medicines available in developing countries and in undertaking increased R&D for diseases disproportionately affecting developing countries.

Taking action to support better national programmes

52.  The following are short summaries of how Taking Action is being implemented by DFID country programmes in Africa, Asia, Europe, Middle East and the Americas. However, DFID's geographical reach is far greater than its 40 country programmes. Working through the multilateral system, the UK reaches a far broader range of countries.

Africa

53.  Within the framework of Taking Action DFID has used a mix of aid instruments including general budget support (eg Ethiopia), sector budget support (eg Malawi and Uganda), and specific bilateral HIV and AIDS programmes to strengthen national government, civil society and private sector responses to country AIDS epidemics. Focus has been on developing political leadership, national planning and priority setting along with better coordination amongst government, civil society, private sector and international agencies to provide comprehensive prevention, treatment (including ART) and care services.

54.  In many African countries there is significant existing financial support available for AIDS treatment via the GFATM and the US President's Emergency Plan for AIDS Relief (PEPFAR). DFID has focused on supporting better coordination and harmonisation of efforts based on the "Three Ones" principles.

55.  Support is being provided to strengthen comprehensive and integrated national programmes to prevent, treat, care and mitigate AIDS. Some examples include:

—    In Ethiopia, DFID provides direct budget support to the government for the implementation of the new strategic plan for 2004-08. In January 2005 the government launched a programme to provide ART free of charge with a target of 140,000 patients served by more than 300 health care facilities by the end of 2006.

—    DFID Malawi is providing £4.5 million direct support to the National AIDS Commission as part of pooled funding to support the implementation of the National Action Framework (2005-2009). This supports comprehensive, integrated programmes, filling gaps that are un-funded by other financing. The groups covered by the interventions include women, the young, the affected, the most at risk and OVCs. DFID Malawi is also providing support for comprehensive reproductive health care, essential drugs and critical human resources in the health sector. Pooled funding covers a number of sectors including ministries of health, education and security.

—    DFID Ghana supports a wide array of programmes including ART, condom procurement and distribution, VCT and prevention of mother to child transmission. This includes support across sectors including education, health and social protection.

Asia

56.  The governments of China and India have both increased their policy and financial commitments to address HIV and AIDS during the past year. The Indian government has committed to provide free ARV treatment in the six high prevalence states plus Delhi. In China, the challenge is to translate policy commitments into action at provincial and county level, and scale up implementation to a level that will have an impact on the spread of infection. Increasing commitment at national level in Indonesia and a doubling of the AIDS budget between 2003 and 2006 are encouraging. There has been an increase in the government of Vietnam's efforts to secure multi-sectoral action in prevention and control, and to scaling up treatment provision. Rising HIV rates in vulnerable groups in Pakistan have contributed to increased political commitment. Political leadership is lacking in Bangladesh and the response relies largely on NGO implementation. Afghanistan has a fledgling national AIDS control strategy and programme, including plans for safe blood transfusion, but very little specific action. The government response in Burma is limited and the space for political advocacy appears to be shrinking, but UN and NGO engagement remains firm.

57.   Some examples of DFID support include:

—    DFID has made a commitment to fund HIV and AIDS activities in Indonesia for the first time (£25 million to the Indonesia Partnership Fund for 2005-08).

—    In China, design of the new £30 million programme with the government, UN and Global Fund is underway, and implementation will start in 2006.

—    In Burma, DFID is closely engaged with the UN in efforts to ensure continuity of implementation in the wake of the GFATM's cancellation of its grant.

—    In India, DFID's £123 million support over seven years to March 2007 to the National AIDS Control Programme (NACO) has been reviewed. It supports targeted interventions with vulnerable groups, education initiatives and care in eight key States. It also funds technical cooperation, and a challenge fund to address key groups such as children affected by AIDS, young people, men who have sex with men, and advocacy to address stigma and discrimination.

—    In Bangladesh support to the NGO-led response continues while HIV and AIDS components are agreed and implemented within the multi-donor supported health sector and urban health programmes.

Europe and Central Asia

58.  Universal access is commonly applied in Eastern European countries and Central Asia, but informal fees for health services and drugs limit access to the poor and vulnerable. There remains significant unmet need for ARVs in Russia. WHO estimates that only 1,000 out of an estimated 50,000 in need of treatment are currently receiving ARVs. Clear gaps in treatment include the need to look at TB/HIV co-infection and multi drug resistant TB (MDR-TB)

59.  All DFID-supported AIDS interventions in the region are fully consistent with Taking Action and are in line with the Three Ones principles. Some specific examples of DFID support include:

—    DFID is providing £6.4 million over four years to the Central Asia Regional HIV Programme, which focuses on scaling-up harm reduction strategies with government and NGO partners. Support is also provided to the regional UNAIDS office (2-years £500k).

—    £0.6 million over two years is provided to the Russia UNAIDS 3-Ones Facility project.

—    £0.5 million over two years is provided to the Ukraine UNAIDS 3-Ones Facility project to support flexible technical assistance delivered through UNAIDS cosponsors to support the government's response to HIV and AIDS.

—    DFID provides £1.5 million over 3 years to Serbia and Montenegro's Regional HIV project.

Overseas Territories

60.  Most Overseas Territories (OTs) (Montserrat, Anguilla, Pitcairn, St Helena, and Turks and Caicos Islands) have national AIDS plans. St Helena is in the process, with help from DFID, of developing one. The plans are based on an expanded response and include prevention and treatment. The priority in the OTs is still prevention, as many have low prevalence. All OTs, where there are HIV cases, have ART available.

61.  Priorities for 2006 include: improve expanded response through a new DFID-supported regional programme; improve involvement of Caribbean OTs in regional programmes through EU funding; ensure St Helena remains HIV free.

Caribbean

62.  Small island states should work more collaboratively to procure lower cost ARVs. The Pan-Caribbean Partnership Against HIV and AIDS (PANCAP) has developed a collaborative agreement with support from DFID with Brazil for south-south technical cooperation and provision of free first line ARVs for countries in the Organisation of Eastern Caribbean States (OECS). DFID funding for the Clinton Foundation in close cooperation with the regional Pharmaceutical Procurement Service (PPS) has slashed procurement costs from $1,200 at the start of the programme to $275 per patient per year (for AZT 3TC and NVP). Second line treatment is now $532, down from over US$4,000. There remains a need to maintain a balance between effective prevention and the provision of treatment given a tendency in Caribbean programmes to focus too heavily on provision of treatment.

63.  Stigma and discrimination is a major factor in the spread of HIV in the region, causing people to not present for care and treatment. DFID is working with CIDA and PANCAP on programmes to tackle stigma and discrimination.

Latin America

64.  DFID is supporting Brazil in maintaining and expanding its leading role in the local manufacture and distribution of generic ARV drugs, particularly first line treatments. Brazil is playing a key role in negotiating with multi-national drug companies to significantly reduce the costs of second line ARVs. Brazil is also providing technical assistance and advice on local generic manufacture to Russia, China, Thailand and India.

65.  DFID is working jointly with the government of Brazil, UNAIDS and the German Technical Cooperation Agency (GTZ) on a new International Technical Cooperation Centre (ITCC), the first of five centres (three others in Africa, one in SE Asia) to develop south-south technical cooperation. DFID, with GTZ, is also supporting south-south cooperation in Latin America, including Brazil's support for first-line ARV treatments for 10,000 people in Bolivia, Ecuador and Peru, which is soon to expand to cover Honduras and Nicaragua.

66.  Expertise from Brazil is also critical in improving the technical quality of AIDS programmes in the region. Brazil strongly believes that universal access cannot be achieved without a strong rights-based approach. Brazil has been leading on innovative prevention strategies, involvement of civil society, involvement of the private sector and encouraging greater involvement of faith-based groups. There is a need to increase the focus on stigma and discrimination, a major factor in Central America and the Andes, and maintain a balance between effective prevention and the provision of treatment.

67.  DFID was the earliest supporter of the south-south model of technical cooperation, supporting Brazil and helping them expand into other parts of Latin America. This is now expanding into the Caribbean (PANCAP and OECS see above), Lusophone countries in Africa, and collaborative ventures with Portugal are under discussion. DFID inputs, through the Latin America regional programme, have been relatively modest (£1 million) but have started the work and encouraged the later involvement of GTZ and UNAIDS. DFID will provide additional inputs for the development of the ITCC and a second phase of the Latin America Regional Programme (estimated £2 million).

Taking action in the long term

68.  In Taking Action the UK committed to increase our support for research into: microbicides; treatments and new technologies for the poor, women and young people; and the social, economic and cultural impact of AIDS.

69.  DFID continues to support R&D for new technologies to prevent HIV, including significant funding for microbicide development and funding to Product Development Public Private Partnerships (PDPs) for the development of HIV vaccines.

70.  The UK was the first government to fund the International AIDS Vaccine Initiative (IAVI), with an initial grant of £200,000 in 1998. This was followed by a grant of £14 million for 2000-05. An additional grant of £4 million was made for 2005-06. Further multi-year funding is currently under review. DFID is also supporting microbicide research, and provided an initial grant of £16 million to the MRC for the Microbicide Development Programme (MDP) in 2001. In 2005 an additional £23.8 million was provided to support Phase Three clinical trials for the leading MDP microbicide candidate, PRO 2000. A grant of £1.2 million (£300,000 per year for four years) was provided in 2002, to support the International Partnership for Microbicides (IPM) work on microbicide research, policy and advocacy. Further funding for IPM is currently under consideration.

71.  In 2005 DFID's Central Research Department launched nine Research Programme Consortia on health in developing countries, including work on communicable diseases, sexual and reproductive health, maternal health and HIV. DFID has also funded research on the appropriate use of existing medicines in developing country settings including, clinical trials demonstrating the efficacy of cotrimoxazole prophylaxis in reducing mortality among children living with HIV and co-funding of the DART Trials with the MRC exploring HIV treatment modalities in resource limited settings.

72.  The UK has also been active in developing innovative financing to encourage additional R&D investment into treatments and vaccines for diseases disproportionately affecting developing countries, including for HIV and AIDS. R&D tax credits for small and medium sized companies were introduced in 2000, and for large companies in 2002. In 2003 the "Vaccine Research Relief" was introduced for R&D investment on HIV, TB or malaria treatments or vaccines focused on the needs of developing countries. The UK has worked with G8 partners to develop proposals for "Advance Market Commitments" as a "pull incentive" for priority vaccines, such as for HIV. Under such proposals, donors would commit in advance to guarantee a developing country market of a certain size for a new vaccine that meets pre-agreed criteria (eg for efficacy).

73.  DFID has also provided support to the WHO Commission on Intellectual Property, Innovation and Public Health (CIPIH), which is exploring how investment in and access to new public health goods that better meet preventive and therapeutic health needs can be increased.

Accountability and monitoring

74.  DFID is held accountable through internal and external scrutiny, including through the Public Service Agreement which sets our objectives and how we intend to achieve them, the DFID Departmental Report which reports on progress towards the Public Service Agreement targets, and Resource Accounts, which are primary financial statements recording the full costs of activities, assets and liabilities as well as providing information on how resources have been used to meet objectives.

75.  DFID, through Ministers, is held accountable to Parliament, including through individual MPs and parliamentary committees. In the period from November 2004 to November 2005 DFID received a total of 467 letters from MPs on HIV and AIDS. Over the same period DFID Ministers responded to 44 Parliamentary Questions on HIV and AIDS. DFID's work is audited by the National Audit Office, with the last audit of work on AIDS in 2004. In addition, DFID is subject to scrutiny from the general public, the media, NGOs and the private sector.

76.  In terms of internal monitoring of the effectiveness of Taking Action, two independent evaluations are planned. Both will concentrate on the work of DFID, which is the lead government department, but will also look at some work of other government departments. An interim evaluation will take place in 2006 and a final evaluation in 2008-09. The objective of the interim evaluation is to produce recommendations in four areas:

—    to improve implementation and monitoring of the current strategy

—    on indicators of success to be used in the final evaluation

—    for the UK Government's next steps on AIDS and

—    lessons for other UK (especially DFID) strategies on development issues.

77.  The final evaluation will be for accountability purposes and is expected to concentrate on assessing the overall effectiveness and efficiency of the policy and its implementation.

Policy coherence on HIV/AIDS across Whitehall

78.  The UK's work to tackle HIV and AIDS in developing countries requires concerted and coherent work across Whitehall, led by DFID. Key issues are noted below. Much of this work is coordinated through two formal Cross-Whitehall Groups. The Cross-Whitehall Coherence Group on Tackling HIV and AIDS in the Developing World comprises representatives from No 10, HMT, FCO, Home Office, Department of Health, DTI, MOD, NAO, HMRC, Patent Office, Scottish Executive and Welsh and Northern Irish Assemblies. Many of these departments are also on the Cross-Whitehall Group on Access to Medicines, including representatives of HMT, FCO, Home Office, Patent Office, and DTI.

79.  DFID, No 10, the FCO and HMT have worked closely and with other departments through 2005 on issues of international development and financing (including aid and debt relief) and specifically on G8 and EU commitments on HIV and AIDS, including the G7 Finance Ministers and G8 Africa communiqué text on AIDS treatment.

80.  DFID has worked extensively across Whitehall to further the UK Government's work to increase access to medicines in developing countries, including for the treatment of HIV and AIDS. This is an area that relates to many departments work areas. Key issues include: trade policy, and specifically the Trade Related Aspects of Intellectual Property (TRIPS) agreement; R&D incentives for diseases affecting developing countries; engagement with the pharmaceutical industry.

81.  The 2001 Doha Declaration on TRIPS and Public Health and the 30 August 2003 Decision on compulsory licensing for export have provided a balanced framework that respects the importance of intellectual property rights and the need for countries to have the flexibility to important generic medicines where needed. DFID worked with Whitehall Departments, notably the Patent Office and DTI, on the UK's position in the run up to the 30 August agreement, and on the subsequent EU legislation implementing the 30 August Decision, and the EU's position at the WTO for how the TRIPS agreement needs to be amended to permanently reflect the Decision.

82.  The UK has taken a lead internationally in developing innovative incentives to promote R&D for diseases affecting developing countries. These include the R&D tax credits introduced in 2000 and 2002, and the Vaccines Research Relief introduced in 2003 which specifically seeks to incentivise the development of treatments and vaccines for HIV, malaria, and TB. In addition, Advanced Market Commitments represent a significant opportunity to accelerate the development of a preventative vaccine for HIV. The development of these initiatives has involved close collaboration across Whitehall, and particularly with HMT and HMRC.

83.  DFID has also worked closely with Whitehall Departments, including HMT, DTI and the Department of Health as part of the department's engagement with the pharmaceutical industry. This engagement led to the development of Increasing poor people's access to essential medicines in developing countries: a framework for good practice in the pharmaceutical industry, which was jointly published by DFID, the DTI and Department of Health in March 2005.

84.  Shortages of health workers are an obstacle to progress in expanding access to services including the provision of AIDS treatment in a number of countries, particularly in sub-Saharan Africa. Three of the factors compounding health worker shortages are:

—    Chronic under-investment in health systems and services.

—    HIV and AIDS is tipping already stressed systems in some countries into crisis.

—    Movement of health workers to non-health sector jobs, and to wealthier countries.

85.  Over the last two to three years there has been increasing global attention directed to the shortages of health workers, particularly in sub-Saharan Africa, and increasing national and international initiatives to find appropriate solutions.

86.  DFID is supporting country-led, systemic approaches to increase the supply of health workers. This includes increasing training capacity, improving working conditions, pay incentives, morale and motivation, effective and active management. Although the primary agenda is long-term, DFID is working with the international community to identify fast-track efforts and to accelerate the availability of health workers where countries are facing acute shortages. One example is DFID's support to the government of Malawi's Emergency Human Resource Programme, which will almost double the number of nurses and triple the number of doctors in Malawi over the next six years.

87.  In addition to the work that DFID does to support many countries to address the "push" factors associated with migration of health workers (low morale, poor pay, career paths and working conditions generally, including lack of supervision, poor housing, workloads etc), the UK also has systematic policies that prevent the targeting of developing countries in the international recruitment of health care professionals including:

—    Guidance and a recently revised Code of Practice embodying ethical principles for the international recruitment of healthcare workers.

—    An agreed list of developing countries that should not be targeted for recruitment.

—    A Memorandum of Understanding has been signed with South Africa, that will give opportunities for exchange of knowledge and skills.

88.  The UK is also putting significant investment into the expansion of training of healthcare professionals to meet our healthcare needs, for example, the numbers of nurses and midwives entering training in England is currently increasing year on year.

89.  The UK has extensive and comprehensive services available to treat and care for people with HIV and AIDS. DFID contributes to the work of other Whitehall departments, notably the Department of Health and Home Office, on issues related to access to HIV services by immigrants, including in terms of charges for overseas visitors. Under the provisions of the NHS (Charges to Overseas Visitors) Regulations 1989, as amended, treatment for HIV is not free if the patient is an overseas visitor liable to pay for any hospital treatment received. The regulations also contain a large number of exemptions from charges so that, for example, asylum seekers and people coming here to work are eligible for free NHS hospital treatment, including HIV treatment.

90.  To mark World AIDS Day this year DFID, working with other departments under the banner of the EU Presidency are hosting a High Level meeting of Ministers for International Development on 30th November, at which an EU Presidency Statement on HIV Prevention agreed by the European Commission and all member states will be launched.

91.  A new UK government policy paper on harm reduction relating to drugs use and HIV prevention in the developing world will be launched for World AIDS Day. The paper builds on cross-Whitehall consensus on harm reduction, ensuring a coordinated and collaborative UK voice. DFID's work on harm reduction covers needle and syringe access and disposal programmes, drug substitution therapy and information/advice on sexual and reproductive health.

92.  DFID, the FCO and the British Council developed a joint HIV and AIDS workplace policy in 2002. This covered a number of "good practice" management policies including the principle of non-discrimination against HIV positive staff and provision of voluntary counselling and testing on a confidential basis. DFID, the FCO and the British Council amended the policy in 2005 to extend provision of antiretroviral therapy so that as well as employees and one partner, dependent children up to the age of 21 would also qualify.

November 2005







1   The Three Ones Principles are one agreed AIDS Action Framework for each country that drives alignment of all partners, one national AIDS authority, with a broad-based multi-sectoral mandate and one agreed country-level monitoring and evaluation system. Back


 
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