Memorandum submitted by Professor Tony
Barnett, London School of Economics
This brief note covers the following areas of relevance
to the deliberations of the Select Committee:
1. The lessons of 3x5.
2. Long term considerations of ARV therapy: resistance,
paediatric provision and the next generation of medications.
3. DFID accountability and monitoring.
4. Policy coherence across Whitehall.
Observations are kept purposely brief to facilitate
consideration by the members of the committee. One document is
appended for information in relation to para 12.[11]
1. The lessons of 3x5: this was always
an over-ambitious target. It has not been met but the slogan served
a useful motivational purpose. We have learned from the experience
that introduction of ARVs in resource poor settings can be done
but that the process is heavily dependent upon local health infrastructures.
Experience in some poor communities, notably in Khayelitsha in
South Africa under the auspices of Médecins sans Frontie"res
and in Haiti under the auspices of Partners in Health, demonstrates
that in very special circumstances such programmes:
(a) provide a motivation for HIV-positive people
to be aware of their status: whereas without treatment as an option,
knowledge that one is HIV-positive can be seen as offering little
more than stigmatization;
(b) promote openness and reduces stigma, as HIV
is no longer an inevitable death sentence;
(c) can fuel educational initiatives supported
by a pool of HIV-positive people open about their status;
(d) improves the morale of health care workers
who can offer something beyond temporary treatment for opportunistic
infections;
(e) help to keep families intact and economically
stable, thereby protecting the most vulnerable (women and children)
and minimizing at-risk populations.
2. There can be no doubt that such outcomes are
desirable and the committee's attention is particularly drawn
to para 1(e) above. The point is that the long term benefits of
such interventions are very great indeed. They point not only
to the returns to the individual in terms of improved health
in increased life expectancy, but also to the implications of
such interventions for among other things: orphaning averted,
intergenerational support systems maintained, transmission of
knowledge between generations, improved socialisation of children,
returns on educational investment and many other areas of what
may broadly be described as "investments".
3. In addition, the overall level of happiness
is improved. Use of this term may surprise some committee members
but recent developments in welfare economics now suggest that
such a variable may be a useful measure of returns on investment.
In addition, very recent fieldwork in South Africa indicates that
people there are well able to relate to this concept in considering
the negative effects of the epidemic and the potential returns
to interventions such as micro-finance provision.
4. An additional indication from recent fieldwork
is that people in South African communities (specifically in Limpopo
Province) were well aware of another area of HIV/AIDS impact that
could be relieved via effective ARV programmes: the loss of the
various types of essential but unpaid labour that goes on in any
community, glues it together and takes it forward. This is usually
omitted from standard economic analyses of the returns to investments.
In this case, respondents identified such contributions that they
had personally experienced as serious community losses, the deaths
of: the choirmaster and of the pastor from the Zionist Christian
Church. They pointed in each case to the role such people play
in mobilisation of community action, the creation of local level
public goods and counselling people about how to deal with personal
problems.
5. The significance of the preceding is that
inevitably the returns to successful investments in ARVs are much
greater than formal economic analysis reveals when it limits itself
to financial or proxy financial criteria for evaluation.
6. However, we have also learned from 3x5 that
the mode of introduction of ARVs is very sensitive to (a) local
heath infrastructure (b) levels of poverty in the community. Two
examples will suffice. In Nigeria, in Benue State, potential demand
for such treatments is very large indeed but on the ground observation
suggests that there is little realistic expectation that such
provision can be effective in the context of the state medical
system (local DFID staff can probably update on this). In Uganda
where the health infrastructure is superior to that in Nigeria,
provision of ARVs is moving on apace and many centres now offer
such services. The problem is one of effective demand.
Research in Kyebe village a year ago revealed a representative
case: a woman in her 40s who is probably ready to enter treatment
(I have followed her life from time to time since 1989). She has
five children under 12 and survives by cultivating a smallholding
and has no significant cash income. Her problem was how to raise
the 70 pence she requires each month to take her to the nearest
treatment centre, where to stay when she arrived there and how
to pay for a treatment partner to accompany her. In other words,
poverty makes it impossible for her to effectively demand treatment.
If she dies her children will be orphaned with all the attendant
long term sequelae.
7. Long term considerations of ARV therapy:
resistance, paediatric provision and the next generation of medications:
A major problem in ARV provision in these circumstances is
the emergence of viral resistance. This can take two forms:
(a) acquired resistance where the viral population
in an individual becomes resistant to the treatment regimen; and
(b) transmitted resistance where an individual
is infected by an already resistant version of the virus.
The former is quite common (about 27% of people
on treatment in the UK under excellent clinical conditions experience
some form of acquired resistance requiring changes in treatment
regimen), the latter is currently rare but some cases have been
reported.
8. The danger is that in resource poor settings
acquired resistance could become more common and make a contribution
to increased epidemics of transmitted resistance. This process
is poorly understood but it has to be taken into account very
seriously in any deliberations.
9. The safest view to adopt is probably that
given such possibilities we probably have an ARV window of
opportunity of at most 10 years before it is possible that
the epidemic will reassert itself in some regions (particularly
in Africa) through the appearance of drug resistant infections.
It is therefore of the utmost importance that we do not assume
that we can move forward steadily into the sun-lit uplands of
ARV treatments as a "solution". We need to be thinking
ahead to a possible next round of epidemic with all the problems
of impact and impact mitigation (of which we still know very little
and have learned even less over the last 30 years). This should
be a high priority for DFID.
10. With regard to paediatric provision, the
state of knowledge of such provision in poor countries is quite
limited and more effort is required.
11. There are new ARVs on the horizon: we need
to be thinking now about how to make sure they will be made available
for resource poor settings and should engage with the development
process early on to ensure that issues of prices, generic production
and suitability for viral strains and treatments conditions are
taken into account at the design stage rather than as an add on
to medications produced for use under optimal conditions in rich
countries—the new injectable drug Fuseon (Roche Pharmaceuticals)
is a case in point.
12. The balance between prevention and treatment:
we should recognise (a) that we do not understand what happened
in the two "successes" in Africa—Uganda and Senegal.
We have some good hypotheses. By and large prevention has failed.
(b) It has failed because we have really not untangled the complex
causalities as between individual behaviour change and its impossibility
in circumstances of great poverty where survival sex enters into
the equation. Attached paper discusses these issues in more detail[12]
(Barnett and Parkhurst, Lancet Infectious Diseases, September
2005).
13. Accountability and monitoring: there
is no doubt that DFID was highly motivated in its response to
the largely negative National Audit Office report on its engagement
with HIV/AIDS issues. There is currently no clear indication that
its proposed evaluation method will really reveal whether it is
being effective in this field. In many respects the efforts of
DFID are likely to be compromised by (a) inappropriate evaluation
methods which fail to take full account of the specificities of
the epidemic (b) poor use of excellent human resources within
the organisation as responses to cost saving demands. The effect
of this is to ensure that people with years of experience are
often expected to multi-task to a degree where there is loss of
institutional memory and resulting inefficiency. Careful use of
resources does not come cheap and it is my judgement that within
DFID the effective cost saving margin in relation to this field
was passed several years ago.
14. Policy coherence across Whitehall:
the most disgraceful policy incoherence exists between the Home
Office IND and DFID. We are sending people back to Africa who
are currently on ARVs in the UK. Apart from human rights issues,
such people are then likely to develop acquired resistance as
their viral loads increase as they cease to be able to access
treatment. They are then likely to pass on resistant virus. This
is an area of policy where the Select Committee should give serious
thought. UK Government policy with respect to ARV treatment for
illegal immigrants, people awaiting the outcome of asylum appeals,
and others in similar circumstances is often contradictory to
the aims of overseas development.
November 2005
11 "HIV/AIDS: sex, abstinence, and behaviour
change", Lancet Infectious Diseases, September 2005.
Copy placed in the Library. Back
12
Ibid. Back
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