Select Committee on International Development Written Evidence


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   IbidBack


 
previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries index

© Parliamentary copyright 2006
Prepared 2 February 2006