Memorandum submitted by UNICEF
UNICEF UK is one of 37 National Committees based
in industrialised countries that raise funds for UNICEF's programmes
around the world and advocate for change on behalf of all the
world's children. UNICEF is the world's leading organisation working
specifically for children. We work with local communities and
governments in 157 countries, areas and territories, to provide
emergency relief and run long-term development programmes in areas
such as health, education and child protection.
UNICEF UK welcomes this opportunity to contribute
to this evidence session on HIV/AIDS and the provision of anti-retroviral
treatment. Significant momentum has been achieved in the global
response to HIV/AIDS. For example, the "3 by 5 Initiative",
begun in 2003 and supported by WHO, UNAIDS, UNICEF and other partners
has generated considerable momentum to expand access to treatment.
Since 2003, the number of people receiving anti-retroviral treatment
(ART) in low- and middle-income countries has doubled. By June
2005, about one million people in the developing world were receiving
ART. UNICEF UK welcomes the UK Government's contribution to the
fight against AIDS and acknowledges that it is the second largest
governmental donor to HIV/AIDS and was one of the first to specifically
allocate money to children affected by HIV/AIDS.
Whilst this momentum is welcome, the response for
children needs to be scaled up significantly. An estimated funding
gap of at least $18 billion from 2005 to 2007 still exists and
just 15% of those in need of immediate treatment in developing
countries are receiving ART. Children continue to be the missing
face of AIDS. Globally, less than 5% of children who need ART
are receiving it and less than 10% of pregnant women are being
offered services to prevent transmission of HIV to their infants.
SUBMISSION
1. On 25 October 2005 UNICEF launched its global
campaign "Unite for Children, Unite Against AIDS" which
calls on governments and organisations around the world to join
together to put the care and protection of children, adolescents
and young people at the centre of the HIV/AIDS agenda.
2. As part of our global campaign, we are working
to scale up the prevention of mother to child transmission (PMTCT)
of HIV/AIDS. Globally, less than 10% of pregnant women are being
offered services to prevent transmission of HIV to their infants.
As a result more than 95% of HIV infected infants in Africa acquire
HIV from their mothers during pregnancy, at the time of delivery
or post-natally through breastfeeding, whereas North America and
Europe have reduced HIV infections in young children to almost
zero. Treatment options include a one-month course of zidovudine
(AZT) during the last weeks of pregnancy, or a single dose of
nevirapine given to the mother at delivery, followed by a single
dose to the infant within 72 hours of birth. Our campaign aims
to increase the coverage of women being offered these services
to 80% by 2010.
3. One of the major impediments to progress is
the cost of anti-retroviral drugs, which remain prohibitively
high for the vast majority of HIV positive people worldwide. Today,
some generic combinations cost just $150 yet in some of the most
affected countries, average earnings make this cost unaffordable.
In Malawi for example, the average wage is only $170 per year.
Anti-retroviral drugs must be free to the user, as they are in
Brazil, Cuba, Botswana and Malawi, for example.
4. In 2005, an estimated 660,000 children needed
anti-retroviral therapy worldwide, but less than 2% of them are
receiving it. Investment in paediatric formulations and their
distribution is therefore urgently required. Now that we have
the new commitment to universal access to treatment, we believe
that no child should be denied access to treatment.
5. In addition to improved access to ART, the
antibiotic cotrimoxazole must be made more widely available. Cotrimoxazole
has been shown to reduce mortality in children living with HIVAIDS
by as much as 43%. It is highly effective protection against opportunistic
infections including malaria and pneumonia, and can postpone the
time at which ART needs to begin. In 2005, an estimated four million
children need cotrimoxazole, although with early detection of
HIV in young infants the number can be reduced to 2.1 million
children. At just US$0.03 a day, cotrimoxazole is a feasible,
low-cost intervention that could make a real difference to children
living with HIV/AIDS.
Barriers to paediatric treatment
6. There is a lack of age-specific data on the
numbers of children who could benefit from ART. This has hampered
efforts by countries to plan treatment and improve drug supply
and distribution. New research, commissioned by UNICEF and undertaken
by the Institute of Child Health in London, has developed a statistical
modelling exercise that can be used to estimate the scale of the
number of children who might need medication. This provides a
basis upon which countries can now set treatment targets for children.
7. There is also a lack of affordable polymerase
chain reaction (PCR) tests for diagnosis of HIV infection in infants
less than 18 months' old. The prices of the PCR test kits need
to be reduced so that they are available in all the necessary
clinical and health settings.
8. Anti-retroviral treatment is not appropriate
or effective for every HIV-positive child. The drugs are necessary
only when the number of CD4 cells falls below a certain level.
Ascertaining when a child should start treatment requires regular
testing to monitor their viral load and CD4 count. This can be
an onerous task where health services are already overstretched.
9. Even when HIV is suspected or diagnosed, and
ART providers recognise the need for medication, drug formulations
that are appropriate for children are not easily available. The
paediatric formulations that are on the market are expensive compared
to adult formulas. For example, a fixed-dose treatment that is
available for about US$200 per adult patient per year will cost
around US$1,300 for a child formulation of the same drugs. Furthermore,
existing formulations are not packaged in child-friendly doses,
leaving unskilled, often elderly, carers to break and crush adult-sized
pills or try to persuade children to swallow bad tasting, difficult-to-measure
syrups. Pharmaceutical companies who produce anti-retroviral drugs
have hesitated to invest in the development of paediatric products
because HIV infection among children in rich countries has been
almost eliminated and the demand for child-oriented products has
not yet been made forcefully enough in low-income countries.
10. Finally, health, procurement and supply management
systems need to be strengthened. The inequalities in health care
between affluent and poorer countries, for example, are already
stark but as HIV prevalence grows, more demands are placed upon
an already overburdened health system exacerbating these inequalities
further. Set against this backdrop, the international recruitment
of health workers is felt deepest by countries and communities
with a high prevalence of HIV/AIDS. For many countries and communities,
the loss of health workers serves only to undermine an already
inadequate, under-resourced health infrastructure and therefore
denies greater numbers of children affected by HIV/AIDS access
to essential health care. The situation is particularly severe
in Africa. According to the World Health Organization, Africa
has a quarter of the world's health burden and just 1.3% of the
world's health workers. In Ghana, about 70% of young doctors leave
the country within three years of qualifying, resulting in just
1,500 doctors serving a population of 20 million. UNICEF UK welcomes
the Government's efforts to strengthen health care capacity in
countries such as Malawi and Zambia and urges them to develop
and spread existing good practice.
November 2005
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