House of Commons - International Development

Select Committee on International Development Written Evidence

Memorandum submitted by the Working Group on Orphans and Vulnerable Children[25]

1. The Working Group on Orphans and Vulnerable Children of the UK Consortium on AIDS and International Development welcomes this opportunity to make a submission to the International Development Committee.

2. Children are neglected in AIDS treatment: HIV positive children are invisible. The needs of children have been one of the most neglected aspects of the HIV and AIDS pandemic and particularly those children living with HIV in the developing world. At the end of 2004 2.2 million children under the age of 15 were living with HIV,[26] of whom two million (88%) live in Africa. In the first half of 2005 alone, 410,000 of these children died.[27] AIDS has already caused infant mortality in Africa to increase by more than 19%,[28] and under-five mortality has risen by 36%. Globally, less than 5% of all HIV positive children have access to treatment they desperately need.[29] Without this treatment, 80% of children born with HIV will die before their fifth birthday.[30] Committing to treatment ensures the child's right to not only to health but also to life, survival and development.

3. End mother to child transmission: The rapidly increasing number of HIV positive children is driven by a failure to prevent mother to child transmission (MTCT). Without preventative services, roughly one third of infants born to HIV positive mothers will acquire the virus during pregnancy, labour, delivery or breastfeeding. Globally, 90% of all HIV positive children are infected through MTCT.[31] A single dose of the drug nevirapine to the mother as she begins labour, and another to the infant within the first three days of life, reduces transmission by 50%.[32] Providing a mother with a full range of preventative MTCT services, including elective caesareans and alternatives to breast milk, can reduce risk of transmission to less than 2%.[33] However, less than 10% of all women are offered these essential services.[34] This is a gross violation of the rights of both these women and their children.

4. Prevent opportunistic infections: Cotrimoxazole is an antibiotic that is highly effective in preventing opportunistic infections in children,[35] When given to children known to be HIV positive, and to those whose HIV status is unknown, cotrimoxazole prophylaxis can increase child survival and delay the need antiretroviral therapy. A study in Zambia found up to a 43% drop in mortality when young children had access to cotrimoxazole.[36] In June 2005, an estimated four million children needed this life saving treatment,[37] costing less than $.03/day per child.[38] A small price for saving many lives.

5. Establish national and international treatment targets for children: Children's right to treatment is specifically outlined in General Comment 3 on HIV and AIDS and the Rights of the Child, part of the Convention on the Rights of the Child[39] Children can and do respond well to treatment, such that where treatment is available, more than 80% of children live to see their sixth birthday.[40] However, governments are failing to prioritise children in national HIV treatment targets. As of 2005, an estimated 660,000 children need anti-retroviral therapy (ART).[41] Globally, less than 2% of children in need of ART receive it.[42] In Malawi, children are only 5% of those treated, while in Mozambique the proportion is 7%.[43] For equitable access based on treatment need children should make up at least 13% of those treated.[44] The explicit consideration of children is crucial—treatment targets translate to treated children.

6. Demand affordable diagnostics: Treatment cannot start without diagnosis. The most commonly available, easy to use diagnostic test is inaccurate with children under 18 months of age.[45] Infants must be diagnosed through a more complicated test that measures the HIV virus instead of antibodies.[46] Unfortunately, current tests require technical expertise as well as costly equipment, placing them out of reach of resource-constrained settings.[47] As of the end of 2005, multinational diagnostic companies have shown little interest in developing accurate, simple, fast and affordable tests for diagnosing children.[48] Their lack of interest is fatal for children.

7. Increase child-focused research and development: Despite urgent needs for paediatric formulations, child appropriate treatments are sorely lacking. Alarmingly, few drugs in current WHO ART guidelines are available in formulations that are affordable, feasible or acceptable for use in young children,[49] The limitations of current formulations are substantial:

— Most paediatric formulations are available either in liquid form—raising issues of volume measurement, palatability and refrigeration—or in a powder form—which must be mixed with clean water.

— Many drugs have adverse side effects that make administration to children much more difficult.

The lack of research and development means that treatment of children is often imprecise. Health care workers and caregivers are forced to make due with what is available, often crushing adult tablets and estimating dosage requirements. This is complex for the caregiver and imprecise for the child, reducing lifesaving treatment to a guessing game.

The development of new drugs has mainly focused on adults, as is seen in the fixed dose combination pill (FDC) which simplify treatment and increase adherence. Each pill combines three drugs, enabling patients to take only one pill twice a day. This simple treatment regime is essential for children and their caregivers. Unfortunately despite these advantages, FDCs are largely unavailable for children and no FDCs are currently pre-qualified by the WHO.[51]

8. Deliver free treatment: It is essential that care and treatment for children be provided free and not subject to user fees. Recent research has demonstrated that abolition of health fees could prevent hundreds of thousands of deaths of children under five.[52]

9. Fully implement the Doha Declaration and immediately end "TRIPS Plus" provisions: Flexibility is provided to TRIPS by the 2001 Doha Declaration of the WTO. Crucially, under compulsory licensing, a government can site public interest in order to allow generic drugs to be produced without the agreement of the patent holder. Compulsory licensing is essential for ensuring research and development in the name of public interest instead of corporate profits. Alarmingly, trade pressures by some governments have made governments reluctant to cite public interest in order to override patent laws. Furthermore, bilateral trade agreements pushing for increased levels of patent protection, known as "TRIPS Plus", undermine the ability of developing country governments to exercise the flexibilities of the Doha Declaration. Full and immediate implementation of the Doha Declaration and an end to TRIPS Plus is the only way to meet ART treatment needs in developing countries. Governments must be enabled to grant compulsory licensing in order to ensure research and development of FDCs and other child treatment needs.

10. Strengthen national health systems: All treatment must be supported by a strong health care system that can provide essential health services as well as care and support. In Africa, this means upholding the Abuja Declaration, in which African states pledged 15% of GDP to health sector spending, a commitment that has been largely unmet.[53] International donors must work with national governments to strengthen health care systems capable of meeting both the diagnostic and treatment needs of children. Treating children is different from treating adults and health professionals must be trained must be trained to respond to the particular needs of children and provided with appropriate treatment guidelines.

11. Lead the G8 Commitment to deliver universal access to treatment by 2010: The OVC Working Group strongly welcomes the leadership shown by the UK Government to gain the commitment of G8 leaders to work with African partners to "ensure that all children left orphaned or vulnerable by AIDS or other pandemics are given proper support." Likewise, we applaud the commitment made at the UN Summit that, as part of reaching the goal of universal access to treatment by 2010, governments committed themselves to "the reduction of vulnerability of persons affected by HIV/AIDS . . . in particular orphaned and vulnerable children and older persons." We also recognise that the UK Government has already provided funding of research on cotrimoxazole and on anti-retrovirals for children, as well as supporting UNICEF to mobilize global opinion on the need to develop paediatric AIDS treatment. We look to the UK to continue this crucial role in leading the response in 2006 to ensure that we reach the ambitious goals established this year.

12. Key Priorities for 2006: In order to achieve the commitment to universal access to treatment by 2010 the OVC Working Group is calling on the UK Government to continue providing leadership on HIV and AIDS in order to continue to raise the profile of children. We specifically call for the UK Government to challenge national governments, UN agencies and donors to do the following:

— As a matter of priority, provide the resources needed to scale-up programmes, which include life-prolonging cotrimoxazole as part of basic health services.

— Ensure that governments and UN agencies set national and international HIV treatment targets, which explicitly include children through your continued leadership in these areas.

— Provide resources for research and investment in simple and affordable diagnostic kits for children and make them widely available.

— Increase funding for research and development of child-specific treatments, including fixed dose combinations for children.

— Contribute to the scale-up of programmes to prevent mother-to-child transmission of HIV (PMTCT), by providing increased resources and technical assistance, and providing new medicines to all women and children who need them.

— Commit the $6.4 billion that UNAIDS has calculated will be needed between 2006-08 for orphans and children affected by AIDS—reflecting 12% of all HIV and AIDS expenditure.

— Encourage national governments and other donors to press the Global Fund to Fight AIDS, TB and Malaria to focus on the needs of orphans and children affected by AIDS in Round 6.

— Fully implement the Doha Declaration and immediately end "TRIPS Plus" provisions.

— Support African governments to meet their commitment to devote 15% of GDP to health sector spending and enable them to abolish health user fees for children.

November 2005

25 The Working Group on Orphans and Vulnerable Children consists of Amref, British Red Cross, Cafod, Care International, Child Hope, Christian Aid, European Forum on HIV/AIDS, Children, Young People and Families, Healthlink, HelpAge International, Hope HIV, International HIV/AIDS Alliance, Mildmay International, Plan UK, Religions for Peace (UK), Save the Children UK, Tearfund, Uganda AIDS Action Fund, The Diana Princess of Wales Memorial Fund, UNICEF UK, USPG, UWESO, VSO and World Vision UK. Back

26 UNAIDS (2004) "AIDS Epidemic Update: December 2004" Joint UN Programme on HIV/AIDS Geneva. Back

27 UNICEF (2005)-"A Call to Action: Children the Missing Face of AIDS" (As of May 2005, for children 0 to 14.) Back

28 ANECCA (2004) "Handbook on Paediatric AIDS in Africa" African Network for the Care of Children Affected by AIDS. Back

29 UNICEF (2005) "A Call to Action: Children the Missing Face of AIDS". Back

30 UNICEF (2005) "A Call to Action: Children the Missing Face of AIDS". Back

31 Médecins Sans Frontie"res (2005) "Paediatric HIV/AIDS" Fact sheet, MSF Campaign for access to essential medicines. June 2005. Back

32 Glaser Foundation (2005) "What about us? Childrens Battle to Access AIDS Treatment." Elizabeth Glaser Pediatric AIDS Foundation. Back

33 Glaser Foundation (2005). Back

34 UNAIDS (2004) "AIDS Epidemic Update: December 2004" Joint United Nations Programme on HIV/AIDS, Geneva. Back

35 WHO (2005) "Progress on Global Access to HIV Anti-Retroviral Therapy-an Update of `3x5'". Back