Appendix: Government response
[Paragraph 4] We are concerned that DFID's indicators
of success are linked primarily to funding targets rather than
to outcomes. We recommend that in the interim and final evaluations
of Taking Action, success is measured against
transparent 'outcome indicators' as well as 'funding indicators'.
Outcome indicators should set out DFID's contribution to achieving
the international targets on HIV/AIDS treatment, prevention and
care.
AIDS is a global epidemic and the UK government recognises
that it cannot halt the spread of the disease alone. In addition
to its spending target on HIV and AIDS of £1.5 billion over
the period 2005/6-2007/8, set during its 2005 G8 leadership, the
UK government is coordinating with other donors to ensure that
the target of delivering comprehensive HIV prevention programmes,
treatment, care and support by 2010 is met (as agreed at the United
Nations General Assembly High Level Meeting on AIDS, 2 June 2006).
In 2005, the UK, as EU President, initiated the process to develop
and lead negotiations to achieve an EU-wide statement on HIV Prevention.
Countries have committed themselves to setting ambitious
national targets to achieve universal access, a process we lobbied
strongly for at the UN General Assembly High Level Meeting on
AIDS. Overall global impact will be measured against the aggregated
targets and results from countries. We are working closely with
UNAIDS and with other international agencies on this important
issue.
According to UNAIDS, by the end of October 2006,
84 countries had provided target data, of which 44 countries
had set outcome targets for all three programmatic target areas
and at least 21 countries had proceeded with costing their strategic
plans. It is anticipated that a number of countries will continue
with their target-setting process during the course of 2007. The
UK, working with G8 partners, is pressing UNAIDS to undertake
an early review of the strategic plans and to aggregate country
targets to better understand global funding needs.
DFID fully agrees that outcome indicators and a focus
on results are necessary in addition to financial
inputs to meaningfully track progress and we are considering ways
to better track inputs, outputs and outcomes. For example, the
final evaluation of Taking Action: The UK's strategy for tackling
HIV and AIDS in the developing world will cover the issue
of transparent outcome indicators as well as input and output
targets. However we would question whether donors should seek
to attribute specific outcomes to their own support. As donor
support is increasingly channelled through general budget support,
our role is one that supports partner governments to develop their
own systems for monitoring the progress of programmes towards
meeting specific outcomes. We believe that country-set targets
should achieve the most effective outcomes.
[Paragraph 7] We see a clear contradiction between
a policy of routinely charging those failed asylum seekers who
want to start a course of treatment after their application has
been rejected and Government advocacy of the universal access
goal. We believe that undermining the needs of minority groups
in this way is a denial of their human rights and weakens DFID's
international leadership on this issue. We believe that DFID should
play a role in ensuring that asylum seekers living with HIV are
not returned to countries where access to ARVs [anti-retroviral
therapy] is not practical. We regret that more progress has not
been made on these matters since our last report.
The treatment of asylum seekers who are HIV positive
involves balancing the needs of the individual with the overall
need to ensure that we have a strong immigration system in place.
DFID's task is reducing poverty in developing countries, and the
right thing to do must be to scale up access to treatment, prevention
and care in developing countries to ensure in the future that
asylum seekers living with HIV are not returned to countries where
access to anti-retroviral therapy is not available. The figures
on increasing access to treatment are encouraging; for example,
in Sub-Saharan Africa, the number of people on treatment rose
tenfold between 2003 and 2006, to over 1 million.
More specifically, HIV positive asylum seekers to
the UK whose application is pending are entitled to NHS hospital
treatment free of charge until such time as a final decision on
their claim, including any appeals, has been made. The eligibility
for NHS treatment is set out in the NHS Regulations 1989 (Overseas
Visitors Hospital Charging Regulations). Asylum seekers may also
register with a GP and most are eligible for free prescriptions
on the basis of low income.
Once appeal rights have been exhausted, unsuccessful
asylum seekers are expected to return home as soon as possible
and are no longer eligible for free NHS treatment. However an
easement clause provides for an existing course of treatment to
be continued free of charge until the patient leaves the country.
Treatment for any new condition is chargeable, although treatment
received in an Accident and Emergency Department remains free
to all. Some NHS services provided in NHS trusts are free to everyone
regardless of the status of the patient. This includes certain
diseases, including TB, where treatment is necessary to protect
the wider public health. In the case of HIV, only the initial
testing and any counselling is free.
The public health risks around TB are different from
those of HIV. The routes of transmission are different. TB is
an airborne infection not easily transmitted from person to person,
and usually requires prolonged close contact with an infectious
person. HIV is not airborne but is spread through specific practices
and behaviours. Changing those behaviours can contribute greatly
to reducing the public health risk. That is why diagnosis of HIV
and associated counselling are free to all.
An asylum seeker's state of health can have no bearing
on the outcome of the asylum claim itself, which is decided in
accordance with the 1951 UN Convention on the Status of Refugees
and its Protocol. A number of people who are HIV positive or
have other serious health conditions seek to remain in the UK
on human rights grounds. They include both unsuccessful asylum
claimants and others who have not applied for asylum but have
no lawful basis of stay in this country. Such applications are
considered by the Home Office on their individual merits in accordance
with the UK's obligations under the European Convention on Human
Rights (ECHR). It can be a breach of Article 3 of the ECHR to
remove someone from the UK if to do so would constitute inhuman
or degrading treatment because of the suffering caused due to
their medical condition. However, both the European Court of
Human Rights and domestic case law have set a very high threshold
for inhuman or degrading treatment in such cases. The House of
Lords case of N (2005) clearly establishes that states are under
no obligation to allow those otherwise liable to removal to remain
in their territories for the purpose of receiving medical treatment.
If the claimant's circumstances were so extreme that a grant of
discretionary leave to remain was appropriate, this would enable
the NHS to treat them as resident for the purposes of their Regulations
and thus eligible for free treatment.
The NHS needs to devote its resources to treating
UK residents who are entitled to receive its services. AIDS affects
millions of people worldwide and for that very reason we cannot
take on the obligation to provide NHS treatment for anyone with
HIV or AIDS who enters the country. However, although charges
cannot be waived, treatment would never be withheld if in a doctor's
clinical judgement it was immediately necessary to save life or
to prevent a condition from becoming life-threatening, regardless
of eligibility for free treatment or ability to pay.
[Paragraph 8] We are concerned that Taking
Action, although billed as the UK strategy on HIV/AIDS
in the developing world, is in reality only the strategy of DFID.
We recommend that DFID work closely with other Departments, particularly
the FCO and the Home Office, to develop a truly integrated strategy
for the UK's action on HIV/AIDS internationally. This should draw
the FCO fully into the governance and human rights aspects of
HIV/AIDS and the Home Office into broader UK advocacy of the international
goals on HIV/AIDS, such as universal access to treatment.
The cross-Whitehall relevance and usefulness of Taking
Action as a strategy is being considered through the current
evaluation. We look forward to its findings.
DFID works well with other government departments
on HIV and AIDS and has very strong relationships with the FCO,
especially overseas and through the UN missions. In 2005, a Cross-Whitehall
Working Group on tackling HIV and AIDS in the developing world
was set up, comprising the following government departments: DFID,
FCO, Home Office, DoH, MOD, No 10, HMT, DTI, NAO, HM Revenue and
Customs, Patent Office, Scottish Executive, Welsh Assembly, Northern
Ireland Assembly. The group meets approximately three times a
year to discuss a range of issues, including:
1. To support implementation of Taking Action
by HMG by increasing coherence across government departments.
2. To exchange information about policy initiatives
and directions related to Taking Action.
3. To identify opportunities for closer co-operation
across departments to maintain UK and international political
momentum, provide briefing, and consider new policy.
To date, the group has considered issues that have
required close co-operation between DFID and FCO, and between
DFID and the Home Office and Department of Health. These include
collaboration to secure a good outcome from the UN General Assembly
High Level Meeting on AIDS (June 2006); on the development of
a progressive workplace policy on HIV and AIDS agreed between
DFID, FCO and the British Council; and on harm reduction interventions
in developing countries (involving collaboration with the Home
Office and FCO). The group continues to reflect on and respond
to the issues raised by the International Development Committee
in its annual review of AIDS, including issues on charging and
asylum seekers highlighted by the IDC in October 2005 (involving
DFID, Home Office and Department of Health); it has also worked
closely on AIDS in the context of the G8.
In September 2006, the Health Protection Agency joined
the Group. It was also agreed to invite NGOs to the next meeting
in 2007, both as observers and to discuss how best to ensure effective
future engagement between civil society and the group.
During 2007 we expect the Cross-Whitehall Working
Group on tackling HIV and AIDS in the developing world to be an
important forum for discussion of what comes after Taking Action,
which ends in March 2008. It will reflect on the findings of
the interim evaluation of Taking Action, and on how best
to ensure that any future strategy involves effective cross-Whitehall
co-operation.
[Paragraph 11] As emerging epidemics become more
generalised, we recommend that DFID ensure that its experience
of best practice in Africa is put at the disposal of governments
elsewhere, including in Asia and Eastern Europe.
DFID already supports South-South collaboration,
including mutual learning and skills transfer. However, there
are also limitations on transferring examples of best practice
due to differing epidemic profiles. For example, the nature of
the disease in Africa is considerably different to the epidemiology,
causes of HIV transmission, and cultural and behavioural factors
in the Asian epidemic. For these reasons, care and sensitivity
are needed when designing programmes which encourage lesson learning.
An example of mutual skills transfer is the Brazil
STD/AIDS Programme, which has done a good deal of work providing
technical, management and logistics technical assistance in the
Lusophone countries of Africa. Likewise, there are examples of
good practice from Africa being communicated elsewhere. A recent
example is the work of faith-based organisations in Southern Africa,
who have visited the Caribbean to encourage local faith-based
leaders to become involved as "Champions for Change".
Skills transfer can also take the form of study tours. For example,
Ukrainian NGOs working with males who have sex with males visited
similar projects in the UK, with some success.
In the area of harm reduction, the UK and Australia
have a long history of work which is increasingly being drawn
on as good practice. Success in addressing injecting drug use,
which drives the epidemics in many parts of Asia, comes from within
Asia, including Thailand, Cambodia and, more recently, China.
In India, lessons learnt from recent reductions in HIV incidence
and prevalence in four southern states are being built into the
next phase of the Government of India's AIDS control programme,
with DFID support.
DFID also supports more informal sharing between
countries. Many of the case studies for the current evaluation
of Taking Action involved DFID staff from one region reviewing
programmes in another.
[Paragraph 18] We believe that programmes which
address the drivers of epidemics, rather than generalised programmes,
will be most successful in combating the spread of HIV/AIDS. Social
and legal barriers to effective prevention and treatment programmes
for key groups need to be addressed in some countries to ensure
successful implementation of national HIV/AIDS strategies. We
support such a rights-based approach and recommend that DFID ensure
that all national programmes it supports address stigma and discrimination
to prevent further marginalisation of those at highest risk of
infection. We recommend that, as well as continuing to make these
points bilaterally and internationally, DFID make specific efforts
to encourage the repeal of restrictive policies, at both domestic
and international level, that impede effective services.
We agree with the IDC's recommendation that programmes
must address the drivers of an epidemic and—where the epidemic
is concentrated in key populations—they must be provided
with targeted services to effectively combat the spread of HIV.
HIV and AIDS-related stigma and discrimination have
been, and continue to be, the most challenging obstacles to the
uptake and use of AIDS services. We welcome the recommendation
that an analysis of stigma and discrimination and ways to address
them should be integrated into all national programmes. Indeed,
through our Country Assistance Programmes (CAPs) and other in-country
analyses, we are committed to identifying socially excluded groups.
We would expect any new government strategy on HIV and AIDS to
commit to actions to address stigma and discrimination.
Stigma and discrimination on the basis of sexuality
or health are human rights violations and undermine public health
efforts to combat HIV and AIDS. Acts of discrimination deny essential,
life-preserving services to those most in need of them. Fear of
stigmatisation and discrimination discourages people from seeking
information on protection, and from coming forward for voluntary
counselling and testing, treatment, care and support. DFID supports
approximately 100 projects and programmes throughout the world
that aim to reduce stigma, challenge discrimination and promote
and protect human rights.
DFID also works to create legislative environments
supportive of the human rights of people living with HIV and AIDS
and marginalised groups, through revision and reform of laws and
regulations, legal education and rights awareness programmes,
and access to justice and legal support. In Asia, DFID supports
several programmes on legal reform and the inclusion of the rights
of vulnerable groups and women in policies and laws. The programmes
concentrate on women's rights (Bangladesh, China, Pakistan), rights
of injecting drug users and sex workers (China, Vietnam), and
trafficking of children and women into prostitution (China, Nepal).
In Ukraine, the Community Centres for Men programme provides
legal education and awareness of rights as well as legal support
to males who have sex with males. In Tanzania, the project 'Promoting
the Rights of people living with HIV and AIDS' provides rights-based
community training to raise awareness of the rights of people
living with HIV and AIDS—in particular inheritance rights—and
ensure that people living with HIV and AIDS have access to redress
when their rights are violated.
[Paragraph 20] A series of initiatives will be
necessary to maintain momentum towards achieving the challenging
targets for tackling HIV/AIDS. DFID should remain open-minded
about this and should keep under review the case for further bilateral
and multilateral representatives to push for progress in neglected
areas of HIV/AIDS advocacy.
The UK works closely with bilateral and multilateral
partners to help ensure that the global response to AIDS is comprehensive
and that neglected areas are addressed. The UK's Presidencies
of the G8 and EU in 2005 achieved major advances in tackling HIV
and AIDS, with, respectively, the development of the target to
achieve Universal Access to AIDS treatment by 2010 and an agreed
EU position on HIV prevention. We are working closely with Germany
to help maintain momentum on AIDS during its G8 and EU Presidencies
in 2007.
We are also focused on working with the major international
AIDS donors—the US, the Global Fund to Fight AIDS, TB and
Malaria (GFATM), and the World Bank. GFATM is a key instrument
in supporting the global response to AIDS. The UK is working to
ensure that GFATM makes the most effective contribution to delivering
a robust response to the disease. It is especially important that
GFATM performs well in Africa. We are currently reviewing our
collaboration with the US to ensure that our efforts are complementary
in support of national AIDS programmes.
We will retain an open mind and seek to find innovative
and appropriate ways to have the maximum impact on tackling AIDS
and meeting the Universal Access goals.
[Paragraph 22] We recommend that DFID ensure that
key populations are involved in policy formulation consistently
across the range of programmes that DFID designs, implements and
funds. We also recommend that DFID ensure that its partners, whether
NGOs or national governments, support the involvement of people
living with HIV and AIDS and marginalised groups in guiding governments
and NGOs in their policy-making and in providing the right services.
DFID remains firmly committed to the active involvement
of people living with HIV and AIDS in the response to the disease,
and has demonstrated this commitment through Taking Action,
endorsement of the 2001 UNGASS Declaration on AIDS, the 2006 Political
Declaration, and the principle of greater involvement of people
living with HIV and AIDS. Organisations of people living with
HIV and AIDS have a clear role in representing the interests of
HIV positive people. DFID supports networks which strengthen the
voice of people living with HIV and AIDS (PLWHA) in policy processes,
particularly where decisions are being made that affect their
lives. Moreover, people living with HIV and AIDS have demonstrated
they can bring about change and have been behind many innovations
in HIV and AIDS prevention, treatment and care—treatment
literacy and home-based care being just two examples. Through
their own initiatives to tackle stigma and discrimination, PLWHA
can help build demand for more formal programmes which address
stigma and discrimination. They also play an important role holding
governments to account for the services provided to PLWHA.
DFID has committed £1.75 million over three
years to strengthen global networks of PLWHA and to build their
organisations' capacity to contribute to the development and implementation
of effective AIDS policies and programmes. We will continue to
meaningfully involve representatives of key populations and PLWHA
in our activities wherever possible, including through our workplace
policy.
Department for International Development
2 February 2007
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