Memorandum submitted by World Vision
1. World Vision welcomes this opportunity
to make a submission to the International Development Committee.
Evidence is submitted in three sections: Asia, Eastern Europe
and children's access to paediatric treatment.
2. ASIA: MARGINALISED
POPULATIONS AND
EMERGING EPIDEMICS.
[60]
National HIV infection levels in Asia are low
compared with some other continents, notably Africa. But, populations
of many Asian nations are so large that even low national HIV
prevalence means large number of people living with HIV. Latest
estimates show 8.3 million (5.7-12.5 million) people living with
HIV in 2005 of whom 2.0 million are women. In 2005 the number
of newly infected people with HIV was 1.1 million (600,000-2.5
million) adults including children and the number of deaths due
to AIDS was 520,000 (330,000-780,000) adults, including children.
Asia is not just vast but diverse, and HIV epidemics
in the region share that diversity, with the nature, pace and
severity of epidemics differing across the region. Overall, Asian
countries can be divided into several categories, according to
the epidemics they are experiencing. While some countries have
been hit early (for example, Cambodia, Myanmar and Thailand),
others (Indonesia, Nepal, Vietnam, and several provinces in China)
are only now starting to experience rapidly expanding epidemics
and need to mount swift, effective responses. In Myanmar and parts
of India and China HIV has become well-entrenched in some sections
of society, despite efforts to halt the virus spread. Other countries
(for example Bangladesh, East Timor, Laos, Pakistan and the Philippines)
are still seeing extremely low levels of HIV prevalence, even
among people at high risk of exposure to HIV, and have golden
opportunities to preempt serious outbreaks.
(b) World Vision's experience of working
with marginalised populations in Asia
World Vision has been implementing HIV and AIDS
programmes for more than a decade. In light of the enormity and
severity of the pandemic, World Vision has developed an organisation-wide
"Hope Initiative." The Initiative's strategic framework
aim is to reduce the global impact of HIV and AIDS, through the
enhancement and expansion of programmes and partnerships focusing
on HIV and AIDS Prevention, Care and Advocacy. World Vision has
pioneered three core programming models to address the needs of
the children and others affected by HIV and AIDS and they are:
Community Care Coalitions caring for children and chronically
ill adults, Church Based/FBO mobilisation and Life-Skills training
for children aged 5-18.
World Vision has health teams in 16 countries
in Asia and HIV prevention programmes in almost all of them, as
well as STI programmes. World Vision tested innovative demonstration
models of HIV interventions targeting female sex workers and their
clients in six countries—Nepal, Bangladesh, Mongolia, Thailand,
Papua New Guinea and Vietnam. The STI programmes were integrated
in reproductive health and HIV programmes. STI projects focused
on developing comprehensive models to reach sex workers and their
clients and IDU's through four components: knowledge and awareness,
friendly reproductive health services, participatory processes
and an enabling environment. In most programmes, training was
provided to both public and private health care providers in STI
management and counselling and stigma reduction.
In Nepal, World Vision partnered with local
NGOs to run mobile STI clinics, whilst in Vietnam, World Vision
pilot-tested STI screening for sex workers. In Papua New Guinea,
World Vision has worked with the Ministry of Health and a local
university to introduce periodic presumptive treatment for sex
workers and their clients (three rounds over nine months) and
this provided the evidence base for the development of national
policies and protocols in STI management.
In Bangladesh, World Vision conducted operations
research with sex workers, rickshaw pullers, transport workers
and college students and also ran an HIV and AIDS project (COX's
Bazar) providing STI services to sex workers, men, women and youth
in the community, including migrant workers. A peer educators
model was used to refer people to Hospital, for diagnosis and
treatment of STI's.
In Thailand, the PHAMIT project (Network of
Prevention of HIV and AIDS) works with migrant population in 27
provinces and provides STI services as one of the key objectives.
This project has been run in collaboration with other partners,
including UNFPA, for over 12 years with the migrant population
along the provincial border of Thailand and Myanmar. The migrants
are helped to access the HIV and AIDS information, knowledge and
health services through service delivery points. These services
are provided to all the migrants with specific focus on sex workers,
fishermen, MSM, youth and housewives. Other components include
capacity building for the community health workers and volunteers,
as well as providing quality, gender-sensitive integrated and
age-specific reproductive health services (inclusive of HIV and
AIDS prevention, counselling and care).
In India, World Vision has worked with MSM's
in the state of Kerala with funding from the government. And in
PNG, World Vision has worked with several MSM's who have become
a backbone for the prevention of HIV in the Havana Bada project,
funded by the Government through AUSAID.
World Vision has worked very successfully with
churches and other faith communities in India, Papua New Guinea
and Philippines to decrease stigma and promote constructive behaviour
change and the potential of this work is enormous. The key component
of the strategy is to mobilise faith leaders, and volunteers by
intensive three day training which includes elements that will
equip them and assist in engaging them in issues of HIV and AIDS,
especially stigma and discrimination.
(c) Recommendations
World Vision recommends the following:
— Stigma is still the number one
problem on HIV and AIDS which needs to be addressed in Asia. Leaders
in government, faith communities and civil society must be more
proactive in tackling the issue of stigma and discrimination and
raising the profile of HIV and AIDS, as an emergency issue.
— All agencies involved in the
fight against HIV and AIDS must document and scale-up work based
on the evidence from lessons learnt from successful models that
have been piloted in the region.
— Government and donors must ensure
that they make long-term funding commitments for HIV and AIDS.
Sustainability will only be achieved when people who have AIDS
are able to support themselves and are brought more fully into
designing and implementing programmes.
— Governments, civil society and
faith communities must work together to establish and implement
policies that will ensure that there is 100% condom use amongst
high-risk groups.
— IDU's is another area that has
significant gaps. It is critical that governments, CSO's and leaders
are mobilised to address this problem and tackle the inter linkages
between drugs, sex workers, and transmission of HIV among them.
— Prioritising gender vulnerability,
specifically among girls aged 10-24, is very critical to any prevention
efforts in the region. It is also critical to include boys as
part of solution rather than regarding them as a problem.
3. EASTERN EUROPE
AND CENTRAL
ASIA: MARGINALISED
POPULATIONS AND
EMERGING EPIDEMICS
(a) Nature of the epidemic[61]
Eastern Europe and Central Asia Region has the
fastest growing rate of HIV in the world. Unfortunately, the epidemics
in Eastern Europe and Central Asia continue to expand—around
1.5 million [1.0 million-2.3 million] people were living with
HIV in the region at the end of 2005—a 20-fold increase
in less than a decade. In 2005, some 220,000 [150,000-650,000]
people were newly infected with HIV. AIDS claimed the lives of
an estimated 53,000 [36,000-75,000] adults and children in Eastern
Europe and Central Asia in 2005—almost twice as many as
in 2003. An estimated 420,000 [270,000-680,000] adult women were
living with HIV in Eastern Europe and Central Asia in 2005—a
third more than in 2003. Antiretroviral coverage remains inadequate
in the region with only 21,000 of the estimated 160,000 people
in need of treatment receiving it in 2005. Injecting drug users
account for more than 70% of HIV cases in the region but represent
only 24% of people receiving antiretroviral therapy (WHO/UNAIDS,
2006). In Eastern Europe, harm reduction programmes in 2005 reached
only 9% of injecting drug users. The majority of people living
with HIV in this region are in two countries: Ukraine,
where the annual number of new HIV diagnoses keeps rising, and
the Russian Federation, which has the biggest AIDS epidemic
in all of Europe. More recent epidemics are underway in Kazakhstan,
Tajikistan and Uzbekistan, where the annual number
of new HIV diagnoses has been rising steeply. With the variety
of international HIV and AIDS research based evident scenarios
and predictions about the direction of the epidemic in Eastern
Europe, it is expected that for most countries in the region HIV
and AIDS will continue to grow over the next decade.
(b) Needs of marginalised groups
The socio-political context of Eastern Europe
and Central Asia contributes to the trends of the epidemic described
above. The profound societal changes that have swept across the
MEER have created conditions that make the region particularly
vulnerable to the spread of HIV. In Eastern Europe and Central
Asia, most countries have epidemics concentrated in Most At-Risk
Populations (MARPs) [62]and
the so-called special risk groups[63]
that "bridge" the epidemic between MARPs and the general
population. They together with PLWH comprise the marginalised
groups. In most cases the risks faced by marginalised groups are
compounded by virtue of the fact that they belong to more than
one "risk group".
In Eastern Europe and Central Asia unsafe behaviours
prevail amongst MARPs and special risk groups and are exacerbated
by a number of factors, including: women's perception of family
fidelity which allows men to have sexual contacts with Sex Workers
(SW) combined with the fact that sex outside marriage is regarded
as the "norm" especially in the post-Soviet block. In
addition, there is high out-migration for seasonal work to countries
with concentrated epidemics/high prevalence and lack of social
integration for children in institutions. Finally, there are unfavourable
policies for targeting MARPs and special risk groups for HIV prevention.
The marginalised groups need to be supported
to advocate for their rights to quality prevention and continuum
of care.
(c) World Vision's experiences of relevant
interventions with these marginalised groups
In line with World Vision's integrated approach
to development, and the well-being and improved quality of life
of beneficiaries, World Vision in Eastern Europe and Central Asia
has mainstreamed HIV and AIDS interventions with a comprehensive
mix of actions to meet the realities of the local context.
Although a child focused organisation, World
Vision's focus in the concentrated epidemic context is the environment
of the vulnerable child, which mostly includes IDU parents/mother,
who might also be sex workers etc.
In Tashkent city, the capital of Uzbekistan,
World Vision works with IDUs (1,193), sex workers (1,120), MSM
(123) and their dependents. In Armenia, WV is the principal-recipient
of GFATM and is managing a large grant facilitating the 12 projects
implemented, 80% of which are targeting for IDUs, SWs and MSM.
Both, the Uzbekistan project and Armenia programme are also targeting
PLWH, who at times are in both groups, providing more complication
for quality service provision. In a number of countries, including
Russia, World Vision targets children that are at significant
risk (those categorised as special risk groups) and tries to influence
their behaviours through sensitised and mobilised faith leaders.
(d) Recommendations
World Vision recommends the following:
(i) Facilitating the documentation and replication
of best practice. World Vision itself has some projects that are
demonstrating some promising results but such projects are still
pockets rather than being at scale. The MARP need to be provided
with services in a much more accessible manner to reduce risk.
Needle exchange, drug rehabilitation and condom promotion programmes
adhering to recognised good practice need to be rolled out at
scale.
(ii) Governments must work with civil society
to find better ways to provide services to enable IDUs and other
marginalised groups to access treatment.
(iii) There is also a need to integrate responses
because there is a significant overlap of people engaged in sex
work who are also injecting drugs.
(iv) Governments must be encouraged to be
more open to talk about HIV and AIDS and make it a greater priority.
While donor funding is important, national level leadership on
the issue is a critical component.
(v) Children protection programmes must be
undertaken to protect children from being exploited as sex workers
and from becoming injecting drug users. These must also include
the children whose parents are sex workers and/or injecting drug
users.
4. CHILDREN AS
A MARGINALISED
GROUP: GLOBAL
ACCESS TO
PAEDIATRIC TREATMENT[64]
Children living with HIV are a particularly
marginalised group and yet are virtually invisible. Some 2.3 million
children under the age of 15 are living with HIV worldwide—more
than 95%—live in developing countries with no access to
any form of care or treatment they desperately need. Some 2,000
children are infected with HIV every day, principally through
parent to child transmission and in 2005 alone 570,000 children
died of AIDS-related diseases. Yet these children are virtually
invisible and, by virtue of their absence from decision-making
forums, their needs are frequently overlooked.
Without treatment, most children with HIV will
die before their fifth birthday. In Africa, where children have
the least access to any treatment—both to prevent infection
and to combat the disease—AIDS has already caused infant
mortality to increase by more than 19% and contributes strongly
to increases in under-five mortality.
The deaths of these children are not inevitable;
HIV-positive children can and do respond to antiretroviral treatment.
However, despite recent increases in the number of adults on antiretroviral
therapy (ART), the number of children receiving treatment remains
unacceptably small. Currently, 8% of HIV-positive children have
access to the paediatric AIDS treatment they desperately need.
They must be given their chance at life.
(a) Prevention of Mother-to Child-Transmission
(pMTCT)
The failure to prevent mother-to-child-transmission
(MTCT) drives the rapidly increasing number of HIV-positive children.
Globally, 90% of all HIV-positive children are infected through
MTCT. Without prevention of mother-to-child-transmission (pMTCT)
services, about 35% of infants born to HIV-positive mothers will
acquire the virus during pregnancy, labour, delivery or breastfeeding.
Providing a mother with a full range of pMTCT services can reduce
this risk of transmission to less than 2%. But less than 10% of
HIV-positive pregnant women globally and 6% of pregnant women
in sub-Saharan Africa are receiving pMTCT services. [65]This
is a gross violation of the rights of both these women and their
children.
(b) Access to
cotrimoxazole
Cotrimoxazole is highly effective in preventing
life-threatening opportunistic infections in HIV infected children.
For example, a study in Zambia found up to a 43% drop in mortality
when HIV infected children had access to cotrimoxazole alone.
[66]Because
HIV is more aggressive in children, they are highly prone to opportunistic
infections, particularly during the first few months of life when
HIV diagnosis in children is extremely difficult. Given these
realities, cotrimoxazole is recommended for all children born
to HIV infected mothers until the HIV status of the child is confirmed
negative. As of June 2005, an estimated four million children
need this life saving treatment, costing less than three cents
of a dollar a day per child. [67]This
is a small price for saving many lives.
(c) Diagnostics
Treatment cannot start without clear diagnosis.
The most commonly available and easy to use diagnostic test is
inaccurate in children under 18 months of age. [68]Infant
diagnosis requires a complicated test measuring the presence of
the HIV virus. [69]Unfortunately,
these tests require technical expertise as well as costly equipment,
placing them out of reach of poor countries. [70]The
lack of widespread diagnosis of children with HIV/AIDS hinders
accurate forecasting of the demand for pediatric drugs and personnel.
According to Médecins Sans Frontie"res,
up until 2005, multinational companies that produce diagnostic
tests have shown little interest in developing accurate, simple,
fast and affordable tests for diagnosing HIV infection in children[71]
or in supporting national owned initiatives. Without treatment,
up to 60% of HIV infected children will die before their second
birthday[72]—delayed
diagnosis and treatment is simply not an option.
(d) Children's access to treatment
At the end of 2005, 700,000 children needed
antiretroviral therapy. Where treatment is available, more than
80% of children live to see their sixth birthday. Some children
are surviving until their 20s. [73]Denying
children the right to treatment denies them the right to survival,
growth and development.
The number of children on treatment has doubled
over the last year from approximately 20,000 to 52,500. [74]However,
given that roughly 1.3 million of the six million adults in need
of treatment are on currently receiving antiretroviral therapy,
approximately 140,000 of the 700,000 children in need of treatment
should be on ART.
Children's right to treatment is specifically
outlined in the 2003 General Comment 3 on HIV/AIDS and the rights
of the child issued by of the Committee on the Rights of the Child.
[75]Ultimately,
it is the responsibility of signatory governments to uphold a
child's right to prevention, care and treatment. Children can
and do respond to treatment.
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;
— Some tablet and capsule formulations
are available only for adult consumption, forcing practitioners
to chop or crush them;
— Even with access to first line-regimes,
expensive second-line drugs must be available to address issues
of resistance and intolerability.
The lack of research and development means that
treatment of children is often imprecise. Health care workers
and caregivers are forced to make do with what is available, often
crushing adult tablets and estimating doses. This is complex for
the caregiver and imprecise for the child, reducing lifesaving
treatment to a guessing game. Drug treatment is only one part
of a comprehensive package of care and support that children require.
But as long as drug treatment for HIV-positive children remains
inadequate, their overall treatment needs cannot be met.
Recommendations on: World Vision calls on the
UK Government to continue providing leadership on achieving universal
treatment for all by 2010 and as part of this uphold children's
right to HIV and AIDS treatment. We specifically call for the
UK Government to challenge national governments, UN agencies and
donors to do the following:
1. Prevention of Mother to Child Treatment:
To achieve the Abuja Call made by African Heads of State for Accelerated
Action Towards Universal access to HIV and AIDS that at least
80% of HIV-positive pregnant women have access to prevention of
mother-to-child-transmission (pMTCT) services. Governments, donors
and NGOs must immediately:
— Increase the resources needed to
scale-up the number and size of pMTCT programmes to provide HIV-positive
women with appropriate interventions to prevent mother-to-child
transmission that includes infant testing, nutritional supplementation,
and long-term ART.
— Develop and implement action plans
to provide cotrimoxazole to all children known to be HIV-positive
and to all those born to HIV-positive mothers until their HIV
status is determined.
2. Diagnostics:
— Governments and donors must
negotiate lower prices on diagnostic test kits and test equipment.
— Diagnostics manufacturers must
accelerate research into point-of-care infant diagnostics.
3. Paediatric treatment
By 2010, in line with the Abuja Call, governments,
UN agencies and donors must:
— Ensure that at least 80% of
all children in need of treatment have access to HIV and AIDS
treatment, including antiretroviral therapy;
— Include children explicitly
in international treatment initiatives and national treatment
targets and then track treatment distribution by collecting data
by age and gender;
— Encourage developing countries
to make use of TRIPS flexibilities, including providing technical
assistance on the use of existing flexibilities, and, where feasible,
helping develop domestic generic manufacturing capacity;
— Improve health care systems
of poor countries to deliver drug treatment, member states must:
prioritise the health care sector in national budgets; provide
comprehensive treatment guidelines; and training packages on treating
HIV positive children for health professionals;
— Make healthcare free and increase
investment in health systems. Health systems should provide holistic
care, including emotional support and access to home-based care
that enables mothers to stay in their homes and care for their
children. However, this should be undertaken without increasing
the burden of care that women and girls carry, through providing
appropriate support and compensation.
Industry must:
— Prioritise children's rights
over market interests and urgently invest in the development and
production of fixed-dose combination antiretroviral therapy for
young children as well as grant voluntary licenses to allow generic
production of ARVs and develop simple and affordable diagnostic
tests for children and infants.
October 2006
60 UNAIDS Report on the Global AIDS Epidemic
(2006). Back
61
UNAIDS Report on the Global AIDS Epidemic (2006). Back
62
These are populations within a country at the highest risk of
transmitting HIV, constituting injecting drug users (IDUs), sex
workers (SWs), and men who have sex with men (MSM). There is a
lack of data on MSM, and hence disagreement over whether MSM are
really one of the MARPs. Back
63
Those having frequent sexual contact with MARPs, consisting of
partners of IDUs, children/youth that are in institutions (orphanages,
boarding schools, vocational schools, homeless shelters, etc),
those trafficked or under the risk of being trafficked, migrants/seasonal
workers (including truck drivers). Back
64
This evidence draws substantively on Saving Lives: Children's
Right to HIV and AIDS Treatment, published by the Global Movement
for Children, of which World Vision is a member. Back
65
UNAIDS, Report on Global AIDS Epidemic, May 2006. Back
66
UNAIDS (2005) AIDS Epidemic Update: December 2005 Joint
United Nations Programme on HIV/AIDS, Geneva. Back
67
UNICEF (2005) A Call to Action: Children, the Missing Face
of AIDS. Back
68
The Elisa test is an HIV antibody test that measures the body's
immune system response following infection. It is not accurate
in children under 18 months because maternal antibodies can still
be in the child's body until this time. Back
69
HIV DNA Polymerase Chain Reaction tests (PCR)-for more information
see www.aidsmap.com Back
70
Medécins Sans Frontières (2005) Paediatric HIV/AIDS
Fact sheet, MSF Campaign for access to essential medicines. June
2005. Back
71
Medécins Sans Frontières (2005) Paediatric HIV/AIDS
Fact sheet, MSF Campaign for access to essential medicines. June
2005. Back
72
UNAIDS Report on the global AIDS epidemic (2004) Joint
United Nations Programme on HIV/AIDS, Geneva. Back
73
Global AIDS Alliance (2005) Treat the Children: Accelerating
Action for Universal Antiretroviral Treatment for Children in
Resource-Limited Countries by 2010, Advocacy Brief. July 29,
2005. Back
74
Global AIDS Alliance (2005) Children Left Out: Global Community
Failing to Scale Up the Prevention and Treatment of Pediatric
HIV/AIDS. Advocacy Brief, August 2006. Back
75
Committee on the Rights of the Child, CRC/GC2003/1. Back
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