Examination of Witnesses (Questions 1-17)
DR ANINDYA
CHATTERJEE, MR
KIM MULJI
AND MR
JOSEPH O'REILLY
16 NOVEMBER 2006
Q1 Chairman: Good afternoon and thank
you very much. May I first of all apologise for the delay in starting
the meeting. It does not in any way reflect the importance of
the issue, not least because we took a decision last year that
we wanted to have an annual update on progress to achieving the
international targets on AIDS reduction and elimination. The fact
is that this meeting has had to be rearranged twice because of
ministerial engagements and unfortunately the week of the Queen's
Speech is always a difficult week for Members' diaries, but there
are one or two colleagues, I hope, who will join us as we proceed.
Perhaps you could briefly introduce yourselves for the record.
Mr Mulji: Good afternoon. My name
is Kim Mulji and I am the Executive Director at a small NGO called
the Naz Foundation International. We focus on addressing male-to-male
sex and HIV and AIDS issues, mainly working in south Asia, but
also looking elsewhere in developing regions.
Dr Chatterjee: Good afternoon.
I am Anindya Chatterjee and I work as the Senior Adviser on Prevention
and Public Policy for UNAIDS, the joint United Nations programme
on HIV/AIDS.
Mr O'Reilly: I am Joseph O'Reilly,
the Senior Policy Adviser for the International HIV/AIDS Alliance.
Q2 Chairman: Thank you very much.
As I said at the beginning, we attach enormous importance to achieving
the international objectives on AIDS, not least because aid and
development and the achievement of all of the other Millennium
Development Goals (MDGs) could be destroyed by a failure to grapple
with the AIDS epidemic and I think that is generally recognised.
Although we have set ambitious targets, we are already failing
to meet them and we have missed the "three-by-five"
and, although progress has been made, it would appear that we
are not very close to achieving what we have set out to do. Perhaps
I could ask you briefly as a starting point what, in your assessment
from where you are on the basis of the progress which has and
has not been made, do you think realistically are the prospects
of achieving the universal access to treatment by 2010, and the
reversal of the spread of the epidemic by 2015 as things stand
at the moment?
Mr Mulji: My expertise comes from
addressing male-to-male sex and HIV and AIDS. I think we are going
to be a long way from reaching this target certainly by 2010,
certainly in South Asia, which I know, and also, I think, elsewhere
in Asia and maybe in other areas, like sub-Saharan Africa and
North Africa for a number of reasons. The first reason is that
it has not really been addressed in many of the countries' national
AIDS plans and where it has been addressed, it has either been
addressed poorly or it has been addressed, but without necessarily
the power to implement those services that are required. For example,
in India where they have just developed a new strategic AIDS plan,
it does not include the issue of male-to-male sex, so, for example,
developing 350 projects across the whole of India to specifically
address prevention work around male-to-male sex, 350 small community-based
projects, which is, in our opinion, the right way to do this,
but it is without necessarily the power to enforce it. For example,
in India there is a federal structure where the local states decide
their policy, so we are not entirely sure how the policy at one
level is correct, but how that will transpire into projects on
the ground. In other regions, such as China, they are just starting
to recognise male-to-male sex as an issue, but elsewhere it is
more tricky. In Bangladesh, for example, a recent proposal for
the global AIDS fund, the Global Fund to fight AIDS, TB and Malaria,
said that they were happy that there was enough coverage on male-to-male
sex and HIV prevention work which clearly does not ring true in
terms of what we know is happening on the ground from people we
know who are working there. Elsewhere, in sub-Saharan Africa,
for example, countries just refuse to acknowledge that there is
male-to-male sex, so we do not really know what is going on. Elsewhere
in the region, for example, in Latin America and the Caribbean,
there is a lot of misrepresentation of what is going on and it
is represented as not really a male-to-male sex epidemic and it
talks about the regendering of AIDS which is fine, but it tends
to leave out crucial vulnerable groups which is still in many
respects the core where the epidemic is happening. Just as a final
bit of information on this, I have just recently been in Egypt
and talking to UNAIDS there, where, from what we know, the HIV
prevalence level is very low, but a recent study, unpublished,
I have to say, by an NGO there will show, I am sure when it is
published, that HIV prevalence levels have been about 5% to 6%
amongst males having sex with males there, so there is actually
a problem in Egypt amongst males having sex with males, but the
Government of Egypt does not recognise it and no one else is really
recognising it. There are hidden epidemics which really need some
political commitment and also the power to make sure that these
projects happen on the ground, so I think there is a lack of political
leadership and recognition, there is a lack of a means to do that
and also I am not entirely sure that bilateral funders, such as
DFID and other people, have created the mechanisms to enable us
to ensure that there is universal access to prevention, treatment
and care.
Q3 Chairman: Perhaps I could insert
a supplementary question for you to consider and that is, reading
the DFID memorandum[1]
to the Committee and the general international statements, they
are quite strong on funding as a standard political commitment
to inputs, "We'll deliver this amount of money", but
not so good on outcomes, so the money is going in, but the question,
I suppose, which has to be taken as a supplementary is, is it
being wasted or spent on the wrong things or is it addressing
the right issues, just perhaps as an additional point to comment
on?
Dr Chatterjee: If we look at the
way the programmes have been scaled up globally, both prevention
and treatment, compared to 2003 and 2005, there has been quite
a bit of an increase in volume of programming globally. However,
having said that, it is nowhere near a level which would halt
or reverse the epidemic and, as we stand here today, another serious
problem is that the programmes are failing to reach those who
are at the highest risk and those who are most vulnerable. This
is a fact and, therefore, the political process in the High Level
meeting this year and the national target-setting exercises that
are taking place as we talk here today, provide us with opportunities
to dramatically scale up both prevention and treatment. Whether
we make it or not, I do not want to be commenting on that, but
there is no other alternative than to try all means to dramatically
scale up. The alternative is not there.
Q4 Chairman: So it is money as well?
Dr Chatterjee: It is money as
well.
Mr O'Reilly: First of all, I think
it is very important to say that the commitment to universal access,
which the British Government played a very important part in our
securing and which this Parliament really prompted them to do,
is extremely important and it is one that we all welcome. However,
the meetings at which that universal access commitment was secured,
such as the High Level meeting earlier this year at the UN in
New York, I think provided us with a stark indication of the struggle
that we are going to have in realising the promise of universal
access for members from marginalised communities, the subject
of this inquiry. I and many of my colleagues, who are behind me
today, were at that meeting and were enormously frustrated at
the failure of the international community at that meeting to
even acknowledge, let alone do anything about, recognising the
special needs of those key populations and for a time during the
course of those negotiations they were stymied by a failure to
come to any agreement about even referencing in the text gay and
other men who have sex with men, injecting drug-users and their
special needs and, as a result, the document is completely silent
on them, so I think it gives you an indication of how far we have
to go from making the rhetoric about universal access true on
the ground. In addition to that of course, there are other real
problems. The populations that we are talking about, drug-users,
commercial sex-workers and men who have sex with men, face enormous
amounts of official hostility in many developing countries. They
are silenced and made invisible. This has enormous implications
for programming, so one of the first things is that in terms of
research and knowing what we have to deal with, there is not only
indifference, but an absolute failure to undertake research which
seeks to understand how many men, sex-workers or injecting drug-users
there are, what their patterns of risk behaviour are and what
could be done to address them, so there is a gap in the political
will and there is a gap in the knowledge that we have. I just
want to close this answer by saying that there is a huge services
gap as well. Despite the fact that outside of sub-Saharan Africa,
injecting drug-use constitutes one third of new HIV infections,
only 5% of injecting drug-users around the world have access to
the most basic forms of prevention services, clean needles, information
and peer support, to help them to change their risk behaviour.
For men who have sex with men, less than one in 10 men who have
sex with men have access to the basics, such as condoms and lubricants.
It is slightly better for commercial sex-workers, but about 85%
of them do not have access to any of those services, so there
are huge gaps. The promise of universal access is an important
one and it is one that we have to work to, but I think a real
question for us is what will constitute universal access. Universal
access for the general population will be extremely important
and valuable, but in most countries there is a huge gap to be
overcome in securing access to the most basic services for the
populations which this Committee is concerned with.
Chairman: I think in the background evidence
that we have had, those points have been quite strongly made.
The point that has been made basically is that these marginalised
groups are not only marginalised in terms of their rights, but
very often they are the drivers of the epidemic, so if you only
concentrate on the mainstream, you are not going to turn the problem
around. When the Committee was in Botswana, for example, we asked
the Health Ministry there what they were doing about male-to-male
sex, what they were doing about the sex trade and sex traffic,
which is very rife on the borders of Botswana, and the answer
was, "They're illegal". That was the answer and that,
I think, we will come back to because that is the whole problem,
actually accepting that you can address that problem without necessarily
condoning or legitimising it.
Q5 Richard Burden: The impact of
the HIV pandemic on sub-Saharan Africa is pretty well known these
days, but there is obviously some increasing evidence, and you
mentioned it today, that it has been perhaps understated elsewhere,
and you have mentioned Egypt, but Central Asia, the other parts
of Asia and indeed parts of Eastern Europe are also showing some
very worrying signs. Now, if we are going to ensure the universal
access to both treatment and prevention in the way you say, what
are the kind of policies that we need to be looking for? Obviously
we need the research because without the research, you do not
know how to do the targeting, but what are your views about the
kind of implications there are in those countries and what we
need to be doing about it?
Mr O'Reilly: When we talk about
responding to HIV and particularly with respect to prevention,
there is the Holy Trinity of interventions: there is risk reduction;
vulnerability reduction; and impact mitigation. Our contention
is that, by and large, we can see some work, albeit often not
sufficiently comprehensive and evidence-informed, in respect to
helping communities reduce their risk and there is some work around
impact mitigation, particularly, for instance, the mobilisation
around treatment which is extremely welcome and important, but
the biggest failure, in our view, across those three areas is
in vulnerability reduction. This of course relates to the Chairman's
very point about the legal status of most of these groups, the
fact that marginalisation, discrimination, stigma and invisibility
fuel HIV infections for these groups which makes them much more
vulnerable to HIV, their legal status, their inability to access
services, their treatment by official service-providers, but not
only that, which is a big issue, but once people are either infected
with HIV or imputed to be so, HIV stigma and discrimination exacerbates
the impact of HIV. Therefore, a whole range of human rights violations
fuel and exacerbate the impact of the virus on these populations,
so you kind of have a problem with the legal status and the rights
and the ability to claim those rights for all of these populations.
For instance, let me say this with respect to injecting drug-use,
that in almost all of the countries in which we operate, injecting
drug-use is illegal as is often commercial sex-work and homosexuality,
and that means that people are often not able to come forward
and access services for fear of imprisonment, arrest, torture,
arbitrary detention, or when those services are provided, say,
for instance, to injecting drug-users, so you might have needle
and syringe exchange programmes often operating in the shadows
of the law, if individuals are picked up with clean needles and
syringes, then they are taken to police headquarters, and that
is the same for all of these groups, so it is very difficult to
create what the international AIDS Non-Governmental Organisations
call "an enabling environment" in which these issues
are addressed, so vulnerability reduction for us is crucially
important. The other area too is that one of the biggest human
rights violations which fuels the epidemic is the violation of
the right to health because of that health services gap that I
talked about. You cannot have a right to health and you certainly
cannot exercise it without basic access to health services and
for people who are vulnerable to, and heavily burdened by, HIV,
those health services are essential to exercise their rights to
health, so in fact their right to life is put in jeopardy by their
inability to access health services. Therefore, a combination
of this Holy Trinity of interventions, risk reduction, impact
mitigation and vulnerability reduction is important, but, for
us, we have seen probably not enough attention to any of these
areas, but certainly insufficient attention paid by the international
community in general and many developing country governments in
particular to reducing the vulnerability of these groups and helping
them to safeguard, and exercise, their rights.
Mr Mulji: Just to follow up what
Joseph has been saying, I think that the top-level answer really
is about political commitment, that we really do need to advocate
for working appropriately with marginalised groups, with injecting
drug-users, with female commercial sex-workers and males who have
sex with males. We need to provide political leadership and the
United Kingdom Government needs to work further on this in terms
of kind of having a level where things should be done at, so in
terms of addressing laws which make consensual adult behaviour
between men illegal, for example, in India, supporting work around
legal reform around the decriminalisation of drug-use and so on,
so creating an enabling environment, as Joseph has said, on the
legal issues, but also an enabling environment on human rights
issues, so addressing stigma and discrimination. It is not only
finances, Chairman, as you said. There are the finances available,
but it depends on that political leadership for wanting to call
down those funds as well to address work on marginalised communities,
so I think it really very strongly is about political leadership
and certainly a role for the UK Government could be continuing
this. It is very, very good, I think, about providing that leadership,
but it is about continuing on that track to do that work so that
countries do address the marginalised communities and behaviours.
Q6 Richard Burden: Could you give
perhaps some examples of the kind of things you would be looking
for. If, say, a Minister from the UK, or indeed from elsewhere,
said, "Ok, you're right and we're prepared to provide that
political leadership to address that Holy Trinity of issues. I
want to get the political profile of this up, but how do I do
it? What do I actually need to do? What are the things I actually
need to be arguing for? What can the international community do
on that", do you have any ideas?
Dr Chatterjee: In all of the emerging
epidemics, a key disconnect is between the ministry of health,
the national AIDS programme or the national AIDS council; and
the ministry of the interior, the ministry of home, the drug control
organisations and the criminal justice system. Therefore, a key
issue for political advocacy is to speak with one voice, to bring
multiple ministries' perspectives together and that will make
programming possible in a much bigger way. For example, in China
for a long time, despite a very serious epidemic in the southern
part among injecting drug-users and subsequent spread all over
the country and a rising sexual transmission, it was very difficult
there to start up clean needles programmes or methadone treatment
until the Public Security came on board. And here is an example
where the Public Health and Public Security could come together
and could agree on a common agenda of intervention. The international
community played a big role, the UK Government's programme in
China played a big role. The policy statement that was issued
by the UK Government on harm minimisation brings together different
ministries of the UK and it gives a clear indication that all
the government entities and departments are together and have
a common view. We try to do the same thing in the UN. I think
we all have to work together in bringing these perspectives together
for two reasons, the first being, as Joseph said, that we have
to systematically address all legal barriers and subsequently
social barriers that are stopping us from scaling up and, secondly,
it is at the end of the day political leadership that brings everyone
under one forum and not the law enforcement perspective clashing
with the public health perspective, thereby making programming
really difficult.
Mr O'Reilly: If I might answer
Mr Burden's question as well, it is a crucially important one.
One of the things I would say too is that the UK Government has
done a lot and one of the initiatives that they took last year
as President of the EU and G8 was on World AIDS Day to issue a
statement on the UK Government's approach to harm reduction. I
think in our written evidence[2]
we point to the fact that that is one of the areas where there
is an inconsistent approach among the international donor community
to this issue. The United States, for instance, opposes the use
of any of its funding for harm reduction activities and, in particular,
the provision of clean needles and syringes. In terms of international
policy-making, in our view, the UK Government's statement last
year, which was very clear in respect of their position, was extremely
important, as, I might add, was the Secretary of State for International
Development's speech to the UN General Assembly at the High Level
meeting on AIDS where he took on international opposition, including
that of the United States Government, to condom promotion and
to the promotion of safe sex to general populations, so it is
extremely important and those things have already played an important
role, but our view is that the British Government could do more,
and I want to give you a couple of very specific examples quickly.
One is that we could do more and better by having a more coherent
approach to these issues across government departments. I think
there could be a lot more consistency and coherence between the
Foreign and Commonwealth Office (FCO) and the Department for International
Development. The FCO has a range of initiatives, the Human Rights
Challenge Fund, and its global diplomacy initiatives which could
integrate HIV much more readily and around which some of the themes
which they take up could address HIV issues and I think a joint
strategy on both of their parts would be extremely important.
The other thing is that we can look at other government departments'
initiatives in these areas for some inspiration. Earlier this
year the Secretary of State for the Foreign and Commonwealth Office
appointed an international ambassador, a special representative
for climate change, and that individual is using his good offices
on behalf of the British Government to create a focal point internationally
for action on this issue. One of the things which we have written
about and you have heard about already today is the lack of consensus
at the international level amongst the international community
around the rights of sexual minorities. Now, that should not come
as a surprise to us, but one of the things that the British Government
has done, and done well, is promote the rights of sexual minorities
in this country, so we have the capacity in a sense to go to the
international community in a way with that background. We have
a good approach to the rights of gay and lesbian people in this
country, to anti-discrimination legislation and to dealing with
the HIV epidemic vis-a"-vis them, and we are calling
on the Government, and we would encourage the Committee to consider
recommending this, and for the Department for International Development
to appoint a special representative, in exactly the same way as
the Foreign and Commonwealth Office has on the question of climate
change, for sexual minorities. The international community at
the UN is not at a point of agreement around an international
declaration, for instance, or a new convention on the rights of
sexual minorities, but what I think the good offices of the British
Government could do is work with countries on a bilateral basis
to generate greater community interest and political will aimed
at securing greater recognition of the special needs of sexual
minorities in the international community and the UN in particular.
The final thing I would say in respect to HIV and human rights
is that the United Nations' AIDS programme is the focal point
for human rights and HIV issues internationally, but that remains
massively under-resourced and unsatisfactorily addressed, in our
view. The international community, led by UNAIDS, needs a human
rights and HIV action plan and it needs a special representative
on HIV and human rights so that that person can create a focal
point for exploring the relationship between those issues. The
Special Representative of the United Nations on the Right to Health,
Paul Hunter, a British citizen, supports this initiative on our
part because his mandate, in his view, is not sufficiently broad
to incorporate those issues and address them, so we believe that,
by this very simple, in a way, series of initiatives, a great
deal more focus could be brought to bear on these issues and the
British Government could play an important part in providing the
political leadership which would make a real difference to them.
Q7 Chairman: That is helpful, but partly
in response to Mr Burden's question, perhaps could you also address
the regional variations and what is being learned or failing to
be learned. For example, I mentioned Botswana earlier and we actually,
when we visited Botswana, were looking at a programme there. There
is an opt-out rule where if you don't opt out, you automatically
get tested and, as a result of that, they have identified many
of the AIDS sufferers and been able to give them treatment. Is
that something which could be replicated elsewhere and are there
other good practices or bad practices that could be highlighted
and would even be relevant to whatever a special envoy might usefully
do internationally?
Mr Mulji: I want to talk briefly
about three things. In terms of good practice, the UK Government
has been actively, and closely, working with the Government of
India in preparing their third national AIDS plan and they have
included marginalised groups and marginalised behaviours very
clearly in that plan. It is a very good strategy, talking to our
colleagues on the ground, so that has been a very, very good thing
which the UK Government has done. I want to touch on three things
though, which is the UK Government's support to changing the legal,
policy and social environment in countries. I think specifically
in bilateral discussions with countries, such as India, we should
address their failure to decriminalise consensual adult homosexual
behaviour and the specific barriers to working with communities.
I think we do need to specifically go to these countries and say
that they need to change the laws and create enabling environments.
On funding, the UK Government will provide bilateral funding,
for example, to India to implement their strategy which we have
helped to develop. I am very concerned though that we will just
give the money to the Indian Government and they will spend it
on their particular priorities and it will not necessarily get
spent on what the UK Government think are their priorities. I
think there should be some accountability because if we give money
to the Indian Government, we should know where that money is going
and it should follow some of the priority areas.
Q8 Chairman: That is a bit of a problem
when we believe in country ownership of programmes.
Mr Mulji: But if we are helping
them to develop the strategy, we should hold them accountable,
I think, and it is UK taxpayers' money, so we should get them
to spend it on things which we think are appropriate and are priorities.
Also with multilateral funds, we give money to the EU and it funds
HIV and AIDS work in developing countries which is to ensure that
their policies and where they spend the money are correct and
funds, such as the Global Fund to fight TB, AIDS and Malaria,
we should ensure that where they spend their funds and their priorities
are coherent with the UK Government's policies. Thirdly, I think
the UK Government should also take a strategic approach on how
it funds and supports work specifically on marginalised communities,
so whether that is work on male-to-male sex or work with drug-users,
we need to have a strategic approach. For example, the UK Government
and DFID, through their office in India, are funding the scaling
up in four states around male-to-male sex and we have been implementing
this programme for the last number of months and it has been very
successful, but the UK Government cannot hope to scale up bilaterally
all the work that we need to do even just in India, so I think
we need to be more strategic and to fund organisations and to
fund programmes which will help pull in those funds. There are
funds, for example, through the Global Fund to fight AIDS, TB
and Malaria, but I think the UK Government could be a much more
strategic player in addressing marginalised groups and behaviours.
Dr Chatterjee: We are dealing
with extremely diverse epidemics and even within countries there
are many epidemics at the same time and we really need to invest
in understanding what drives these epidemics. So we are moving
from understanding rates and prevalence to drivers more and more.
Secondly, we are also dealing with changing situations. We see
the emergence, and the rapid explosion, of HIV among men who have
sex with men in many Asian countries, we are seeing injecting
drug-use in sub-Saharan Africa, and epidemics are maturing and
changing and we really need to be on top of that. I think we have
two sets of problems, if I may classify. One is the problem of
coverage, that we are not reaching enough people and there are
many barriers which we have talked about, human rights being one
of them or the neglect of human rights being one of them. The
second set of issues is whether our money is going where it is
needed and tracking the resources, the deployment of resources
on the ground. If we have a better system, we will definitely
be able to improve on our performance. I am giving a simple example,
that in tracking AIDS funding, the national AIDS accounts in Latin
America showed that whilst male-to-male sex is a major driver
of the epidemic in that region, very few resources are being deployed
in that area. There are countries for example in western Africa
where you would see that 95% of infections are in the context
of paid sex, whereas only 5% of the national AIDS budget is being
deployed for that, so that is a serious problem. And along with
understanding the drivers, we do need to track the resources at
the ground level, not only at the international level, which we
can do much better than before. We have to invest in finding out
where the money is deployed, whether it is the best use of the
money and whether we are being able to address the drivers of
the epidemic as it is unfolding, changing and emerging.
Mr O'Reilly: Perhaps I can follow
up very briefly on that?
Chairman: Just briefly.
Mr O'Reilly: One of the things
that we have suggested in our written evidence is that the UK
Government can lead the way in some of that, because knowing where
the money is going and how you are spending it is very important
at a country level, but for international donors they can provide,
I think, a very useful role model in doing exactly the same. One
of the things that we have said is that we welcome the Government's
commitment to the whole populations in Taking Action, the
Department's strategy on HIV/AIDS and its reference to those things,
but I think it is a failure to detail what it is going to do,
and certainly a failure to tell us where the money is going. The
Department's evidence before the inquiry was very illustrative
for us of that problem. It was great to see all of the examples
but if it were not for the inquiry asking, it would not be easy
for us to find out that information because there is no tracking
of that data and that effort. Effort is no doubt there, so it
is something that we should take credit for and use to leverage
internationally other people's support for similar work, and we
would like to see better and more transparent data on those questions
from the British Government.
Chairman: As you will appreciate, the
Minister is going to be here immediately after you, so we will
have a chance to address that.
Q9 James Duddridge: Both in the evidence
received before and the evidence heard today everything keeps
coming back to the key populations—the sex workers, male-to-male
sex, prisoners and injectors, which is enormously sensitive politically
within countries and also religiously for people who hold moral
views about people who practise those types of behaviour. Are
these the main factors that deter policy-makers from really engaging
in these situations, and as policy-makers or people holding policy-makers
to account how do we overcome these deterrent factors?
Mr Mulji: It is partly about providing
evidence about what is really going on on the ground. I remember
at a previous conference on AIDS an Indian doctor standing up
and denying that there was any issue to do with male-to-male sex
in India, so having some facts to present to people, some clear,
cold facts, is helpful, but it is partly about getting an evidence
base as well. There is creating an evidence base and also creating
a coherent picture and doing the research so that we know what
is driving an epidemic within communities and outside those communities,
so that we have a clear picture. What is very much lacking in
the data is that we really do not know the prevalence of male-to-male
sex in lots of the regions in the world. We have very little accurate
data on HIV prevalence, the HIV incidence between men having sex,
so we lack a very good data set, so, of course, it is very easy
for people to say, "There is not a problem here really",
because some of these issues, as has been mentioned before here,
have been hidden and swept under the carpet. They are issues that
people do not want to talk about—commercial sex work, injecting
drug use, male-to-male sex, issues which are socially stigmatised
and discriminated against, so it is much easier for people to
ignore them. The reason we do not have the evidence is that they
are so discriminated against and stigmatised, so it is part and
parcel of it and we have to have break up the vicious cycle and
open it up. I always think that HIV falls into the cracks in society,
the cracks that we do not like to look into because they are homosexual
sex, drug use, paid sex work. We need to shine a light onto those
cracks, see what is going on and present the evidence with an
argued case.
Q10 James Duddridge: Does opt-out
testing help in that? Do you have any evidence, for example in
Botswana, that if somebody thinks they have got AIDS and they
might feel they have got ill, they might generally, say, access
the health system and they automatically get tested, so that is
one way of bringing them in? Is there evidence that that works
in Botswana, and if that is the case is it something that could
be used elsewhere?
Dr Chatterjee: Despite having
reasonable access to health services and anti-retroviral treatment,
a major barrier which stops people from seeking treatment is stigma
and discrimination. It is very obvious in many countries in sub-Saharan
Africa. Botswana has had much more access than the neighbouring
countries in terms of access to health services and anti-retroviral
treatment. The way testing is organised in Botswana definitely
has led to more uptake in the last couple of years, and Botswana
is one of the countries which has, by its `three-by-five', targets,
been able to put many people into treatment. In the first round
of experience and audit the success has been to enrol more people
into treatment because of the way HIV testing was organised, that
you have to say no; otherwise you will be tested. Having said
that, we have to be very careful advocating that approach for
every country because situations vary enormously and stigma and
discrimination are rife. In many settings there is no confidentiality
in the healthcare sector. And therefore, whichever way testing
is organised, "Confidentiality, Consent, and Counselling"
can never be ignored. And the Botswana approach holds promise
in many high prevalence settings if these conditions are adhered
to and maintained.
Mr O'Reilly: The question of routine
or opt-out testing is one that is exercising the international
AIDS community at the moment and it is quite a controversial one
in some ways. The fact that it has a different role to play in
different country epidemics is very important. In generalised
epidemics one can understand the rationale for encouraging people
to test. In epidemics that are more contained, and certainly in
places where epidemics are concentrated among some of the key
populations that we are talking about, encouraging members of
key populations to test is a good idea if there are services in
place that follow the results, if there is capacity to provide
people with information about positive prevention and if there
is also information and, obviously, access to treatment. Those
things are very important, but knowing your HIV status is not
necessarily that important if you do not have access to things
that allow the consequences of that to be delivered. The quick
thing I would say in places where epidemics are more concentrated
is that if the epidemic is associated with those populations and
you test people then people are often imputed to be part of an
illegal community or an illegal behaviour and so the stigma and
human rights violations that follow from that association can
compound and exacerbate and fuel infection, and so you want to
be careful about routine or opt-out testing in places where it
really is not fit for purpose and where the results of those sorts
of things are not necessarily going to advance how you treat and
deal with the impact of HIV.
Q11 James Duddridge: One of the reasons
we are engaged on this problem is probably one of the wrong reasons
in that the general population is being affected by the behaviour
of a minority. It is good that the general population are getting
involved in these minority issues but normally people on lower
or middle incomes who are suffering from these health issues do
not have advocates. What can DFID be doing to create a better
advocacy of those groups generally rather than simply relying
on that the general populace is scared of getting infected through
heterosexual sex within their own country and an epidemic taking
place elsewhere? What can be done from an advocacy perspective?
Mr Mulji: DFID can continue what
it started already, for example, supporting the network we have
created in India and elsewhere in South Asia and other areas in
Asia, which is a network of organisations and individuals and
groups working around male-to-male sex. It is very important and
a powerful advocacy tool to have networks and organisations which
come together. In addition to that, DFID have specifically funded
a human rights network in India which we have been helping to
set up. You were talking about coherence between the Foreign Office
and DFID. Initially the Foreign Office supported a study that
we undertook in India and Bangladesh around legal barriers to
working around male-to-male sex and HIV, a very interesting study
of which I can send a copy to the Committee if you would like[3],
which shows some of the barriers around discrimination, lack of
education and legal reasons why people do not access services.
We have helped create standing committees at a national level
in India and Bangladesh which will focus on human rights and male-to-male
sex, and also local advocacy cells, so if the police start attacking
people for cruising in a local park the local advocacy cell can
help address that. If it is a more national issue they can also
help deal with that, so it is supporting networks of organisations
generally looking at HIV and AIDS, the networks within and without
those, specifically focusing on different issues, be that drug
users as well.
Mr O'Reilly: It is an extremely
important area. The Alliance has been working, for instance in
Cambodia with the assistance of the Bill and Melinda Gates Foundation
since about 2001, with key populations—men who have sex
with men, injecting drug users and commercial sex workers and,
just by way of example, the approach that we have taken is to
support the creation and development of capacity of community
based organisations of those very groups at a very local level
to provide peer support, to provide training, to distribute condoms,
but also to identify their needs, to develop a shared understanding
of their needs and to begin advocacy work. At a local level that
can often be talking to the local police, encouraging them not
to harass the sex workers of the local brothel, to take a more
benevolent approach to men who have sex with men (MSM), and I
have to say it works, but not only has it worked locally in that
particular country. In 2001 our linking organisation in Cambodia,
the Khmer HIV/AIDS NGO, went to the government and started talking
about MSM and the government said, "There aren't any MSM
in this country. They just don't exist". The creation of
these support groups at a local level, then at a provincial level
and then nationally in the form of a national network took place
with the support of the Alliance over that period of time, and
since then, through their efforts, through demonstrating that
they exist, through demonstrating their needs, through making
them visible, the government has not only recognised that men
who have sex with men are key to the epidemic in Cambodia but
they have also recognised that they are key to responding to it.
They are part of the new Cambodian National AIDS Plan; they are
enumerated in the plan as a key group. Only last year the government
committed to including men who have sex with men in its sentinel
surveillance, in its routine data collection on the extent of
HIV prevalence in-country. Those are crucial, important things
that have happened in that country by virtue of doing exactly
what you suggest, which is supporting the creation of community
organisations which can advocate for themselves, claim their rights
and interact with government to try and influence and create more
space around those very questions.
Q12 James Duddridge: Can I extend
the question: is there also any contrary evidence that a more
liberal attitude towards these activities and provision, for example,
of condoms to target groups and needles for injecting could encourage
greater use as well in some communities, or is it your belief
that there has been no evidence whatsoever of that argument that
you quite often hear, certainly from the religious right in America?
Dr Chatterjee: There is no evidence
in any country that programmes have led to increased drug use
or increase in sexual activity.
Q13 Chairman: There is genuine debate
amongst activists, is there not, that by working with people you
can perhaps engage in the moral issues without actually criminalising
or marginalising them, that actually you may have more success
rather than less success? Mr Duddridge hits on an obvious sensitive
button with the like of the President's Fund. All the practitioners
on the ground say it does not work but puts quite a lot of money
in. Bob Geldof is quoted as saying it sometimes gives women the
right to say no. I do not know how effective that is but that
was his assertion. I suppose what I am asking is, is there an
inevitable contradiction between the moral right and the practical
argument or is it possible to pull them together?
Mr O'Reilly: It is interesting
because, in terms of the United States at least, many of the proponents
of some of the moral strictures on the use of US funding, including
the prostitution law to go for an abstinence earmark, were also
the most vocal proponents of extra funding for HIV. On the one
hand you have Senator Santorum saying, "We have to enforce
the constitution loyalty oath and we are forcing organisations
that are in receipt of US funds to sign a declaration that says
they oppose prostitution", which I think is very problematic
for some of them and I will return to that in a minute, but on
the other hand sponsoring the amendments in the Senate to increase
contributions to the Global Fund, and he did both of those things
undeniably out of his Christian conviction, so I think in some
ways they come together in terms of the need to respond at a human
level to the imperative of HIV, but unfortunately how you do it
in respect to the moral and ethical questions vis-a"-vis
sex does risk becoming extremely problematised. In respect of
this very question those strictures on the part of US funding
are highly problematic. I am not sure whether or not abstinence
and the programming empower women to say no to sex but what it
definitely does is stigmatise condom use where you have programmes
being funded by the US that say abstinence is the choice that
you should make, except if you are a sex worker or a man who has
sex with men, in which case you should use a condom, which immediately
suggests that anyone who uses a condom falls into those immoral
groups. It is highly problematic in terms of creating a popular
culture of safe sex and of universal precautions. What we should
be doing is encouraging everyone who is having sex to have the
information and the skills and the support to make decisions about
their sexual practices which are safe. Promoting abstinence only
and restricting people's access to the information and the commodities,
such as condoms, that enable people to make those decisions and
have the resources to exercise them, is highly problematic, as
is the prostitution loyalty oath which forces organisations who
are working with sex workers to say that they oppose sex work.
It is not as though organisations support sex work but in order
to work with sex workers they often have to take a non-judgmental
approach, and in order to do that it is a bit contradictory to
suggest that they have to oppose sex work on the one hand but
on the other hand work in an open and honest way with their clients,
who are often sex workers.
Mr Mulji: We have absolutely no
evidence that abstinence-only education would work, for example,
around male-to-male sex. We have evidence that suggests that it
would be counter-productive. We often work with very marginalised
men who are often undertaking sex work in public sex environments
at parks and railway stations and railway tracks, who specifically
go to those places to have sex. If we start talking to them and
saying, "You should not be having sex", number one,
they went to that locale to have sex and we are immediately going
to be alienating them in our opinion. Secondly, I think there
is a problem with US funding and at least a perceived notion that
you have to promote abstinence. I have seen a leaflet published
by an organisation in south east Asia around male-to-male sex,
and the first message it says is, "The first thing you should
think about is not having sex", but the rest of the leaflet
is actually very good. I talked to this group and said, "There
is no evidence that abstinence works so why have you put it on
the leaflet?", and they said, "Because we get funded
by the US Government. We have to talk about abstinence".
I said, "There is no evidence that it works", and they
said, "We just put it there on the front of the leaflet".
There is no evidence it works and we strongly believe it could
be counter-productive.
Dr Chatterjee: At the national
level it could be put together. If we look at Malaysia and Iran
these countries have very conservative, strict drug laws, but
because of their HIV epidemics and the emerging reality of HIV
epidemics both those countries have been able to develop harm
minimisation programmes, condoms in prisons, methadone. Sex work
in Thailand is technically illegal but that has not stopped Thailand
from rolling out a large HIV programme for sex workers. Many countries
have found ways of addressing the moral and pragmatic considerations
and have been able to put together decent and large-scale programmes.
But it will be diverse, it will be taking different shapes in
different countries.
Q14 James Duddridge: When looking
at abstinence and condom use what was the experience in Uganda?
Was that a good case study of proof that it does not work, going
back to abstinence after a successful condom programme, or have
I been misled?
Mr O'Reilly: No, I think that
is absolutely right.
Chairman: Have things gone down? Have
the figures moved in the wrong direction?
Q15 James Duddridge: My understanding
was that AIDS was coming down in Uganda and there was good condom
use and good discussion of AIDS related subjects, and then there
has been a trend, for whatever reason, towards more of a purist
abstinence viewpoint and AIDS rates have gone up.
Mr O'Reilly: That is absolutely
right, the general history which you talk about there. One of
the challenges that we have with respect to rates and looking
at an epidemic and its course over a period of time is the question
of attribution. There is a debate internationally at the moment,
in respect of Uganda, as to whether or not we can link the increasing
HIV incidence rates that have occurred recently in Uganda with
a less than full commitment to condom promotion, but certainly
Uganda was held up internationally as an example of what needs
to be done using an ABC approach which was "Abstinence, Be
faithful and Condoms". All of those things in Uganda at the
time that it was held up as an example were treated equally and
they were all genuine options for people and were presented as
such. What has happened in Uganda, and there is lots of evidence
to suggest this, is that the promotion of condoms has diminished,
and there is certainly lots of discussion about how that has happened
and why, what has influenced that, and there is a very useful
Human Rights Watch report which I have encouraged the Committee
to refer to, called The Less They Know The Better, about
diminution in condom promotion in Uganda and the links to US influence
in respect of that.
Q16 James Duddridge: What is the
pre-eminent research in terms of the key populations and the interactions
between the key populations that you are talking about? For example,
are these marginalised groups completely isolated or is the man
that has heterosexual sex with a sex worker also an injector or
a prisoner who has male-to-male sex? What is the overlap or do
we not have that information?
Dr Chatterjee: There are constant
interactions between the groups because in most parts of the world
where we have emerging epidemics of HIV, for example, among men
who have sex with men in Asia, many of them are married and have
regular sex with women. And there are clear data from several
national programmes to show that. There is a huge turnover of
prisoners in every country all over the world; it is estimated
that about 30 million people go in and out of prisons globally
in a year. Most people stay for a short duration in prison. Prison
is a very high risk context for acquiring and passing on HIV,
and prisoners come out and interact with the general community,
so HIV prevention within prisons has clear-cut public health implications
for HIV prevention in the general community. Similarly, in a lot
of countries in Central Europe, Eastern Europe and Central Asia,
Vietnam, a significant proportion of sex workers also inject drugs.
There are empirical data from national surveys which show different
overlaps between different groups and with the general population
at large. Better mapping of these risk profiles and risk behaviours
will make us understand about the drivers of the epidemic I was
talking about and thereby fine-tune our intervention in terms
of intervening at strategic points.
Q17 Chairman: We are running out
of time. We started a bit late and the Minister is waiting and
so we may have to draw it to a close. Just on the point that Mr
Duddridge has made, can you say whether the international donors
and other agencies have been successful in involving these groups
themselves in the policy-making process in the countries, because
one of the things that you have all been saying is how their views
do not really appear to be taken into account because they are
excluded, because they are illegal or whatever it be. What success
is there in ensuring that they do have an input into the policy
of national programmes?
Mr Mulji: There is not with the
international community. I think there is sometimes at a country
level, and I cited India as a good example, but if we take, for
example, the Global Fund to fight AIDS, TB and Malaria, which
is a multinational fund, there has been in my opinion a very poor
involvement from the key communities. For example, in India, Bangladesh,
Nepal and Pakistan there has been very little involvement with
those key communities in helping develop proposals. There are
examples around drug use where drug users have had to go outside
the country co-ordinating mechanism for funding, so I think there
has been a failure to engage some of those communities, partly
because they are very bad at advocating for themselves. Some of
the males we work with were never organised until we came along
and helped them set up community based organisations, so there
has been no-one to advocate for them. There is also a very closed-shop
attitude in some countries where there are some very well known,
linked-in-with-government NGOs who are very powerful voices to
the exclusion of other NGOs, so I think the politics is a very
big issue about who gets a voice and who even gets in there. I
think it has been very patchy and I do not know whether the government
has really supported getting civil society to talk to governments
and multinational agencies.
Mr O'Reilly: It is important,
Chairman, to take that work to scale. It is quite ironic. One
of the things that we did, and it was a success of the international
community's advocacy, was that we convinced the Global Fund to
change the rules about the composition of country co-ordinating
mechanisms at the country level, so the country co-ordinating
mechanism included representatives from civil society that was
most affected by the epidemic in that country, so in many places
like Cambodia, Ecuador, et cetera, where we were working,
it required the country co-ordinating mechanism to have sex workers
and men who have sex with men, injecting drug users on it. The
problem was, of course, having advocated for that, that in many
places there were not organisations and individuals who were sufficiently
capacitated for that role, and that is I think where the real
work is, supporting those community organisations, and we need
to be in that for the long haul. We talk about scaling up HIV
prevention and treatment and services, and at least at a rhetorical
level we pay lip service to the fact that the communities are
key to the provision of those services and to accessing them,
but one of the things that more often does not follow is any resources
to allow those communities to mobilise and organise themselves
so that they are able to play a useful role. One of the things
I have left with the Committee this afternoon is a publication[4]
which we are launching later today at the Commonwealth Club, which
is the result of a participatory photo project in Cambodia, India
and Ecuador in which members of those key populations—sex
workers, people living with HIV and men who have sex with men—took
photographs and detailed their experiences, their lives, their
aspirations and their hopes, and it is part of that project that
I alluded to before in Cambodia that we have been implementing
with the Blue Moon Fund and the Gates Foundation. This in a sense
is an antidote to the invisibility and the silencing which we
have been talking about today, and in each of those places we
are not only supporting this sort of initiative but also all the
individuals who are participating in this project come from community
organisations that we have been supporting. We believe that is
where the real work is because without their visibility, without
their voice, the programming and the decision making which we
make on their behalf will not meet their needs, or it certainly
will not have as good a chance of doing so unless we hear from
them and see them. They have to be at the table and that is what
this initiative was partly about addressing.
Chairman: Thank you all very much. As
I say, I am sorry for the late start, but it has been extremely
helpful. It is obviously a complex issue and clearly setting targets
is one thing but finding policies that will actually deliver them
is a wholly different set of issues. You have really helped us
to move down that road and we now have the opportunity to ask
the Minister some questions, which I have no doubt you will be
listening to as well. Thank you, all three of you, very much.
1 Ev 19 Back
2
Ev 32 Back
3
NFI, From the Front Line, www.nfi.net Back
4
International HIV/AIDS Alliance/Frontiers Prevention Project,
Unheard Voices, Hidden Lives: Stories from the frontiers of
the HIV epidemic, http://www.aidsalliance.org/sw40083.asp
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