Examination of Witnesses (Questions 40-57)
MR GARETH
THOMAS MP, MR
ANDREW ROGERSON
AND MS
ROBIN GORNA
16 NOVEMBER 2006
Q40 Mr Davies: No, of course. Clearly
there is no point in making people inclined to use them if they
are not available. I do think that the really tough nut to crack
is the inclination to use them. Let me finally give you a bouquet,
if you would like that, for DFID this afternoon. I thought you
were absolutely right to support paying nurses more and trying
to increase the supply of nurses in Malawi. We were there, as
you know, earlier this year and we visited one hospital which
I recall very clearly which had one qualified doctor. He was absolutely
brilliant and doing a fantastic job but he was also the director
of the hospital and trying to diagnose the patients. There were
four qualified nurses, 400 beds and somewhere between 600 and
800 patients. I think just saying that gives you an indication
of the conditions in which those patients were. A number of them,
of course, were HIV positive, I do not remember whether we had
a figure for that, perhaps the hospital did not know itself. The
need for qualified medical personnel is absolutely key in these
areas.
Mr Thomas: Mr Davies, thank you
for that, and perhaps by way of trying to return the favour let
me try and give you some sense of optimism about Nairobi. One
of the things that we are doing is to fund through the National
AIDS Commission in Kenya a network so that sex workers can come
together to get support to start this type of peer education work
that I have described is happening elsewhere around the globe.
It is a start and there is a lot more to do, I accept that.
Q41 Chairman: I think Joan Ruddock
will want to develop that point but I just want to ask a question
first. We raised this matter last year, which continues to be
a matter of concern, which is how we treat asylum seekers in this
country who are HIV positive. First of all, if they are failed
asylum seekers we understand that it is still the case that they
have to pay for treatment. Can I ask if that is the case? I know
it is not directly DFID's responsibility but it does not help
DFID's appeal to the wider world and the desire to eliminate it
if we are pursuing policies in the UK that do not seem to quite
fit. Is it still the case as far as you are aware that failed
asylum seekers have to pay? What happens if they cannot afford
to pay? What steps are taken when they are being returned to their
communities that they are not actually being sent back (a) with
their own human rights challenged in terms of continuing treatment
if they are getting it here, and (b) the circumstances in which
they might well be sent back to re-infect the population from
which they came? Is DFID taking any initiatives across government
to address those issues?
Mr Thomas: Those issues, as you
describe, are probably the responsibility of the Department of
Health.
Q42 Chairman: Well, I accept that
but you take my point that they do rather undermine international
development if they apply.
Mr Thomas: I am not sure I do.
Let me try and explain the policy. My understanding is that asylum
seekers are exempt from charges for hospital treatment, including
anti-retroviral treatment for HIV infection, as long as their
application is underway. My understanding is that if a course
of treatment has started before their application is rejected
then until they leave the country their programme of treatment
can continue, but there is an issue about payment, as you rightly
say, if they want to start a course of treatment after their application
is rejected. I am happy to check that and if I need to give you
further clarity I will do in a letter.
Q43 Chairman: Can I press the difference
of opinion that you do not accept the point. First of all, just
in terms of the UK Government's credibility challenging the world
to try and eliminate it if we are pursuing domestic policies at
home which do not seem to be consistent with giving everybody
access and putting them into limbo, do you accept that is not
consistent with the overall objective? My second point is we may
well be returning those people once they are finally deported
back to the country with an HIV infection for which they personally
may not be able to get treatment and where they will help to re-infect
people in the country where they came from. I am surprised you
say you do not accept that cuts across the development strategy.
Mr Thomas: There has to be a balance,
Chairman, between the needs of an individual who is HIV positive
and the overall need to ensure that we have a strong immigration
system in place. I think, broadly speaking, we have got that policy
right. As I have indicated, I am happy to check the detail of
the answer I have given you.[7]
What I do think we have a responsibility to do very much so still
is to scale up access to treatment. We have got a responsibility
to scale up access to prevention and care as well in the countries
where there is not enough availability in that area. We have seen
in recent years a substantial increase in access to anti-retrovirals
in many countries but I will accept that there is a lot more that
we need to do.
Q44 Chairman: I am afraid that answer
is slightly consistent with the argument we had in the previous
evidence session of the difficulty one has in persuading a number
of governments to deal with marginalised groups because they are
perceived to be outside the law or criminal or in some way have
been deemed to be antisocial. If I may say so, we seem to be using
an argument that sounds rather similar.
Mr Thomas: What I would point
to, Chairman, by way of response is the encouraging figures that
there are about access to treatment. There has been almost a doubling
in the numbers on treatment in 2005 in sub-Saharan Africa. The
numbers have increased eight-fold between 2003 and 2005, up from
100,000 on treatment in sub-Saharan Africa to some 810,000. I
think there is much greater international community recognition
and, indeed, domestic government recognition of the need to increase
access to anti-retrovirals and it is right that the focus is in-country
rather than, if I may say so, looking at the particular issue
from the domestic immigration control end.
Q45 Joan Ruddock: Just on the point
that you mentioned, which is access to anti-retrovirals and those
who are in treatment, I wonder what kind of long-term follow-up
there is going to be to answer the question how effective the
treatment is. I must say that I was as thrilled as everyone else
around this table who visited Malawi to hear the success of the
support for professionals in Malawi, but one of the things that
we learned was although the drugs might be available it is incredibly
difficult to run the regimes of constant testing to ensure that
the drugs are given appropriately to increase the survival of
the patients. I think that it would be very useful to know how
ultimately we are going to measure this. It may be that drugs
become available, people get given them initially, but the health
systems are not sufficiently robust to see the process through.
Mr Thomas: I think the first thing
to say is that there is research underway being led by the World
Health Organisation to monitor the effectiveness of treatment
regimes. I think it is relatively obvious that if we cannot increase
the number of health workers, which was Mr Davies' point, we are
going to have real difficulties in helping to keep people being
tested and supported through that process and getting access,
particularly if they live in rural areas, to the anti-retrovirals
in the first place. Part of the discussions we are having now
internally looking ahead to our bid to the Treasury under the
Comprehensive Spending Review is whether or not there is more
that we can do in a variety of countries around health workers.
There is then the issue about improving through the research funding
we get the quality of the diagnostics and improving the efficacy
of the anti-retroviral treatments, particularly issues around
access to paediatric anti-retroviral treatment, and we are working
on a number of fronts as a result to try and deal with those issues
too.
Q46 Joan Ruddock: I think that would
be very welcome and I am sure we would like to hear more about
that as the programme unfolds if you are successful in your bidding.
I want to return to the marginal groups that you mentioned at
the outset today. The UNAIDS four key populations appear, from
most of the evidence we have got, to be central to tackling and
halting emerging epidemics. In your own evidence, if I can just
quote you, you said: "There are... both human rights and
public health rationales for countries facing emerging epidemics
to take immediate action to reduce vulnerability to HIV in marginalised
groups." I think it is well recognised that the UK has linked
human rights with marginalised groups with HIV treatment and access
to programmes, and this has been very much applauded in the evidence
that we have had from NGOs and contrasts, I think, from our own
experience certainly with the more moralistic approaches of particularly
the United States. My question really is to what extent can that
leadership role which DFID has already had be expanded? Do you
see that there are any ways in which there should be new international
forums, especially UN human rights forums, which DFID should directly
address in terms of the HIV/AIDS programmes?
Mr Thomas: Well, as you say, we
have tried to take a lead in a series of international forums,
for example the Board of UNAIDS in terms of the Harm Reduction
Policy debates that have taken place in the last 12 months, also
during the UN General Assembly discussions on AIDS to make sure
that the needs of marginalised groups were heard. In the end the
real difference is going to happen at country level. We have to
persuade political leaders, which was Mr Davies' point, in a sense
to lead that change. One of the things that we can do as ministers
in discussions that we have is to make the case for that change.
I have responsibility for the Caribbean and I have made the case
for change in laws in the Caribbean which help to stigmatise people
who are vulnerable to HIV infection or, indeed, who are HIV positive
already. We have supported that direct face-to-face advocacy with
programmes that seek to bring in a range of cultural and sporting
personalities to deliver positive role model messages about HIV
prevention issues. For example, we have got a further programme
working with the media in the Caribbean to take place in December,
again hoping that through the media we can change the attitude
of journalists to some of these issues and help to get the issues
covered in a more sensitive way. I think it is at country level
where the change has got to come. International forums in a sense
help to create the right mood for the decisions, they help to
create the right policy documents on occasion in the right policy
context but it is at country level where the change has got to
come where advocacy is needed both from ministers going into a
country but also from people in-country. We seek also to support
HIV positive groups themselves to make the case for change in
their country.
Q47 Joan Ruddock: I wonder if you
might include business as well. You did not mention business but
I hoped you would because I remember meeting business people from
Debswana in Botswana and they had very good programmes for their
workers but, of course, no programmes for the sex workers who
their workers were having contact with and, indeed, they denied
the fact that the sex workers were around the plant at all.
Mr Thomas: In the Caribbean, just
to go back to the previous example I was giving, we work directly
with the business community in the region. There are a number
of international business people and business organisations who
have given a very powerful and very strong lead through the Global
Business Coalition, for example, around workplace policies, on
occasion giving money to the Global Fund and on occasion through
the wider prevention messages that they give. As an international
community we have to continue to work with business, with sporting
personalities, with cultural figures to help get these HIV prevention
messages out not only to marginalised groups but also to make
sure that, in a sense, the wider population feels comfortable
with these messages.
Q48 Joan Ruddock: Does your reply
about it being more a country based issue rather than United Nations
and forums of that kind mean that you would reject a proposal
which has been made for a UN Special Rapporteur on HIV/AIDS and
Human Rights, which was one of the suggestions that NGOs submitting
evidence to us made?
Mr Thomas: I would not reject
it but I would point to the fact that the UN Secretary-General
has already appointed a number of special envoys on HIV and AIDS.
Stephen Lewis, the—
Q49 Joan Ruddock: If I may interrupt,
Minister, I think it is the connection between HIV and human rights
which is the distinction being made here.
Mr Thomas: I accept that. What
I would say is those envoys have made on occasion a series of
interventions around the linkages between human rights and AIDS,
both in Asia and in Africa, where I know Stephen Lewis has been
particularly strong on this issue. I think we would need to look
at what has already been established and the extent to which this
issue is not already being covered. As I say, at the moment I
think the envoys who have been appointed are doing a very good
job in these areas. I accept it is something that we need to keep
under review.
Q50 Chairman: Just on the back of
that, in the UNAIDS report, which was published in May, they said,
particularly talking about women in this context: "Women
must be adequately represented in policy and decision-making on
AIDS" and then it quotes that a 2004 UNAIDS assessment found
that, "Women participating in the developmental review of
the National AIDS Framework was non-existent in more than 10%
of 79 countries and inadequate in more than 80%." Has that
situation improved? Does DFID have any particular strategy for
it? On the back of that I think James Duddridge may have a specific
question.
Mr Thomas: It does relate to the
question about human rights and the way in which women are perceived
in many of the countries in which we are working where AIDS is
a significant issue. I would like to be able to say to you that
the situation has dramatically changed but I do not think it has
as yet. One of the things that we seek to do in our aid programmes
is support the ability of women to make their own case in-country
and in the direct conversations that we have, the Secretary of
State and I, we advocate for change in terms of the position of
women in society and, indeed, for women's groups to make sure
that they are heard within debates about AIDS policy in-country.
I think the situation is one where we still need to see radical
change, frankly.
Q51 James Duddridge: The Prime Minister
in the foreword to the UK's strategy on HIV and AIDS singled out
women, children, orphans and older people at the heart of the
AIDS problem who, in his words, "bear the brunt of this global
disaster right at its heart". What specific concerns do marginalised
groups seeking access to treatment have, these marginalised groups
specifically, and how successful has DFID been in addressing those
problems and what metrics have you got around success rather than
inputs?
Mr Thomas: In China, for example,
the epidemic is overwhelmingly concentrated amongst marginalised
groups at the moment and some of the targeted interventions that
we have made in China have been recognised by the government for
the difference that they have made and the government are now
taking on those changes and seeking to replicate those policies
across the whole of the country. The example that I gave of the
clinic in Sonagachi in Calcutta has now been taken forward by
the Government in India and they are seeking to replicate that
work across India. Some of the work that we did around harm reduction
in Serbia and Ukraine has been recognised by the governments in
those countries for the difference it made and, again, they are
seeking to scale up the work we have done across the whole of
their countries.
Q52 James Duddridge: Perhaps I am
suffering, Minister, from being an ex-banker, but I like my numbers.
Would you be able to provide the Committee with some harder metrics,
harder numbers, around the success of specific programmes, perhaps
in writing?
Mr Thomas: I will certainly look
at what information we have got. We can certainly give you details
of where the increase in prevalence is scaling off where we have
programmes and where we like to think we have made a contribution.
I will certainly try and give the Committee that information,
Chairman[8].
Q53 Chairman: Thank you for that. At
the end of the UNAIDS report they say, in one sense positively,
"For the first time ever the world possesses the means to
begin to reverse the epidemic". It says: "We know with
increasing certainty what disaster awaits if the response to AIDS
continues to be inadequate. We also know how to strengthen that
response in a way that will save millions of lives and billions
of dollars". Presumably that is what has motivated the international
community in a number of very positive declarations to make the
commitments that they have for 2010 and 2015. The only scary bit
about all of that is that 2010 is three or four years away, the
commitment to that particular point on women is for 2010 and we
have not met the "three-by-five" targets. In all seriousness,
as things stand at the moment what chance do we have of meeting
those targets? What do you think both DFID and the UK as part
of the international community would need to do, given the big
commitment, to raise even more the determination to achieve these
targets? The reason we are having this session and making it an
annual session is that we feel they are pretty tough targets and
unless you monitor them pretty continuously they are not going
to be met.
Mr Thomas: They are ambitious
targets but I think they are achievable. If they are going to
be achieved then donor nations need to follow through, for example,
on commitments that were made in Gleneagles in terms of making
extra resources available for development and for Africa in particular.
Since that initial declaration in Gleneagles around universal
access we have taken forward with UNAIDS through the Global Steering
Committee process the effort to get in each country national plans
that are costed with clear targets so that each country has their
own strategy for making sure that everybody who needs access to
treatment and, indeed, also to prevention and care can get them.
Once those national plans are in place then the international
community needs to get behind those plans and make resources available.
Within that I think I have described already, Chairman, some of
the particular challenges that we face. In many parts of sub-Saharan
Africa, for example, health workers, and a shortage of health
workers, is one of the key issues to getting access to anti-retrovirals
sorted. I would point you to the encouraging statistics that I
did give about the way in which there has been a very significant
increase in the numbers who have got access to anti-retroviral
treatment in the two years between 2003 and 2005, albeit I accept
that there is a long way to go.
Q54 Mr Davies: If I could just take
you up on that. You quoted these figures in terms of percentage
increases but, of course, they are percentage increases from a
very low base. I think it might be more helpful if you gave us
the actual numbers. Could you just do that?
Mr Thomas: Sure. In sub-Saharan
Africa the numbers on treatment increased from 100,000 to 810,000
from 2003 to 2005 and about 1.3 million people were receiving
anti-retrovirals in lower and middle income countries by December
last year.
Q55 Mr Davies: That is what proportion
of those who are HIV positive or estimated to be HIV positive?
Mr Thomas: I would estimate it
is just under 25%. The last estimate I saw was that about six
million people in developing countries are in need of access to
anti-retrovirals. I will check whether that statistic is broadly
right but that is in the right ball park.*
* The witness has confirmed that this is accurate.
Q56 Chairman: The reason why we,
and you, are concentrating on these marginalised groups is all
of the evidence is they are the drivers of the epidemic so you
want to ensure that you are not just increasing the treatment
but containing the epidemic otherwise you are chasing a moving
target and from the reports we have at the moment it looks like
we are holding our own but we are not turning the corner. That
is the impression one gets. Last year under the British Presidency
there was an EU Declaration made on World AIDS Day, do you anticipate,
and is the British Government seeking to encourage, a similar
declaration by the EU on that?
Mr Thomas: I think the EU has
made its declaration and we are now seeking, with other European
donors, to work on the implementation of that declaration through
our programmes in-country. We used that declaration to get a united
European position in the run-up to the UN General Assembly Special
Session in June 2005. I do not think we need another declaration
as such, we just need to go ahead and continue implementing that
declaration, and that is what we are seeking to do. **
**Witness has since provided the following clarification,
"Since attending the hearing I understand the Finnish Presidency
has drafted a statement that will be released on World Aids Day".
Also see supplementary memorandum submitted by witness, Ev 29
Q57 Chairman: It is our intention, which
is why we have been pushed to fit this in the timetable, to get
this evidence and our report published to coincide with International
AIDS Day and it is our continuing intention as a Committee to
monitor this situation. As I said at the outset, all the evidence
tells us that if we do not deal with the HIV/AIDS epidemic then
many of the other MDGs and development objectives will be undermined.
That is why we regard it as sufficiently important. It is not
just in deference to Jeremy Hunt who, I think it is fair to say,
single-mindedly took that issue up and persuaded both the Committee
and the Government, and through them the international community,
that it was desirable because the targets are tough and if you
do not monitor them annually you are not going to meet them. Thank
you for coming in and giving us this evidence. In spite of some
of the differences in the questioning, I think there is a general
recognition that DFID does play a lead role nationally and internationally
in this which the Committee broadly supports, but given the challenges
are tough it is inevitable that you are going to be pushed as
to whether you can do more and whether what can be done can be
done more effectively. I think that is a constructive engagement
and certainly hope that you think so too. Thank you very much
indeed.
Mr Thomas: Thank you.
7 The witness has confirmed that this is accurate. Back
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