Memorandum submitted by Results UK
INTRODUCTION
This submission will primarily address the question
of how HIV/AIDS interacts with other diseases, especially tuberculosis
(TB), and how effectively this interaction is dealt with by donors
and funds. This will be followed by some concerns about DFID's
New HIV/AIDS strategy in relation to monitoring and evaluation
and measuring impact.
TB AND
HIV: BACKGROUND
INFORMATION
Despite being preventable and treatable, TB
remains the most common life-threatening opportunistic infection
and a leading cause of death among people living with HIV/AIDS
(PLWHA).1 In Africa, which has the highest rates of both diseases,
TB is the leading killer of PLWHA.2 Autopsy studies have produced
results ranging from 14% to 54% of people with HIV infection co-infected
with undiagnosed TB.3 Without proper treatment, approximately
90% of PLWHA die within months of developing TB.4 Drug-resistant
TB strains pose a particular threat to those with HIV, with mortality
rates from extensively drug-resistant TB (XDR-TB) exceeding 95%
in Africa.5
For more than two decades the international
community has known that TB and HIV/AIDS are intimately linked,
particularly in sub-Saharan Africa where HIV/AIDS has caused TB
incidence to triple since 1990.6 In 2002, officials from the World
Health Organisation (WHO)'s Stop TB Department clarified the need
for TB testing for PLWHA, stating "... those found to be
both HIV-positive and with active TB need referral for TB treatment;
those without active TB should be offered TB preventive treatment
with isoniazid".7 In 2004, WHO and UNAIDS unveiled plans
to expand collaboration between national TB and HIV/AIDS programmes,
promising that "TB case finding will be intensified in high
HIV prevalence settings by introducing screening and testing for
TB into HIV/AIDS service delivery points".8
INTERNATIONAL
RESPONSE
According to the most recent data available,
a mere 1% of PLWHA are reported to have been screened for TB.
Of those who were screened for TB, more than 1 in 4 had TB.9
Country-level HIV/AIDS programmes are not the
only actors failing to address TB/HIV. The leading sources of
international HIV/AIDS funding; PEPFAR, the Global Fund to Fight
AIDS, TB and Malaria and the World Bank Multi-country AIDS Program
do not routinely monitor how many PLWHA are being screened for
TB in HIV/AIDS programmes that they support, although PEPFAR does
urge funding recipients to screen PLWHA for TB. As of August 2008,
none of the three biggest donors were reporting the proportion
of PLWHA being screened for TB within their programmes.
Progress towards Universal Access to HIV/AIDS
treatment will not be made as long as people living with HIV are
dying of TB. The global community's collective failure to address
TB/HIV co-infection has led to unnecessary disease and death and
has allowed TB to undermine the global response to HIV/AIDS, including
the reductions in morbidity and mortality achieved through scaling-up
of antiretroviral therapy. Civil society groups, including those
from affected communities, are therefore calling for universal
access to high-quality TB-HIV care by 2015, including diagnosis,
treatment, preventive therapy, and infection control. Achieving
universal access to existing TB-HIV interventions by 2015 is both
necessary and achievable. Accomplishing this goal would reduce
TB deaths in PLWHA by 80-90% with an investment of US$19 billion,
according to WHO calculations.10
RESPONSE
TO HIV/AIDS STRATEGY
DFID's 2008 HIV/AIDS strategy has a welcome
focus on prioritising achieving Universal Access to comprehensive
HIV prevention programmes, treatment, care and support. The revised
strategy also recognises the value of an effective, integrated
and co-ordinated response to HIV, prioritising HIV prevention
as well as responding to the needs and protecting the rights of
those most affected. RESULTS UK agrees that the UK is well placed
to deliver the strategy within a wider development context, to
promote political leadership and aid effectiveness in line with
previous commitments.
RESULTS UK believes, that despite high-minded
aspirations, the strategy suffers from a number of significant
problems. These problems revolve around a central concern that
there is an unclearness and disjuncture between the means and
the ends of the strategy. More specifically RESULTS UK is concerned
about:
1. The lack of a more substantial emphasis
on the global TB/HIV co-epidemic, including the absence of specific
policy recommendations or investment targets.
2. The method of aid delivery.
3. The lack of an effective monitoring framework
to assess the progress of the strategy.
1. The lack
of a more substantial emphasis on the global TB/HIV co-epidemic
1.0 In November 2007, RESULTS UK produced
a report An Inadequate Response: More than two decades of complacency
in addressing the TB/HIV co-epidemic in which in which it
recommended that DFID should "Address TB and TB/HIV in the
updated AIDS strategy", and set out specific recommendations
for actions that should be included.11 The acknowledgement of
the need to address TB/HIV—absent from the UK Government's
previous AIDS Strategy "Taking Action"—was
therefore welcome and reinforces the UK Government's commitment
to addressing the co-epidemic.
1.1 Specifically, the new strategy states
that "It is important to improve rates of TB diagnosis among
PLWH—and to improve HIV diagnosis among people living with
TB—in places where both diseases are endemic" (page
21). The strategy also recognises that "TB and HIV are fuelling
each other, and the need for integration is made more urgent by
the steep rise in drug resistant TB infections" (page 35).
1.2 Despite acknowledging the need to tackle
TB/HIV and the threat posed by drug-resistant forms of TB, the
strategy fails to state what measures DFID will take to address
TB/HIV or drug-resistant TB. DFID outlines its commitment to support
"closer integration of AIDS, TB, malaria and SRHR, including
maternal and child health services" but provides no further
clarification on how it will fulfil this commitment and how it
will measure success (page 4).
1.3 The strategy notes on page 8 that "We
have seen encouraging progress in the implementation of integrated
HIV and tuberculosis (TB) interventions in Africa". It is
important that this progress not be overstated. There has been
some progress in screening TB patients for HIV but still less
that 15% of TB patients are currently being tested for HIV.12
Furthermore, as noted above less than 1% of PLWHA are currently
being screened for TB.
1.4 TB control is a necessary component
in the fight against HIV and AIDS and essential to the achievement
of Universal Access. There is a growing amount of evidence which
attests to the value of integrating efforts to confront TB and
HIV. In the Evidence for Action accompanying the AIDS strategy
DFID highlights WHO's recommendation of "isoniazid preventive
therapy to reduce the risk of TB in people with HIV" but
recognises that this will require "much greater integration
of HIV and TB care if it is to be successful" (page 36).
Studies in South Africa have shown that integrated TB and HIV
treatment can enable up to 150,000 co-infected people to start
antiretroviral therapy earlier and therefore prevent around 10,000
deaths per year.13
1.5 The strategy commits to increase funding
for research into an AIDS vaccine and microbicides. It does not
make any similar commitment to increase funding for new tools
for TB which will be crucial to reducing morbidity and mortality
among PLWHA. A new regimen of drugs is required that can combat
TB in a shorter time period and that are compatible with ART.
New diagnostics that can detect all forms of TB in PLHA and that
can be used in low resource settings are urgently needed to detect
TB earlier. Ultimately, to eliminate TB as a public health problem
and threat to PLWHA a new TB vaccine is needed.
1.6 The success of the new AIDS strategy
will depend on how recommendations are implemented at country-level.
The House of Lords Select Committee on Intergovernmental Organisations
recently released its report, Diseases Know No Frontiers
in which it recommends that before committing funds DFID "should
satisfy itself ... that there is adequate local recognition of
the problem of TB/HIV co-infection and that there are sound programmes
in place to address it".14 An Inadequate Response
also recommends that in order for DFID to improve their response
to TB/HIV, central policy should be more closely reflected at
country level. A survey of DFID country offices in high TB burden
countries last year found that only two out of eighteen were providing
direct support for TB/HIV collaborative activities suggesting
that many DFID country offices are not giving sufficient priority
to TB or TB/HIV.
2. The method
of aid delivery
2.0 Unlike Taking Action, the new
AIDS strategy is not accompanied by a specific financial commitment
for HIV and AIDS. The strategy does outline welcome financial
commitments; £6 billion for strengthening heath systems and
services up to 2015 and £200 million for social protection
programmes over the next three years, as well as noting the £1
billion pledged in 2007 to the Global Fund to Fight AIDS, Tuberculosis
and Malaria up to 2015. The new strategy does not detail how exactly
this new funding will reach those most affected by HIV or, for
example, how it would be used to strengthen the integration of
TB and HIV services.
2.1 The House of Lords Select Committee
on Intergovernmental Organisations recently recommended that "UK
funding to combat HIV/AIDS in developing countries should be conditional
on the adoption of an integrated approach to fighting TB-HIV co-infection".15
2.2 The new AIDS strategy has been developed
at a time when DFID is reducing the quantity of disease-specific
programmes that it supports, instead favouring sector-wide budget
support to country governments.16 The House of Commons Public
Accounts Committee have recently raised concerns over DFID's preference
for budget support, their recent audit concluding "DFID has
not established the effectiveness of budget support relative to
other types of aid, or been able to conclude whether, as currently
implemented, it represents value for money".17
2.3 The House of Commons International Development
Select Committee 2007 report on DFID have also suggested that
DFID place too much emphasis on inputs and not enough on outcomes
in the delivery of its aid.18
2.4 At present, DFID does not track spending
on specific diseases through general budget support or health
sector support. It is therefore difficult to evaluate how much
DFID is actually spending on TB, malaria and other diseases and
what impact DFID's aid is having in reducing their burden. As
DFID's support for HIV and AIDS moves in a similar direction it
will become equally challenging to monitor what impact DFID's
support is having and whether it is reaching the intended recipients.
2.5 Targeted investments are important for
addressing priority diseases as part of a broader approach to
improve health systems. An effective balance is needed between
"vertical" and "horizontal" health interventions
and balance will be different in different contexts. Without "vertical"
interventions, progress would not have been made to date in the
fight against AIDS, TB and malaria. The AIDS strategy promotes
"stronger, more effective systems", but notes that "evidence
gaps" persist concerning how "disease-specific funding|contributes
to the wider health system". DFID's move away from funding
programmes that focus on a specific disease should not be based
on a lack of evidence.
2.6 The strategy does not address the question
of how strengthening health systems might undo progress in tackling
the spread of priority diseases. The recent report Healthy
Aid by Action for Global Health cited with evidence the case
of Zambia, in which the introduction of general budget support
and a sector-wide approach (SWAps) to health led to "the
collapse of the Zambian TB programme". The report concluded
that general budget support "only helps the Government deal
with regular health problems and not extraordinary problems such
as HIV, AIDS and TB".19
3. The lack
of an effective monitoring framework to assess the progress of
the strategy
3.0 In An Inadequate Response, RESULTS
UK recommended that DFID's new AIDS strategy should include specific
targets to address TB/HIV co-infection with clear steps outlining
how they will be achieved. This recommendation was not taken on
board and, in fact, the new AIDS strategy contains very few specific,
quantifiable and time bound targets against which it can be held
to account. Without clear targets the strategy will be both difficult
to implement and monitor. DFID's overall Public Service Agreement
(PSA) targets (as detailed in the 2008 DFID Annual Report), include
no TB/HIV indicators and no TB indicators for Africa where the
burden of TB is greatest. It is therefore crucial that TB/HIV
targets are included in the new strategy's monitoring and evaluation
framework in order to have some way of assessing the outcomes
of DFID's efforts in this area. Suggestions for targets that could
be used to monitor the progress of a DFID supported country in
achieving TB/HIV collaboration are included in Appendix A.
3.1 The strategy states that an independent
review will be commissioned in three years time, and the Government
will also work through the cross-Whitehall working group on tackling
AIDS to monitor implementation. Without more detailed spending
targets and a monitoring and evaluation framework which outlines
how DFID will measure impact and outcomes it is not clear how
useful any such review will be.
CONCLUSION
In the foreword to the strategy Douglas Alexander
states "This strategy places people at the heart of the response".
RESULTS UK strongly endorses this approach and agrees that civil
society and those most affected by HIV/AIDS should be involved
at all levels of a multi-sectoral approach to achieving Universal
Access. To effectively implement the new AIDS strategy the UK
will need to address the specific challenges presented by the
co-epidemic of TB/HIV and demonstrate a much stronger emphasis
on outcomes; connecting the means of the strategy with the ends.
Without this, the strategy may fail to benefit those people whom
it intends to reach.
APPENDIX A
SUGGESTED TB/HIV INDICATORS TO MONITOR
THE PROGRESS OF DFID SUPPORTED
COUNTRIES IN ACHIEVING TB/HIV COLLABORATION
1. TB treatment for PLWHA in care.
— Number of adults and children enrolled
in HIV care who have started TB treatment.
2. HIV testing of TB Patients.
— Proportion of all registered TB patients
with documented HIV status recorded on the TB register.
3. ART in TB Patients with HIV.
— Proportion of HIV-positive registered
TB patients given ART during TB treatment.
4. TB status assessment in PLWHA in care:
Intensified TB case-finding among People living with HIV.
— Number of adults and children enrolled
in HIV care who had TB status assessed and recorded during their
last visit.
5. Proportion of HIV-positive TB patients
who receive co-trimoxazole preventive therapy (CPT).
— Number of HIV-positive TB patients
who receive (at least one dose of) CPT during their TB treatment.
6. Proportion of adults and children newly
enrolled in HIV care given treatment for latent TB infection.
— Number of adults and children newly-enrolled
in HIV care who are started on isoniazid preventive therapy (IPT)
for latent TB infection.
7. Percentage of estimated HIV-positive
incident TB cases that received treatment for TB and HIV.
— Number of adults with advanced HIV
infection who are currently receiving ART in accordance with the
nationally approved treatment protocol (or WHO/UNAIDS standards)
and who were started on TB treatment (in accordance with national
TB programme guidelines).
REFERENCES
1 World Health Organization. 2008. The Three
I's: Intensified Case Finding (ICF), Isoniazid Preventive Therapy
(IPT) and TB Infection Control (IC) for people living with HIV.
Report of a WHO Joint HIV and TB Department Meeting. Geneva, Switzerland,
April 2-4, 2008. Online.
http://www.who.int/hiv/pub/meetingreports/WHO_3Is_meeting_report.pdf.
Accessed 3 August, 2008.
2 WHO. 2008. The Three
I's.
3 World Health Organization. TB/HIV: General
Context and Implementation Issues. Presentation delivered to the
2008 Lambeth Conference July 28, 2008, Kent, UK.
4 WHO. Frequently asked questions about TB and
HIV. Online. http://www.who.int/tb/hiv/faq/en/. Accessed 3 August,
2008.
5 Gandhi N, et al. 2006. Extensively drug-resistant
tuberculosis as a cause of death in patients co-infected with
tuberculosis and HIV in a rural area of South Africa. The Lancet.
368:1575-1580.
6 World Bank. 2008. The World Bank's Commitment
to HIV/AIDS in Africa: Our Agenda for Action, 2007-2011. Washington,
DC.
7 Godfrey-Faussett et al. 2002. How human immunodeficiency
virus voluntary testing can contribute to tuberculosis control.
Bulletin of the World Health Organization vol 80 no 12.
8 World Health Organization. 2004. Interim Policy
on Collaborative TB/HIV Activities. World Health Organization,
Geneva. Ref. in http://www.who.int/mediacentre/news/releases/2004/pr5/en/
9 World Health Organization. 2008. Global tuberculosis
control: surveillance, planning, financing : WHO report 2008.
(Data from 2006) WHO/HTM/TB/2008.393. Nigeria data from Nigeria
Country TB-HIV report, 2008. (Data from 2007).
10 K. Floyd, WHO, June 2008. unpublished calculations
based on the Global Plan to Stop TB, 2006-2015.
11 RESULTS UK, November 2007. An Inadequate Response:
More than two decades of complacency in addressing the TB/HIV
co-epidemic. Online http://www.results-uk.org/userfiles/inadequateresponse.pdf
12 World Health Organisation. Global Tuberculosis
Control—surveillance, planning, financing. WHO, March 2008.
Online: http://www.who.int/tb/publications/global_report/en/
13 Centre for the AIDS Programme of Research
in South Africa (CAPRISA) study findings released 17 September
2008. Cited online at Aidsmap: HIV treatment at same time as
TB treatment halves death rate in South African study: http://www.aidsmap.com/en/news/81BF3B62-9197-42D6-9DB3-44A784E2F0B1.asp
14 House of Lords Select Committee on Intergovernmental
Organisations. July 2008. Diseases Know No Frontiers: How effective
are Intergovernmental Organisations in controlling their spread?
London. The Stationery Office. Page 48.
15 House of Lords Select Committee on Intergovernmental
Organisations. July 2008. Diseases Know No Frontiers. London.
The Stationery Office. Page 48.
16 National Audit Office, February 2008. Department
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countries. London. The Stationery Office. Page 6.
17 House of Commons Committee of Public Accounts,
May 2008. Department for International Development: Providing
budget support for developing countries. London. The Stationery
Office. Page 5.
Online: http://www.publications.parliament.uk/pa/cm200708/cmselect/cmpubacc/395/395.pdf
18 House of Commons International Development
Select Committee. Department for International Development Annual
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19 Action for Global Health, June 2008. Healthy
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health Millennium Development Goals. Page 19.
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