Examination of Witnesses (Questions 1-18)
MS LUCY
CHESIRE
28 OCTOBER 2008
Q1 Chairman: Good morning, Lucy. Can
you hear and see us?
Ms Chesire: Yes, I can hear you
loud and clear. Can you hear me?
Q2 Chairman: Yes, we can hear you.
That is fine. Thank you very much. First of all, can I say thank
you very much for coming into the DFID office to talk to us. Some
of us met you when you were in London in June and, obviously,
we felt that you would be a very good person to share your experiences
with us. I just wondered if you would perhaps start by saying,
as somebody who has been living with HIV and TB, what are the
biggest challenges that you face, and feel free to express what
you think are the most important issues for you?
Ms Chesire: Okay. Thank you very
much. It is excellent of you. First of all, the challenges and
experiences of people living with HIV are very clear. Are you
able to hear me?
Q3 Chairman: Yes, we can hear you
now. There was a slight scramble, but carry on.
Ms Chesire: Okay; cool. What I
wanted to say was that some of the challenges that people with
HIV face in relation to TB/HIV, co-infection is the issue around
the main diagnosis. The challenges are around diagnosis because,
if I can give my own experience, what basically happened is that
I was already living with HIV and I went for a chest x-ray but
the truth was that none of them were actually showing that I had
TB. So that is the biggest one. The kind of techniques that are
being used should actually be updated. If you look at the chest
x-ray, it has been used for over 100 years (inaudible), and that
technically means that if you want to see a diagnosis for having
HIV, for TB, it means, despite being in an area of (inaudible)
it becomes very difficult for the patient to be able to survive.
Q4 Chairman: It is very difficult;
I do not know whether we can get a better sound quality. While
that is being done, can I say I certainly understood the main
point you were making, which is that you believe that the diagnosis
for TB is inadequate and outdated. I can perhaps ask you the question,
if you can understand me, to follow that up: are you, therefore,
saying that you would like to see priority given to improving
the diagnosis and then also giving people with HIV routine screening
with better techniques?
Ms Chesire: In relation to that,
I think it is pretty clear what the demand for interaction activities
is. When you look at the TB and HIV collaborative activities (inaudible)
it states very clearly what programmes are supposed to do. Something
that they need to do is establish mechanisms for co-infection,
because here we have a reasonable ambition and, therefore, the
programmes need to cognate together. The issue is around decreasing
the burden of TB among people living with HIV/AIDS and, of course,
decreasing the burden of HIV among TB patients. What basically
programmes are supposed to do is be able to create each and every
part. When you look at TB/HIV co-infection—
Q5 Chairman: Lucy, can I stop you?
Ms Chesire: Yes.
Q6 Chairman: The sound quality is
variable and what they are suggesting is it might be better if
we redial and see if we can establish a better connection. We
are getting quite a lot of what you say, but it is very difficult
to get a complete record. So if we can stop and see if we can
re-establish the connection, I think it would be better for all
of us.
Ms Chesire: That is fine.
Q7 Chairman: Hopefully we will see
and hear you more clearly in a minute or two.
Ms Chesire: Okay.
Chairman: I am sorry about this, but
I am assuming that people are all having difficulty with the sound.
The Committee paused whilst a new video link connection
was established
Q8 Chairman: Hello, can you hear us?
Ms Chesire: Yes, we can.
Q9 Chairman: Okay. I think that is
better. We will certainly try. I am sorry about that. Technology
is great when it works but it is a problem when it does not. You
were saying to us that you find the techniques for diagnosing
TB are primitive. Perhaps you would just say it again. Are you
really saying more should be invested in improving the techniques
for diagnosing and are there particular problems with people who
are HIV positive? Do they require dedicated diagnosis?
Ms Chesire: I do not think they
necessarily require dedicated diagnosis. The issue is that the
diagnoses that are currently available are not all sufficient
to be able to detect micro-bacterial problems with HIV, and what
that basically means is that it calls for more research into TB/HIV
co-infection with regard to diagnostic provision and co-ordinating
bodies. Now, on reflection (inaudible) whereby it takes over six
hours to be able to get a conclusive test. Of course, the challenge
here is that the current diagnosis is not able to pick up the
micro-bacteria and that is why we have to look at the global TB
side. They are trying to see what can be done in relation to advancing
the diagnostics for TB/HIV so that every person who has HIV is
screened for TB, but, equally, antiretroviral therapy is continuing.
When you look at the three basic donors for HIV, which is PEPFAR,[1]
Global Fund and the World Bank, none of them are actually charting
how many people living with HIV are being screened, and to me
that is a crisis, because we cannot have over seven or eight hundred
thousand people who are already infected and only less than 2%
of them are being screened, and that shows that even the global
donors are not really able to adopt and address co-infection as
being a problem.
Q10 John Battle: I wonder if I could
ask whether the problem in detection of TB is an issue of screening
personnel staff and clinics, or is it a scientific problem that
once a person has HIV scientifically the bacterial infections
make it more difficult for even the best doctors to detect TB?
What is the basic issue here? Is it scientific detection or is
it lack of staff, medical personnel actually physically screening
people?
Ms Chesire: The problem is actually
both. It is both scientific and also it is medical. Why I say
it is both scientific and medical is because all the TB/HIV programmes
that are currently implementing the co-infection activity, only
less than 1% of persons living with HIV around the world are actually
being screened for TB, which to me is a disaster. We cannot afford
to delay diagnostics. Programmes are not even doing the actual
screening and at the same time, not even for the very few that
are doing it, like in Kenya, Malawi and Rwanda, they are recording
and reporting a problem, and that is why when you look at the
countries' plans they do not even have a specific indicator for
TB/HIV, which to me is a disaster.
Q11 John Battle: Could I follow that
up? Are the health authorities screening for TB for people who
are not yet diagnosed as HIV positive? In other words, is there
a general anti TB campaign and screening running?
Ms Chesire: Absolutely. For those
who are symptomatic, they are being screened, but the screening
is not done for the generalised population. That is one thing
we need to understand. What I am also trying to say is that when
you look at the TB/HIV co-infection activities, when it comes
to decreasing the volume of TB among people living with HIV, one
requirement is each of us, for example, living with HIV should
be screened for TB. Currently that is not happening. That is why
I was trying to give examples of countries that are even implementing
co-infection activities, we still see that it is just not happening.
Q12 Chairman: DFID are targeting
a lot of their funding over the next few years to strengthening
health services. Do you think this will help or do you think the
HIV/TB at-risk patients will kind of get lost in the general service?
In other words, do you think you need to continue to have a targeted
service, and, if you have a targeted service, can you deliver
it if you do not have an effective health service?
Ms Chesire: That is very interesting,
because I always look at it as you have to do both—you cannot
have one and not have the other—and so, at the end of the
day, what we have seen in the past is that because of the burden
of TB, HIV and malaria actually this whole area is a symptom of
our current healthcare standards, and it shows everybody it means
how do each work together so that at the end of the day even specific
programmes are actually contributing to health system strengthening.
If you look at the health system strategy, screening states that
one of the clear components is the issue around the whole of the
health strategy. How do we look at the six blocks in relation
to that? You are talking about healthcare workers having adequate
healthcare providers, healthcare financing, monitoring and evaluation
in place—all these components are really significant, so
we know that we cannot have one without the other because we have
got to have both of them working in tandem so that at the end
of the day the strengthening means that we have an efficient service
so that at the end of the day somebody is able to actually get
adequate services.
Q13 Sir Robert Smith: On that point,
how do you think DFID should measure the effectiveness of its
strategy? What sort of outcome should it be looking for to see
if it has made a difference?
Ms Chesire: One of the things
that DFID needs to do is that when you look at the current AIDS
strategy there is not really much on what they are going to do
specifically on TB/HIV, and that provides an opportunity, so it
is important that it is clear-cut in terms of how much of DFID's
money is actually going even to contribute to addressing the issue
of the co-infection alongside the health system. Then, of course,
the issue of monitoring, which is really critical. It is pretty
clear that if DFID wanted to go that way, one of the indicators
we will be looking at is how many persons are being screened for
TB? How many TB/HIV co-infected patients are benefiting from prophylactics,
which is Isoniazid preventive therapy, and then at the same time
how many of these are being started on HIV antiretroviral therapy?
So these are inherently difficult to look out for, and I think
they are pretty well spelt out when you look at the TB/HIV co-infection
activities but it is important that through the AIDS strategy,
which is lacking currently, there is no allocation of funding
that is going to address the co-infection, despite (inaudible),
or people living with HIV around the world, and then, of course,
the issue of monitoring and evaluating to see what progress is
being made at the country level and within the country plan.
Q14 Chairman: Is the problem that
not only are you not screening and diagnosing people who are vulnerable
to TB and are HIV positive, but if you do not actually have the
health infrastructure, you cannot treat it? It is almost worse
to be told you have got TB but there is no valid treatment available.
So is access to treatment at least as big or bigger a problem
than diagnosis?
Ms Chesire: I think we have seen
the issue of access to treatment being much more available to
many people. It was a big challenge actually when starting antiretroviral
therapy for many people, and today we have over 280,000 people
who have been started on treatment. So we have come a long way
in relation to that, but the thing is we have also got to be able
to address the challenges that are coming up today, and that is
why TB/HIV co-infection as a challenge has been very, very important
in one area where we are having multi-drug resistant TB and also
XDR,[2]
and so, with resistance to most of the drugs, it becomes much
more scary because it is becoming more expensive to be able to
treat it. The cost is $5,000 to treat one person for multi-drug
resistant TB over a period of two years, and this is something
where we have drawn on the South African experience whereby the
very first people who were diagnosed to have MDR-TB were actually
people living with HIV, and so it means that we have got to look
back and say what are the challenges and the plusses, think where
(inaudible) has exposed the takeover healthcare and what can be
done in order to be able to bring progress so that we are actually
able to contribute to a period where we can offer our services,
which will become an impediment if the challenges that are coming
along are not being addressed as we go by.
Q15 Chairman: If I am right, the incidence
of multi-drug resistant TB has got a lot to do with not having
early diagnosis. So clearly for a developing country finding $5,000
for a patient is extremely challenging, but presumably you can
find a smaller amount of money to actually catch them before they
develop multi-drug resistant TB. Am I right in that judgment,
and is that really one of the things you are focusing on?
Ms Chesire: You are pretty right
in that, but I do not think your figure is right because when
it comes to multi-drug resistant TB the issue of making the difference
becomes also another greater challenge, because when you look
at XDR and MDR, most countries do not even have the laboratory
facility to be able to screen that, and that is why now the World
Health Organisation has been trying to see if it can set up a
laboratory within Africa, so that patients can get better services
with the screening being done so that it does not become an impediment.
Q16 Chairman: I was going to ask
you, because really this is an opportunity for you to provide
from your experience your thoughts, as to how DFID could better
deliver on HIV/TB; so do you have a specific point or points that
you would like DFID to take on board if they are spending, as
they are, or offering, substantial amounts of money that would
meet your concerns and objectives? In other words, if you were
writing DFID policy, what would your priority be?
Ms Chesire: I think my priority
would be one of accommodation in terms of a financial commitment
within the HIV strategy to be able to address the co-infection,
and then, of course, secondly, the opportunity for DFID to be
able to track the amount of money that it is spending on some
of the diseases, which is currently not happening, and then, of
course, most importantly, the issue of monitoring and evaluation.
Q17 Chairman: Do you have a view,
then, about the Global Fund, because that clearly is designed
to try and deliver that, but you feel that it is falling short?
Ms Chesire: The Global Fund has
played its role, but it has also had its challenges along the
way. I was going through some of the proposals from the first
round of funding to the seventh round. It is pretty sad, in as
much as it is either the fault of the countries. When they are
putting in either HIV or TB proposals, they should be able to
incorporate a TB/HIV indicator. Most countries actually do not
do that. So we are seeing HIV proposals falling to the ground,
particularly TB/HIV co-infection being addressed, and I think
in the up and coming Global Fund meeting, which is taking place
on the seventh and the eighth, part of the recommendation is to
make sure that when they have a net core of proposals which are
coming up, one of the requirements would be that all countries
when submitting HIV proposals should specifically have a dedicated
allocation for TB/HIV and also specify the type of activities
that should be undertaken to be able to address that.
Q18 Chairman: Thank you very much.
I am sorry we had a problem with the line and the sound. It was
actually much better the second time. We are very grateful to
you. I think it would have been nice for you to be here, because
I think you are a very good witness, and the technology has slightly
got in the way of us. Nevertheless, I think we have had a useful
exchange and you have had an opportunity, I think, to give us
some food for thought. I sincerely hope our report will reflect
some of the things you have said. DFID, of course, are listening,
both given that you are in the DFID offices in Kenya they are
listening, but here as well. Can I thank you very much indeed
for coming in and can I wish you very well with your campaign
and your own personal health too.
Ms Chesire: Okay. Thank you.
1 1 US President's Emergency Plan for AIDS Relief. Back
2
2 Extensive Drug Resistant TB. Back
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