Examination of Witnesses (Questions 177
- 179)
WEDNESDAY 5 DECEMBER 2007
PROFESSOR PETER
GODFREY-FAUSSETT,
PROFESSOR CHARLOTTE
WATTS AND
MS CATHARINE
TAYLOR
Q177 Chairman: Good morning, ladies
and gentlemen. Before we go into the session I would just like
to say that we have as a committee each year marked World AIDS
Day by taking some particular evidence. This is obviously part
of our inquiry into maternal health but focuses particularly on
the impact of HIV/AIDS in that area. The Committee was not actually
here on 1 December; this is the closest date to it. The point
that I feel sure this will bring out is that, clearly in those
countries where HIV is prevalent, the impact of that on maternal
health is pretty closely linked. One or two figures which have
been highlighted are that HIV positive women are four times more
likely to die in pregnancy or childbirth than women without HIV;
HIV positive women face a higher risk of infectious diseases,
such as TB and malaria, and yet less than 10 % of pregnant women
with HIV are estimated to be receiving any anti-retroviral therapy;
and in 2005 more than half a million children were newly infected
with HIV through mother to child transmission. So pulling these
things together is clearly significant. I think the point we have
already identified in this inquiry is that too often maternal
health is one thing, malaria is something else and HIV/AIDS is
something else and yet pulling them all together is clearly logical;
so what we are looking at is how DFID[1]
and the Global Fund can actually help in that process as well
as the other issues such as gender inequality and sexual violence,
which aggravate the problem. It is just to put those issues in
context and connect it specifically to the Committee's annual
commitment to acknowledge World AIDS Day and make a contribution
to that. With that preamble, I wonder if the panel, for the record,
would perhaps introduce themselves and then we can go into the
more specific questions related to the inquiry.
Professor Watts: Shall I start?
Good morning. My name is Charlotte Watts. I am from the London
School of Hygiene and Tropical Medicine. I am not an expert in
maternal health but I have been working for many years on HIV,
in particular gender issues around HIV, and I head a research
centre working on gender-based violence and health.
Ms Taylor: Good morning. My name
is Catherine Taylor. I work for HLSP, which is a consulting firm
that specialises in health system strengthening in low and middle
income countries and I am the lead specialist in maternal health.
My background in maternal health is that I worked in the NHS for
14 years as a midwife and as a midwifery tutor and then overseas
for 15 years on a number of long-term projects working in maternal
health, reproductive health and, more recently, HIV/AIDS. I have
just taken over the Programme Manager post in South Africa for
the DFID funded multi-sectoral programme for HIV/AIDS.
Professor Godfrey-Fausett: Good
morning. My name is Peter Godfrey-Faussett. I am a professor of
international health also at the London School of Hygiene and
Tropical Medicine, but I am here really standing in for the Global
Fund to Fight AIDS, TB and Malaria. I serve as the Chair of the
Technical Review Panel for the Global Fund, which is the body
that recommends to the Board of the Global Fund which projects
should and should not be funded. I am glad to say that to date
the Board has always accepted our recommendations. Our role on
the Technical Review Panel is independent of the Global Fund and,
when the Global Fund were asked to come and give evidence to the
Committee, they, unfortunately, were not able to send one of their
technical people and so they asked if I could come and speak to
the issues. They pointed out to me that I was entitled to speak,
as I do for the Technical Review Panel, as an independent witness
rather than formally representing the views of the Global Fund,
but I know the processes of the Global Fund very well because
I have been deciding what to recommend for funding over the past
four years.
Q178 Chairman: Thank you very much
for that. On the general review that this Committee has done on
the progress towards the targets on HIV, the concern has been
that the target was set for 2010, not interim targets, and to
the extent that there are interim figures available, they do not
look like being on a line that would achieve those targets. There
has been some increase, apparently, in those receiving treatment
from anti-retroviral therapy. It has gone up from 7 % in 2003
to 12 % at the end of 2004 to 20 % at the end of 2005, but that
still leaves about 4.7 million people in Africa who need anti-retroviral
therapy who are not receiving it, and, as I said in my opening
remarks, less than 10 % of pregnant women living with HIV/AIDS
are receiving necessary treatment, even though it is demonstrated
that if they do their survival rates are much higher. Very specifically
in the context of the Department for International Development,
what can DFID do to improve access to anti-retroviral therapy
that they are not doing already specifically to ensure that pregnant
women who have HIV can get access to the drugs that they need,
given the evidence is quite clear that, if they do, it greatly
increases their survival rate, so it not only reaches the HIV/AIDS
target, it also delivers on one of the Millennium Development
Goals which is most off track?
Professor Godfrey-Fausett: Shall
I kick off. I think that the environment around care for HIV changed
hugely, of course, with the arrival of anti-retroviral drugs,
and we have seen a massive scaling up of treatment for people
living with HIV with anti-retroviral drugs in poor parts of the
world, so the numbers have gone up a lot. I think that the emphasis
on providing treatment for people living with HIV has, to some
extent, distracted attention from what was happening before those
big treatment programmes started going. In particular, the early
programmes on prevention of mother to child transmission started
usually with the assistance of UNICEF,[2]
who led the first pilot programmes, and they have not continued
to scale up. I think that is because people's attention has been
more focused on getting treatment out to adults who need it.
Q179 Chairman: You think it is that.
In other words, you reach the easiest people first and it is harder,
without the infrastructure, to reach more or actually the will
has diminished?
Professor Godfrey-Fausett: No,
I think it is a matter of focus. It may be a matter of the resources
available in ministries of health and other relevant ministries
to provide, but if you take, for instance, the example of Zambia,
where I have worked and lived for many years and which I visit
regularly, the number of adults now receiving anti-retroviral
drugs is more than 120,000, so they have dramatically scaled up
over the past five years; and it is not that those people are
easy to reach, those are big, difficult programmes, often supported
by PEPFAR,[3]
the Global Fund and the Ministry of Health in Zambia, but, at
the same time, women who come to a regular antenatal clinic are
not always offered an HIV test, do not always receive anything
to prevent infection of their infant; in fact the rates of services
to prevent mother to child transmission for those women is still
unacceptably low. My own perception is that that has been because
there has been a focus issue, and I think that focus is now shifting
back a bit. I think people are accepting the importance of prevention,
which perhaps we had lost a little bit in the push to get people
on to treatment, and I think perhaps we are becoming a bit more
balanced, not least because, as more people are treated, many
of those people have been treated through programmes that have
been established in order to treat people and they are based within
the health service; they, nonetheless, have their own reporting
and recording systems often. There is a degree of disease-specific
focus around that, and the obstacle to continuing to expand those
programmes is the weak health infrastructure, and the weak health
infrastructure in turn relates to why women may not want to go
to the health service in the first place; it relates to the inefficiencies
in the health service in delivering what should be a much more
straightforward intervention. If one talks about the medical side
of it, and I think it is very important that we move beyond just
thinking of the medical part of preventing mother to child transmission,
but if we think of the medical side alone, it is a much more straightforward
intervention than the idea of starting someone on treatment and
then keeping them on treatment for the rest of their lives because
it is a time-limited intervention that is just for the period
in the run up to labour, in labour and thereafter. It should be
much more straightforward. So, I do not believe that it is because
it is more difficult, I believe that it is because of the attention
that has been placed upon it.
1 Department for International Development (DFID) Back
2
The United Nations Children's Fund (UNICEF) Back
3
The United States President's Emergency Plan for AIDS Relief
(PEPFAR) Back
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