Examination of Witnesses (Questions 180
- 199)
WEDNESDAY 5 DECEMBER 2007
PROFESSOR PETER
GODFREY-FAUSSETT,
PROFESSOR CHARLOTTE
WATTS AND
MS CATHARINE
TAYLOR
Q180 Chairman: Can I ask the other
witnesses. Is there anything specifically you think DFID could
be doing to help address this shortfall?
Ms Taylor: In fact, I would just
like to go one step back before answering that question, if I
may. My fellow witness here has alluded to this fact. Often HIV/AIDS,
TB and malaria are seen as disease specific and activities involved
in actually addressing those diseases are not integrated into
their health system and so they often run as parallel systems,
and I think that that is historical in that HIV/AIDS was almost
taken out of reproductive health and placed over here and so we
have actually had fragmentation of the issues. I think that that
is playing out in the fact that often maternal health services
and health systems in low income countries are poorly resourced,
both financially and in terms of human resources, in relation
to HIV programmes. So that is the context. In relation to what
DFID could be doing, I think from the work it has been doing recently
it is going in the right direction. It is working at a global
and regional level with policy-makers to address this lack of
integration and is highlighting the need for reproductive health
services and family planning services as part of PMTCT[4]
activities as well as looking at continuing care throughout pregnancy
and after. For example, it recently funded the maternal and newborn
health programme in Zimbabwe which actually linked very closely
with the HIV/AIDS programme, and it was specifically designed
to do that; so that they are, for example, at a policy level,
talking with the major agencies and funding and then, at a country
level, they are actually leading by example and funding programmes
where there is linkage between maternal health and HIV/AIDS. What
more could DFID do? I think definitely more of the same. There
is a lot of lobbying and the new International Health Partnership
that they introduced in the autumn, I think, is a very good step
in that direction, looking much more at health as an integrated
approach rather than in silos, as they are called. As I said,
more of the same, lobbying at an international level, but also
at a country level. We know that there has been a shift over the
last few years towards budget support, and I believe that that
has a lot of advantages in many areas, but when you are giving
budget support there is also a need for very good technical knowledge
at a country level so that you can enter into negotiations at
a country level and be seen as credible in those negotiations
with government, so that you can actually influence policy at
a country level, so that the budget support is well spent, but
also keeping up technical support for countries that do have budget
support. In the more neglected or marginalised areas, such as
youth, for example— I use youth as a marginalised area—we
often think of neglected or marginalised groups in terms of commercial
sex workers or males having sex with males, but youth are quite
neglected and marginalised areas and often governments are quite
reluctant to deal with those areas.
Q181 Chairman: The Committee addressed
that in our report on AIDS last year, but it is still relevant.
Ms Taylor: I think there is still
a need for a varied basket of aid instruments at a country level.
Yes, budget support, because that has many advantages, but also
not forgetting that there are other areas that are neglected which
sometimes require integrated programmes to perhaps kick-start
or help governments develop evidence in their own country which
then they can act upon.
Q182 Chairman: Professor Watts, the
evidence we have had so far on the general issue of maternal health
has been that the cost of accessing health services, particularly
if they are of poor quality and a long way away, is high, and
also women may not be able to get transport or even have their
own money. Is this the same problem— that access to anti-retroviral
drugs or even the knowledge that you have a problem is exacerbated
by the fact that there is no infrastructure? Does it bring us
all back to that same problem?
Professor Watts: I agree, there
are large issues around infrastructure, accessibility, weak health
systems. I agree completely with my colleagues. The point that
they have not touched on which I think is also important to consider
is the gender issues about the barriers that women face in terms
of actually getting HIV tested. You might have a woman coming
to a facility but being too scared to find out her HIV status
because the implications of knowing her status are very scary
for her. She might fear violence if she does find out that she
is HIV positive, and what we see from prevalence surveys in low
and middle income countries are figures like one in three women
are experiencing physical or sexual violence by their partner.
This is a very common reality and, even if a woman is not in a
violent relationship, that fear of violence is often very much
there. Thinking about how we can strengthen health systems, a
component is to try and think about how we can support health
workers to start talking about these issues with women. There
are some research studies talking about increased experiences
of violence for women who test positive. Often this is a continuation
of previous violence that is happening in their relationship.
How can the health sector be involved in engaging with women around
these issues?
Q183 James Duddridge: Of the women
that do go along to get tested, what percentage manage to do so
without their partner or close community actually knowing?
Professor Watts: I do not know
the figures on that, but my sense (and my colleagues can correct
me if I am wrong) is that if you are thinking about antenatal
settings, women are getting tested on their own, they are not
there with their partners, so there is quite an important opportunity
there, and health workers are being trained in counselling around
HIV; they could also be receiving training around gender, around
violence, how to respond if a woman fears violence, what are the
issues around how to disclose and think about the procedures around
disclosing in a safe way to their family, to the community? In
terms of how many women succeed in doing that, I do not think
we have figures on that.
Professor Godfrey-Fausett: No,
but I think the point is well made. I think one of the advances,
perhaps, that has been made in the HIV testing field is to encourage
more family-based and couple-based counselling where both husband
and wife might know their result together, because it allows one
to negotiate and to think about it. The danger for a woman who
finds out she is HIV positive, if she discloses that to her husband
or to her sexual partner, is that he will often assume that she
brought it into the relationship, whereas, of course, who knows
what the real story is and how it came about. I would certainly
agree with Charlotte that many women do not disclose their status.
I think increasingly, to come back a little bit to the question—
I am sorry, I cannot remember which of you posed it— of
whether it is the difficulty in getting to the health centre,
certainly that is part of the issue, but the fact is that technological
advance has meant that the technology of HIV testing is extraordinarily
straightforward now. You can have HIV tests that do not need to
be stored in a fridge, that are accurate, reliable, work in 15
minutes on a spot of blood that is put on the filter paper, on
the stick, and give a reliable test. So many women are passing
into antenatal care— though by no means all— and of
course we should be pushing rates of antenatal attendants and
skilled attendants up, but many more women are having a skilled
attendant in attendance at some stage during their pregnancy and
yet many of those same women are not being offered an HIV test,
which could dramatically reduce the chance of their infant being
infected with HIV. HIV in children virtually does not exist in
this country now. Children are not becoming infected because of
a policy of routine screening of all women, whether they are thought
to be at risk or not, and they will all have an HIV test, routinely,
unless they specifically say, "You must not test me for HIV."
The same policy is gradually being rolled out across most other
countries, a provider initiated HIV test. Again, the traditional
approach to HIV testing has been much more softly, softly, has
been based very much on being really sure you want to know your
HIV status because there are risks associated with that; whereas
I think the system is changing now so that in many antenatal clinics
the aim is that women should routinely be offered an HIV test
unless they say they do not want to have an HIV test, and then,
depending on the results of that test, a number of other actions
follow. Can I add one extra thing that came out of this: the role
of men. We talk about the prevention of mother to child transmission;
in our Technical Review Panel at the Global Fund we like to try
and think about parent to child transmission, because this business
of involving the father or the sexual partner is extremely important
in the whole process. The first aim, of course, is to prevent
the mother from becoming infected with HIV, which also has a lot
to do with the partner's behaviour. Specifically there are examples
where sexual intercourse during pregnancy is seen as taboo or
is not permissible in many cultures and, as a result, there is
some pressure on the man to seek other sexual partners during
pregnancy, and, of course, that puts the man at risk of acquiring
HIV infection and we know that the period shortly after acquisition
of HIV infection is the most infectious period. So a man who goes
and acquires HIV infection because his wife is pregnant is particularly
likely to infect her when they do have intercourse, and, if she
is recently infected, similarly, studies show that she is particularly
likely to pass it on to her infant, because she has a high viral
load around the time of infection. One can see a sort of scenario
where cultural norms enhance the possibility of transmitting HIV
to both the mother and to her infant, and, therefore, we do need
to be involving men in the situation. I am sure many of you have
visited health centres or antenatal centres in developing countries.
They are not at all male friendly. Men are very much kept out
of maternity suites and so on because many women are in labour
side by side, or whatever, and it is often not seen as appropriate
for men to be there. Managing to create a more male-friendly environment
is very important, I think.
Q184 Hugh Bayley: You have begun
to answer my question without prompting. Clearly the health environment
is one of the factors that increases rates of mother to child
transmission, but even when the woman knows her HIV status there
are a number of simple, cheap, easy to use in developing countries,
clinical interventions that can dramatically reduce the risk of
transmission at birth. Why has the spread of that knowledge, the
use of that knowledge, in developing countries been so slow and
what can be done by DFID to speed it up?
Ms Taylor: May I just make a quick
point on another question before I answer yours. I think we sometimes
fall into the trap of thinking about PMTCT as only the third of
the four prongs. PMTCT is not just about pregnancy and HIV testing
in pregnancy and the use of anti-retrovirals, et cetera. PMTCT
starts in actually ensuring that women do not become HIV positive
whether they are pregnant or not. That is the first issue. It
also involves women making reproductive health choices: "Do
I want to get pregnant? If I do not, how do I ensure that I have
access to services so I can get contraceptives for dual protection
purposes: both from pregnancy and from HIV?" Then we come
to the question, as you mentioned, of services during pregnancy,
but after that there are also services for making sure that the
woman who is HIV positive remains healthy, and often women fall
off the cliff, as it were, in the postnatal period when they then
do not have access to anti-retrovirals, and of course the likelihood
that she will die and then her child will die is increased. I
just want to mention that when I talk about PMTCT I am not just
talking about in pregnancy. To go to your question around PMTCT
in low income countries, many low income countries have increased
their services for PMTCT during pregnancy and they have introduced
antenatal care testing facilities. Somewhere like South Africa,
for example, I think probably about 90 % of their primary health
care clinics would put their hands up and say, "We provide
PMTCT services", but as my colleague said—
Q185 Hugh Bayley: But doing it in
South Africa is hugely easier than doing it in Malawi or Zambia.
It ought to be, it is a much richer country with a much stronger
health infrastructure, more trained personnel, and so on.
Ms Taylor: Yes, but still the
rates there vary very dramatically. If you look at Cape Town,
for example, over 70 % of the women who need it will have it.
If you look at some rural areas, you are looking at an uptake
of PMTCT as low as 24 %. Offering the service is one thing, but
during that period there are a lot of things that can go wrong;
so the service may be there but then the woman has to actually
go to antenatal care, and over recent years— and I am making
a link with maternal health here— the focus has gone away
from antenatal care, because in maternal health we were thinking
that really lives are saved at delivery and after, which is true,
and then there was less focus put on antenatal care, I believe,
for a number of years. So, you have a situation where the services
for antenatal care are perhaps not as good as they should be because
there has been lack of resources and there is not the quality,
and then you are asking them to add another service, which is
PMTCT. The woman has to agree to actually go to antenatal care
(and this is an access issue), then she has to agree to have a
test, then she has to have the results and there are rapid tests
where she could have the results that day, but often services
do not provide that, so she may have the test and then not go
back.
Q186 Hugh Bayley: By all means explain
what the difficulties are, but the question is what can be done
by DFID or other agencies to help to improve the state of provision?
Ms Taylor: I think perhaps, if
I may go back to this, the fact is that we always think about
PMTCT as a point of contact, say, in the antenatal clinic or a
VCT[5]
testing centre. Perhaps one of the things that we could be doing
is to look at how we can really expand opportunities for people
to actually know their status for HIV. So, rather than thinking
of it purely along the lines of those areas, examples would be
family planning clinics: make sure they have VCT testing, make
sure that ordinary primary healthcare clinics have the facilities
for VCT testing and that they do not just have it in one room
where people have to actually go to a room but that it is part
of the general service. I think it has been a problem that often
it is not seen as being an integral part of the health service
but something separate. I would say increase opportunities for
people to understand their status but at the same time, I think
when we are looking at health services, as my colleague said,
we forget the community aspects of that, and I think civil society
and community groups have a huge role to play in reducing stigma
and discrimination against people who are HIV and I think often
that is a neglected area. So, it is funding health services to
increase access but at the same time ensuring that resources are
going to civil society and community groups to reduce stigma and
discrimination.
Q187 Hugh Bayley: Could I ask further
about the balance between prevention and treatment? Are any of
you able to give the Committee a ball park figure of the cost
per HIV infection avoided for, on the one hand, prevention for
women of child bearing age and, on the other, prevention of a
mother to child transmission? Which is the more cost-effective?
Professor Godfrey-Fausett: I thought
they were both same.
Q188 Hugh Bayley: Prevention of infection
for a woman of child bearing age as against prevention of mother
to child transmission at birth.
Professor Godfrey-Fausett: I can
give a ball park figure for the first.
Q189 Hugh Bayley: Perhaps a general
cost—
Professor Godfrey-Fausett: Charlotte
has done some work around this. Around 250 dollars per HIV infection
averted.
Q190 Hugh Bayley: ---of general health
education.
Professor Godfrey-Fausett: There
are a number of approaches, but somewhere around that sort of
value. That was the value that came out of one of the trials.
Q191 Hugh Bayley: The cost of preventing
mother to child transmission. I understand it is not just giving
anti-retrovirals at birth, it is providing a whole package.
Professor Godfrey-Fausett: I am
afraid I have not brought the data with me. Elliot Marseille has
done work on this.
Q192 Hugh Bayley: Behind the question
is this. If I was a policy-maker, have we got the balance right
between prevention and treatment of an HIV positive pregnant woman
and her baby?
Professor Watts: I find the comparison
a bit hard. You are saying is it better, is it cheaper, is it
more cost-effective to prevent an infection of a woman—
Q193 Hugh Bayley: These are always
hard choices.
Professor Watts: I know. ---or
the subsequent transmission to her child, but if we prevent the
infection of that woman we also prevent the subsequent transmission
to her child. If we are talking about $250 to avert an infection
amongst women, then we are actually averting two infections potentially,
if she is likely to become pregnant over that period.
Q194 Hugh Bayley: Or perhaps, given
the birth rates in Africa, more than two?
Professor Watts: Maybe that. We
have a one in three transmission probability.
Q195 Hugh Bayley: The question is:
have we got the balance right between prevention and clinical
interventions to deal with people who are HIV positive, but rather
than just talking in general terms, we have to do as much as we
can for both? Given resources is a huge constraint in sub-Saharan
Africa, it would be helpful to know how many lives are saved or
how many lives avoid infection by one emphasis over the other.
Professor Godfrey-Fausett: I entirely
appreciate Catharine's comments about not focusing just on the
medical side, but I want just to focus on—
Q196 Hugh Bayley: I think it is very
important.
Professor Godfrey-Fausett: Nonetheless,
since you raised the question of treating them, there is no doubt
that finding that a mother is HIV positive and giving her and
her infant a short course treatment with anti-retrovirals is certainly
a very cost-effective way of ensuring that that infant is not
infected. If we look at the Global Fund's programmes, for instance,
I think that currently 130,000 HIV positive mothers have received
such treatment through Global Fund programmes up-to-date, but
I think it comes back to your earlier question about what DFID
can do and how it is doing it, and it comes to the question of
a country's own priorities. When one puts in budget support, then
to a large extent the country is deciding what are its priorities,
and there are many political pressures on that priority setting
process in-country as well and it is not always clear, but the
budget is often not supported to the extent that everything they
would want to do is being done. Unfortunately, ministries of health
and, indeed, ministries of education often get less out of the
budget than might be anticipated and, as a result, it is not only
that you find that peripheral clinics do not necessarily have
the facilities to do HIV testing and offer a cheap way of preventing
mother to child transmission, they often do not have antibiotics
in the cupboard, they often do not have this or that, and that
relates to procurement systems, it relates to delivery systems,
it relates to the quality of the roads, it relates to the quality
of the staff, it relates to development in fact. So, of course,
as one wants to develop, one has to work out how to encourage
countries to develop and then they will be much better at that.
The alternative is to take a more targeted approach where you
say that we think that this particular problem should not be allowed
to go on but we can do something very concrete about it, and that
tends to lead to more specific interventions around maternal and
child health or around tuberculosis or around the delivery of
anti-retroviral care. You ask: why are things different? The reason
things are different for anti-retroviral care is that the international
community made a very strong push and pushed, through the World
Health Organisation, perhaps through its Three by Five initiative,
and through PEPFAR, which is a very big programme from the American
Government for putting large numbers of people on treatment. They
were very focused on targets and they said, "This is what
we want to achieve"; whereas the targets that were set up
at UNGASS[6]
to achieve 80% reductions, and so on, they did not have an action
plan to follow. They were aspirational targets and very different
from, if you like, a PEPFAR target to say, "We are going
to treat this many people with anti-retroviral drugs and prevent
this many new infections and this is how we are going to do it."
I think I would echo what you said, Catharine, but perhaps I am
slightly further on one side than that. You mentioned in your
comments the need for multi-modes of funding. My own view is that
if you put all the money into budget support, many of these programmes
simply will not happen, they will not work. We know that things
are extremely difficult in the poorest countries of the world
and that those governments have many competing priorities of which
ensuring there is a rural clinic where the people do not have
much political clout, ensuring that the women there have adequate
care, maybe quite low on the political agenda and may not be something
that is easily funded out of budgetary support. It is, of course
(and I am arguing from the Global Fund standpoint), a good reason
for support through a mechanism like the Global Fund that takes
internationally recognised priority areas of HIV, TB and malaria,
including reproductive health within the HIV focus, and says,
"We are going to give money for what the country chooses."
It is a demand driven process. The country has to say, "These
are the things that we want to do." The Global Fund provides
money, if they seem technically appropriate, but also ensures
that they are doing what they said they were going to do. So,
I strongly support this view that you cannot simply give budget
support and say, "We have done our bit and we can encourage
the country to go down that way." I think more targeted interventions
are much more likely to have an impact on specific disease levels.
Chairman: Can I give a time warning here,
because we have quite a lot of questions and we are going to run
out of time. Can I say to both sides, shorter questions and shorter
answers and we will get through them.
Q197 Hugh Bayley: How important is
it to have a skilled birth attendant at the time of birth to reduce
mother to child transmissions, which is extremely important, and
do you think sufficient emphasis is given to training staff, paying
whatever incentives you need to get them into rural areas, as
against some of the other priorities of the Global Fund? I understand
the political pressures from the West for universal medication.
It is the sort of thing you have just been criticising me for,
for looking at interventions and thinking that that alone will
solve the problem, but the cost of a life-year gained through
anti-retroviral drugs is usually higher than the cost of a life-year
gained through preventing, avoiding mother to child transmission.
Is it important to divert some of the Global Fund's resources
into training of more qualified birth attendants and midwives?
Ms Taylor: Yes.
Q198 Hugh Bayley: Perhaps we should
ask the Global Fund to comment.
Professor Godfrey-Fausett: I would
also say yes, but I would follow that by saying, and you may think
that I am dodging the question, that the Global Fund is a financing
mechanism. The Global Fund does not decide what countries should
ask for. I would say that the Global Fund, certainly at our Technical
Review Panel, are frustrated in the area of mother to child transmission
in its broadest sense, that countries themselves frequently focus
precisely on testing and giving Nevirapine. We cannot do anything
about that, because our job is to recommend to the Board, yes,
or, no, on the technical merits of a programme. The Global Fund
does not tell countries, "That is what you should do."
That is the role, if you like, of the technical partners, of the
international NGOs, the people who work with the countries to
encourage them as to what they should apply for.
Q199 Hugh Bayley: Let me ask you
this question. If you had a free hand, knowing what you know having
been Chair of this Technical Panel for some time, would you say
we ought to be giving advice about the shape of a cost-effective
health intervention, a mother and child strategy for a developing
country? You cannot control the whole thing, but do you think
more emphasis should be placed on this?
Professor Godfrey-Fausett: I think
that we should be engaging countries in a conversation about what
they see as their priorities. I think we should be working hard
to build the public health capacity of the countries themselves
so the countries do not feel that they are being, if you like,
dictated to. It should be that they can enter that conversation
in a less asymmetric way than they do at the moment. The more
we can build up the ability within countries to have that conversation
the better. I would be careful. I would not want to say we should
say this is how it should look; one size will certainly not fit
all in different situations. Certainly we should be laying out,
"These are the possible benefits of things", and letting
countries come and say, "Yes, that is what we want to do."
4 Prevention of Mother to Child Transmission (PMTCT) Back
5
Voluntary Counselling and Testing (VCT) Back
6
The UN General Assembly's 26th Special Session (UNGASS), meeting
in 2001, issued a Declaration of Commitment on HIV/AIDS Back
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