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Written evidence submitted by the All Party Parliamentary Group on AIDS
September 2009
Q1 The process established by DFID for monitoring the performance and evaluating the impact of the Strategy
1.a It is too early to tell how effective the strategy itself and the M&E process will be since we have not got our first set of data. Since the first set of data will simply be a baseline, even having received it, it will still be impossible to monitor the impact of the strategy.
1.b. In the absence of two sets of statistics for comparison it would be useful to know the mechanics of how, one year on, the priorities laid out in the strategy have been translated into priorities at country-level offices and have some concrete examples of changed programming to reflect the strategy.
Q2 Progress on health systems strengthening and on an integrated approach to HIV/AIDS funding
2.a One of the problems of having health systems strengthening as a goal is that it is difficult to measure. The World Health Organization (WHO) defines health systems as "all the organizations, institutions, and resources that are devoted to producing health actions." However there is no agreed definition of what a strong health system looks like.
2.b. Success across a range of disease specific goals is measurable and can reflect the strength of a health system and its ability to deliver health outcomes. This is why the APPG believes it is important to set and monitor disease specific goals as part of health systems strengthening.
2.c. A 2009 report by Action (Action to Control TB internationally) called, 'Living with HIV, Dying of TB' says, "DFID's increasing focus on health system strengthening and sector-wide approaches (SWAps) to health has resulted in a reduction in support for targeted disease control programs and presents challenges for the accurate monitoring and evaluation of its impact on TB-HIV." (page 36)
2.d The Global Fund has adopted health systems strengthening as part of its funding portfolio, this has been partly as a result of DFID pressure. The APPG welcomes this development, since it complements the Global Fund's disease specific programmes.
Q3 Integration of HIV/AIDS prevention, treatment and care with other disease programmes, particularly tuberculosis and malaria
3.a There has been international improvement on integrating HIV and TB programmes together, and DIFD has been an important advocate and instigator of this change. A 2008 survey reported in Action's (a consortium of TB organisations) 'Living with HIV, Dying of TB' 2009 and conducted by DFID itself for the APPG on TB found that 12 out of 24 DFID country offices surveyed felt that there was insufficient TB-HIV collaboration to address their national TB epidemic.
Q4. The effectiveness of DFID's Strategy in ensuring that marginalised and vulnerable groups receive prevention, treatment, care and support services
4.a. It is impossible to know this in the absence of any data since the inception of the strategy.
4.b. The APPG believes that the Foreign Office has a particularly important role to play in this aspect of the AIDS strategy, because of its human rights work for the rights of men who have sex with men (MSM) and because problems faced by vulnerable groups such as MSM or injecting drug users are often not an issue about resource, but about political will. Diplomacy is therefore very important. The APPG will be interested to hear about how DFID and the FCO are working together on these issues, as they committed to do in the strategy (Page 59). Whilst data may not yet be available, examples of actions taken to progress this agenda would be useful.
Q5 The effectiveness of social protection programmes within the Strategy
5.a The APPG cannot comment in the absence of any data since the inception of the strategy.
Q6 Progress towards the commitment to universal access to anti-retroviral treatment and its impact on the effectiveness of care and treatment, particularly for women.
6.a Progress towards Universal
Access, the importance of maintaining We are off track on the Goal of
Universal Access to HIV treatment, care, support and prevention. This goal was
established under
6.b The All Party Parliamentary Group on AIDS in partnership with
the International AIDS Society is therefore calling for a high-level meeting to
be convened in early 2010, to agree on a way forward for accelerating progress,
and to demonstrate continuing political commitment. Without such an early
meeting the issue is likely to be subsumed in the run-up to the
6.c Despite being off target, there has been considerable progress towards universal access. Over a third of those who need HIV treatment have access to it - and achievement that would have seemed almost impossible a decade ago. DFID should build on this success.
6.d Access to treatment should have other positive effects, such as limiting the number of children newly orphaned by AIDS, sustaining family livelihoods, and reducing onward transmission of HIV, since treatment reduces an individual's infectiousness.
6.e The importance of prevention and the challenges of funding it Prevention of mother to child transmission has also been scaled up very effectively, through the work and funding of organisations such as the Clinton HIV/AIDS Initiative, UNITAID and UNICEF. Nonetheless, too many children are still born with HIV, they will need treatment for the rest of their lives. PMTCT must be a top priority if we are to manage the epidemic.
6.f. It is less easy to measure the impact of prevention programmes other than PMTCT. There will often be pressure on Governments and donors to de-prioritise such prevention in favour of instant and measurable 'wins' such as new people on treatment. Urgent work needs to be done to help countries decide on the most effective treatment:prevention spending ratios. DFID could help support such research.
6.g Long-term access - planning beyond the MDGs. The All Party Parliamentary Group on AIDS recently published a report on long-term access to HIV medicines in the developing world. 'The Treatment Timebomb' report urged the UK Government and other leaders to consider the likelihood of treatment cost per individual rising over the next two decades as more people become resistant to first-line treatments. It also highlighted some projections done by epidemiologists at University College London and Imperial College London on the numbers of people needing HIV treatment by 2030. The figure cited in our report of 55million people (compared to 9 million now) is a conservative one. The combination of high treatment prices and high numbers in need, makes for what the report describes as a 'treatment timebomb'.
6.h We therefore urge DFID to consider in advance how treatment prices can be minimised before huge numbers of people with HIV find their basic treatments stop working. Work on this is already in progress. The Access to Medicines team and DFID should be commended for the support they are giving to UNITAID for the establishment of a patent pool, which would address the price of improved first-line and second-line medicines and help stimulate the development of new medicines for developing country settings. This project is currently being held up, not by lack of political will, but by the reluctance of pharmaceutical companies to engage in dialogue with UNITAID on the issue. It would be most useful for the IDC to add its weight to DFID's call for companies to engage with UNITAID on the patent pool.
6.i. A full list of recommendations directed at DFID from the reported is attached as an annex to this response as is a copy of the report itself - The Treatment Timebomb.
Q7 Additional Comments
7.a. Part of the DFID strategy is the cross Whitehall Working Group on
HIV/AIDS. This features both in the initial strategy and the M&E document.
The All Party Parliamentary Group on AIDS believes that policy coherence across
7.b. The most pertinent
7.c. Given the importance of the cross-Whitehall working Group - to which DFID provides an informal secretariat - the APPG feels it is under-resourced. It has no budget and no additional staff time has been allocated to ensure follow up between meetings. Indeed the secretariat and overview functions are being carried out by a sexual and reproductive health team at DIFD which has significantly reduced in staff numbers over the last three years. Currently the group meets in private without making public its agenda or minutes. Whilst the APPG on AIDS recognises there may be advantages to full and frank discussions without minutes between departmental representatives, it does feel there needs to be some transparency and accountability from the from the cross-Whitehall group. We invite them to suggest solutions. Annex: Recommendations for DFID from recommendations in the Treatment Timebomb report
§ HIV is a long-term condition and funding will be needed to maintain progress well beyond the MDGs, even if the MDGs are achieved. People with HIV need treatment for life. DFID should work to catalyse discussions with its counterparts and the multi-lateral organisations it works with to agree on a common message to drive and maintain progress beyond 2015. § It is difficult to measure the impact of prevention and prevention activities can be an easy target for cuts in a numbers-driven environment. DFID, preferably in partnership with other key HIV players such as UNAIDS, should support the development of best-practice recommendations for treatment/prevention spending ratios. The recommendations would differ for different epidemic types and there would be an understanding that recommendations would need to be further adapted locally. They would provide a starting point for health departments and major donors. § All donors, including DFID should promote PMTCT of HIV that is more sophisticated than giving just a single dose of Nevirapine to expectant mothers. Neverapine is much better than nothing but too many babies continue to be born HIV+. § There is a need for research on common opportunistic infections associated with HIV and the cost of treating them so that AIDS programmes could include realistic financial allocations for the treatment of such infections. This fits in with DFID's integrated approach to health. § DFID is already working on an independent analysis of the costs and benefits of various models of pharmaceutical company access programmes, which we are pleased to see. This was one of the recommendations in the report. § DFID should support developing countries to use their TRIPS flexibilities to promote public health. They should discourage the adoption of TRIPS+ measures (that typically limit flexibilities) in European Economic Partnership Agreements (EPAs) with developing countries. This is an area for consideration by the Cross-Whitehall Working group, because of its implications for The Department for Business, Innovation and Skills. § DFID should continue to advocate for the establishment of a UNITAID patent pool for HIV medicines. § Countries have to make difficult decisions about the types of treatment they are prepared to fund. For example they need to decide whether they provide cheap treatments that are difficult to tolerate and adhere to, but cover more people, or whether they provide more expensive, more tolerable treatments. DFID should help fund health economists in its partner countries who can inform national aids strategies. § DFID, in communication with its counterparts from other donor countries and with UNITAID, should look into the workability of a prize fund for key missing HIV/TB medicines and diagnostics.
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