4 INTEGRATION OF HIV/AIDS WITH
OTHER DISEASE PROGRAMMES
27. We highlighted the importance of an integrated
approach to tackling HIV, tuberculosis (TB) and malaria in our
Report last year.[43]
In its Strategy, DFID recognised the link between AIDS and other
diseases and the need for more integrated care. It says that "in
hyper-endemic countries, 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".[44]
DFID pointed out that around one-third of AIDS deaths worldwide
are due to TB, and that TB is the most common cause of death in
people receiving anti-retroviral therapy.[45]
28. In our 2008 Report we said that we were not convinced
that DFID was taking sufficient steps to ensure that the specific
challenge of interaction between HIV and TB was tackled, nor had
it set out how it would measure the effectiveness of its Strategy
in addressing the interaction. We requested a clearer indication
of how this work would be taken forward and measured in DFID's
Monitoring and Evaluation Framework.[46]
In its response, DFID pointed out that the data which it now plans
to collect from its country offices on a biennial basis will include
specific questions on how DFID is supporting the integration of
HIV and AIDS with TB, malaria and sexual and reproductive health
and rights (SRHR). It could not, however, provide details on specific
programme plans that we had asked for: DFID said that detailed
information on implementation was documented in country and regional
assistance plans.[47]
29. Witnesses told us that a lack of clarity remained
about how DFID would support integration. Sally Joss said that:
Unfortunately, the M&E framework which has
been set up for the new AIDS strategy does not require DFID offices
to measure progress on TB and HIV integrated programmes and there
is no indication of how much of the £6 billion that is to
be spent on health systems will actually go to those programmes
[....] there needs to be something added into the monitoring and
evaluation framework which does track the integration of programmes
of co-infections and other diseases like TB and malaria.[48]
In its written evidence, the non-governmental organisation
Results UK said that "the integration of HIV-TB services
appears to have been unevenly prioritised in DFID's work in the
last twelve months". Despite the progress that has been made
by DFID, there was still a lack of integration in a number of
high-burden countries. It urged DFID to "re-emphasise the
need for tailored integrated service delivery and that a framework
for such be incorporated into all Country Assistance plans".[49]
Similarly, Kanco appealed to DFID to integrate specific TB and
TB-HIV related interventions in the health programmes it supports.[50]
30. Another of the issues we raised last year was
that of diagnostic tools for TB. We highlighted the reliance on
outdated diagnostic techniques, such as x-rays, which were not
sufficiently effective in identifying the disease. The Minister
stressed then that "improving diagnostics is right at the
heart of creating improved universal health systems".[51]
Results UK, in its written evidence to us this year, pointed out
that, while DFID's Strategy committed it to increase funding for
research into an AIDS vaccine and microbicides, it had not made
a similar commitment to increase funding for new diagnostic tools
for TB.[52] These tools
would be crucial to reducing morbidity and mortality among PLWH.
Sally Joss of the UK Consortium told us:
DFID's future support for HIV in research and
development should be looking at faster and more effective diagnostic
tools for detecting TB because often current tests miss TB in
people living with HIV, which means that there is a very high
death rate.[53]
31. World Vision highlighted that children, particularly
those aged under five, are extremely vulnerable to contracting
TB from infected adults in their households. It noted that the
diagnosis of TB in HIV-infected children is "notoriously
challenging" and that this difficulty could result in the
under-reporting of the level of co-infection in children. The
lack of paediatric drug formulations for TB made treatment of
these children difficult.[54]
32. Much of the focus is on co-infection with TB
and malaria, but effort is also required to integrate HIV prevention
with other disease programmes. Sally Joss stressed that "there
are also co-infections like hepatitis that need to have an integrated
programme of HIV services."[55]
The Alliance noted the "urgent need for greater integration
between hepatitis C and HIV responses among people who use drugs".
Large numbers of injecting drug users have HIV and hepatitis C
virus (HCV) co-infection. The interaction of the two diseases
produces more rapid disease progression and higher rates of mortality
and morbidity. Diagnostic and treatment outcomes for both diseases
could be significantly enhanced with greater integration. The
Alliance stated:
Rates of HCV testing are low, and despite being
increasingly successful, access to treatment for HCV is very poor
due to the high cost of patented drugs and the lacking capacity
in health systems and community organisations to manage HCV treatment.[56]
The World Health Organisation (WHO) in its recent
report on HIV/AIDS, Towards Universal Access, highlighted
that: "Underlying viral hepatitis is becoming a major cause
of death among people with HIV and hepatitis."[57]
33. We were disappointed that no measures for
monitoring the integration of HIV/AIDS, TB and malaria programmes
were included in the Monitoring and Evaluation Framework. An integrated
approach to tackling these diseases is a key element in an effective
AIDS strategy, given that so many people with HIV die from TB
and malaria and that people with TB and malaria are more vulnerable
to HIV. More resources are needed to promote early detection of
TB, including funding for new diagnostic tools, as well as support
for research into new drug treatment regimes. Greater attention
must also be given to interaction with other diseases, particularly
hepatitis C. We recommend that, in response to this Report, DFID
provides us with information on its plans for developing programmes
and funding research into co-infections between HIV/AIDS and other
diseases, beyond TB and malaria.
Integration with sexual and reproductive
health
34. In our Report last year, we stressed that "there
are close intersections between sexual, reproductive and maternal
health and HIV/AIDS."[58]
We welcomed DFID's acknowledgement in the Strategy of the need
to integrate sexual and reproductive health and rights services
(SRHR) with HIV/AIDS programmes. The Strategy pointed out that
nine out of ten people with HIV were infected through sex or mother
to child transmission. It emphasised that "sexual and reproductive
ill health and HIV are influenced by the same underlying factors
and can usually be tackled through the same channels".[59]
35. Interact Worldwide agreed that the causes of
poor SRHR and HIV/AIDS are closely related and highlighted that
they have common drivers: poverty, gender inequality, marginalisation,
stigma, discrimination and denial.[60]
The Alliance noted that DFID's Maternal Health and SRHR Strategy,
initially planned for publication in mid-2009, had been postponed
indefinitely and that DFID had lost the opportunity to "concretise"
its position:
Beyond the promise to intensify efforts to halve
unmet need for family planning by 2010, neither the Strategy nor
the M&E framework include a target related to universal access
to comprehensive reproductive health, as articulated in
the MDG target 5b, or to sexual health, and the realisation of
sexual and reproductive rights as a critical component of HIV
responses.[61]
It believed that:
Upgrading the 2004 SRHR Position Paper to the
level of a strategy to guide the UK's support for maternal health
and SRHR, with its accompanying targets and M&E framework,
will reinforce and support the operationalisation of the emphasis
on linkages with HIV outlined in the Strategy.[62]
36. We welcome DFID's acknowledgement of the close
links between promoting sexual and reproductive health and tackling
HIV/AIDS. We were, however, disappointed to learn that DFID had
postponed indefinitely the publication of its Maternal Health
and Sexual and Reproductive Health and Rights Strategy, initially
planned for mid-2009. We urge DFID to publish this important document
as soon as possible and to ensure that it takes full account of
the need for the integration of HIV/AIDS programmes with sexual,
reproductive and maternal health services.
43 Twelfth Report of Session 2007-08, HIV/AIDS:
DFID's New Strategy, HC 1068-I, paras 39-48 Back
44
Achieving Universal Access, p 35 Back
45
Achieving Universal Access-evidence for action, p 36 Back
46
Twelfth Report of Session 2007-08, HIV/AIDS: DFID's New Strategy,
HC 1068-I, para 44 Back
47
First Special Report of Session 2008-09, HIV/AIDS: DFID's New
Strategy: Government Response to the Committee's Twelfth Report
of Session 2007-08, HC235, p 6 Back
48
Qq 7-8 Back
49
Ev 67 Back
50
Ev 56 Back
51
Twelfth Report of Session 2007-08, HIV/AIDS: DFID's New Strategy,
HC 1068-I, para 43 Back
52
Ev 67 Back
53
Q 7 Back
54
Ev 85 Back
55
Q 7 Back
56
Ev 53 Back
57
World Health Organisation, Towards Universal Access: Scaling up
priority HIV/AIDS interventions in the health sector, Progress
Report 2009, September 2009, p 54 Back
58
Twelfth Report of Session 2007-08, HIV/AIDS: DFID's New Strategy,
HC 1068-I, para 76 Back
59
Achieving Universal Access, p 35 Back
60
Ev 47 Back
61
Ev 53 Back
62
Ev 53 Back
|
