7 ACCESS TO TREATMENT
Anti-retroviral treatment
56. We now turn to consider the provision of anti-retroviral
treatment (ART) for people living with HIV/AIDS. As we have noted,
42% of people requiring treatment in low- and middle-income countries
received ART in 2008, up from 33% in 2007. However, this is well
short of the target of universal access to treatment by 2010 set
in Millennium Development Goal 6.[94]
The number of people requiring ART in the future will continue
to increase due to a number of causes. Firstly, the number of
people becoming infected with HIV is still growing, with new infections
continuing to outpace the number receiving treatment. Secondly,
the total number of people living with HIV will rise as people
receiving ART live longer and continue to require treatment: ART
is a lifelong intervention. Thirdly, as the All Party Parliamentary
Group on AIDS pointed out in its report The Treatment Timebomb,
improvements in health systems and the quality of care and support
given to those living with HIV will also contribute to people
living longer.[95]
Fourthly, as testing programmes become more readily available
the number of diagnoses will increase. The International AIDS
Vaccine Initiative estimates that 55 million people will require
access to ART by 2030.[96]
Alvaro Bermejo told us that:
WHO in the next few weeks will issue new guidelines
lowering the time in which you have to start treatment, so asking
for people to start treatment with higher CD4 counts because that
has been seen to be the most productive approach. That will immediately
put millions of people onto our list of those in need of treatment.[97]
57. Although we welcome the increase in access
to anti-retroviral treatment which has been achieved, it is a
serious concern to us that the global commitment to provide universal
access to treatment by 2010 will not be met. We urge DFID to expand
its programmes to increase access to anti-retroviral treatment.
Provision of treatment for women
and children
58. The particular
impact of HIV on women and children and the resulting need for
effective treatment remains a serious concern. In sub-Saharan
Africa, women now account for almost 60% of the adults living
with HIV. HIV is the leading cause of mortality among women of
reproductive age worldwide. Maternal morbidity and death have
devastating effects on children's health, well-being and survival.
More than 90% of children living with HIV are infected through
mother-to-child transmission during pregnancy, around the time
of birth or through breast-feeding.[98]
For those children born with HIV, early treatment with ART within
the first few months of their lives can dramatically improve their
survival rates. World Vision said that in South Africa mortality
was reduced by 75% in infants living with HIV who were treated
before they reached 12 weeks of age.[99]
59. At the United Nations General Assembly Special
Session on HIV/AIDS in 2001 the international community committed
to reduce the proportion of infants with HIV by 50% by 2010 by
ensuring that 80% of pregnant women and their children had access
to essential prevention, treatment and care services.[100]
In its latest report on progress towards universal access, the
World Health Organisation stated that access to services for the
prevention of mother-to-child-transmission (PMTCT) in low- and
middle-income countries continued to expand: 21% of pregnant women
received an HIV test in 2008, an increase from 15% in 2007; 45%
of pregnant women living with HIV were receiving anti-retroviral
drugs to prevent mother-to-child transmission.[101]
World Vision told us that:
Without access to services to prevent this 'vertical
transmission', about 35% of infants, born to mothers living with
HIV, will acquire HIV during pregnancy, labour, delivery or breast-feeding.
Without proper care particularly related to breast-feeding and
nutrition, as well as anti-retroviral treatment, more than half
of these children will die before their second birthday […]
An unacceptable two thirds of pregnant women living with HIV remain
without access to these crucial services that prevent transmission
to their children.[102]
60. Interact Worldwide highlights that, when women
in developing countries are diagnosed with HIV during pregnancy,
care at this stage may be focused on preventing onward transmission
of HIV to her child, while there is neglect of the woman's wider
health and psychological needs. It calls for PMTCT services to
cater to women's wider needs in line with WHO guidelines. It believes
that action would increase the uptake of HIV testing and ensure
better health outcomes for women and their children.[103]
61. Fionnuala Murphy of Interact Worldwide told us
of the stigmatisation that women can suffer on being diagnosed
with HIV:
[She] can be thrown out of her home and have
her children and property taken away from her. She will be accused
of bringing the virus into her family. She will face violence
from her husband and her in-laws. In terms of a woman who is pregnant
and already physically and emotionally vulnerable because of that,
plus a HIV positive diagnosis, to put those two things together
and expect women to cope with no backup is really impossible and
it is no surprise that many women will refuse HIV tests in an
antenatal care setting or where they think that those tests will
be pushed on them.[104]
Interact Worldwide had documented cases of women
being tested without their consent. The result of this intervention
is that some women avoid any form of antenatal care altogether.
Ms Murphy continued:
The DFID strategy talks about PMTCT in terms
of the delivery of anti-retrovirals to prevent onward transmission
of the virus to babies and that is a really important part of
PMTCT, but we also need to think about all the other parts, such
as meeting the mother's health needs beyond pregnancy and birth
but also meeting all of the mother's needs and making sure that
women get the counselling they need and also have the backup services
so that if they do face violence and eviction they have somewhere
to go.[105]
62. According to World Vision, despite weak health
systems in many developing countries and those that have the highest
burden of HIV, more than 70% of all pregnant women in these countries
make at least one antenatal care visit. It says that this provides
an "excellent opportunity" for delivery of PMTCT interventions
and to engage women and their children in a "comprehensive
continuum" of HIV prevention, care and treatment services.
However:
[…] if PMTCT
is to be successful, women must have expanded access to quality
reproductive health services, including family planning, antenatal,
delivery and postpartum care, and must use the existing services
more frequently and earlier in pregnancy than they do currently.[106]
63. We are seriously concerned that the number
of women receiving prevention of mother-to-child transmission
treatment (PMTCT) remains well below target levels. DFID and its
donor partners should prioritise treatment to women and children
and use the opportunities presented by antenatal care to promote
the take-up of HIV/AIDS treatment by women. DFID should also ensure
that the PMTCT services which it supports recognise the wider
health needs and potential vulnerability of women living with
HIV/AIDS.
First- and second-line drugs
64. Many people in developing countries who are receiving
HIV/AIDS treatment are provided with "first-line" drugs.
These are drugs which were developed at a relatively early stage.
They are usually the most readily available and are comparatively
cheap, due to the high volume of usage. Over time patients on
first-line drugs may develop resistance to them and they become
less effective. This process is accelerated when patients fail
to adhere to their treatment programmes, which happens more frequently
when people are poor and have little access to health services.
Some people on first-line treatments also experience side effects.[107]
More patients in developing countries will, over time, therefore
need to transfer to more expensive second-line drugs. Alvaro
Bermejo of the HIV/AIDS Alliance highlighted that one first-line
drug is only prescribed in developing countries: in developed
countries "it is seen as too toxic and with too many side-effects
to be able to prescribe it but we call it first-line for developing
countries just because it is cheap".[108]
65. The World Health Organisation's latest report
on achieving universal access stated that treatment had become
more widely available in recent years, due to a significant decline
in the prices of the most commonly used anti-retroviral drugs,
with the cost of most first-line regimens decreasing by 10-40%
between 2006 and 2008. However, second-line drugs continue to
be expensive.[109]
The cheapest price for a second-line regimen is US$590 per patient
per year, making it seven times more expensive than the cheapest
first-line drugs.[110]
The Global Fund works on the basis of 5% migration from first-
to second-line medicines each year.[111]
Sally Joss of the UK Consortium told us that:
[…] ultimately this is going to mean that
the drugs that are cheaper now will go out of use and that more
expensive drugs will have to come in and countries will find it
extraordinarily difficult to sustain the level of treatment that
they presently have and particularly if they want more.[112]
WHO found that, in 2008, only 2% of adults on ART
were receiving second-line drugs. It cautioned that:
An increase in the use of second-line drugs […]
implies a rise in the cost of drugs for HIV programmes in low-
and medium-income countries. This represents a major challenge
for country programmes, national authorities and the international
development community, who will need to raise additional resources
to sustain and expand treatment access.[113]
UNITAID and patent pools
66. UNITAID was established in 2006 as a joint initiative
between the UK, France, Norway, Chile and Brazil to supply poor
countries with lower cost life-saving medicines for AIDS, tuberculosis
and malaria. It is administered by the World Health Organisation
with a mission "to contribute to scaling up access to treatment
for HIV/AIDS, malaria and tuberculosis, primarily for people in
low-income countries, by leveraging price reductions for quality
diagnostics and medicines and accelerating the pace at which these
are made available." It is now supported by 29 countries
and by the Bill and Melinda Gates Foundation.[114]
DFID has made a 20-year commitment to UNITAID with the possibility
of providing £760 million in the period to 2027.[115]
67. Sally Joss welcomed DFID's "financial and
moral support" for UNITAID and highlighted the benefits of
patent pools.[116]
A medicine patent pool functions on a voluntary basis. Patent
holders voluntarily submit patents for pharmaceutical production
methods and particular medicines. A third party then obtains a
licence from the pool to reproduce a single patented medicine,
or to use several patents to develop a new fixed dose combination,
in return for a percentage of its sales as a fee for each patent
used. Licences issued to third parties are restricted to developing
countries. Patented medicines are subsequently produced by several
manufacturers well before the expiry of a patent term, thereby
increasing the availability of certain medicines, increasing competition
and lowering the price of AIDS treatment in low- and middle-income
countries.[117] Patent
pools make it easier for researchers to develop combination therapies
as they can access permission to use component drugs from a single
source, rather than having to negotiate with a number of companies.[118]
The UK, as a member of the UNITAID board, will consider the agency's
proposals for a patent pool at a board meeting in December. [119]
68. A growing number of people living with HIV
and AIDS will require access to anti-retroviral treatment (ART)
if the target of universal access is to be reached. The number
of people requiring ART is increasing because more people are
being infected; the increased rate of testing is leading to more
diagnoses; and people with HIV are now living longer due to successful
treatment. We welcome DFID's co-operation with pharmaceutical
companies to reduce the cost of first-line drugs for developing
countries and to increase their accessibility. Wider availability
of second-line drugs is now needed. We recommend that DFID provide
us with more details, in response to this Report, of its plans
to increase availability and reduce the cost of vital HIV/AIDS
treatments through its co-operation with UNITAID and use of patent
pools.
94 Millennium Development Goal Target 6b is to "Achieve,
by 2010, universal access to treatment for HIV/AIDS for all those
who need it". See http://www.undp.org/mdg/basics.shtml Back
95
All Party Parliamentary Group on AIDS, The Treatment Timebomb,
June 2009, p 7 Back
96
Ev 49 Back
97
Q 18 [Alvaro Bermejo] Back
98
World Health Organisation, Towards Universal Access: Scaling up
priority HIV/AIDS interventions in the health sector, Progress
Report 2009, September 2009, pp 88-89 Back
99
Ev 87 Back
100
United Nations General Assembly, Declaration of Commitment
on HIV/AIDS, 2001 Back
101
World Health Organisation, Towards Universal Access: Scaling up
priority HIV/AIDS interventions in the health sector, Progress
Report 2009, September 2009, p 5 Back
102
Ev 87-88 Back
103
Ev 48 Back
104
Q 13 Back
105
Q 13 Back
106
Ev 88 Back
107
The Treatment Timebomb, July 2009, p 12 Back
108
Q 18 [Alvaro Bermejo] Back
109
World Health Organisation, Towards Universal Access: Scaling up
priority HIV/AIDS interventions in the health sector, Progress
Report 2009, September 2009, p 74 Back
110
The Treatment Timebomb, p 12 Back
111
ibid Back
112
Q 18 [Sally Joss] Back
113
World Health Organisation, Towards Universal Access: Scaling up
priority HIV/AIDS interventions in the health sector, Progress
Report 2009, September 2009, p 72 Back
114
http://www.unitaid.eu/ Back
115
Ev 33 Back
116
Q 18 [Sally Joss] Back
117
http://www.thecommonwealth.org/files/214504/FileName/CommonwealthHIVMeeting-PatentPoolBriefingPaper.pdf Back
118
The Treatment Timebomb, p 28 Back
119
HC Deb, 9 November 2009, col 101w Back
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