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
(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.
(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
(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 organisations, institutions, and resources that
are devoted to producing health actions." However there is
no agreed definition of what a strong health system looks like.
(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.
(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)
(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
(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
(a) It is impossible to know this in the
absence of any data since the inception of the strategy.
(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
(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
Progress towards Universal Access, the importance
of maintaining UK leadership and momentum
(a) We are off track on the Goal
of Universal Access to HIV treatment, care, support and prevention.
This goal was established under UK leadership of the G8 in Gleneagles
in 2005. If future goals are to be taken seriously, it is important
that the international community and the UK in particular reflects
on what it can do to accelerate progress and when they think Universal
Access can be achieved by. Glossing over a failure to meet the
target, however shared that failure is, will undermine political
credibility on not just this issue, but a whole range of developmental
goals.
(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 UK election.
(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.
(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.
The importance of prevention and the challenges of
funding it
(e) 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.
(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.
Long-term access—planning beyond the MDGs
(g) 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".
(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.
(i) A full list of recommendations directed
at DFID from the report is attached as an Annex to this response
as is a copy of the report itself—The Treatment Timebomb
(not printed).
Q7 Additional Comments
(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 Whitehall
on HIV/AIDS is very important, and has identified several areas
where it is not evident.
(b) The most pertinent Whitehall inconsistency
to this inquiry is universal access to HIV treatment in the UK.
The Universal Access target applies to all signatories, including
those in the developed world. There are still a number of asylum
seekers who are not eligible for free HIV treatment in the UK,
since such people are also not eligible to work and are therefore
living in poverty, this sometimes means they are denied access
to life-saving treatment. The APPG does not necessarily argue
that such people should be allowed to stay indefinitely by virtue
of their HIV status, but that whilst they are here, and in many
cases the Home Office recognises that they cannot safely go home
in the short term, they should be treated free of charge. The
numbers of people who fall into this category are very small,
and the cost implications are minimal (we are happy to supply
data if this is useful); however the APPG feels strongly as a
matter of principle that if we are asking developing countries
to provide universal access then we should provide it ourselves
in the UK.
(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.
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