Written evidence submitted by the Department
for International Development
EXECUTIVE SUMMARY
1. The UK AIDS Strategy Achieving Universal
Access sets out how the Government will assist developing
countries to reach the goals of Universal Access (UA) and halting
and reversing the spread of HIV. It makes comprehensive prevention
a priority and shows how we will continue to promote the needs
and rights of women, young people, children and vulnerable groups.
It also sets out the commitments required to accelerate progress
towards building a long-term, sustainable response.
2. Implementation of the seven-year Strategy
is at an early stage; much of the required data are not yet available
and it is not possible to provide a rigorous assessment of impact
at this point in time. We published our planned process for monitoring
and evaluating the Strategy in December 2008. Subsequently, in
October 2009 Achieving Universal Access: a 2008 Baseline was
published. We draw the attention of the Committee to this document,
which sets out the basis for our future reporting—with a
first report due in 2010. This memorandum focuses on main achievements
and challenges since the launch of Achieving Universal Access.
3. We believe that it is time to move on
from the protracted international debate on the merits of disease-specific
versus horizontal health financing. Stronger health systems are
critical to tackling AIDS. The evidence we provide in this memorandum
demonstrates our commitment to strengthening health systems through
progress in the International Health Partnership Initiative and
country-level support, and through promoting the integration of
HIV/AIDS with other health services, malaria and TB services in
particular.
4. This memorandum provides evidence of
the Government's commitment to expand services for marginalised
and vulnerable groups by continuing to pioneer work on harm reduction
and supporting international advocacy efforts for an equitable
provision of services to men who have sex with men.
5. In Achieving Universal Access,
we committed to reviewing the effectiveness of social protection
in meeting the needs of OVCs. There is a strong international
consensus on the need for a stronger focus on comprehensive social
protection systems and programmes to support children and families
affected by AIDS. In the light of this, we remain confident that
our approach is strongly supported by current evidence and emerging
global best practice.
6. Expansion of access to anti-retroviral
(ARV) treatment, and its impact on the effectiveness of care and
treatment, particularly for women, are critical areas. The memorandum
provides evidence of our efforts to increase the affordability
and availability of ARVs and to expand access to treatment by
women, particularly by supporting the scale up of prevention of
mother to child transmission services, as well as our support
to global advocacy on women and girls.
7. Finally, despite progress being made,
we recognise that more needs to be done to reach Universal Access
to prevention, treatment, care and support, and we highlight several
specific challenges which will continue to drive our and the international
community's efforts.
INTRODUCTION
8. The Government welcomes the International
Development Committee (IDC) inquiry into the implementation of
its HIV/AIDS Strategy, Achieving Universal Access, published
in June 2008. This provides an opportunity to assess progress
a year on from the Strategy's launch and as we approach the challenging
2010 targets, which the international community has set for universal
access to comprehensive HIV prevention, treatment, care and support.
9. The Government's new White Paper: Eliminating
World Poverty: Building our Common Future, reaffirms our commitment
to the goal of universal access to comprehensive HIV prevention
programmes, treatment, care and support, and our determination
to meet our existing financial commitments to respond to the HIV/AIDS
epidemic. This includes spending up to £6 billion on health
systems for better health and HIV outcomes and £1 billion
to the Global Fund for AIDS, TB and malaria. The White Paper also
commits us to delivering on other promises we have made, including
our work on increasing access to medicines by supporting fairer
pharmaceutical markets for the poor.
10. Achieving Universal Access, our
response to this challenge:
— reiterates our commitment to play a leadership
role, helping developing countries to reach the goals of Universal
Access and halting and reversing the spread of HIV;
— prioritises HIV prevention—as the
best means to minimise the impact of the disease on future generations;
— sets out how we will continue to promote
the needs and rights of women, young people, children, and vulnerable
groups, and how we will support countries in providing stronger
health, education and other basic services;
— prioritises UK support for an international
system involving strong partnerships, from community to international
level;
— includes commitments on prevention, sustainable
treatment, social protection for those made vulnerable by the
disease, and £6 billion for stronger health systems and services
up to 2015—for improved health and HIV outcomes.
11. We published our planned process for
monitoring and evaluating the Strategy in December 2008. Subsequently,
in October 2009 Achieving Universal Access: a 2008 Baseline
was published. We draw the attention of the Committee to this
document, which sets out the basis for our future reporting—with
a first report due in 2010.
12. It is too soon to attempt a full and
rigorous assessment of the impact of the seven year strategy.
Implementation is at an early stage and much of the required data
are not yet available. This memorandum focuses on main achievements
and challenges since the launch of Achieving Universal Access.
We want to highlight the following specific challenges:
— Curbing the growth in new infections
through effective behaviour change programmes (eg reducing concurrent
multiple partners and unsafe sex).
— Unblocking obstacles to scaling up prevention
to meet Universal Access targets (such as widespread stigma and
discrimination against people living with HIV).
— Ensuring long-term sustainability of
programmes for treatment, care and support in the light of the
financial crisis and increasing demands for anti-retroviral treatment—defusing
what the All Party Parliamentary Group on AIDS have called the
"treatment timebomb."
— Integrating AIDS programmes into broader
health care provision, and in particular reproductive maternal
and child health services, to ensure that efforts to curb the
AIDS epidemic also impact on these related MDGs and that the synergies
for integrated services are exploited where possible.
— Ensuring the international community
maintains its financial commitments to tackling AIDS in the midst
of an unprecedented global financial downturn.
— Ensuring that national governments can
increase and sustain their financial allocations to HIV and AIDS
budgets.
13. This memorandum provides a snapshot
of progress at this early stage. Below is our response to the
six issues highlighted by the Committee.
1. The process established by DFID for monitoring
the performance and evaluating the impact of the Strategy
14. Achieving Universal Access commits
us to action in five priority areas:
Priority 1: Increase effort on HIV prevention;
sustain momentum for treatment; to increase effort on care and
support;
Priority 2: Respond to the needs and protect
the rights of those most affected;
Priority 3: Support more effective and integrated
service delivery;
Priority 4: Making money work harder through
an effective and co-ordinated response;
Priority 5: Turning the strategy into action.
Effective monitoring of performance and evaluation
of impact are core components of this.
15. The Government published Achieving
Universal Access—Monitoring performance and evaluating impact,
on 1 December 2008. This plan, developed in consultation with
civil society, commits us to assess progress against the UK priorities
for action in Achieving Universal Access through an independent
evaluation and a series of biennial reports.
16. Our aim, throughout the monitoring and
evaluation process, has been to provide an accurate picture of
progress towards Universal Access and to capture the particular
contribution made by the UK, without creating new burdens of reporting
that could deflect energies from implementation.
17. Our work in-country supports the implementation
of national HIV and AIDS plans. Decisions about DFID supported
programmes are taken at country level, in collaboration with national
governments and other partners. Information from these programmes
will form the basis of our future reports, together with information
on our multilateral engagement, from DFID corporate performance
systems and other Government Departments, as well as global data.
18. It is important that we use internationally
and nationally agreed targets and indicators—such as the
Millennium Development Goal and United Nations General Assembly
Special Session on HIV /AIDS (UNGASS) indicators and country-specific
indicators. This approach is in line with the Paris Principles
on Aid Effectiveness and the "Three Ones" principles.
19. The Government published the baseline
report in October 2009, available at www.dfid.gov.uk.
A copy is submitted with this memorandum. This report gives a
snapshot of the global situation when Achieving Universal Access
was published in June 2008.
20. This provides the basis for our future
reporting. We have committed to report on our performance once
every two years—starting with a first progress report to
be published for World AIDS Day in December 2010. We will publish
a second progress report for World AIDS Day 2012 and a third one
for World AIDS Day 2014.
21. In addition, DFID will commission an
independent review after three years of the strategy period. The
evaluation report will be published for World AIDS Day in 2011.
This will allow time for lessons to be learned, which can help
inform the remaining years of the strategy.
2. Progress on health systems strengthening
and on an integrated approach to HIV/AIDS funding
22. Recent years have seen much international
discussion on the relative merits of "vertical"—or
disease-specific—and "horizontal"—or systems-focused—approaches
in tackling diseases like AIDS and in improving global health.
We believe that stronger health systems are needed to scale up
the AIDS response and achieve universal access. Equally, an effective
response to AIDS serves as a platform from which other MDGs—for
example those on reproductive, maternal and newborn health—can
be reached.
23. In the long term, however, sustainable
funding for health systems and services provides the strongest
foundation for Universal Access; and that is why, in 2008, the
Government pledged to spend £6 billion on health systems
and services to 2015. Stronger health systems will facilitate
the scale up of preventative measures, such as prevention of mother
to child transmission of HIV. They will help more effectively
address co-morbidity of HIV with TB, malaria and other diseases
and they will help deliver ARVs to those who need them.
24. The baseline report shows that DFID
spent £776 million on health systems and services in 2007-08.
Since the launch of the Strategy in June 2008, the estimated spend
for 2008-09 is £959 million.
25. The UK has made a 20 year commitment
to UNITAID which could see us providing as much as £760 million
up to 2027. Our Research Strategy for 2008-13 outlines how DFID
will double its investment in research, including health, to £220
million a year by 2010. The new research strategy includes a focus
on developing drugs and vaccines for HIV and AIDS, TB, malaria
and other diseases that most affect poor people.
26. New signatories to the International
Health Partnership (IHP), launched in 2007, which seeks to strengthen
health systems and sector wide approaches, bring the total number
of developing countries participating to 13. Country compacts,
through which donors commit to coordinated support to national
health plans, are now being implemented in Ethiopia, Mozambique,
Nepal and Mali. Progress made includes that on simplifying World
Bank procurement agreements with UNICEF (to be extended to other
UN agencies), and on a joint assessment approach to national health
and disease strategies, which integrates work on assessment of
HIV/AIDS plans. The Global Fund to fight AIDS TB and Malaria (The
Global Fund) piloted the joint assessment approach for its first
funding applications based on national disease strategies.
27. An IHP working group on monitoring and
evaluation is guiding work to strengthen country health systems
surveillance. This work consolidates health systems and disease
specific indicators, including those on HIV and AIDS, and makes
them accessible to countries and donors.
28. The UK is mobilising support behind
the recommendations made by the Taskforce on Innovative International
Financing for Health Systems, co-chaired by the Prime Minister,
which reported in July to the G8 Summit. The Taskforce report
includes recommendations for raising additional finance for health
systems, channelling resources effectively, and ensuring effective
monitoring and accountability. The UK will contribute towards
an expanded International Finance Facility for Health Systems.
The UK also strongly supports the recommendation to establish
a joint health systems funding platform for the Global Fund, GAVI
Alliance and the World Bank.
Examples of the UK's support
29. In China: DFID's health programme
focuses on pro-poor health system reform and development, TB control
and HIV and AIDS control. Our bilateral aid is aligned with the
Government of China's priorities: innovation, complementarity,
risk taking, and poverty focus. Since 1999, DFID has committed
more than £100 million to health and HIV/AIDS support for
China. This approach has shown good results. For example, DFID's
support to the China Basic Health Services project (£21 million
between 1999 and 2007) helped improve access by 47 million people
to basic health services in 10 provinces in the mid and west of
China. In addition, 12 million of the poorest people enrolled
in the medical financial assistance scheme. Independent evaluations
have also shown that the project has achieved increased immunisation
and promoted birth in hospitals with skilled attendants present,
resulting in falls of 40% in maternal mortality in the counties
covered.
30. China's HIV and AIDS programmes are
well integrated with sexual and reproductive health services.
Increasing coverage of services to Injecting Drug Users (IDUs)
is currently the highest priority at this stage of the epidemic.
DFID has supported pioneering work amongst the most at risk populations,
including IDUs. The work consisted of awareness raising, peer-to-peer
outreach, needle exchange and methadone maintenance (MMT) treatment.
The MMT was particularly successful and in July 2006 was approved
by the Chinese Government for nationwide roll-out. By 2007 MMT
was being provided through 397 clinics in 22 provinces, with 88,000
IDUs enrolled. Coverage has continued to increase. Accurate figures
will be available at the end of 2009.
31. In addition, DFID supports care services
for persons living with HIV/AIDS (PLWHA) nationally and in seven
provinces. By end 2008 over 31,000 PLWHA were receiving ARVs and
over 28,000 received treatment for opportunistic infections, having
exceeded targets set.
32. In Cambodia: DFID supports the
health sector in partnership with the World Bank, AusAID, UNICEF,
UNFPA, France and Belgium. DFID has contributed £35 million
as part of a pool of over $130 million to support the government's
2008-15 health strategy. The strategy gives priority to maternal
and child services, including reproductive health, for the rural
poor and will benefit around 10 million people in 24 rural provinces.
The programme will expand successful innovations including health
equity funds to pay for hospital costs for the poor, performance
based contracts with rural district health service providers and
performance pay schemes for staff. Expected outcomes include:
21,000 under five child deaths averted; 1,300 women deaths prevented;
increase in the number of women giving birth in a hospital or
health centre from 95,000 to 180,000 a year; and increased public
primary care and hospital clinic visits from 7.5 million to over
11 million a year.
33. This support includes the training of
government staff in safe abortion care and counselling—by
end 2008 an additional 129 midwives and doctors have been trained
in the delivery of safe abortion care. In addition, DFID supports
the government's 100% condom use programme, which is seen as a
mainstay of Cambodia's HIV prevention strategy. The expansion
of family planning and safe abortion services is expected to contribute
to further reductions in HIV prevalence, and to prevention of
mother to child transmission of HIV.
34. In Kenya: DFID has spent about
£25 million on health and HIV/AIDS in 2008-09, focusing on
strengthening the delivery of essential health services, health
systems, malaria, and reproductive health. The Insecticide-Treated
bed-net (ITN) programme delivered DFID's 14 million new bed-nets
in March 2009, reducing under five mortality and putting Kenya
on-track to meet MDG 6. HIV prevalence has halved in the last
10 years, from over 10% in the mid 1990s to 5.1% in 2006. DFID
support has helped provide anti-retroviral drugs to 230,000 people,
and supported provision of home-based care to 64,000 people living
with HIV/AIDS and 110,000 orphans and vulnerable children.
35. In Ethiopia under the umbrella of the
IHP, DFID has been at the forefront of efforts to help the Ministry
of Health establish the "MDG Performance Fund" to support
the implementation of the Health Sector Development Programme,
focussing on strengthening health systems and services for women
and children, including reproductive health, malaria and HIV/AIDS
control. Indicative funding of $240 million has been pledged to
the fund over the next three years.
36. In Ethiopia HIV prevalence was 2.1%
in 2006-07 with wide variations across regions. There has been
a steep increase in the number of people living with HIV who have
accessed ART in recent years, with ART now provided free of charge.
The number of people started on ART has increased from 8,276 in
2004-05 to 180,000 in 2009. The percentage of people needing ART
who are accessing it is estimated at 58%. The health systems'
strengthening initiatives described above have allowed an expansion
of health workers and facilities in the country leading to improvements
in ARV provision as well as other health essential commodities
and services in the country.
37. In Sierra Leone, a DFID supported
youth reproductive health programme has resulted in a 19% increase
in the level of sexually active young people who are faithful
to regular sexual partners; and condom use has increased by 36%
amongst the group. There was also a 7% increase in young people
who were able to identify major symptoms of sexually transmitted
infections and an increase of 9% in the number of young people
who were able to identify methods of contraception and prevention
of HIV transmission.
3. Integration of HIV/AIDS prevention, treatment
and care with other disease programmes, particularly tuberculosis
and malaria
38. Achieving Universal Access recognises
the important links between AIDS and other diseases and highlights
the need for more integrated care It is too soon to provide a
detailed assessment of progress against Strategy commitments in
this area. There are, however, important points we wish to highlight
to the Committee and, below, we provide country examples that
give a flavour of the work we now have in progress.
39. There are particularly close links between
HIV and tuberculosis. The AIDS epidemic has been largely responsible
for the doubling or tripling of TB incidence rates in Sub Saharan
Africa in the last 15 years. About 15% of new TB cases globally
are HIV positive; in Sub Saharan Africa it is 70%.
40. At an institutional level, many countries
have historically separated TB treatment services from general
health services which has made the integration of diagnosis, treatment
and care more difficult. There has been great progress in scaling
up integrated TB/HIV activities, but these need to be further
expanded to cover all cases of co-infection. The majority of HIV-positive
TB cases do not know their HIV status, and the majority of HIV-positive
TB patients who do know their HIV status do not have access to
antiretroviral therapy. The biggest challenge to integration in
resource limited settings is human resources.
41. The relationship between malaria and
HIV is not as close as that between TB and HIV. But there are
nevertheless some important links.
42. For example, malaria increases blood
levels of HIV, making patients more than twice as likely to transmit
the virus to a sexual partner. HIV also makes people more susceptible
to malaria, especially in those with advanced immunosuppression,
which may have accelerated the spread of malaria in places where
HIV is highly prevalent. For both of these reasons, efforts to
prevent and treat one disease will synergistically lower incidence
of the other. There is also often little integration between planning
and service delivery of HIV/AIDS and malaria programmes—an
important issue in the context of shortages of skilled health
personnel.
43. Achieving Universal Access supports
the integration of AIDS services with other health services, including
TB. Our commitment to spend £6 billion over seven years to
2015 to strengthen health systems and services, includes the integration
of HIV and TB services. We are also committed to work with international
partners to support countries with health worker shortages to
provide at least 2.3 doctors, nurses and midwifes per 1,000 people,
which will help build the capacity of health systems to manage
HIV and TB co-infection issues.
44. The Global Fund is at the forefront
of work on integrating HIV/AIDS prevention treatment and care
with that of TB and Malaria. The UK Government have made a long-term
commitment of up to £1 billion from 2008-15 to the Fund,
in addition to the £6 billion on health systems and services
announced in the Strategy. We have provided £524 million
to date to support the Global Fund to fight AIDS, TB and Malaria—our
principle support to the provision of TB drugs.
45. DFID advocated for further integration
of HIV and TB services during the Global Leaders' Forum on HIV/TB,
held at the United Nations on 9 June during which important principles
for further progress were successfully negotiated and reflected
in the document "Call for Action on HIV/TB." These include:
the need to scale-up efforts to deliver universal access to TB
and HIV prevention, treatment, care and support services by 2015;
the need to strengthen health systems and services; the integration
of health services, including HIV and TB; and to increase investment
and facilitate research to promote development of better tools
for prevention, diagnosis and treatment of TB.
46. We will also work to integrate HIV with
other disease programmes by: implementing the International Health
Partnership (IHP) as described in our response to question 2 above.
Examples of country level support
47. The first formal assessment of progress
at country level will be made in our 2010 report. In the meantime,
examples of our country work include:
48. In Southern Africa, DFID is finalising
the design of a new Regional Health and AIDS programme which plans
to provide £55 million over five years, to address both AIDS
and broader health issues, to support countries scale up their
responses to AIDS, TB and malaria in women, children and other
vulnerable groups.
49. Zambia is implementing two joint
HIV/TB projects under the auspices of the Zambia AIDS Related
TB (ZAMBART) Project, a collaborative effort between the University
of Zambia, School of Medicine and the London School of Hygiene
and Tropical Medicine. The work focuses on the overlap between
HIV and TB in order to improve the quality of life of people affected
by the dual epidemic. DFID is providing £3.75 million to
this project for the period 2006-11.
50. We are also providing support directly
to strengthen national TB programmes. For example, in China,
DFID has allocated £23 million over seven years towards reducing
TB morbidity and mortality through an effective and sustainable
National TB control programme focused on the poor.
4. The effectiveness of DFID's Strategy in
ensuring that marginalised and vulnerable groups receive prevention,
treatment, care and support services
51. In 2006, the Committee focused its inquiry
on marginalised groups and emerging epidemics. It identified "four
key populations" in which new epidemics were driven: sex
workers, injecting drug users, men who have sex with men (MSM)
and prisoners.
52. Achieving Universal Access makes
clear that understanding and addressing the needs of these groups
will be fundamental to tackling the epidemic outside Sub-Saharan
Africa. The strategy places the needs and rights of these groups
at its heart, and we will continue to advocate for increased,
evidence-based responses for these groups.
53. Achieving Universal Access identifies
four priorities for action:
— supporting the empowerment of People
Living With HIV (PLWH) and vulnerable groups;
— ensuring that gender analysis is integrated
within national AIDS plans, and that targets and indicators are
developed to measure the impact of AIDS programmes on women and
girls;
— promoting and taking action on neglected
and sensitive issues—including adolescents sexual and reproductive
health and rights (SRHR); the needs and rights of MSM, and harm
reduction; and
— working with our partners to ensure increased
action against HIV stigma and discrimination.
54. It includes a specific commitment to
work in countries where injecting drugs is a major driver of the
epidemic to increase the coverage of harm reduction services for
injecting drug users.
55. In addition to ensuring support for
groups marginalised by responses to HIV, we need to focus on groups
particularly vulnerable to the epidemic. Foremost amongst these
are women and girls.
56. It is too soon to provide a detailed
assessment of the Strategy's effectiveness in supporting marginalised
and vulnerable groups. We will focus on this in future reports.
The following examples, however, demonstrate that important work
is underway.
Examples of HMG's work with vulnerable populations
include
57. Data shows that men who have sex with
men (MSM) are nearly 20 times more likely to be infected than
the general population in low and middle-income countries. Despite
this fact, less than 2% of global funding for HIV-related programming
is directed at MSM. In an effort to combat soaring HIV rates among
gay, bisexual, and other MSM we have recently (May 2009) approved
a grant of £755,000 over three years to the Global Forum
on MSM and HIV. This funding will support implementation of a
new international advocacy strategy promoting equitable access
for MSM to effective HIV prevention, care and treatment services
in developing countries.
58. In Nigeria DFID has supported the BBC
World Service Trust (BBCWST) to develop radio and television programmes
on HIV and AIDS. A subsequent survey estimated that over 12 million
vulnerable youths were reached with reproductive health and HIV
messages through 6,000 episodes of the radio programmes aired
by 95 radio stations across Nigeria. The TV drama "wetin
dey" attracted more than 6 million people in nine months.
59. DFID's work on HIV and AIDS in China
focuses on helping the poorest and most vulnerable people
have access to prevention treatment and care. DFID has supported
pioneering work with injecting drug users, sex workers and MSM.
This has enabled more than 25,000 IDUs receive Methadone Maintenance
Treatment, 386,000 people receive VCT, more than 31,000 be put
on ARVs, more than 28,000 PLWHAs receive care for opportunistic
infections, as well as 212,000 people from high risk populations
and 2.2 million youth receive behaviour change communication programmes.
60. In Pakistan HIV infection is
low among the general population (fewer than 0.55% are infected)
but has increased rapidly in groups at high risk of infection,
including drug users and sex workers. DFID support to the National
AIDS control Programme helps these groups protect themselves and
helps control the epidemic. For example, female sex workers are
more likely to use condoms: the percentage using a condom during
their last sex act increased from 34% in 2005-06 to 45% in 2006-07.
Intravenous drug users are more likely to use clean needles and
syringes: the percentage using new needles and syringes in the
last month increased from 22% in 2005-06 to 48% in 2007-08.
61. In 2008-09, DFID made a substantial
contribution to curb the spread of HIV in Vietnam by funding the
Government's HIV prevention programme. DFID funding has increased
the availability of condoms for sex workers, with over 95% of
street-based sex workers and 65% of sex workers working in clubs
and bars gaining access. Transmission among drug users drives
the country's epidemic. There is compelling evidence[13]
that increasing the availability and utilisation of sterile needles
contributes significantly to reductions in the rate of HIV transmission.
Accordingly, the project distributed 15 million clean needles
and syringes to drug users in 2008, an increase from zero in 2004
to 15 million in 2008. The programme now accounts for 75% of all
needles distributed across the country. During the year DFID also
contributed to the start-up of a long-resisted methadone treatment
programme, piloting treatment with 800 patients, and to be scaled
up in 2009-10.
62. In Argentina, the FCO has sponsored
a local NGO to promote humane and evidence-based drug policies
in Latin America during a two day regional conference. Supporting
this type of events is key from a harm reduction perspective since
HIV transmission cannot be reduced amongst IDUs in environments
where stigma and discrimination drive government policies.
5. The effectiveness of social protection
programmes within the Strategy
63. Robust evidence shows that Social Protection
can strengthen families affected by HIV and AIDS. A recent review
of 300 documents by the International Food Policy Research Institute
highlights how cash transfers can help secure basic subsistence,
reduce poverty and protect children's access to education, health
and good nutrition. Cash transfers should be seen as part of broader
social protection measures that include family support services
to protect children from abuse, accessible and affordable health
care and education, psychosocial support and broad livelihoods
support.
64. That is why Achieving Universal Access
pledges the UK to spend £200 million on social protection
programmes; and to work in at least eight African countries to
develop social protection policies and programmes that provide
effective predictable support for the most vulnerable households,
including orphans and vulnerable children.
65. This policy reflects findings that have
come out of the Joint Learning Initiative on Children and AIDS
(JLICA) and the Inter-Agency Task Team on children and AIDS sub-group
on social protection, for which DFID has been the co-chair. In
Achieving Universal Access, we promised to review the effectiveness
of our approach in meeting the needs of OVCs in the light of the
biennial Global Partners Forum (GPF) on Children Affected by HIV
and AIDS.
66. At the 2008 GPF, held in Dublin, there
was a strong consensus on the need for a stronger focus on comprehensive
social protection systems and programmes to support children and
families affected by AIDS. In the light of this, we remain confident
that our approach is strongly supported by current evidence and
emerging global best practice.
67. The need for social protection has become
more acute with the global economic crisis. The Government's new
White Paper Eliminating World Poverty: Building our Common
Future, sets out DFID's aim to help build social protection
systems to get help to 50 million people in over 20 countries
over the next three years. The G20 London Summit agreed to make
resources available for social protection to help the most vulnerable,
including through contributions to the World Bank's Vulnerability
Framework and Rapid Social Response Programme. DFID committed
£200 million to the World Bank to support social protection
programmes and we are working with the World Bank on how this
money will reach the poorest households. Bilateral expenditure
on social protection activities in 2007-08 was £45.5 million.
68. On expanding partnerships to deliver
the strategy, DFID is a signatory to the Joint Agency Statement
on Child-Sensitive Social Protection, launched by partners (including
Unicef and the World Bank) in August 2009.
Examples of country level support to improve social
protection policies include
69. Presently, the UK supports social protection
responses and social welfare ministries in a range of countries
most affected by the epidemic such as Zimbabwe, Kenya, Zambia,
Malawi, Rwanda and Mozambique. Bilateral support is also provided
via UNICEF's Children and AIDS Regional Initiative (CARI), covering
South Africa, Botswana, Angola, Namibia, Swaziland and Lesotho.
DFID also supports the provision of south-south technical support
on social protection system development from the Government of
Brazil to Kenya, Ghana, Angola and Mozambique.
70. In Kenya: DFID supports (£122.6
million over 10 years) cash transfers for orphans and vulnerable
children, a Social Protection strategy, and a Hunger Safety Net
Programme in fragile pastoralist arid areas (450,000 people).
This uses innovative private partnerships and technology for transfers
to enhance poor people's inclusion and access to local markets.
71. In Mozambique: DFID has made
a long-term commitment (£20 million over the period 2008-18)
to help the Government improve and expand its unconditional cash
transfer programme for vulnerable households, mainly headed by
older women caring for orphans and vulnerable children (expected
to reach 500,000-700,000 beneficiaries), and to help develop a
strategic framework for social protection.
72. In South Africa results from
the Kwa-Zulu Income Dynamics Study contributed to a better understanding
of the impact of social grants on child welfare outcomes, such
as better nutritional status and lower incidence of stunting.
This evidence has helped accelerate the extension of the child
support grant to 12 million recipients.
73. In Botswana, DFID's support through
UNICEF's CARI, has provided a social policy adviser to the Department
of Social Welfare for 12 months, and has supported a review of
direct social assistance programmes, with government shifting
from provision of food baskets to coupons for households caring
for orphans.
6. Progress towards the commitment to universal
access to anti-retroviral treatment and its impact on the effectiveness
of care and treatment, particularly for women
74. While significant progress has been
made in improving access to HIV treatment over recent years, 70%
of people who need the drugs still cannot get them. Access to
anti-retroviral treatment (ARVs) for all who need them is a key
element of Universal Access. We seek to address this through our
long-term support to the Global Fund, our research programme and
our health systems strengthening work.
75. Achieving Universal Access commits
the UK to work with others to reduce drugs prices. DFID is collaborating
with the Clinton Foundation HIV/AIDS Initiative (CHAI) on a project
to reduce the prices of key first and second line ARVs for AIDS
(and also anti-malarial drugs). We have also supported UNITAID's
efforts to develop an operational plan for a patent pool for ARVs.
76. This project seeks to improve the affordability,
availability and level of quality assurance for AIDS and malaria
drugs provided by Indian and other manufacturers, and to increase
capacity in African countries to access these drugs. This complements
efforts by governments, international agencies and regional groupings
to strengthen programmes for the control of AIDS and malaria.
A key target of the three year programme is to help reduce spending
on ARVs by more than $100 million by 2011 in low and middle income
countries (other than Thailand and Brazil), compared to what would
have been spent for the same medicines in 2008.
77. On 6 August 2009, the Clinton Foundation
announced two important and complementary agreements between CHAI
and pharmaceutical companies, as a result of the work part-funded
by DFID (£9 million between 2008-09 and 2011-12). These agreements
will result in better and more affordable second-line treatment
options:
— agreement with Matrix (an Indian generic
drug manufacturer) to provide a once daily four drug second line
therapy at $475 per annum in 2009, and $425 per annum in 2010.
For the first time, a second-line ARV regimen will be available
for under $500 annually; and
— agreement with Pfizer to provide the
TB drug rifabutin at $1 per 150mg dose ($90 for a full six month
treatment). Treatment with rifabutin avoids complications with
important second line drugs that people with HIV may be taking.
This means the cost of the most effective treatment for TB in
patients using second-line ARVs has been reduced substantially.
TB is the leading killer of those living with HIV.
FOCUS ON
WOMEN
78. Achieving Universal Access highlights
the particular challenge of improving access to ARVs for HIV positive
pregnant women, in order to prevent transmission to the unborn
child. Latest data show encouraging trends in the expansion of
Prevention of Mother to Child Transmission (PMTCT) services for
women and children. However, we are still far from reaching the
80% target set by 2010 and more needs to be done. Working with
others at national and international level, the UK is strongly
committed to strengthening efforts to scale up PMTCT services.
79. Mother to child transmission of HIV
has been virtually eliminated in developed countries. This is
because in these countries, women of reproductive age have access
to high quality family planning and maternity care services into
which HIV prevention, treatment and care has been integrated.
DFID works to ensure that women in poor countries have the same
choices and opportunities.
80. Through the High Level Task Force for
Innovative International Financing for Health Systems, which the
Prime Minister co-chairs with Robert Zoellick, we are also leading
efforts to secure additional resources to help countries build
the stronger health systems required to make durable progress
on maternal and newborn mortality, including through enhanced
access to PMTCT services.
81. We also provide core funding to UNICEF,
WHO, and UNAIDS (US$ 42.3 million, US$54.7 million and US$38 million
respectively per year), working to end mother to child transmission
of HIV. In addition to core funding, DFID has provided more than
US$1.5 million to an "Accelerating Action for Children Affected
by HIV and AIDS" programme. DFID has also recently become
a member of the Inter-agency Task Team on Prevention of Mother
to Child Transmission (co-convened by UNICEF and WHO). And on
21 May we held a consultation with UK stakeholders in collaboration
with the AIDS Consortium to discuss ways to accelerate the scale
up of PMTCT services.
82. More broadly, the Strategy recognises
gender inequality as a key driver of HIV infection and regards
empowering women to negotiate safer sex as a key element of prevention.
In our evidence to last year's inquiry, we pledged support for
UNAIDS advocacy for women and girls, including the development
of gender guidelines to help countries assess and mitigate the
impact of AIDS on these and other vulnerable groups. We are delighted
that these guidelines were agreed at the UNAIDS Programme Coordinating
Board (PCB) in June this year.
83. It is worth noting that efforts to improve
access of ARV for women globally have received particular attention.
In fact, emerging evidence suggests that the international community
has been more successful at providing ARV to women than to men.[14]
Examples of country level support
84. In Zambia DFID has provided financial
and technical support (£20 million, 2003-09) to strengthen
coordination and the expansion of PMTCT services through the "Strengthening
the AIDS Response" (STARZ) programme. This support included
training 520 provincial trainers, developing a communication strategy
and 100 community meetings conducted in 12 of the 72 districts.
By December 2006, 500 public facilities in districts were providing
PMTCT services representing a 262% increase from 2004, while 80,000
pregnant women were being tested for HIV, representing a 29% increase
from 2004. The overall percentage of HIV-positive pregnant women
who received ARVs increased from 18% in 2004 to 47% in 2007.
85. DFID is now providing £5.5 million
to support a multi-sectoral response to tackling HIV, including
support for further expansion of PMTCT services. New figures for
PMTCT coverage will be available later this year.
86. Access to ARV treatment for other PLWHA
has also expanded significantly, with 200,000 people receiving
ARV at the end of 2008, compared to just 3,000 in 2003.
87. In Zimbabwe DFID is providing £25
million to support a programme which addresses maternal and newborn
health, including HIV/AIDS. A key component has been to maintain
access to family planning—the rate of contraceptive prevalence
in the country has increased from 55% in 1999 to 60% in 2006 and
continues to increase, even as the economy and most basic services
have declined. HIV prevalence rate has declined from 18.1% in
2006 to 15.2%[15]
in 2008, partly due to the high availability of male and female
condoms. DFID's contribution to the Expanded Support Programme
for HIV and AIDS has given access to ARV treatments for more than
25,000 people.
88. Similar work supported by DFID in other
focus PSA countries is also achieving significant results. In
Malawi for example, access to ARV has increased dramatically
from 3,000 in 2003 to over 147,000. DFID Malawi is contributing
£14 million to the national response over four years, seeking
to ensure that there is a proper balance between prevention, treatment
and care.
89. And in Mozambique, DFID's support
has contributed to an increase in the number of health units offering
PMTCT services from 386 in 2007 to 744 in 2008. As a result, the
number of HIV positive pregnant mothers receiving treatment to
prevent HIV transmission to their babies increased from 24,320
in 2007 to 46,848 in 2008. The total number of patients receiving
ARV has also increased dramatically, from zero in 2001 to 118,937
in 2008.
13 "Policy brief: Provision of sterile injecting
equipment to reduce HIV AIDS transmission". WHO 2004. Back
14
The Lancet, Vol 374, July 2009. Back
15
Report on the Global Epidemic, 2008. Back
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