House of Commons - International Development Committee

Progress on the Implementation of DFID's HIV/AIDS Strategy - International Development Committee Contents

Written evidence submitted by the UK Consortium on AIDS and International Development

30 September 2009

The UK Consortium on AIDS and International Development welcomes the opportunity to write a submission to the International Development Committee Inquiry on "HIV/AIDS: Progress on Implementation of DFID's HIV/AIDS Strategy."

The UK Consortium on AIDS and International Development is a group of more than 80 UK based organisations working together to understand and develop effective approaches to problems created by the HIV epidemic in developing countries. It enables each agency to bring its own expertise and experience to be shared and used to help all members improve their responses to the epidemic, through information exchange, networking, advocacy and campaigning. The Consortium has a number of working groups made up of member agencies and others who meet to strengthen their capacities through sharing good practice and developing collective policy position and advocacy initiatives. The Stop AIDS Campaign is the campaigning arm of the Consortium.

The UK Consortium's submission is a collaborative effort, which includes text from individual member agencies, which have produced their own submissions. These have been cited where there is an extract or quote directly from the text they have written. The Executive Summary draws the most salient points or recommendations from the answer to each question.

EXECUTIVE SUMMARY

Q1 The process established by DFID for monitoring the performance and evaluating the impact of the Strategy

The strategy would have benefited from an integrated process of indicator selection to ensure a commitment to measuring deliverables.

Q2 Progress on health systems strengthening and on an integrated approach to HIV/AIDS funding

— DFID should publish the breakdown of its spending on health systems strengthening along with mechanisms to collect evidence of impact on health and HIV indicators.

— Through its leadership role in the IHP+, DFID needs to ensure more rapid implementation at the country level, which includes efforts to fill financing gaps for health in the IHP+ focus countries.

— DFID's should ensure that gains in the HIV response are not lost through its focus on HSS, by addressing stigma and discrimination before integration of HIV responses into public health systems is attempted.

— DFID's approach to integrated funding for AIDS should recognise the role of community systems and through its funding and policies ensure adequate support to this sector.

Q3 Integration of HIV/AIDS prevention, treatment and care with other disease programmes, particularly tuberculosis and malaria

DFID to review their practice paper The Challenges of TB and Malaria control (December 2005) and to develop a comprehensive strategy on TB which fully integrates with DFID's overarching health related goals. This TB Strategy should run in parallel to Achieving Universal Access and identify clear monitoring and evaluation targets for HIV-TB integration.

Q4 The effectiveness of DFID's Strategy in ensuring that marginalised and vulnerable groups receive prevention, treatment, care and support services

The limitations to reach marginalised groups inherent in DFID's focus on health systems strengthening need to be counteracted with the development and publication of plans by the FCO and DFID to address the needs of marginalised groups, which continues predictable sustainable financing for community responses most effective at reaching marginalised groups.

Q5 The effectiveness of social protection programmes within the Strategy

Social protection is an essential contribution to providing a safety net for the poorest, including those who are infected and affected by HIV.

Q6 Progress towards the commitment to universal access to anti-retroviral (ARV) treatment and its impact on the effectiveness of care and treatment, particularly for women

— DFID should ensure that its focus on health systems strengthening does not undermine progress towards universal access to HIV treatment, prevention and care & support services.

— We particularly welcome DFID's support of the UNITAID patent pool and their call for pharmaceuticals to get involved. It would be most useful for the IDC to add its weight to DFID's call for pharmaceutical companies to engage with UNITAID on the patent pool.

— PMTCT must be a top priority if we are to manage the epidemic.

1. The process established by DFID for monitoring the performance and evaluating the impact of the Strategy

1.1 DFID has made a real effort in the new AIDS Strategy launched last year to improve on the lack of any measurable targets and indicators in the first AIDS strategy launched in 2004. Civil society was also involved in the process of developing an M&E framework—see below.

1.2 It is too early to tell how effective the M & E process for monitoring the performance and evaluating the impact of the AIDS strategy launched in June 2008 will be, since the baseline position is unpublished and the first progress report will be published for World AIDS Day in 2010.

1.3 Even with the above statistics, overviews and reports produced in 2010, it will still be difficult to know exactly what DFID is doing and how effective the AIDS strategy is or what impact it might be having for the following reasons:

Lack of targets and indicators in the Priorities for Action

Inability to distinguish DFID's role amongst other players

Difficulty of collecting accurate data

The template for DFID country offices asks questions rather than measurements

1.4 However we applaud the fact that DFID has linked its strategy to global targets and indicators, although clearly challenges of attribution remain. This year DFID has actively engaged and led on the process of improving and fostering coherence of internationally agreed indicators. DFID currently co-chairs the interagency Indicators Working Group of the UNAIDS Monitoring and Evaluation Reference Group. It is working closely with the Care and Support Working Group of the UK Consortium on AIDS and International Development to review global care and support indicators to input into the upcoming review of UNGASS indicators. Together, DFID and the UK Consortium on AIDS and International Development have modelled a new independent review process for global indicators that the Indicators Technical Working Group of the UNAIDS Monitoring and Evaluation Reference Group has now endorsed. (VSO)

1.5 Sufficient funding for and meaningful review of these global targets needs continued commitment at the highest level. This is particularly true of the target of Universal Access to Treatment, Prevention, Care and Support by 2010 proposed and led by the UK Government at the G8 in 2005. We urge the Minister for International Development and the Prime Minister to lead on this again next year to ensure a review of progress on this target is undertaken at the 2010 G8 and UN MDG review and that clear new achievable commitments are made. (VSO)

1.6 The process established by DFID to develop the M&E framework presented a groundbreaking approach within the Department of International Development in engaging civil society to assist in developing a monitoring process.

1.6.1The Consortium was told it was a consultative process and we had no responsibility for the final product.

1.6.2The UK Consortium welcomed the engagement of civil society and set up an "Indicators" Working Group' (IWG), composed of members with experience in M&E. This small group of six experts informed DFID from evidence based good practice and the direct experiences of monitoring HIV responses. Whilst the Indicators Working Group was asked to focus on the development of indicators, it was also able to provide support and expertise to inform other parts of the framework.

1.6.3DFID's commitment to the process and involvement of the IWG was clearly shown through the continued engagement of staff and the openness and honesty with which meetings were conducted.

1.6.4Unfortunately, despite DFID's commitment to an inclusive approach, the methodology and nature of the process limited the extent of civil society engagement. The application of Chatham House rules to the IWG proceedings limited the ability of the IWG to consult and engage the Consortium members it was representing. This undermined the credibility of the consultation.

RECOMMENDATIONS

— The strategy would have benefited from an integrated process of indicator selection to ensure a commitment to measuring deliverables.

2. Progress on health systems strengthening and on an integrated approach to HIV/AIDS funding

2.1 There is no doubt among health and HIV professionals globally that health system strengthening is critically under-funded in most developing countries and that health and HIV funding and programming needs to be more closely integrated. There is a sense that DFID are de-prioritising HIV, evidenced by the reduction of clear funding commitments to HIV in the strategy, their criticism of vertical funding programmes and a serious reduction of the number of staff in the AIDS and Reproductive Health Team. This has a big impact on the capacity to drive the AIDS strategy forward within DFID or to continue to play the leading role in global HIV policy discussions. (VSO)

2.2 DFID's commitment to £6 billion for health in the HIV strategy remains controversial in that there is no commitment as to what percentage of that will be spent on HIV. There are very few HIV-specific funding targets. This is a worrying message, as without clarification the implication is that broader health system strengthening should be promoted at the expense of funding for HIV. (VSO)

2.3 Since the launch of "Achieving Universal Access" and the announcement of the UK government's plans to spend £6 billion on strengthening health systems and services, there has been limited information available on current or future use of these funds. Since the launch of the Strategy, the UK government has made the following commitments:

2.3.1an estimated £450 million until 2011 to support national health plans for eight IHP+ countries at the UN High Level Event on the Millennium Development Goals in September 2008;

2.3.2£40 million to the Affordable Medicines Facility for malaria and an increase in malaria research spending to at least £5 million per year by 2010; and

Contribution to World Bank and Global Fund

2.4 In mid December 2007 Douglas Alexander announced the UK will contribute £2.134 billion to the World Bank over the next three years. This contribution makes the UK the largest donor to the World Bank over this funding period. The announced commitment of DFID to the Global Fund on AIDS TB and Malaria was £1 billion over seven years until 2015. The long term nature of this commitment is exemplary, but the amount is insufficient considering the fact that the Global Fund announced in July a budget shortfall of about $3 billion in order to simply maintain and finance programs planned for 2010. DFID should be congratulated as a leading donor but encouraged also to re-analyse this funding balance as well as to push other donors to commit more funds. (VSO)

2.5 This setting of the funding balance should also be based on an honest evaluation of how effectively the money is being spent. This was demonstrated clearly by a comparison of the evaluation reports of the World Bank Independent Evaluation Group (IEG) for their "Health Nutrition and Population Portfolio" for 1997-2007 and that of the Global Fund for AIDS, TB and Malaria. The World Bank's report states that only 18% of their HIV projects in Africa were satisfactory. The Global Fund report stated however that 69% of their projects met the highest rating.[69] (VSO). The following findings of the IEG are of particular concern:

2.5.1Over the past decade only two-thirds of World Bank health projects showed satisfactory outcomes. In Africa the results were particularly weak, with 73% of projects failing to achieve even satisfactory outcomes.

2.5.2Only half of the Bank's health support was focussed on the poorest people, and much of the Bank's spending ended up helping the richest 20% of people.

2.5.3Only 29% of freestanding HIV projects had satisfactory outcomes and in Africa the figure was only 18%.

2.5.4These findings should influence a re-evaluation by DFID of the effectiveness of prioritising spending through the World Bank.

International Health Partnership

2.6 While the International Health Partnership and Related Initiatives (IHP+) would present an opportunity to DFID to allocate resources to health systems strengthening, implementation progress has been slow, the implementation progress has been slow. Further, while the IHP+ aims to improve the effectiveness of health aid delivery, the IHP+ has not been able to address the initial key concern of financing gaps for health in its focus countries. In Ethiopia, the first country to sign a compact, a funding gap of between US$1.56 billion to US$2.84 billion was identified.[70] However, in response, donors, including DFID, allocated just a fraction of what was required. (International HIV/AIDS Alliance)

Community health systems—stigma and discrimination

2.7 Much of the "health systems strengthening" rhetoric does not refer to a broad system that integrates community level systems into the continuum of care in an affective and sustainable way. Community level systems play a critical role in ensuring access for and involvement of marginalised populations in HIV services. Evidence suggests that integration of the community level systems can result in reductions of hospital readmissions of chronically ill patients, better co-ordination of care, and increased access to services through the delivery of high quality, cost-effective home based care. (International HIV/AIDS Alliance)

2.8 In many places, "stand alone" ARV treatment programs have been developed or implemented due a lack of capacity in the broader health system, and in response to the high levels of stigma and discrimination experienced by people with HIV in health services. Addressing stigma and discrimination in broader health systems is critical to ensuring successful integration or a broader health system role in HIV treatment and care. However there is little evidence of overt plans to address this in many health systems integration plans or discussion documents. This is something that needs to be addressed before integration is attempted, not after the fact once evidence of systematic discrimination becomes known. (International HIV/AIDS Alliance)

2.9 We are pleased to see that DFID has responded by collaborating with the World Bank to start to address these issues by conducting an ambitious evaluation of the community response to HIV and AIDS with a view to increase resource allocation. They have enlisted the support of the UK Consortium to facilitate full civil society engagement. (VSO)

RECOMMENDATIONS

— DFID should publish the breakdown of its spending on health systems strengthening along with mechanisms to collect evidence of impact on health and HIV indicators.

— Through its leadership role in the IHP+, DFID needs to ensure more rapid implementation at the country level, which includes efforts to fill financing gaps for health in the IHP+ focus countries.

(International HIV/AIDS Alliance)

3. Integration of HIV/AIDS prevention, treatment and care with other disease programmes, particularly tuberculosis and malaria

3.1 DFID have stated that addressing HIV-TB co-infection is a priority and have committed to do more to support the integration of HIV/AIDS and TB Services.[71] However, despite ongoing recommendations for the need for specific targets to address HIV-TB co-infection, along with clear steps outlining how these targets will be achieved, these were not incorporated within the HIV/AIDS Strategy Monitoring and Evaluation framework. DFID's overall Public Service Agreement (PSA) targets (as detailed in the 2008 DFID Annual Report), include no HIV-TB indicators and no TB indicators for Africa where the burden of TB is greatest. Due to the lack of specific measurables for each country office on HIV-TB integration (as well as integration of HIV with other services such as Malaria, maternal, newborn and child health) it may not be possible to attribute outcomes to DFID and to evaluate the impact of the strategy. (Results-UK)

3.2 Individual country offices are not required to provide comprehensive and equivalent data on HIV-TB activities. Qualitative evidence collected by RESULTS UK from five DFID offices in Africa,[72] all of which stated in 2008 that there was "insufficient collaboration" between HIV and TB programmes, suggest there have been positive steps toward implementing integrated services, and improvements on the ground. This is, however, not true across the board. (Results-UK)

3.3 Data published in March 2009 reported that 12 of 24 DFID country offices felt "insufficient TB-HIV collaboration" is a challenge to addressing the TB epidemic. Over half of these offices also expected rates of TB-HIV co-infection to rise over the next five years.[73] (Results-UK)

3.4 We were pleased to note that Health Advisors were briefed in HIV-TB[74] and discussed best practice during their 2009 retreat, suggesting DFID centrally are giving integration some priority. Where progress has been seen at country level, RESULTS UK commends DFID's policy work facilitating enhanced integration of HIV and TB services in the succeeding 12 months. (Results-UK)

3.5 The strategy commits to increase funding for research into an AIDS vaccine and microbicides. However, it does not make any similar commitment to increase funding for new tools for TB which will be crucial to reducing morbidity and mortality among PLWHA. A new regimen of drugs is required that can combat TB in a shorter time period and that are compatible with ART. New diagnostics that can detect all forms of TB in PLHIV and that can be used in low resource settings are urgently needed. However, as reported by the APPG on AIDS in July 2009, TB (and Malaria) R&D is particularly neglected due to low commercial value.[75] (Results-UK)

3.6 Due to the changing face of the TB epidemic, with an increasing threat of drug resistant strains and the impact of TB on PLWHA, there is a clear need for a DFID strategy outlining the UK's response to Tuberculosis. RESULTS UK strongly urge DFID to review their practice paper The challenges of TB and Malaria control (December 2005) and to develop a comprehensive strategy on TB which fully integrates with DFID's overarching health related goals. This TB Strategy should run in parallel to Achieving Universal Access and identify clear monitoring and evaluation targets for HIV-TB integration. DFIDs HIV/AIDS Strategy will save many more lives if it is coupled with a clear strategy to address TB in all high burden countries. (Results-UK)

4. The effectiveness of DFID's Strategy in ensuring that marginalised and vulnerable groups receive prevention, treatment, care and support services

Concerns

4.1 There is still no clear plan as to how DFID will act on the commitments it has made in its Strategy to marginalised populations. Neither the FCO nor DFID is proactive or transparent in communicating work plans and planned activities in these areas to UK stakeholders. This has resulted in missed opportunities for synergies and collaborative advocacy. (International HIV/AIDS Alliance)

4.2 Continued staff turnover, the overwhelming dominance of the discussion on health systems strengthening and what appears to be a downgrading of the role of the AIDS and Reproductive Health team within DFID have all contributed to a lower profile for DFID in many international fora and to limited visibility and accessibility of DFID staff. (International HIV/AIDS Alliance)

4.3 It is essential that DFID continues to find and increase direct and numerous ways to deliver significant funding, training and capacity building support to community-based responses to reach out to marginalised groups delivered by civil society. This is vital because there remain significant concerns over the extent to which government strengthening of public health systems will actually increase access to services for the most disadvantaged or excluded in society. Public health services are often not accessible due to factors such as distance, cost, discrimination or cultural dynamics. For example, injecting drug users often cannot access government health services because drug use is illegal and people living with HIV sometimes do not access public health services due to discrimination from staff. In the short to medium term, and until public health systems are dramatically improved, civil society organisations can often target and provide services more quickly and effectively to the hardest to reach communities. (VSO)

Recent DFID funding of Marginalised Groups

4.4 Nonetheless, despite these limitations, the last 12 months have seen some progress in this area:

4.4.1DFID remains supportive of the efforts of the International HIV /AIDS Alliance in relation to IDU, sex workers, transgender people and other marginalised populations.

4.4.2DFID continues to give ongoing support for the International Harm Reduction Association and accomplished excellent advocacy work in support of HIV prevention at the UNGASS High Level Meeting on Narcotic Drugs held in Vienna in June 2009.

4.4.3DFID has made a new commitment to supporting the work of the Global Forum on HIV and MSM. This commitment is a significant step in ensuring strengthened advocacy and commitment globally to meeting the HIV prevention needs of this critically important and underserved population. (International HIV/AIDS Alliance)

4.4.4DFID has funded a national survey on prevalence of HIV and sexually transmitted infections among male and transgender sex workers in Pakistan (See website case study "AIDS Survey highlights at-risk groups in Pakistan", 28 November 2008). DFID has funded a national survey on prevalence of HIV and sexually transmitted infections among male and transgender sex workers in Pakistan (See website case study "AIDS Survey highlights at-risk groups in Pakistan", 28 November 2008). (VSO)

Human Rights

4.5 We hope that DFID will continue to fund such work so that there is more awareness of the existence and needs of these groups and they have greater access to health and HIV services. This applies particularly to IDUs, sex workers, males who have sex with males, transgender and intersex. We would also be interested to hear the extent to which DFID is working with the Foreign and Commonwealth Office to institute and defend the rights of these groups. (VSO)

4.6 In a number of countries, including Senegal, the work of DFID and the FCO in supporting local advocacy has also helped to protect the rights of this highly vulnerable marginalised population. Conversely, the withdrawal of DFID staff and offices from some countries, such as Nepal, presents risks to the continuity of important programmatic interventions targeting vulnerable populations, and threatens to undermine universal access commitments. (International HIV/AIDS Alliance)

Gender

4.7 DFID's commitment to gender equality in the strategy was very welcome and responded to many of the issues and recommendations VSO and Action Aid highlighted in our 2007 policy report on women's access to HIV services Walking The Talk. In research from 13 countries it was found that systemic gender inequality means that poor rural women are among those hardest hit by the HIV pandemic and have minimal access to publicly funded HIV services.[76] There is limited evidence of DFID's implementation of the strategy but it has made some case studies available on the DFID website and in the Gender Equality Action Plan Africa Division document. The projects cited are primarily in the two areas where women's access is most limited and under-resourced—prevention and care and support. Of those listed that focused on prevention, we highlight DFID Nigeria's work training women as peer educators to improve understanding of sexual and reproductive health and make condom use more acceptable. This is key work in a continent where 75% of those infected between the age of 15 and 24 are women.[77] Of those listed on care and support, DFID Zimbabwe and DFID Zambia's work on care for the carers stand out as essential work because most carers for people living with HIV are women, often older women, who seldom receive any recognition, support, training, or equipment to help them do their amazing work.[78] (VSO)

People with Disabilities

4.8 A particularly vulnerable group whose needs have largely been sidelined in HIV policy at national and global level are persons with disabilities (PWDs). We were encouraged to see the reference to PWDs in the DFID strategy and DFID's funding of ZAFOD (Zambian Federation of the Disabled). Direct and focused support is essential to enable disabled persons' organisations to participate in the development and evaluation of guidelines for HIV service delivery, National Strategic and operational plans, and National AIDS councils. The need to mainstream the HIV/AIDS needs of PWDs into national policies for effective handling is urgent. Governments and donors should seek to support innovative projects initiated by PWDs that are deemed to address their specific health needs. At regional level, DFID should actively consider supporting advocacy networks such as The African Campaign on HIV/AIDS and Disability. The Campaign aims to reduce the vulnerability of disabled people to the impact of HIV by promoting HIV policies, programmes, information and services that genuinely include them. (VSO)

RECOMMENDATIONS

— The limitations to reach marginalised groups inherent in DFID's focus on health systems strengthening need to be counteracted with the development and publication of plans by the FCO and DFID that directly address the needs of marginalised groups and continues predictable sustainable financing for community responses most effective at reaching marginalised groups.

5. The effectiveness of social protection programmes within the Strategy

5.1 Social protection is an essential contribution to providing a safety net for the poorest, including those who are infected and affected by HIV. One of the clear and welcomed funding commitments in the HIV strategy was for £200 million for supporting social protection programmes over next three years in at least eight African countries. Unfortunately, DFID have still not defined which countries these are and so monitoring progress remains impossible. We eagerly await more news on how this funding has been distributed and to which countries. (VSO)

5.2 The success of DFID's commitment to cash transfer and social protection programmes will depend on DFID's efforts to address the underlying structural causes of children's and their families' vulnerabilities, such as criminalisation, stigma and discrimination and broader human rights violations. In addition to ensuring the participation of affected and marginalised communities in the development of social protection programmes, social protection programmes must be provided in an environment that ensures the realisation of these communities' rights. (International HIV/AIDS Alliance)

6. Progress towards the commitment to universal access to anti-retroviral (ARV) treatment and its impact on the effectiveness of care and treatment, particularly for women

Treatment

6.1 Despite being off target, there has been considerable progress towards universal access. More than 4 million people in low- and middle-income countries were receiving antiretroviral therapy (ART) at the close of 2008, representing a 36% increase in one year and a ten-fold increase over five years, according to a new report released on 30 September 2009 by the World Health Organization (WHO), UNICEF and the Joint United Nations Programme on HIV/AIDS (UNAIDS).[79] This achievement would have seemed almost impossible a decade ago. DFID should build on this success because, despite this progress, at least 5 million people living with HIV still do not have access to life-prolonging treatment and care and the target date of 2010 is now only one year away.

6.2 There is still much work to be done to make ARVs affordable and accessible to the remaining 58% of people who still do not have access to treatment. In this regard we particularly welcome DFID's support of the UNITAID patent pool and their call for pharmaceuticals to get involved. The Access to Medicines team in DFID should be commended for this. This proposal has the potential to dramatically lower the costs of existing HIV treatments and help stimulate the development of new medicines for developing country settings. It forms part of the Government's commitment to "work with others to reduce drug prices and increase access to sustainable treatment over the long term". 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 pharmaceutical companies to engage with UNITAID on the patent pool.

6.3 In addition to its work on the UNITAID patent pool, DFID's continued and increased support to The Global Fund is critical with the Fund now supporting 2.3 million people on ARVs (as of June 09). The Global Fund to Fight AIDS, TB and Malaria, for example, faces a severe funding shortfall of approximately $4 billion for the 2008-2010.[80]

6.4 The challenge of ARV access is even greater for children living with HIV who, in Sub-Saharan Africa, "are about one third as likely to receive antiretroviral therapy as adults".[81] A renewed focus from DFID on the rollout of paediatric ARVs is an imperative. (VSO)

6.5 UNAIDS/WHO 2007 statistics gathered in 25 low and middle income countries in 2007 showed that although women accounted for 51% of people living with HIV, 57% of those receiving treatment were women. This shows that women are accessing treatment more effectively than men. However concerns remain around women's adherence to treatment due to stigma and fear of revealing their status and there is no consistent global collection of data on adherence to treatment. (VSO)

6.6 There is an urgent need to maintain a focus on gains that have been made to date in addressing the HIV epidemic. This is critical to ensure uninterrupted access to ARV treatment, to ensure consistent drug supply chains and to reduce the frequency of drug stock-outs, to not only save the lives of those already on treatment and those in need in future—but also to reduce the likelihood of drug resistant HIV. (International HIV/AIDS Alliance)

6.7 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 55 million 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".

Prevention

6.8 DFID and the UK Government's commitment at the 2005 G8 and at the UN General Assembly in 2006 was Universal Access to comprehensive prevention, treatment, care and support by 2010. While certainly essential, access to anti-retroviral treatment is not enough on its own. As Alan Whiteside comments, delivering treatment without prevention is like mopping the floor with the tap running. Prevention and care and support have received the least focus of funds and support and now require serious attention by the international donor community. (VSO)

6.9 It is widely accepted globally that work on prevention is in crisis and needs urgent attention. The WHO 2008 progress report noted that an estimated 2.5 million people were newly infected with HIV in 2007—which means that for every two people placed on treatment, five more become infected. DFID has led on prevention globally and should continue to do so. For example, DFID has taken on leadership of the EC Task Team on Prevention. (VSO)

6.10 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.

PMTCT

6.11 Prevention of mother to child transmission has also been scaled up 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.

6.12 Shocking statistics still remain regarding HIV positive pregnant women's access to anti-retroviral treatment to avoid mother to child HIV transmission. As of 2007, only 33% of pregnant women were receiving PMTCT.[82] DFID's HIV strategy committed to work with others to intensify international efforts to increase coverage of PMTCT to 80% by 2010. To this end, DFID organised a workshop on PMTCT with the UK Consortium in May 2009 and produced concrete recommendations on scale up. 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. (VSO)

Care and Support

6.13 HIV care and support is the often forgotten pillar of Universal Access, largely because donors and national governments have left it to poor communities to provide often without support. Strengthening health systems must include direct resources and support for community-based responses, home-based care organisations and carers—particularly women who provide the majority of care and support in the family and community. As mentioned above, DFID is supporting some excellent in-country home-based care, and therefore should take advantage of this to play a much stronger role raising the profile of care and support in global HIV policy discussions. The proposed DFID funded conference with the UK Consortium on AIDS and International Development on Care and Support in 2010 would be an important opportunity to move forward in this area. (VSO)

RECOMMENDATIONS

— DFID should ensure that its focus on health systems strengthening does not undermine progress to universal access to HIV treatment, prevention and care & support services.

— PMTCT must be a top priority if we are to manage the epidemic.

66 http://www.reuters.com/article/middleeastCrisis/idUSL3579451 Back

67 http://www.berr.gov.uk/files/file47158.pdf Back

68 "Health in Crisis: Why in a time of economic crisis Europe must do more to achieve the health MDGs"; Action for Global Health; 2009;
(http://www.actionforglobalhealth.eu/media_publications/afgh_policy_reports/policy_report_health_in_crisis/policy_report_health_in_crisis) Back

69 World Bank Independent Evaluation Group, 2009 Improving Effectivess and Outcomes for the Poor in Health, Nutrition and Population (p.xvi). The Global Fund for AIDS, TB and Malaria, 2009, ScalingUp For Impact: Results Report, P 55. Back

70 Compact between the Government of the Federal Democratic Republic of Ethiopia and the Development Partners on Scaling Up For Reaching the Health MDGs through the Health Sector Development Programme in the framework of the International Health Partnership; Ethiopian Federal Ministry of Health; August 2008
(http://www.internationalhealthpartnership.net/CMS_files/documents/ethiopia_country_compact_EN.pdf) Back

71 Most recently reiterated in a letter from Ivan Lewis to the UK Coalition to Stop TB, 18 May 2009. Back

72 DFID Offices in the Democratic Republic of Congo, Kenya, Malawi, Uganda, Zambia. Back

73 Advocacy to Control TB Internationally (ACTION): Living with HIV, dying of TB (March 2009) Page 26. Back

74 Mark Rotich, DFID Kenya (September 2009). Back

75 APPG on AIDS: The Treatment Timebomb (July 2009) Page 29. Back

76 VSO and Action Aid, Walking The Talk: Putting women's rights at the heart of the HIV and AIDS response, 2007. Back