Written evidence submitted by World Vision
September 2009
INTRODUCTION
1. World Vision is a Christian relief, development
and advocacy organisation, dedicated to working with children,
families and communities to overcome poverty and injustice. Building
on our previous submissions to the Committee on HIV and AIDS,
we welcome this opportunity to provide evidence relative to children
affected by HIV & AIDS.
Question 1: "the process established
by DFID for monitoring the performance and evaluating the impact
of the Strategy"
2. With the AIDS Strategy in place for just
over a year, DFID has had little time to implement the priority
actions, and so comprehensive evaluation is therefore difficult.
DFID has provided little comment on the impact of the strategy,
and has not published the Baseline position report, which makes
it difficult to comment on the type and detail of data that will
eventually be available.
3. Before the publication of the Monitoring
and Evaluation Framework (M&E Framework) for the AIDS Strategy
there were high expectations that it would provide answers to
several important questions about how the strategy would be implemented
and monitored. However, the principal question of exactly what
will be UK Government's contribution towards achieving the Strategies'
goals and how will that be monitored, has yet to be answered.
While the Framework outlines how the collective progress by the
international community will be monitored, it does not attempt
to systematically measure the contribution made by the UK Government.
This impedes monitoring of the Government's performance and evaluation
of the impact of the Strategy on UK Government policy.
RECOMMENDATIONS
4. The M&E process must be open, transparent
and fully engaged with civil society. While the involvement of
members of the UK Consortium on AIDS and International Development
in the Indicators Group was very welcome, there were restrictions
on the scope of that involvement. This involvement needs to be
expanded, to include engagement in the independent review of the
Strategy.
5. Detailed data about the projects and
programmes funded by DFID in each country must be accessible,
even if they are not included in the Baseline report itself. These
data will enable partners in country to learn about the specific
work that DFID is supporting, especially related to the priority
actions, and assess the UK Government's contribution towards achieving
international targets.
Question 2: "progress on health systems
strengthening and on an integrated approach to HIV/AIDS funding"
6. HIV is more than a health issue. Several
components of an effective HIV response fall outside of the remit
of the health sector, including many HIV prevention interventions,
strategies to address stigma and discrimination and care for groups
such as orphaned or vulnerable children. These components must
be funded alongside increasing investments in health systems and
services to better address health related elements. The lack of
data on health spending makes assessment of its impact very difficult.
RECOMMENDATIONS
7. DFID should publish details on how and
where they will spend the allocated £6 billion for health
systems and services up to 2015, including making available a
breakdown of expenditure against this target in the year since
it was announced. This will allow transparency and scrutiny of
their progress.
Question 3: "integration of HIV/AIDS
prevention, treatment and care with other disease programmes,
particularly tuberculosis and malaria"
8. World Vision is concerned about the neglect
of children's issues regarding the integration of HIV with malaria
and TB.
Malaria and HIV
9. The effects of interactions between malaria
and HIV are particularly deleterious to maternal and infant health.
Co-infected pregnant women are at increased risk of anaemia, preterm
birth and intra-uterine growth retardation, and many children
born to women with dual malaria and HIV infection therefore have
low birth weight and are at higher risk of death during infancy.
10. The presence of HIV results in a poorer
response to both intermittent preventative treatment (IPTp) and
clinical treatment of malaria during pregnancy. Furthermore, there
is a risk of adverse drug reactions if sulfadoxine-pyrimethamine
(used for IPTp) and cotrimoxazole, for opportunistic infection
prophylaxis, are taken together, as both are sulfa-containing
drugs.
11. Two key interventions: use of long-lasting
insecticidal nets and use of well-targeted indoor insecticide
spraying to control transmission of the parasite can be effective
in different circumstances. Strategies must reflect local need.
RECOMMENDATIONS
The UK government should:
12. Encourage UN agencies and pharmaceutical
companies to ensure that the necessary research to evaluate potential
interactions between malaria and HIV drugs is undertaken.
13. Ensure increased funding and resources
consistent with the Roll Back Malaria Partnership Global Malaria
Action Plan goals for prevention, treatment and research and development.
14. Provide sufficient resources and technical
support to National Malaria Control Plans to achieve universal
access to LLINs for prevention of malaria and to Artemisinin Combination
Therapies ACTs for treatment.
Tuberculosis (TB) and HIV
15. Children, particularly under 5s, are
extremely vulnerable to contracting TB from adults in the household
as the risk of TB infection increases with the degree of contact.
Children with HIV are at increased risk for contracting TB and
specifically for developing TB meningitis.
16. Diagnosis of TB in HIV-infected children
is notoriously challenging, particularly in children living with
HIV. This can lead to underreporting of the problem of co-infection
in children. Treatment is also difficult as paediatric drug formulations
are not available for TB and there are still not enough suitable
for people living with HIV.
17. TB infection itself can lower the CD4
cell count in children, and exacerbates the immunodeficiency caused
by HIV. Compared with children without HIV, children living with
HIV have a six-times greater risk of dying from TB. The vast majority
of co-infected children live in resource-limited countries.
18. BCG is the only TB vaccine but is not
recommended in HIV-infected children. Because of the difficulty
excluding children with HIV when the vaccine is given (at birth)
many children with HIV, or who become HIV-infected post-natally,
will be vaccinated anyway. Some may develop life-threatening systemic
BCG infections and BCG IRIS.
RECOMMENDATIONS
The UK government should:
19. Encourage pharmaceutical companies to
conduct the pharmacokinetic studies which are desperately needed
to determine the optimal doses for TB drugs for children of different
ages and sizes, especially for second-line drugs and new drugs
in development. This should be done with consideration to when
TB medications are taken along side ARVs.
20. Support research to improve diagnosis
of TB for those with HIV, particularly children.
21. Encourage pharmaceutical companies to
produce a TB vaccine that is affordable for southern health systems,
safe and effective for children living with HIV.
Question 4: "the effectiveness of DFID's
Strategy in ensuring that marginalised and vulnerable groups receive
prevention, treatment, care and support services"
Children with disabilities
22. Children and adults with disabilities
are routinely ignored and marginalised because of fear and misunderstanding
around disability. They are often left out of HIV prevention and
support services. Less than 10% of disabled children in sub-Saharan
Africa receive an education and therefore more than 90% miss out
on school-based HIV-education programmes. Literacy rates are very
low amongst people with disabilities.
23. There is widespread and mistaken belief
that disabled people are not sexually active and are not at risk
from HIV infection. This misapprehension is doubly damaging and
dangerous as children and adults with disabilities are two to
three times more likely to face sexual abuse and violence.
RECOMMENDATIONSThe
UK Government must ensure:
24. Disabled children and adults, across
impairments, are included and targeted in prevention, treatment,
care and support services.
25. Physical access for people with disabilities
to treatment and support services.
26. Action is taken to target and reach
children out of school, not least to highlight their visibility
and equal worth in communities, and to ensure they understand
methods to protect themselves from HIV.
27. Messages on HIV awareness and prevention
are in a form accessible for people with hearing, visual or intellectual
impairments.
Street children
28. Street children are one of the most
marginalised groups when it comes to accessing HIV-related services
and support. Care for orphans and vulnerable children often evolves
from home-based care programmes—which by their very nature
are poorly suited to reaching children who live or work on the
street.
29. Street children are more likely to be
sexually active at a younger age. They are unlikely to use testing
and counselling or treatment services, access to which often depends
on consent from a parent or guardian and a stable, supportive
home life. Street children are in great need of HIV prevention
services, but rarely receive them.
RECOMMENDATION
30. A comprehensive range of HIV services
need to be made available so that those outside of traditional
settings can also access a full range of prevention, treatment
care and support services.
Question 5: "the effectiveness of social
protection programmes within the Strategy"
31. World Vision welcomed the allocation
of £200 million within the AIDS Strategy to develop social
protection policies and programmes in at least eight African countries,
as well as the announcement of a further £200 million at
the G20 London Summit to support the Rapid Social Response Fund.
32. However, there will be many competing
demands for this money. Vulnerable households with children will
be just one group. World Vision is concerned that there is a danger
that funding for social protection will be regarded as limited
to providing cash transfers, which whilst important, are only
one part of the required package of policies and services needed
to care and protect vulnerable children affected by HIV &
AIDS (others include; child and legal protection services, psycho-social
support, and strengthened community support.) Social transfers
do not necessarily benefit vulnerable children living outside
family settings and in households where there is poor intra-household
distribution.
RECOMMENDATIONS
The UK Government must:
33. Work with governments and international
development partners to implement the key steps for promoting
child sensitive social protection as outlined in the Joint Statement
on Child Sensitive Social Protection.
34. Support the robust operations research
agenda for strengthening social welfare systems, in support of
social transfers that was agreed at a meeting on Social Welfare
and Cash Transfers, held in Carmona in April 2009.[1]
Question 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"
35. While rapid developments have been made
over the last two years in the number of adults accessing antiretroviral
therapy, treatment for children has not kept pace. Children remain
about one third as likely to receive antiretroviral therapy as
adults. HIV infection progresses aggressively in children without
optimal HIV treatment and care. HIV & AIDS accounts for 5%
of deaths in children younger than five years of age in Africa
and was the leading cause of death in five countries in and southern
Africa in 2004.
36. Despite the increase in the number of
children under age 15 in low- and middle-income countries who
receive antiretroviral treatment to almost 200,000 in 2007, those
children currently on treatment still only represent 10% of children
who need it. This is despite the target being for 80% of children
to access HIV and AIDS treatment by 2010.
37. Early treatment with antiretrovirals
within the first few months of life can dramatically improve the
survival rates of children with HIV. A recent study in South Africa
found mortality was reduced by 75% in infants living with HIV
who were treated before they reached 12 weeks of age.
38. There are several barriers to children
receiving antiretroviral treatment, such as the treatment being
more complicated due to the special formulations of the medication
needed. When versions for children do exist, they are often not
adapted for use in resource-limited settings (eg they need refrigeration
or access to safe drinking water. Paediatric formulations are
not a priority for pharmaceutical companies as 90% live in resource
poor countries. Patents can provide barriers for generic companies
to develop alternative drugs.
39. There are additional issues such as
mothers who are living with HIV are frequently victims of abuse,
including stigmatization, violence, and property rights violations,
and unable to care for their children.
RECOMMENDATIONS
The UK government must:
40. Work with other governments to set targets
to ensure effective and equitable access to antiretroviral therapy
for children with HIV.
41. Continue to support UNITAID's patent
pool for second generation and child-friendly HIV treatments.
This pool will enable all patent owners to combine their expertise
in order to produce better and cheaper medicine for children.
42. Encourage pharmaceutical companies to
ensure their paediatric formulations are heat stable and available
in appropriate doses and packaging for use at community level.
43. Reduce distribution barriers and increase
the global supply of high-quality, low-cost lifesaving medicines
for children and their families, including ARVs, drugs to treat
opportunistic infections, and first and second-line regimens to
ease dosing and administration.
Prevention of Vertical Transmission
44. Transmission of HIV from mother to child
is the route by which 90% of all children living with HIV are
infected, but in 2008 only 34% of pregnant women living with HIV
in low and middle-income countries in need of antiretroviral treatment
received it. 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 antiretroviral treatment,
more than half of these children will die before their second
birthday.
45. Progress has been made over the past
few years towards preventing vertical transmission. In 2007 in
sub-Saharan Africa, the proportion of HIV-positive pregnant women
receiving antiretroviral prophylaxis to reduce the risk of transmission
was 34%, up from 11% in 2005. Despite this recent increase, this
remains far short of the international target of 80% coverage
by 2010. An unacceptable two thirds of pregnant women living with
HIV remain without access to these crucial services that prevent
transmission to their children.
46. Although health systems are weak in
many of the countries that have the highest burden of HIV, more
than 70% of all pregnant women in these countries make at least
one antenatal care visit. This provides an excellent opportunity
for delivering prevention of mother to child transmission (PMTCT)
interventions and engaging these women and their children in a
comprehensive continuum of HIV prevention, care and treatment
services. Nevertheless, 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.
RECOMMENDATIONS
The UK government should:
47. Assess global barriers to scale-up of
PMTCT services and publish a plan of action to increase quality
coverage.
48. Promote integration of PMTCT+ within
routine MNCH and reproductive health care services.
49. Support national governments in their
development and implementation of national PMTCT+ plans to reach
universal access to PMTCT+ for all pregnant women including access
to a continuum of anti-retroviral treatment, counselling and support
services after delivery.
50. Increase budget support to the health
sector, particularly through the sector wide approach (SWAPS),
to ensure health systems can effectively and equitably deliver
comprehensive services.
51. Support community-based organisations
to mobilise community members to play an active role in creating
awareness about entitlements to PMTCT+ services and monitoring
their access to them.
1 Communique: Social Welfare and Cash Transfer Meeting,
Carmona Spain, 22-24 April
http://blog.case.edu/msass/2009/07/10/Communique_-_Cash_Transfers_and_Social_Welfare_Services.pdf Back
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