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


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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