Memorandum by UNAIDS
Issue 1: A recent report on Communicable Diseases
by the UK Department of Health stated that "post-war optimism
that their conquest was near has proved dramatically unfounded".
What is your assessment of the overall position? More specifically,
is it simply that not enough progress is being made in reducing
the spread of such diseases? Or is the global situation actually
deteriorating? Would it be an exaggeration to talk of a crisis?
1. While there has certainly been progress
in responding to AIDS in recent years, the HIV pandemic remains
the most serious of all infectious disease challenges today, and
will clearly be with us for generations to come. It should also
be noted that AIDS actually drives other deadly infectious disease
such as Tuberculosis and XDR TB: this poses economic and security
threats that go beyond national boundaries.
2. Some 33 million people worldwide are
currently estimated to be living with HIV, two thirds of them
in sub-Saharan Africa. To sustain progress already made, it will
be important to accelerate (and diversify) efforts to prevent
new infections and ensure that the provision of HIV treatment
can be maintained over the longer term. It is critically important
to understand the dynamics of the impact of AIDS as well as of
HIV transmission, stemming from the fact that HIV—unlike
other diseases—is concentrated in the productive adult population.
3. There is still no vaccine or cure
for HIV. Its initially asymptomatic nature means that people living
with HIV may remain unaware of their status for years. These facts,
along with the stigma that still surrounds HIV, the taboos around
the principal means of transmission (sexual relations, sharing
needles for injecting drugs), and the extent to which socio-economic
inequalities influence the spread of the epidemic and intensify
its impact, pose exceptional challenges for both HIV treatment
and prevention.
4. Since the discovery of combination
anti-retroviral therapies (ART) in the late 1990s, most people
requiring HIV treatment in developed countries are now able to
access life-lengthening drugs. Thanks to an increase in international
funding for AIDS since the turn of the century (the Global Fund
to fight AIDS, TB and Malaria and the US PEPFAR programme have
played a major role here), and a growing commitment from national
governments of some of the most affected countries, around one
third of people who need ART in low and middle income countries
can now obtain it. Residents of developed countries whose conditions
become resistant to first line drugs can switch to new regimens.
Relatively few residents of developing countries currently have
this opportunity, though it is encouraging to see countries such
as India initiate efforts to provide second line treatments free
of charge. To make progress on treatment, it will be vital to
keep investing in the development of new drugs, and to ensure
that they are affordable and available to all who require them.
One of the principal challenges facing us today is not just to
scale up access to HIV prevention, treatment, care and support,
but to sustain it.
5. The most important cause of illness
and death among people living with HIV, even among those on antiretroviral
therapy, is tuberculosis. This interaction with HIV, combined
with under-investment in health systems, inadequate research into
new drugs and diagnostics, and complex socio-economic factors
has reversed many of the gains made in TB control since the advent
of effective treatment in the 1950s, resulting in the development
and spread of drug resistant strains of TB and millions of avoidable
deaths.
Issue 2: What reliable data exist regarding
the numbers of people infected globally with the four diseases
on which the Committee is focusing particular attention? What
trends are discernible in both the numbers infected and the patterns
of infection? And what are the main underlying causes of infection
and of any changes in its incidence and pattern?
1. Data on HIV and AIDS is some of the most
accurate and up-to-date for any health issue. There are more HIV
epidemics than there are countries in the world, and tremendous
differences in the ways they are evolving. Overall, HIV prevalence
is stabilizing. The causes of its spread are multiple and complex:
biological, social, and economic.
2. The "AIDS epidemic update"
reports on the latest developments in the global AIDS epidemic
and has been published annually since 1998. The 2007 edition provides
the most recent estimates of the epidemic's scope and human toll
and explores new trends in the epidemic's evolution. This is a
joint UNAIDS and WHO report. It includes estimates produced by
the UNAIDS/WHO Working Group on Global HIV/AIDS and STI Surveillance,
based on methods and parameters that are informed by the UNAIDS
Reference Group on HIV/AIDS Estimates, Modeling and Projections.
These estimates are also based on work by country analysts in
a series of 11 regional HIV estimates workshops conducted in 2007
by UNAIDS and WHO. The process and methodology used by UNAIDS
and WHO were reviewed and endorsed by an International Consultation
on AIDS Epidemiological Estimates convened jointly by the UNAIDS
Secretariat and WHO on 14-15 November 2007 in Geneva.
3. According to the 2007 AIDS EpiUpdate,
33.2 million people were living with HIV in 2007. Every day, over
6,800 persons become infected with HIV and over 5,700 persons
die from AIDS. Nonetheless, the current epidemiologic assessment
is encouraging in that it indicates that the global prevalence
of HIV infection (percentage of persons infected with HIV) remains
steady, even though the global number of persons living with HIV
is increasing. There are four reasons for this: (1) the ongoing
accumulation of new infections with longer survival times, measured
over a continuously growing general population; (2) localised
reductions in prevalence in specific countries accompanied by
changes in behaviour; (3) a reduction in HIV-associated deaths,
partly attributable to the recent scaling up of treatment access;
(4) a reduction in the number of annual new HIV infections globally.
Examination of global and regional trends suggests the pandemic
has formed two broad patterns: generalized epidemics sustained
in the general populations of many sub-Saharan African countries,
especially in the southern part of the continent; and epidemics
in the rest of the world that are primarily concentrated among
populations most at risk, such as men who have sex with men, injecting
drug users, sex workers and their sexual partners.
4. The burden of tuberculosis occurring
in people living with HIV and national responses to the interaction
between the epidemics of TB and HIV have been reported annually
since 2005 in the WHO Global Tuberculosis Report which collates
data from around 200 countries and territories. Efforts are currently
under way to collect additional global data on the impact of TB
on people living with HIV through the UNGASS indicators and global
reporting of HIV care and treatment.
Issue 3: What intergovernmental surveillance
systems exist to give early warning of outbreaks of infectious
diseases? Are these systems adequate? And what improvements might
be made?
1. Detection of an outbreak of an asymptomatic
blood borne infection like HIV is difficult if not impossible.
The typically asymptomatic nature of HIV infection and the inability
to screen contacts or individuals exposed to the virus, limits
the potential to detect outbreaks.[1]
It is therefore recommended that countries develop appropriate
surveillance systems to track the behaviors that expose individuals
to the risk of HIV transmission, as well as to track HIV prevalence
in different populations. Many countries have adequate surveillance
systems; in other countries these systems need to be improved
or expanded. Important investments should be made in data collection
and analysis, to guide prevention programming and to assess the
impact of the AIDS response. Also, the importance of HIV/TB and
the need to work closely with TB programmes to build lab networks/efforts
to improve drug resistance surveillance for X/MDR among people
living with HIV who are more likely to develop TB.
Issue 4: Given the continuance of current
and planned intergovernmental programmes to prevent or control
the four diseases, what predictions can be made of their likely
spread and pattern over the next 10 years?
1. Global HIV prevalence-the percentage
of the world's adult population living with HIV-has been estimated
to be level since 2001 (Figure 1). Downward trends in HIV prevalence
are occurring in a number of countries, where prevention efforts
aimed at reducing new HIV infections since 2000 and 2001 are showing
results. In most of sub- Saharan Africa, national HIV prevalence
has either stabilized or is showing signs of a decline (Figure
1). Cote d'lvoire, Kenya and Zimbabwe have all seen declines in
national prevalence, continuing earlier trends. In South-East
Asia, the epidemics in Cambodia, Myanmar and Thailand all show
declines in HIV prevalence. The estimated number of deaths due
to AIDS in 2007 was 2.1 million (1.9-2.4 million) worldwide (Figure
2), of which 76% occurred in sub-Saharan Africa. Declines in the
past two years are partly attributable to the scaling up of antiretroviral
treatment services.
2. AIDS remains a leading cause of mortality
worldwide and the primary cause of death in sub-Saharan Africa.
HIV incidence (the number of new HIV infections in a population
per year) is the key parameter that prevention efforts aim to
reduce, since newly infected persons contribute to the total number
of persons living with HIV; they will progress to disease and
death over time; and are a potential source of further transmission.
Global HIV incidence likely peaked in the late 1990s (Figure 3)
at over three million new infections per year, and was estimated
to be 2.5 million [1.8-4.1 million] new infections in 2007 of
which over two thirds (68%) occurred in sub-Saharan Africa. This
reduction in HIV incidence likely reflects natural trends in the
epidemic as well as the result of prevention programmes resulting
in behavioral change in different contexts.
3. The Future: It is difficult to predict
the course of incident infections for the next 10 years, although
a conservative assessment can be based on the 2007 estimate of
2.5 million (1.8-4.1 million) new infections per year. This could
however evolve as a result of epidemic dynamics as well as be
influenced by effective prevention responses. Mortality in the
near future is expected to remain stable or even perhaps fall
if there is success in increasing access to ART to the millions
that need it.
Issue 5: What do you consider to be the principal
blockages to achieving progress in the prevention or control of
the four diseases? And how might these blockages be removed by
more, or better-targeted or better-coordinated intergovernmental
action?
1. At the September 2005 World Summit, heads
of state committed to a massive scaling up of HIV prevention,
treatment and care by 2010, as a mid-way point towards achieving
the Millennium Development Goals (MDGs). A UNAIDS-supported review
of individual countries' progress on scaling up access identified
six major challenges. The Joint Programme is working to address
each of these, with a particular focus on providing technical
support at country level:
(a) Setting national priorities: Countries
face difficulties in developing credible evidence-based and costed
plans that reflect national priorities and local realities. This
is partly due to lack of understanding of what is actually driving
the epidemic and the absence of baseline data, in particular for
most-at-risk populations. Moreover, current funding is often insufficiently
targeted towards national priorities.
(b) Predictable, adequate and sustainable
financing: Funding for AIDS falls well short of what is needed—despite
a remarkable increase from less than US$500 million just over
a decade ago to some US$10 billion today. One third of that money
currently comes from low and middle income countries a positive
trend in terms of ensuring sustainability of financing. But they
will not achieve this on their own—particularly in the short
term. For example, given that for every one person who starts
taking ART, another four become infected with HIV, providing treatment
is going to remain an expensive challenge for years to come.
(c) Strengthening human resources and
systems: Lack of human resources and limited institutional
capacity, partly due to internal and external migration and under-investment
in health systems, seriously impede provision of HIV prevention,
treatment, care and support services. This includes inadequate
access to reproductive health services. Weak infrastructure also
represents a serious bottleneck to effective use of the resources
available.
(d) Affordable commodities: The availability
of affordable HIV-related commodities, for both prevention and
treatment, is a critical issue. Current obstacles include the
high price of HIV-related commodities, in particular for second
and third line antiretroviral combinations and paediatric treatment;
taxes and tariffs; weak forecasting, procurement and distribution
systems; and delay in regulatory approval of new products.
(e) Stigma, discrimination, gender and
human rights: While stigma and discrimination, gender inequity,
and human rights abuses continue to fuel the HIV epidemic, limited
action is taken at the country level to address these issues.
UNAIDS promotes and supports the development and enforcement of
supportive laws and the protection of human rights-including the
rights of women and children, people living with HIV and members
of vulnerable groups. The empowerment of women and gender equality
are essential to both men and women to protect themselves from
becoming infected with HIV.
(f) Targets and accountability: Strong
monitoring and evaluation is a prerequisite to track progress
(or lack thereof) and assure effective oversight and accountability.
In many cases, monitoring, evaluation, and reporting capacity
is poor, and mechanisms limited.
(g) Overall recommendations:
— Support the development of prioritized,
evidence-based, inclusive and sustainable multi-sectoral AIDS
plans that "make the money work" and are aligned with
national priorities;
— Ensure sustained multi-year funding:
develop and implement a long-term investment programme for AIDS;
— Achieve cost reductions for HIV commodities—for
example through greater flexibility within the World Trade Organisation
TRIPS agreement;
— Address structural factors (such
as gender inequality) that influence the epidemic via concrete
activities;
— Enhance aid effectiveness through
stronger adherence to Three Ones Principles and the recommendations
of the Global Task Team on improving AIDS coordination among multilateral
donors and international donors;
— Invest in country-level monitoring
and evaluation, support multi-stakeholder planning and evaluation
"Partnership Forums" and encourage joint review mechanisms
and act on their findings; and
— Support closer integration of HIV
services with other health programmes including sexual and reproductive
health services, to strengthen health systems more widely.
Issue 6: What role does your organisation
play in combating the four diseases? Do you believe that it is
correctly configured and adequately resourced to do the job? With
which other organizations do you collaborate? How would you assess
the degree of synergy?
1. The UNAIDS Cosponsors and Secretariat
work on a wide range of cultural, health, social and economic
issues related to HIV. The Joint Programme provides knowledge
leadership, policy guidance and technical support, with a particular
focus on strengthening national AIDS responses. Due to the links
between HIV and tuberculosis, the UNAIDS family works closely
with global partners in TB control to strengthen responses to
the two epidemics.
2. UNAIDS works through regional structures
and through Joint UN Teams on AIDS that are facilitated by Country
Coordinators at country level. The Joint Programme is correctly
configured but under-resourced to optimally support significant
scale-up of responses to AIDS at country level. A Second Independent
Evaluation of UNAIDS, to be concluded in 2009, aims to ensure
that it is strategically and operationally placed to meet the
needs of the community it serves.
3. The UNAIDS Secretariat coordinates efforts
of ten Cosponsors based on their comparative advantages as defined
in an institutionalized Division of Labour. It fosters the active
involvement of civil society including organizations of people
living with HIV, faith-based institutions and the private sector.
UNAIDS also collaborates with major financial mechanisms, notably
the Global Fund to Fight AIDS, TB and Malaria and foundations
as the Gates Foundation. Ongoing efforts to better define roles
and responsibilities (eg the renegotiation of the Memorandum of
Understanding between UNAIDS and the Global Fund) will result
in stronger synergies.
4. The joint and co-sponsored nature of
UNAIDS has paved the way for heightened UN coordination in health
issues beyond HIV and has often been cited in wider UN discussions
as an example of UN reform in action.
Issue 7: What are the main non-health causes
(eg global warming, poverty, changes in land use, international
travel, lifestyle, population) of the spread of the four diseases?
To what extent can intergovernmental action in non-health fields
contribute to alleviation of their spread? What action is taking
place or planned in these areas? And what more needs to be done?
Do you consider that there is a sufficient "joined-up"
thinking in approaching the problem?
1. The AIDS epidemic is, in part, a by-product
of globalisation. The causes of its spread are multiple and complex.
So is its impact. Intergovernmental intervention to address these
causes and impacts is as important as support to more medical
aspects of the epidemic. Action is taking place but there is an
urgent need for more systematic and more consistent approaches,
and for greater cohesion with health-sector responses.
2. Since the early stages of the epidemic,
organizations such as ILO, UNDP, UNFPA; UNESCO, WHO and the World
Bank (all now cosponsors of UNAIDS), have highlighted structural
factors associated with the spread of HIV. Human rights abuses,
income inequality and the low status of women were all identified
as "drivers" of the epidemic. The implications for labour,
productivity and employment, and for society as a whole, all provoked
alarm.
3. It is now well documented, for example,
that gender dynamics are particularly influential in the spread
of HIV. For example, there is a powerful association between gender
based violence and vulnerability to HIV. In South Africa, women
with violent partners have been found to be 50% more likely to
be HIV infected than other women[2].
4. People from marginalised or stigmatised
populations, including sexual minorities, injection drug users,
sex workers, prisoners, migrants, and refugees often struggle
for human rights protection and may well find it harder to protect
themselves from HIV infection and to access HIV services (including
access to male and female condoms), when they need them. Stigma
is a major issue for the entire population. Revealing an HIV diagnosis
can lead to violence, ostracism and job loss for anyone, making
it more difficult for people with HIV to access proper care and
to engage consistently in behaviour less likely to put others
at risk of infection.
5. In many countries, injecting drug users
and sex workers are forced to live clandestinely without access
to information and to health care, and may be unnecessarily sent
to prisons. Imprisonment has been proved to be ineffective and
counterproductive, as access to HIV and TB services are lower
than elsewhere in the community, and the risks of infection higher.
6. Education is another important factor.
HIV and sex education delivered through school curriculum-based
programmes has proved highly effective in reducing sexual risk
taking.[3]
But even simply keeping girls in school longer is now directly
associated with lower risk of HIV infection in most of Eastern
and Southern Africa, empowering girls and women in their sexual
relationships and in escaping poverty[4].
7. The multilateral system has played a
key role in both understanding these complex and changing dynamics
and in supporting countries and communities to respond effectively.
8. For example, in 2005, UNICEF, UNAIDS
and partners launched "Unite for Children, Unite against
AIDS" to put children (aged 0-18) more prominently on
the global AIDS agenda. The ILO integrates AIDS issues in labour-related
policies at all provides guidance for the provision of HIV prevention,
treatment, care, and support through the workplace. Other initiatives
include support for cash transfers to HIV-affected families. UNFPA
supports programmes and youth peer networks (eg Y-PEER, AFRIYAN
and others) which both influence programming and reach young people
with HIV prevention information, skills and services.
9. There is broad recognition among the
international community that poor planning inevitably results
in a lack of priority setting and the ineffective use of available
financing. Therefore, national HIV/AIDS strategies and action
plans that are evidence-informed (addressing the key drivers of
the epidemic), prioritised and costed are a prerequisite for successful
implementation of national programmes. To support countries in
enhancing their national AIDS strategies, UNAIDS set up the AIDS
Strategy and Action Plan (ASAP) service in 2006 hosted by the
World Bank. The ASAP service is demand-driven and provides a one-stop
shop where countries can seek guidance and support to enhance
their national AIDS strategies, to translate those strategies
into action plans, and build capacity. ASAP has also developed
tools that countries can use to promote coordination and harmonisation
in strategic planning.
10. Alongside its analytical work on the
associations between HIV and a wide range of structural issues[5],
UNDP has pioneered a methodology to examine the relationship between
the potential impact of development policies on HIV, and the impact
of AIDS on development outcomes.[6]
UNDP has also contributed to research into the links between urbanization,
migration, HIV/AIDS and food security[7]
and is currently leading the UNAIDS effort to develop and promote
new country-oriented guidance and action strategies on gender,
sexual minorities and human rights. Since 2005, the Joint UNDP/UNAIDS/World
Bank Programme on Building National Capacity to Integrate HIV
in Poverty Reduction Strategy Processes has provided training
to 25 countries to better understand the linkages between poverty
and vulnerability to HIV infection.
11. UNESCO provides the secretariat for
the UNAIDS Inter-Agency Task Team (IATT) on Education. Comprising
UN agencies, bilateral donors[8],
private foundations and civil society partners, the IATT on Education's
actions focus on furthering dialogue, understanding and commitment
to the role of education in the HIV and AIDS response; generating
and sharing research and experiences; and supporting coordination
and partnerships for policy and programmatic action in the area
of education and HIV. The UNFPA led IATT on Young People and AIDS
will soon release seven Policy Briefs providing evidence-based
guidance and operational tools for national partners and UN Country
Teams, including specific strategies for interventions with young
people delivered through a range of settings.
12. UNODC leads the UN's work on HIV prevention
among injecting drug users and for prison settings. The main aim
of this work is to improve the access to HIV/TB prevention care
and support to injecting drug users, in prison settings and for
people vulnerable to human trafficking. The lack of attention
provided to these populations by States, the stigma attached to
them, inappropriate legal frameworks, and the paucity of resources
allocated at national levels mean that needs are still very high.
The legal framework in most places in the world forces injecting
drug users to live clandestinely without access to information
and health care, and often does not allow for the provision of
evidence-based means of prevention, such as opioid substitution
therapies or needles and syringes. People using drugs and/or sex
workers or women are often unnecessarily sent to prison, which
has shown to be ineffective, counterproductive and where the access
to HIV and TB prevention and care is even lower than in the community:
prison management is often poor. In some countries where sexual
relations with people of the same sex is criminalized there is
no access to condoms, especially in male prisons.
13. UNFPA leads the UN's efforts in the
area of HIV and sex work. It promotes a comprehensive, rights-based
approach to address inequalities that can drive women into sex
work, prevention of HIV in sex work settings, alternative economic
opportunities, reduction of stigma and discrimination and strengthen
realisation of human rights. As is the case with injecting drug
users, programmes reaching sex workers and other marginalised
populations are well below actual need.
14. UNAIDS provides a mechanism to coordinate
work in these areas. The development of the Three Ones" and
the Global Task Team have recently helped strengthen that capacity.
But we are still in the very early stages of developing an effective
global approach to the structural factors that influence this
particular epidemic.
Issue 9: Tuberculosis is potentially curable
by long-term antimicrobial therapies. Yet the numbers of reported
cases worldwide seem to be rising. Are the necessary medicines
not getting through to patients? What are the barriers to effective
long-term therapy? Are we now seeing infections which stem from
other conditions- eg HIV/AIDS? Or are there other reasons why
a treatable disease should be spreading? How might intergovernmental
action help to deal with this situation?
1. WHO estimates that the global rate of
new TB cases has peaked, and in most regions is beginning to fall,
albeit too slowly. In Eastern Europe and Africa, case rates have
stabilized after rapid increases over more than a decade, due
principally to economic/social transition in the former Soviet
Union, and due to the HIV epidemic in Africa. The WHO Stop TB
Strategy reaches almost two-thirds of estimated global TB cases
(compared with less than 10% a decade ago) and global treatment
success is now near the target of 85%, so TB is largely curable
even in the poorest settings. However, the interaction between
TB and HIV, weak health systems and inadequate investment in new
ways to diagnose, treat and prevent TB mean that there are still
over 1.6 million deaths from TB each year and the threat of drug-resistant
TB is rising.
2. The WHO Stop TB Strategy lays out the
approaches proven to reach and cure more persons ill with TB,
including people living with HIV. The Global Plan to Stop TB,
2006-15 sets out a plan and budget for what the world needs to
do to achieve the Millennium Development Goals in 2015, specifically
addressing the threats of HIV related TB and drug resistance.
However, in 2008 alone there remains about a 50% gap in financing
for TB control implementation of over US$2 billion, for national
control efforts and global technical assistance.
3. TB is among the most common causes of
illness and death among people living with HIV, despite being
preventable and curable. Up to 70% of TB patients are also infected
with HIV in the African countries hardest hit by HIV infection.
Many opportunities to provide integrated care are being missed
because of poor collaboration between TB and HIV programmes. In
2005, only 7% of TB patients were tested for HIV and less than
0.5% of people living with HIV were screened for TB. Recent evidence
in Southern Africa has shown that the spread of extensively-drug
resistant TB (XDR-TB) in hospitals serving as antiretroviral treatment
sites can be highly lethal. Policies and field best practice models
of integrated TB/HIV care are being applied but need faster scale
up and high level commitment to scale up towards universal access
to quality TB and HIV prevention, treatment and care. Joint efforts
to improve infection control in communities and health facilities
would benefit the response to both avian influenza and tuberculosis
as they are transmitted in the same way.
4. UNAIDS is working closely with the Stop
TB Partnership, WHO and other cosponsors to build joint action
on TB and HIV in order to reduce the burden of TB among people
living with HIV and accelerate towards universal access to comprehensive
TB and HIV prevention, treatment and care.
5. Intergovernmental action is already making
a profound difference through commitments, including by the UK
Government, technical agencies, academics and civil society organizations,
to the Global Plan to Stop TB, 2006-15. Partners are expanding
coordination in support of national scale-up proven effective
control policies, harmonise approaches and align them with national
health sector plans and initiatives, ensure coordinated technical
assistance that meets the demands of recipients, and to increase
powerful surveillance and urgently needed research. However, awareness
of the TB epidemic, its impact and its interaction with HIV is
still sorely limited in donor nations and high TB burden countries
alike and if raised could spur a much faster more integrated response
and broader financial commitments.
Issue 12: To what extent do you consider that
the rise in infections in the four diseases is attributable to
increased microbial resistance to antibiotics? What intergovernmental
actions is taking place in this area?
1. There is no direct evidence that rising
levels of drug-resistant TB have affected national or global trends
in TB incidence. Nevertheless, overall control of TB, as well
as public safety, is at great risk if drug-resistant TB is not
prevented, quickly identified and contained. The terrible mortality,
morbidity and economic consequences of cleaning up MDR TB should
not be underestimated: in the 1980's and 90's New York City spent
USD 1 billion on its micro epidemic which had been largely fueled
by HIV. There is evidence that drug-resistant TB disproportionately
affects people living with HIV, in terms of incidence and mortality
rates. Global efforts are focusing on providing effective TB treatment
to prevent the emergence and spread of drug-resistant strains;
large-scale improvements in laboratory networks worldwide; introduction
of new diagnostics and research; surveillance to monitor the emergence
and trends of drug-resistant TB locally, regionally and globally;
and to expand the treatment of drug-resistant TB. Scale-up of
treatment for drug-resistant TB is far behind the estimated projections
needed in the Global Plan to Stop TB to reach universal access
to treatment for all those detected with drug-resistant TB by
2010.
Issue 14: Are there any difficulties with
regard to patents or intellectual property which are impeding
the flow of medicines or other control methods to those infected?
Is intergovernmental action needed to improve the situation?
1. The cost of anti-retroviral drugs in
low and middle income countries is a major issue—particularly
as resistance to first line treatment increases. The agreement
on Trade related Aspects of Intellectual Property Rights (TRIPS)
attempts to balance two objectives: creating incentives for innovation
through patents and other measures on the one hand and spreading
the benefits of innovation as widely as possible (such as maintaining
a sustainable supply of essential medicines) on the other.
2. The debate around the scope and interpretation
of the TRIPS flexibilities was settled by the Doha Declaration
on the TRIPS Agreement and Public Health[9]
which affirmed that public health considerations can and should
shape the extent to which patents on pharmaceuticals are enforced
and that flexibilities in the TRIPS Agreement should be used to
this end. This was re-enforced by the 30 August 2003 Agreement
which allowed developing countries and LDCs with insufficient
or no manufacturing capacity to import generic medicines produced
under compulsory license. Although more countries have utilized
TRIPS flexibilities in recent years, most developing -country
WTO members are still in the process of amending their intellectual
property legislation to make full use of these flexibilities.
3. However, the unsuccessful conclusion
of recent WTO rounds has encouraged several countries to pursue
trade liberalisation agendas at a bilateral level. This has resulted
in a proliferation of bilateral trading agreements. Based on analysis
conducted on some recently concluded bilateral trading agreements,
countries appear to be committing themselves to obligations that
extend significantly beyond those contained in the TRIPS Agreement
and which may prove to be contrary to the objectives contained
in the Doha Declaration. This development has been noted with
concern by several UN agencies and has been the subject of resolutions
at the World Health Assembly[10]
of the WHO in recent years for instance.
4. Inter-governmental action has yielded
some important benefits to date. For example, UNDP's HIV Group
provides technical support to countries to analyse TRIPS flexibilities
and WTO obligations in order to inform their strategies with regard
to access to essential HIV drugs. The WHO's Commission on intellectual
property rights, innovation and public health for instance has
made important recommendations which are the subject of implementation
through the inter-governmental working group on public health
innovation and intellectual property. Continued co-operation between
developed and developing countries especially regarding the transfer
of technology as provided for in Article 66.2 of the TRIPS Agreement
should be encouraged and strengthened by WTO member states as
well as the relevant international organistions.
Issue 15: What interchange exists between
States in regard to knowledge of and training in the diagnosis
and treatment of the four diseases or regarding preparations for
dealing with outbreaks? What improvements might be made through
intergovernmental action?
1. UNAIDS as a Joint Programme, and through
the governance mechanisms of its individual Cosponsors, sets global
standards and provides technical collaboration with member states
at the global, regional and country levels for diagnosis and treatment
and control of HIV. It works with partners at the global, regional
and country levels for the diagnosis and treatment of HIV and
dealing with outbreaks. While great progress has been made in
establishing a global framework for detecting and responding to
HIV, increased intergovernmental collaboration and cooperation
are needed at the regional and country levels to strengthen surveillance
and disease control activities. In the past, the UK seconded experts
from academic and public health institutions which greatly helped
improve national responses to the different diseases. It is recommended
that this continue.
Issue 16: The International Health Regulations
2005 are intended to provide a global framework for the rapid
identification and containment of public health emergencies. How
effective do you consider this response system to be? Do improvements
need to be made?
1. The Regulations make no reference to
HIV, which does not fit the criteria for a notifiable public health
threat. However, recent experiences with the identified international
air travel of passengers with multi-drug resistant TB suggests
that the systems that need to be supported to enable countries
to fully comply and participate in the aims of the IHR are rudimentary
and need committed investments and significant human resources.
21 January 2008
1 Detection of such an outbreak would require large
scale blood screening and regular (serial) blood tests for a selected
population of individuals. Occasionally, outbreaks of blood borne
pathogens can be detected in closed populations (prisons and hepatitis
B or C), but usually these types of investigations require the
presence of and detection of one symptomatic individual, confirmed
through laboratory tests as an incident case, and then subsequent
case findings through large scale contact tracing and screening
programs. Back
2
Dunkle & Jewkes, Lancet Back
3
c.f. Kirby D, Laris BA, and Rolled L., 2007; and ActionAid International,
2006 Back
4
De Walque D. How does the impact of an HIV/AIDS information campaign
vary with educational attainment? Evidence from rural Uganda:
World Bank Development Research Group; 2006. Back
5
HIV and Migration in Asia Pacific, www.UNDP.org.
The UNDP Regional Programme in Asia and the Pacific has recently
formulated a programme on HIV and AIDS, Mobility and Human Trafficking. Back
6
UNDP Regional Service Centre, Johannesburg Back
7
Crush, J. et al. "Linking Migration, HIV/AIDS and Urban Food
Security in Southern and Eastern Africa", Regional Network
on HIV/AIDS, Livelihoods and Food Security, International Food
Policy Research Institute, Southern African Migration Project,
June 2006. Back
8
For the purpose of this request, current members include: Canadian
International Development Agency (CIDA), Department for International
Development (U.K.) (DFID), Deutsche Gesellschaft fur Technische
Zusammenarbeit (GTZ), European Commission (EC), Irish Aid, Netherlands
Ministry of Foreign Affairs, Norwegian Agency for Development
Cooperation (Norad), and the Swedish International Development
Cooperation Agency (SIDA). For a full list of IATT members, please
visit: http://www.unesco.org/aids/iatt. Back
9
The Declaration was adopted at the Fourth Session of the WTO Ministerial
Conference in Doha, Qatar on 14 November 2001. See WTO document
WT/MIN(01)/DEC/W/2. Back
10
For instance, Resolution WHA57.14 of 22 May 2004 urged Member
States to "encourage that bilateral trade agreements take
into account the flexibilities contained in the WTO TRIPS Agreement
and recognized by the Doha Ministerial Declaration . . . " Back
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