Examination of Witnesses (Questions 423
- 439)
MONDAY 31 MARCH 2008
Mr Nick Partridge OBE and Dr Alvaro Bermejo
Q423 Chairman:
Good afternoon. Welcome. Can I first of all tell you that our
main focus in these hearings is on intergovernmental organisations
and how well they are functioning. We obviously have an interest
in the diseases per se, but only in as much as this general issue
of how well are the relevant intergovernmental organisations responding.
This session is being recorded. You will be able to see a record
of your comments and make any factual corrections. If there is
anything you have missed out or think later you would have liked
to have said, please write in with those details. I understand,
Mr Partridge, you are the Chief Executive of the Terrence Higgins
Trust; and, Dr Bermejo, you are the Executive Director of the
International HIV/Aids Alliance. Is there anything you would like
to say first, briefly, before I go into the first question?
Mr Partridge: No, that is fine.
Dr Bermejo: No.
Q424 Chairman:
One other matter. It is just possible we will have a vote in a
moment, so if you hear bells ringing we will get up and leave
and come back in about ten minutes.
Dr Bermejo: We should wait?
Q425 Chairman:
I am afraid so. You will stay, I hope. Can I, first of all, focus
on the World Trade Organisation and the TRIPS Agreement, which
I think you are both familiar with. My understanding, and that
of the Committee, is that it plays an important role in lowering
the cost of HIV drugs, but there is some suggestion now that as
a result of trade agreements that flexibility is being eroded.
I would like to hear a little bit more about whether that is your
view, first of all; and, secondly, if so, why, and what should
we be doing about it.
Dr Bermejo: Thank you, my Lord Chairman. I would
like to contribute a little bit of our experience to that question.
Certainly our view has been that the flexibilities introduced
into the TRIPS Agreement on paper have been very good, they are
the type of thing that we need; but it has been the implementation
of them that has been difficult, complicated by, if one wants
to call it, the bullying behaviour of some of the big players
in trade. In particular, around the link with Free Trade Agreements
is that a number of countries, when signing up to a Free Trade
Agreement, either have been asked to introduce in their domestic
legislation some legislation that would prevent the exercising
of those flexibilities or that has been written into the Agreement
themselves. This is particularly worrying from our perspective,
the HIV perspective, because while TRIPS and the pressure from
advocates and the production of generics have lowered the price
of first-line drugs, in any country, as has happened here in the
UK, as treatment rolls out resistance begins to be generated to
those first-line drugs and one needs to move to second-line drugs.
The price of those second-line drugs has not yet been reduced
and, unless we can exercise these flexibilities, they will not
be reduced and the treatment will thus become unsustainable. We
have already seen that in a number of countries. If one looks
at Thailand, for example, they are spending around about 40 per
cent of their budget for anti-retroviral drugs on buying second-line
drugs for the eight per cent of those on treatment that need second-line
drugs. So the ability to implement these flexibilities without
retaliation from the countries where some of these pharmaceutical
companies are based is critical.
Q426 Chairman:
Before I bring in Lord Hannay, can you tell me which international
organisation do you think would be best placed to intervene in
order to address that problem?
Dr Bermejo: WTO remains a key player, but probably
from the point of view of anti-retroviral drugs in particular
it is UNITAID, a newly created international intergovernmental
organisation which has a specific mandate to reduce the price
of second-line drugs and which is looking at doing that through
pooled patents mechanisms, in a way would take the pressure away
from individual countries that have very little negotiating power
when trying to implement this and bring it to an intergovernmental
organisation that has been created particularly with a niche,
if you want, in this particular area.
Q427 Chairman:
The World Trade Organisation would not take the lead even though
presumably they are aware of the problems you are flagging up?
Dr Bermejo: I think it is more difficult to
see them taking the lead.
Q428 Chairman:
Why?
Dr Bermejo: Because of the politics, I guess,
the dynamics and the difficulties they have had first to reach
the Agreement. Reopening at the WTO and further rounds would probably
mean a move backwards rather than forwards. I think that is particularly
likely.
Q429 Lord Hannay of Chiswick:
I think part of the answer is that WTO does not negotiate Free
Trade Agreements; it is the framework within which countries bilaterally
negotiate. Could I just ask, because there are an awful lot of
Free Trade Agreements now around the world, which ones specifically
are those in which there are the problems you have identified
about lack of flexibility and pressure being put on countries
to commit themselves not to have these generic drugs?
Dr Bermejo: The ones I am more familiar with
that have this are with most of the Latin American countries.
Q430 Lord Hannay of Chiswick:
Sorry, between who and the Latin American countries?
Dr Bermejo: The United States and Latin American
countries, Central America and South America.
Q431 Lord Hannay of Chiswick:
You mean Chile and Colombia?
Dr Bermejo: And Central America in their negotiations
for trying to get a fast track, this was included there. Thailand
clearly saw after they—
Q432 Lord Hannay of Chiswick:
Again, and the United States?
Dr Bermejo: Yes. All the cases we are aware
of are with the United States.
Q433 Lord Hannay of Chiswick:
I see. That is rather an important point because the European
Union has a considerable number of Free Trade Agreements around
the world and it is rather important to know that you are not
talking about the European Union.
Dr Bermejo: Yes.
Q434 Chairman:
Basically UNITAID would be the best one to actually say, "This
is the problem and this is what needs to be done about it".
Are they doing that or not?
Dr Bermejo: They are. It is certainly part of
their new strategy and they are coming up with a way to do it.
It is early days. It is a fairly new intergovernmental organisation,
but it has got it in its strategy and we will see how far it can
get. We think that it needs to be supported to do that.
Q435 Chairman:
You are fairly optimistic about them having the clout to influence
people necessarily, or not? I am pushing you a bit on this because
I am quite interested.
Dr Bermejo: I am not sure that too many organisations
have the clout to change the trade policy of the United States
of America, but if one has then probably that is one of them.
Chairman: That is helpful, thank you.
Q436 Lord Desai:
During our evidence the question of integration of HIV and TB
treatments has come up, and UNAIDS said to us that opportunities
to integrate are being missed because of poor collaboration between
TB and HIV programmes. Is that your view?
Dr Bermejo: I would agree with that generally.
It was truer in the past than it is now. Intergovernmental organisations
have come late to an issue that shaped the response, certainly
in its first 15/20 years, of very little collaboration between
the two programmes, even though it was very clear from the beginning
of the HIV epidemic that it would be the main cause of resurgence
of the TB epidemic. In spite of that, for many years we have seen
little to no collaboration. That has changed and the intergovernmental
organisations have played an important role in that change, particularly
WHO; and the Global Fund, by the nature of picking up funding
for the three diseases has tended to generate some greater integration.
UNAIDS, to their credit, at the next Programme Co-ordination Board
Review of UNAIDS to take place later this month, in April, in
Thailand have selected TB/HIV integration as the main thematic
area on which the UNAIDS Board will focus. We are seeing movements
at the international community level as well as at national level,
where we are seeing greater integration. One can certainly argue
that it has come late, but we feel it is happening now and there
is growing realisation that without it the TB epidemic will not
be controlled and, at the same time, TB continues to be the main
killer of people living with HIV.
Mr Partridge: I would agree with that. Experience
within the UK is that, even though the links are clearly recognised
between HIV and TB, it has still been very hard to get general
practice recognising these links, particularly in African communities
living in the UK, so opportunities for earlier diagnosis of HIV
have been missed. It is not solely an intergovernmental issue
but, right down to GP practice level for the integration, understanding
and recognition of the closeness of HIV and TB. There is still
much more we could do to ensure that is more closely brought together.
Q437 Lord Desai:
Is there a turf war between doctors? Or is there a turf war between
organisations?
Mr Partridge: Between doctors sometimes.
Q438 Lord Avebury:
The statement by UNAIDS was about integrated care, and you answered
the question in the sense of the medical care that has been given,
or not given, in an integrated manner. Who is doing anything about
the integration of prevention in terms of TB and HIV/AIDS? Which
organisations are responsible for that matter?
Dr Bermejo: UNAIDS is responsible mainly for
the prevention of HIV and there is a whole range of organisations
that are related to the prevention of TB from the WHO to organisations
like ILO and others. I think the issue of diagnosis and care,
in our experience working in the field, is one where the issue
of integration and missed opportunities is really there in people
coming up to test at a facility for HIV that does not do TB testing,
for example, and you cannot diagnose if they are co-infected,
or the lack of screening for HIV in TB clinics where they are
separate. I think that is still the main area where we are missing
major opportunities to improve the health of these many people
with co-infection. That is why I focused on that, because I think
it is more an issue than the joint prevention, even though I would
still argue, as I did 15 years ago, that the best way to prevent
TB today is by preventing getting an HIV infection.
Q439 Lord Howarth of Newport:
Good afternoon. The Alliance was eloquent in their evidence to
us on this matter on the contradictions between policy on HIV/AIDS
and on drug use within the UN, and obviously that applies in individual
countries, So that, if drug usage is criminalised, as you note,
drug users can be jailed for possessing clean injecting equipment,
prisons become incubators of HIV, and HIV intervention is not
legally available to drug users. How do you think this tension
should be resolved? And what would you wish to see our own Government
doing to contribute to this resolution?
Dr Bermejo: The reason we were so eloquent was
because we see this as a major impediment to the work of the Alliance
in supporting HIV control in many of the countries where we work,
whether it is Ukraine, Thailand, China, many places where the
HIV epidemic is fuelled by injection of drugs with unclean equipment.
We need to remember that is still responsible for one-third of
the new HIV infections outside of Sub-Saharan Africa. What is
happening is that we have countries supported by UNODC instituting
and being given guidance and technical support around drug control
for measures that really criminalise drug users and those in possession
of drugs. What we see in many cases is services that need to meet
their targets waiting outside some of our clinics, for example,
where methadone is being prescribed as substitution maintenance
therapy or where drug users are coming to get their treatment
and they are being detained outside the doors. This is while the
clinics are being run at the same time by the health services,
so you have this contradiction at country level which is equally
apparent at the intergovernmental organisation level. So, while
we have WHO with a harm reduction policy which is evidence-based
and which has been standing for a long time and approved by the
World Health Assembly, we have UNODC which until January this
year had very little to say as to the evidence behind harm reduction
approaches and was really taking a drug control approach and contributing
to these kinds of responses at country level. What can the UK
do? Our feeling has been that the UK Government has been pretty
consistent in terms of its policy being evidence-based and advocating
for that, and we saw them working two or three weeks ago on the
Commission on Narcotics advocating a policy that would recognise
both the evidence behind harm reduction approaches and the human
rights implications of some of the approaches that UNODC has taken.
The truth is that UNODC still spends three times more money on
drug control and criminalisation than it does on prevention and
treatment. I think one thing is the policy effort the UK is doing,
which is probably in the right direction, and another thing would
be to look at where the money is going and whether or not it is
supporting those same policy objectives, and our view is that
part of it certainly is not.
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