Examination of Witnesses (Questions 460
- 473)
MONDAY 31 MARCH 2008
Mr Nick Partridge OBE and Dr Alvaro Bermejo
Q460 Baroness Whitaker:
The usual complaint is that DFID puts too much into direct credit
support and not enough into the Global Fund. I will not go into
this now, but there is clearly something we have to disentangle
here.
Dr Bermejo: Yes, though I would say that in
the last year our perspective is that that is probably driven
as much from a strategic approach as from the reality of DFID
having more money but fewer human resources. They are making decisions
to increase the amount that is going to multilateral organisations
as well as bilateral support, but that is in a way a reaction
to the wrong incentive, which is trying to do more with fewer
resources, but it does not make sense from a strategic perspective.
Q461 Chairman:
Just before I bring in Lord Avebury, can I make sure, Mr Partridge,
that your understanding of the DFID point that was raised by Baroness
Whitaker is the same as Dr Bermejo's?
Mr Partridge: Yes, it is.
Q462 Lord Avebury:
I just want to go back to a point you were raising earlier about
the Global Fund being very good at targeting vulnerable groups.
I was wondering whether you were saying that in contradistinction
to UNAIDS which is a vertical programme. The Global Fund does
work with the vulnerable, such as the sex workers and prisoners
and so on, and that is one of its major advantages. So, if you
had a marginal extra £100 million to spend in DFID, would
you be putting money into the Global Fund rather than into UNAIDS?
As a corollary to that question, are the Global Fund funds specifically
working on the problems of women and girls that you identify in
Paragraph 4.5 of your paper, where early marriage, sexual harassment
and harmful traditional practices, such as female genital mutilation,
increase women's vulnerability to HIV/AIDS? Is that something
which the Global Fund is specifically addressing? And are they
alone in doing that?
Dr Bermejo: The Global Fund has one principle
that is important, which is country ownership and country design
of the programmes, which they have taken beyond what others who
say they have this principle have done. What they call country
ownership is not just governmental ownership; it is a broader
constituency at country level where these groups themselves are
represented, so that influences their ability to get there. UNAIDS
was the first UN agency, I believe, to create a Board that had
civil society participation on it, but it is participation that
has no vote and that is still a small minority. The Global Fund
took it further by giving them a vote and by having effective
communities on the Board, and that has contributed to shaping
the programme mix, not just on the international Board but it
is also true at national level. I think that explains why the
affected communities and the most vulnerable groups are better
represented in the programming that they implement. UNAIDS is
not channelling resources in the same way, so they are more a
technical response at country level; they are not a grant mechanism
in the same way as the Global Fund. UNAIDS, I think, has also
embraced the realities of marginalised groups and of women and
children, but they have not been able to take it this far, partly
because the mechanisms that the UN has make that more difficult
and the Global Fund has a set-up that allows it to do that better.
Mr Partridge: I would just mention if I may,
certainly from my perspective, the bravery and the leadership
that UNAIDS has shown in demanding that governments really do
tackle the needs of those most vulnerable to HIV infection. It
goes back to its creation. Its first director, Dr Jonathan Mann,
had a very clear leadership role in recognising that many governments
have found it very hard to engage with men who have sex with men
and with those with a history of injecting drug use, sex workers,
genital mutilation and so on, and I would not wish to underplay
the impact that UNAIDS has had at that policy level in leadership
and in tackling very early on and consistently that which many
governments wish to duck.
Q463 Lord Avebury:
Can either of you quote any specific examples where any IGO has
persuaded a host government to address in a practical way these
specific examples that you give of the vulnerability of women
and girls, the cultural disadvantages that they suffer?
Dr Bermejo: UNAIDS, for example, at the policy
level took a decision to create a coalition on HIV women and girls
which had seven key tracts, and Mary Robinson and a few others
were part of the committee that was leading this, which I think
did change the perspective. It first made people realise when
it happened that the epidemic had feminised and had a female face
now in many of the countries, and that the interventions that
we were doing needed to adjust to that in many countries where
that was not happening. I think they have been quite successful
in doing that, in changing policy. Today, if one looks at the
lists of people on treatment and the numbers of people in treatment
around the world, we thought females were going to be under-represented
and that is not the case because I think there has been a conscious
effort to ensure that women and girls had access to treatment
in many of these countries in the same way as men had, and that
has been achieved. So I think there are policy interventions that
have been successful in that sense, but of course, in terms of
changing the gender relations that make women particularly vulnerable
to HIV, I cannot say that I have seen lots of examples or that
we have been really successful.
Q464 Lord Steinberg:
I am one of those people who believe that prevention is better
than cure, and yet it seems as if the amounts of money spent,
which are vast, are much more on treatment and much less on prevention.
I presume that on prevention you would say that education would
be the principal factor of prevention? Would you agree that that
balance, which has focused mainly on treatment, is the right way
to go? Or do you agree with what I am saying, that it is much
better to spend a lot more money on prevention?
Mr Partridge: Shall I start with the experience
we have had in the UK, because I think it is one that helps understand
the dynamics of what happens when effective treatment is brought
in to any country? Certainly, we at the Terrence Higgins Trust
campaigned very hard to ensure that effective treatment was made
available for those for whom it was clinically needed and appropriate,
knowing that in doing so—and going back to 1996 when the
cost of therapy then was much greater than it is now—that
was going to create difficulties for the NHS in how it funded
both treatment and ongoing prevention work. What has happened
since then is that clinical effectiveness and the cost effectiveness
of HIV therapy are so good that we have not needed to focus on
campaigning for treatment access within the UK. It is very obvious
that it needed to be done, but we have seen, particularly at local
primary care trust level, a significant drop in funding for prevention,
continued difficulties in getting sexual relationship education
as part of the core curriculum and little continued leadership
around the need for ongoing HIV prevention campaigning work, both
for those communities at greatest risk and more generally. There
has been a financial trade off in the cost of therapy in the overall
pot. Therapy has taken up a progressively larger amount of money.
Also, good therapy makes people with HIV less visible in any community
because you are healthier; you can remain in work if you have
stayed in work. There is less reason to be articulate and open
about being HIV-positive. At a political level, when therapy is
introduced which makes people healthier it does not reduce but
increases, the prevalence of HIV overall. That can then easily
be misunderstood as a failure of prevention. It also creates an
ongoing need for funding drug therapy which can squeeze out funding
for good prevention campaigns. What is vitally important is that
both go hand in hand. There is, to a degree, a prevention dividend
through good therapy as undetectable viral load reduces new infections.
However that is balanced against a growing number of people with
HIV who are sexually active for longer as they live more productive
lives as a result of therapy. It is a complex interrelationship
which I do not think, either in this country or internationally,
we have yet cracked as to how we manage to continue investment
in prevention because it is much better than going on to a lifetime's
work of treatment.
Q465 Lord Steinberg:
You talked principally about your experience in the UK. On the
basis that the vast majority of HIV occurs in uneducated communities,
wherever they are in the world, is it not time that a switch occurred?
Or are you perfectly happy that the treatment and therapy come
before the prevention?
Dr Bermejo: No, we are not happy in that sense.
I would echo what Nick was saying. It is true internationally.
There is not enough money for prevention. There is no doubt about
that, but I do not think that is because there is too much money
for treatment. I think it is just because there is not enough
money for prevention. That is not exclusively a health ministry
or health sector area. As you have highlighted, those are resources
that probably need to be best invested outside of the health sector
and the health ministry. That is where there is not enough money
being allocated to these issues of HIV prevention. Partly it is
because we tend to see HIV/AIDS just as a health issue and a disease
and partly also it is because we have this myth that HIV prevention
is cheap. Everybody understands that treatment is expensive, that
it is for a lifetime, that you have to buy drugs, that you have
to keep providing them, but people think that HIV prevention is
something you do once and then you have done it and it should
not cost a lot of money. You run a few campaigns, but it does
require resources and we have under-funded it and under-invested
in it. That is what we need to look at, as to how we put more
resources into HIV prevention. That is the big question.
Mr Partridge: Oddly enough, treatment delivery
is the easy part. Now, prescribing pills is not that complex.
Changing behaviour long term is immensely complex and weighted
with a whole load of moral, political and cultural stuff that
is very tough to do. Prevention has become consistently more complex
over the years, whereas treatment has become simpler, clearer
and cheaper.
Q466 Chairman:
My understanding is that in 2000 in the UK there were 3,000 new
cases and by 2007 there were 9,000. Is that a problem about prevention?
Mr Partridge: The figures are slightly different.
3,000 goes up to about 7,800. What we need to be really clear
about is that those are diagnoses. They are not directly linked
to infection within the UK. Part of that considerable increase
has been a result of better diagnosis services and a very minimal
impact of the global epidemic within the UK through migration.
We need to unpick what is happening within the UK. The bulk of
transmission is between gay men in the UK and we have seen an
increase in that, but that which has levelled off in the last
three or four years. It is about how we ensure that those campaigns
which are targeted at groups which are most vulnerable within
the UK are sustained and increased.
Q467 Lord Howarth of Newport:
It is difficult to alter cultures and in many parts of the world
education provision all in all is pitifully inadequate. But should
not sex education be an absolutely major preoccupation and a major
drive? I do not see why it need be particularly expensive. One
must assume that, if it can be effectively designed and delivered
more and more extensively, it really would make a huge difference.
I would be completely authoritarian about this and absolutely
refuse to allow people to opt out of sex education. I would not
be tolerant of schools that neglected it. It is one thing to picture
how it might be done in this country and obviously a very different
thing to picture how it might be done in countries in sub-Saharan
Africa, but surely this must be a crucially important key to prevention?
Mr Partridge: Absolutely, yes. I totally agree
with you. However, we failed to do that within the UK with all
of our resources and so on, not least because of the cultural,
political and religious issues. To expect that to have happened
in Nigeria or Uganda or elsewhere—
Q468 Lord Geddes:
Four weeks ago we had no fewer than four professors of medicine
giving evidence to us, one of whom, Professor Johnson from University
College London, told us. "In the field of AIDS, in one area
you may have several different programmes operating in one town.
That may have advantages, but it may have significant disadvantages
if they are operating in different ways." In the Alliance
evidence, right at the end of main Paragraph 5, there is an assertion
that neither the resources nor the instruments to properly invest
in fighting AIDS are currently available. Ignoring the horrors
of the split infinitive, are those two bits of evidence compatible?
Or are they saying different things? Is there in your opinion
a need for rationalisation of the different programmes and actors,
if you like, including both the IGOs and the NGOs? Are you saying
the same thing there? Or are you saying something completely different?
Dr Bermejo: What we were saying was that we
still do not have all the instruments. There is clearly a need
to invest in more instruments, particularly on the prevention
side. We have technologies and instruments now with which we have
to do the best we can, but that does not mean we can stop investing
in new instruments, whether it is microbicides or vaccines etc.,
without which the epidemic cannot be defeated from a technological
point of view. In terms of the organisation set-up and architecture,
Ann in her statement, which I read, is saying it can be one way
or the other. Our view is clearly we need effective local responses
and that is where the coordination needs to happen. This is not
about some central coordination up here; it is at the community
level. Communities need to be in the lead. We have seen that in
a lot of the places where the Alliance works: we need local authorities
to create some coordination committees that ensure that the interventions
that happen in one locality complement and support each other.
In that sense, we believe it is more of a local coordination issue
and response, this one of a multiplicity of actors, more than
something you can do at international level or national level.
We have seen that work very well. Some of the new figures that
are coming out of Andhra Pradesh in India, which show a dramatic
reduction in the number of new infections, have been driven by
multiple actors. You had there the Indian Government and many
donors working with Melinda Gates, with a huge programme, the
Alliance and many others, but the local authorities were very
clear in assigning coordination and complementarity. That has
worked well. Our view of how to respond to that has to be not
with international architecture, where that is very difficult
to correct, but making sure that at the local level there are
coordination mechanisms that ensure that we are working towards
the same national response and local response there.
Q469 Lord Geddes:
I take your point. Concentrating on this local level, who coordinates
this? I think I heard you say just now local government.
Dr Bermejo: We think it has worked better where
local government creates coordination committees that involve
other actors, so it is not just them dictating but creating local
AIDS coordinating committees, where the mission hospital, the
public hospital, the clinic, the education system, the NGOs, the
sex workers' collective if there is one, all sit around and coordinate
that response. That is what we have seen work best and in most
cases it is chaired by local government.
Q470 Lord Geddes:
The actors themselves are traditionally prima donnas. From experience,
do you find that those prima donnas will take such coordination
from local government?
Dr Bermejo: There are prima donnas, and you
are right that they are not easy to coordinate; but the majority
of the local response is not really one of prima donnas. We see
them at international level and some organisations behave like
that, but they are not the majority. With strong governments,
like the Indian Government or some others, it is easier to impose
that than it is with weaker ones, but the experience we have seen
has been positive.
Q471 Chairman:
You are using the Indian Government but there is good governmental
structure in India. That is not the case with some of the African
governments, for example. That would not apply?
Dr Bermejo: Yes, but we have seen the same.
We have had a great evaluation in Madagascar, which is not one
of the strongest governments. It is true that in Madagascar there
are fewer prima donnas than in Tanzania or Kenya maybe in the
response, but still we do see these things working and that is
what we need to support. We really believe that is the answer.
Mr Partridge: I did wonder whether Professor
Johnson was thinking about the 33 Primary Care Trusts in London!
Chairman: Much as it may seem otherwise, it
is not an intergovernmental organisation.
Baroness Eccles of Moulton: This is a thread
that has run through in great detail and it has been very informative.
I suppose it is just worth saying that there is still a great
amount to be done in building secure, horizontal health structures
with—words you have used—sustainability and capacity
for surviving. You have told us a great deal about that. Thank
you very much.
Q472 Lord Desai:
On prevention and cure, is the problem that prevention cannot
be measured and therefore nobody will pay for it? Cure can be
measured?
Mr Partridge: It is partly that, and that goes
back to what I was trying to say about treatment that is very
measurable. You have clinical trials and you can see the differences.
Q473 Lord Desai:
If you want value for money, you do not prevent; you cure?
Mr Partridge: We know the value of any single,
saved HIV infection, any HIV infection prevented. You have to
throw a lot of prevention money in for it to become not cost effective,
but it is because it is so difficult to measure and to have the
right kind of trials to identify its impact that it is much tougher
to do compared to drug trials.
Dr Bermejo: The prevention constituencies are
not as powerful as the treatment constituencies and we need to
understand that.
Chairman: Can I thank you both very much? You
have been very helpful and you have given us some very clear,
concise arguments. If you have any more thoughts, please write
in as I have indicated.
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