Memorandum by the Global Fund to Fight
AIDS, Tuberculosis and Malaria
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?
In the second half of the 20th Century, the
combined result of improved nutrition and hygienic conditions
with the availability of effective antimicrobials and protective
vaccines brought a dramatic reduction in the burden of infectious
diseases in the most industrialized countries and many believed
that infectious diseases could be eliminated as a public health
problem. As a result research and investment in developing new
diagnostic and therapeutic tools dropped. Only the few interested
in Tropical Medicine or in health development of poor countries
kept being interested in the subject. This period culminated with
the eradication of smallpox in 1979 and with plans for eradication
of other diseases, including polio and malaria.
The reporting of the first AIDS cases in 1981
marked the end of the optimistic view that infectious diseases
can be controlled and eliminated. Since 1981, more than 20 new
human pathogens have been discovered, including Ebola, SA RS and
H5N1. In addition, many infectious agents are becoming resistant
to the available antimicrobials and relatively few new antimicrobial
agents are in the research pipeline. Old diseases like TB and
malaria that had never disappeared stage an important comeback
driven in part by drug resistance and in part by HIV.
The 20th Century has witnessed major achievements
in the fight against infectious diseases. However, the increased
awareness and media coverage that accompanied the AIDS epidemic
(and more recently SAO and Avian Flu) have resulted in the recent
increased attention to infectious disease threats. Epidemics have
accompanied the history of the human race and new pathogens have
probably emerged undetected in the past. There is no hard evidence
of an actual deterioration of the situation or the acceleration
of the emergence of new diseases. However, recent social and economic
trends may contribute to increasing the spread of infectious diseases.
For example, the massive urbanization in poor countries which
forces millions of people to live in close proximity and poor
hygienic conditions create a fertile ground for the spread of
diseases. Or the changes in the way animals are raised and fed
can contribute to the emergence of new diseases (usually of zoonotic
origin) or the development or antibiotic resistance.
While we cannot simply eradicate all infectious
diseases, prevent new ones from emerging or stop the development
of drug resistance, we do have the capacities, resources, technical
tools to control them and dramatically reduce the disease and
death burden. Too many people die every day for infectious diseases
that can be prevented or cures with available tools. They die
because they live in unhealthy conditions and because they do
not have access to basic vaccines, drugs or basic health services.
This can and must change.
Driven in particular by the recognition of
the dramatic impact of the AIDS pandemic, towards the end of the
90s world leaders and decision makers finally realized that tackling
major global disease problems was not only possible but also necessary
on both humanitarian, social and economic grounds. This led to
the launching of several major global initiatives, including the
Global Fund to Fight AIDS, TB and malaria, PEPFAR and the more
recent US President Malaria Initiative, that aim at ensuring that
sufficient resources are made available to poor countries to scale
up all the necessary prevention and treatment activities and finally
reduce the burden of these diseases. After the MRS outbreak and
the epidemic of Avian Flu, a similar global effort has led to
the approval of the revised International Health Regulations and
the development of improved surveillance tools to respond effectively
to emerging epidemics threats. It might be too early to say if
these global initiatives are achieving the stated goals, but initial
successes are being documented in access to HIV treatment, detection
and cure rate for TB and prevention of malaria in children. This
shows that we are probably on the right track.
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?
AIDS: Starting in 1986 with the WHO Global
Programme on AIDS, major investments have been made in the collection
and analysis of HIV/AIDS data. This has allowed WHO and (MAIDS
to provide regular updates of disease burden and the response
to the epidemic for most countries in the world. Yearly estimates
of HIV prevalence, incidence, mortality and other key indicators
are published yearly by MAIDS and WHO just before World AIDS Day.
Global estimates were reduced recently thanks to better data collected
through population-based studies. Trends differ considerably in
different countries and among different population groups but
overall HIV incidence appears to have peaked and prevalence, in
spite of the increasing number of patient being treated, has started
to decline. Still, in 2007 UNAIDS estimated that 2.5 million people
became newly infected and 2.1 million people died of AIDS.
TB: Since the establishment of the STB Partnership,
important efforts have been made in improving availability and
quality of TB data (DOTS coverage, burden of disease, detection
rate, and drug resistance patterns). Key TB indicators are published
regularly and the latest global report with TB estimates was released
in 2007. However, good data is only available from few selected
countries it would be essential to improve on data collection
and analysis at country, level to allow for better monitoring
of TB burden and trends.
Malaria: Our appreciation is that malaria
data is of insufficient quantity and quality, to allow for the
necessary monitoring of disease trends, prevention and treatment
coverage, and drug resistance patterns. We believe that a major
effort is required to improve the quality and availability of
malaria data, particularly if we are to embark in efforts towards
elimination or eradication of the disease in selected countries.
The latest World Malaria Report was published in 2005.
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?
4. Given the continuance of current or 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?
Predicting future trends is never particularly
easy. Based on the current observations (reduction in HIV incidence,
initial reduction of TB prevalence and reports of reduce malaria
incidence and mortality where sufficient coverage with long-lasting
bednets and other preventive tools is achieved) we would expect
that if the level of investments in HIV, TB and malaria is sustained
or increased, we will achieve major reduction in the disease burden
and mortality due to these three diseases, though we might not
be able to fully achieve the ambitious targets set by UNGASS,
RBM and STB or the health MDGs. However, a reduction in financial
support and national commitment could easily reverse these trends,
particularly for malaria.
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?
The establishment of the Global Fund to fight
AIDS, TB and malaria and other bilateral initiative like PEPFAR
and PMI aimed at removing one of the major barriers in the prevention
or control of HIV, TB and malaria: the lack of financial resources.
While we are still far from covering all needs, substantial funds
are now being made available to national programmes in many countries.
Weaknesses in the health system of many developing
countries, and in particular the lack of trained health workers,
have been identified as major barriers for the scaling up of disease
prevention and control activities. WHO estimates that it will
take an additional 2.4 million physicians, nurses, and midwives
to meet the needs, along with an additional 1.9 million pharmacists,
health aides, technicians, and other auxiliary personnel.
Several international initiatives have been
launched to address system weaknesses and remove obstacles to
scaling up of interventions, including the GA VI HSS initiative
the International Health Partnership. The Global Fund has also
revised recently its policy to better support health system strengthening
activities aimed at removing bottlenecks to achieving wide coverage
of HIV, TB and malaria interventions.
Inadequate financing of research and development
for new diagnostics, drugs and vaccines is also a major barrier.
Simpler, cheaper and more effective tools, including simple rapid
diagnostics and vaccines could greatly facilitate access to prevention
and treatment, particularly in remote and poor areas. Malaria
or TB elimination will be unlikely without an effective vaccine.
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 organisations do you collaborate? How would you assess the
degree of synergy?
The Global Fund was created to finance a dramatic
turn-around in the fight against AIDS, tuberculosis and malaria.
The Global Fund currently provides two-thirds of the international
resources for the fight against malaria and tuberculosis, and
20% of the international funding to fight AIDS. As a partnership
between governments, civil society, the private sector and affected
communities, the Global Fund represents an innovative approach
to international health financing, enshrined in the principles
of additionality, performance, national ownership and participation.
To date, the Global Fund has committed up to
date US$ 10 billion in 136 countries to support aggressive interventions
against all three diseases. During the second replenishment meeting
of the Global Fund in September 2007, additional pledges have
been received for 9.7 billion dollars for the years 2008-2010,
with the perspective of increasing further, if convincing levels
of demand are expressed by countries through the submission of
good quality proposals to the Global Fund. Donors, partners and
civil society advocates consider that funding for up to 8 billion
annually by 2010 can become a realistic target, if demand is sustained.
Sustaining demand, in line with the existing needs in countries,
will be indeed a major challenge for the future for the partnership
of the Global Fund with implementing countries, technical partners,
the private sector and the civil society.
The Global Fund's purpose is to attract, manage
and disburse resources to fight AIDS, TB and malaria. We do not
implement programs directly, relying instead on the knowledge
of local experts. The Global Fund is committed to relying on existing
financial management, monitoring and reporting systems, where
possible.
As a financing mechanism, the Global Fund works
closely with other multilateral and bilateral organizations involved
in health and development issues to ensure that newly funded programs
are coordinated with existing ones. Intergovernmental organizations
like WHO, the WB and UNAIDS are also members of the Board of the
Global Fund and representatives of the intergovernmental organizations
are members of many Country Coordinating Mechanism (CCMs) that
lead the application process and oversee Global Fund grant implementation
at country level. In many cases, these partners participate in
local Country Coordinating Mechanisms, providing important technical
assistance during the development of proposals and implementation
of programs. The Global Fund has been advocating for increased,
predictable and sustainable resources to countries to scale up
their interventions. Therefore the Global Fund acknowledges the
UK commitment to ensuring long-term financing for health as a
way to increase predictability, sustainability and effectiveness
in the health and development architecture. The Global Fund is
a signatory of' the Global Health Partnership "Working together
for better health: Evidence for Action" launched by the UK
and aimed, inter alia to improving the effectiveness of international
funding for health. The Global Fund is also a signatory of the
Rome and Paris declarations on aid effectiveness and has taken
the responsibility of monitoring indicators of progress as part
of its performance assessment system and of facilitating the work
of the global partnerships around the Paris approach.
7. What are the main non-health causes (e
g 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 sufficient `joined-up' thinking
in approaching the problem?
8. Cases of Tuberculosis fell progressively
in the UK until the mid-1980s but started to rise again in the
early 1990s. Around 6,500 cases are now reported each year, an
increase of about a quarter since the early 1990s. What are the
main factors of the revival of Tuberculosis infections in Britain?
And how could intergovernmental action help to reverse the trend?
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?
WHO estimates that TB prevalence and death rates
have probably been falling globally for several years. In 2005,
the TB incidence rate was stable or in decline in all six WHO
regions, and had reached a peak worldwide. However, the total
number of new TB cases was still rising slowly due to both population
growth and the impact of HIV. In Africa, case rates have stabilized
after rapid increases over more than a decade, due principally
to the HIV epidemic in Africa. TB case detection rate globally
is approaching the 70% target and has reached the 85% cure rate
target set by the WHO for 2005 thanks to an acceleration since
2001 supported, among others, by the Global Fund.
Each year, nearly 2 million people die of TB,
despite the availability of inexpensive treatments that are effective
in up to 95% of cases. However, increasingly patients are receiving
the appropriate treatment though access is not universal, particularly
in poor rural areas, and the emergence of drug resistance is threatening
to reverse the positive trend of the recent years.
Global Fund grants are helping to increase access
to TB treatment. With Global Fund support 5 million additional
cases of infectious tuberculosis are being detected, 3 million
people are being cured through the internationally approved DOTS
treatment strategy and treatment is being provided to 24,000 new
cases of multi-drug resistant tuberculosis.
The STB Partnership has proven an effective
mechanism for coordinating international action by different stakeholders
including Governments, technical agencies, academics and civil
society organizations in support to the Global Plan to Stop TB,
2006-2015. Partners are expanding coordination in support of national
scale-up proven effective control policies, harmonize 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.
10. To what extent do you believe that the
2004 Stockholm Convention limiting the use of DDT against Malaria-carrying
mosquitoes has been a factor of increases in the spread of the
disease? Has any risk analysis been carried out comparing the
relative dangers to human health posed by DDT and Malaria?
Under the 2004 Stockholm Convention DDT may
be produced and used only for disease vector control and according
to the recommendations and guidelines of the World Health Organization.
DDT can be used when safe, effective and affordable alternatives
are not locally available in a country. The World Health Organization
considers the use of DDT as an effective prevention method but
recommends only indoor residual spraying (spraying only on the
inside walls of buildings) of DDT for disease vector control.
The Global Fund will therefore support the use of DDT for indoor
residual spraying where accepted by the national malaria programme
and the WHO.
However, only a limited number of countries
have included indoor residual spraying with DDT as part of their
national strategy, in part due to the Stockholm Convention. WHO
has recently released a position paper summarizing the findings
about efficacy and toxicity of DDT for vector control.
11. What intergovernmental action is planned
or in hand for early detection of the transmission of Avian Flu
from birds to humans and of human-to-human transmission in potential
source countries? Is this proving sufficiently effective to prevent
an Influenza pandemic? What more could be done?
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 action
is taking place in this area?
The major impact of increased antimicrobial
resistance is on malaria control. HIV drug resistance, though
an important problem for the management of the individual patient,
is still low at population level and has limited or no impact
on transmission of HIV MDR and XDR dramatically increase the cost
of treating the individual TB patient but are not more transmissible
that regular TB and the impact on incidence and prevalence of
TB is probably limited or none.
In malaria, the rapid spread of resistance to
cheap and widely available drugs (CO and SP) has contributed to
the high death burden, especially in young children, and the high
transmission rates due to the endemicity of the infection. Vector
resistance to common insecticides has also probably contributed
to the malaria burden.
Global schemes for surveillance of HIV TB and
malaria drug resistance have been established but coverage is
still limited and data is patchy. Additional action is indeed
necessary to ensure that resistance is detected at early stage
and remedial actions can be put in place in order to preserve
the efficacy of available drugs for as long as possible.
13. In a number of countries, including the
UK, there is a problem with hospital-acquired infections. What
intergovernmental sharing of knowledge is taking place to help
bring this problem under control?
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?
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?
Several international conferences and technical
fora exist for the exchange of scientific and programmatic knowledge
and information on best practices for the prevention and treatment
of NIT/, B and malaria. In addition, global and regional partnerships
(eg, STB and Roll Back Malaria Partnerships) have been established
to allow for the participation of all stakeholders, including
academia and civil society, in the sharing of information and
development of global policies and strategies.
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?
17. What intergovernmental planning has been
undertaken to cope with the impact of an outbreak of infectious
disease caused by deliberate release of micro-organisms into the
environment? Is there adequate liaison between the various agencies
involved, including intelligence, law enforcement and health care
professionals? How could action by intergovernmental bodies help
further?
18. Though our remit is focused specifically
on known infectious diseases, we would be interested to know how
you view the global threat from new or previously unrecognized
ones and from the transmission of infections from animals to humans.
19. What resources (subscriptions, staff,
training, medicines etc) does the UK Government commit to intergovernmental
bodies to help in the fight against the four diseases listed?
Concerning the Global Fund the UK has regularly
and substantially increased its financial support over the years.
The UK is currently the second largest donor to the Global Fund,
taking into account cumulative pledges and contributions made
since 2002. To date, the UK has contributed an amount of USD 668.6
million to the Global Fund. For the next replenishment period
2008-2010, the UK pledge is GBP 360 million. In line with its
approach to multi-year funding, the UK has also pledged up to
GBP 640 million for the Global Fund over the five years from 2011
to 2015, conditional to evidence of demand, performance and impact.
20. Do you wish to provide any other relevant
information in addition to what you have said in answer to the
above?
February 2008
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