Select Committee on International Development Minutes of Evidence

Examination of Witnesses (Questions 220 - 233)



  220. Who is doing that research? Are the baby formula manufacturing companies involved?
  (Mr Stirling) I am sure that they are also doing some of this research. The stuff that we have been more aware, which is coming through UN/AIDS, is being done by professionals working within settings which are implementing, for example, programmes of mother to child transmission. A number of research groups in South Africa are not being supported by these companies. They are independent researchers who are concerned about the impact of HIV on children.

Ann Clwyd

  221. Can you tell us how the partnership between the Government and NGOs works? Who has responsibility for that? Are there clearly defined responsibilities or is it a muddled area?
  (Ms Bellamy) I think this differs from country to country.
  (Mr Stirling) The issue is that it does differ very much from country to country. In some countries, there is a reluctance and even a resistance within government to working with non-governmental organisations, which means that in national strategic plans there is little mention of the role of civil society or non-governmental organisations. In others which are more successful—I think that probably includes Uganda and Zambia—the seeds are being sown in Mozambique, certainly in South Africa and there has been a very strong role of non-governmental organisations defined in planning documents, an appreciation that NGOs do have the opportunities of making contact with people outside of government sectors, reaching communities, being in touch with youth organisations or particular groups who might be extremely vulnerable to HIV infection, who have contacts with child prostitutes, street children and domestic workers, so that they have that capacity of contact. Those more enlightened governments in response to HIV have embraced NGOs as a part of the national strategy.

  222. Can you tell me what progress UNICEF has made in voluntary HIV testing and counselling for pregnant women, particularly in the most severely affected parts of sub-Saharan Africa?
  (Mr Stirling) I personally feel that this is probably the critical constraint to address, increasing people's understanding of their own status and the ability to deal with it. Our appreciation of the importance of counselling and testing is relatively short. Much of the evidence has really only surfaced within the last two to three years of how powerful a tool it is. Progress has been painfully slow. In my experience in a number of countries, there has been resistance to moving rapidly with counselling and testing, basically saying the costs are high and we cannot afford those additional costs. It is not sustainable. We do not have the capacity to invest in counselling. It is time consuming and too labour intensive. In the Gaborone meeting that I was referring to, this was seen to be one of the critical constraints which needs to be addressed, not only on mother to child transmission but also in expanding work amongst young people. Within that, a number of recommendations were made on improving use of rapid tests which are low cost, about $1.20 for a rapid test with high specificity. Secondly, trying to find different ways of providing counselling and support to people who are going through the process of testing without necessarily involving a health professional all the time because these people are so scarce. Progress has been strong in some countries. Uganda has made good progress. There was some good progress in Zambia for a while. It came unstuck but I think it is back on track. In South Africa, it is expanding but across all countries it is not being done to scale and being sustained at a level required to have the effect which it can potentially have.
  (Ms Bellamy) First and foremost, our agency is there in partnership with the governments. As you might expect, those governments where there is less movement, where the leadership has not responded, where it has been reluctant to engage with NGOs, it has taken longer, which is why our effort is both at focusing very specifically on prevention and mobilisation. To get our programmes directly front and centre focused on these issues, we have to help move the governments along and that is why in some cases it has been slower. We all wish it had moved a little faster.
  (Mr Stirling) What are the triggers that can make a difference in responding to the epidemic? Goals and targets are important. We have been suggesting that this be a target and that there be strong lobbying at national, regional and international level to have a target on expanding access to voluntary counselling and testing, particularly for young people.


  223. Are AZT and nevirapine or other drugs currently available to pregnant women and mothers in the worst affected sub-Saharan countries?
  (Mr Stirling) No. People who have access to cocktail therapies are generally rich people who are gaining those services through private providers, normally outside of government services and regulations at the moment. Many people in many countries are going to private clinics or even going out of their countries to get treatment of their HIV infection. The purpose of this MTCT work is precisely to expand access to anti retroviral treatment for the prevention of vertical transmission. The purpose of those 12 projects is to see what needs to be done to achieve that.
  (Ms Bellamy) We have entered into an agreement with Glaxo Wellcome and they are providing AZT for these pilot projects. In that instance, it is available on a limited basis but it is not available to the general public. You also mentioned nevirapine. There has been one study done in Uganda with very positive results but it is only one study and we are still looking to our colleague agency, WHO, to give more of a go ahead to see if there is a way for this to be more widely distributed.

  224. Has an estimate been made of the total cost of providing nevirapine to HIV positive mothers and their infants in sub-Saharan Africa, both the direct cost of the drug and the associated cost of the necessary health service provision, or is it too early?
  (Mr Stirling) There has been some work done by UN/AIDS and by UNICEF in the context of this pilot project to get those costs. The costs as they now stand for nevirapine are about $4, the price of one pint of beer, for the management of one case, which is a dose for the mother in labour and immediately afterwards for the child. We know the basic figures through those estimates. The challenge at the moment is looking at what needs to be done to scale up the use of these drugs. Here, the critical constraint is testing and improving women's access to HIV testing.
  (Ms Bellamy) Let me give you a contrast. The AZT regimen cost is estimated at about $50, whereas it is $4 to $5 for nevirapine. It is still too high, but we are getting closer.

  225. This is what I was trying to assess, whether it is capable of being accommodated in the normal health budgets of these countries, because their health budgets per capita are pretty small anyway, are they not?
  (Mr Stirling) We are doing some work at the moment in Mozambique looking into the costs of these therapies, tests and drugs for averting HIV against the opportunity costs. If we do not avert it, how much will it cost us to manage a sickly, HIV positive child? I think this is probably a much more useful form of inquiry because the costs in human terms are obviously huge but the economic costs are many, many times more.

  226. It is still a considerable increase in cost, is it not, as a percentage of the health budgets?
  (Mr Stirling) We need to do both.

  227. Is it a 50 per cent increase in health provision?
  (Mr Stirling) It will depend on the country. In a place like Mozambique, the per capita health expenditure is only about $10. The cost here of managing one case would probably be about $6-$7.

  228. Even this provision is quite considerable.
  (Mr Stirling) That is the public expenditure. The private expenditure which that family is going through in the management of that sickly child will be many times more.

  229. What other interventions, other than drugs and infant formula, have been shown to reduce the risk of mother to child transmission?
  (Mr Stirling) There are a number of things. Any actions which improve the health and nutritional status of women in pregnancy, particularly their micronutrient status—certainly there has been a strong correlation seen between transmission risk and vitamin A status. This is important. Similarly, there have been strong correlations between the levels of anaemia amongst pregnant women. Issues like malaria are important, and the rollback malaria programme is important in this context of providing for safe motherhood and reducing HIV transmission risk. During delivery, to reduce the mixing of bloods, to reduce physiotomies, for example. There are a number of things which can be done which, in small fashions, can reduce the transmission risk. However, the bottom line is that significant reduction will take place through the use of anti retrovirals.
  (Ms Bellamy) It is very important to prevention of HIV/AIDS that young women be empowered through education. Their ability to make choices about their lives plays a role here.
  (Mr Stirling) Primary prevention is the first thing, to prevent it in the first place so that mum does not have it.

Ms Kingham

  230. In your written evidence you state, "UNICEF estimates that an additional US$2-4 billion per year for 10-15 years will be needed to control the epidemic. Much of these resources will come from within affected countries. However, as HIV/AIDS is a global problem, its response demands global action." How much is UNICEF now spending on HIV/AIDS related work? UNICEF states that you are considering the reallocation of funds from other aspects of its programmes. Which programmes would lose out?
  (Ms Bellamy) I cannot give you an exact figure. I always find these questions very difficult to respond to. I could add up the amount of money we are spending very specifically on HIV/AIDS[2]. We have now added staff very specifically in the HIV/AIDS area but that does not take into account the Mozambique country programme, which is now trying to build in HIV/AIDS on a more horizontal level rather than just a vertical intervention. There has been a dramatic increase in the resources that we are allocating to activities that impact on both mobilisation and prevention of HIV/AIDS in the last couple of years.

  231. If you are thinking of reallocating funds from other aspects of programmes, presumably you have budget lines that you work to either within country programmes or thematically across your activities. If you are considering reallocation of funding, you must have an idea of roughly how much that reallocation will be and what percentage of your budget in approximate terms it makes up. I am sorry to come back on it, but I find that a bit surprising considering that, when we have received direct mailshots from UNICEF or appeals, they usually state very clearly how much has been spent on—
  (Ms Bellamy) We can say what it costs to immunise a child and what the cost of a Vitamin A capsule is. We can say what a particular project, let us say in Zambia, is going to focus on. Let us say moving ahead youth friendly services. We could put a price tag on that but the way we are trying to approach HIV/AIDS is not to have separate immunisation programme, the girls' education programme and the HIV/AIDS programme, but to try and have it somewhat more horizontally. The region that is the most focused on it and that has done the calculation about the kinds of resources they think are necessary is eastern and southern Africa.
  (Mr Stirling) Within eastern and southern Africa, there have been a number of decisions taken to ensure that every programme opportunity, mid-term reviews, annual reviews, the preparation of new country programmes, is an opportunity to make sure that we triple check how we are doing everything which we could possibly be doing to respond to the priority of HIV. That is translating more specifically on those five priority areas which Carol went through. This does not mean that other things we are doing are not important in the context of AIDS. They are even more important. In the societies and communities which are affected by HIV, it is even more important to make sure that you have access to good immunisation services; you deal with diarrhoea; the management of common illnesses, dealing with access and quality of water supply, ensuring that girls get into school and stay there. These are the priorities of our regular, normal programmes. They need to be reinforced, quality improved and adjusted in many ways to be more HIV sensitive. That is the principal focus of our programming exercises. Many countries within the region have gone through expanded reprogramming for HIV. In the case of Mozambique, over the last couple of years, we have gone from three years ago a budget dedicated to those five core areas of $100,000 to, this year, being close to $4 million. Next year, we have a target of trying to be $6 million. We are trying to mobilise additional resources for that. Part of that strategy is this resource mobilisation programming exercise going on now within eastern and southern Africa, where we seek to raise an extra 250 million to support action on HIV within the region. The issue at the moment is to seek additional funds, not to take away from other important programmes.

  232. It is not reallocation?
  (Mr Stirling) At the moment, the strategy is more and the climate seems to be supportive of more on HIV.
  (Ms Bellamy) Particularly in eastern, western and central Africa, we have added very specific staff on HIV/AIDS. We have added a senior adviser at headquarters on HIV/AIDS. We have seconded some people from UNICEF to UN/AIDS itself. The board of UNICEF gives the executive director a modest flexibility of something over seven per cent set aside. I used it this year for HIV/AIDS and polio. We are getting close to wiping out polio and that is a high priority.

Mr Khabra

  233. By the end of 1999, there were approximately 11.2 million children who lost one or both parents to HIV/AIDS. In many cases, a remaining parent is found to be quite ill and dependent on the child for assistance. Before AIDS, about two per cent of all children in developing countries were orphans. By 1997, the figure had jumped to seven per cent in many African countries. In some countries, the figure ran as high as 11 per cent. What is being done to ensure that orphans and children in distress are being cared for within communities? What is being done to remove stigma from children related to those with HIV or who are living with HIV themselves? What issues are emerging in terms of the legal and human rights of children affected by HIV/AIDS?
  (Ms Bellamy) The numbers are growing, as we indicated before. The traditional coping mechanism, which was the extended family, is being stretched beyond capacity now. You are increasingly finding grandmothers who are taking care of nine, ten or eleven kids. You are now having an increasing number of child headed households. You cannot put a little spot on a child's head and say, "You are an AIDS orphan" and, "You are a war orphan" and, "You are a different kind of orphan." We are approaching the issue of orphans more generally. There are some things that you have to deal with specifically. I said in my opening remarks that many of these AIDS orphan then become outcasts in their own communities because it is assumed that they are infected themselves, or for some other reason. One does have to give some specific attention there, but we are looking to try and provide, very often with NGOs, some kind of supportive activities in communities so that children can be reintegrated into their community and also so that they can become full participants in education or some kind of training.
  (Mr Stirling) It is a pity the question is towards the end of this session because this is probably one of the greatest challenge areas which we are confronted with. The problem is not here yet; it is still another five or ten years down the track, when this population of orphans is going to be doubled and may be even higher than that. What is taking place? Many UNICEF programmes are working with governments, particularly with non-governmental organisations, on strategies to strengthen family and community capacities, to identify and to care for families and children in distress. There is a role for orphanages, for improving services, health education, but the critical solution to this is that the only capacity upon which we can rely in the long term is at the level of family and community, so it is trying to strengthen those capacities. What does that mean? It means providing families with more information and education on children and child care, strengthening community leaders' capacities to identify kids in need. Some of the work which we are doing in Mozambique is trying to mobilise people around some basic principles. All children must be healthy and well nourished. All kids must be in school and education. All kids should be clothed and living in safe shelter. All kids must have the right to participate in the decisions affecting their future and all kids must live under the protection and care of an adult. For example, that is what we are doing. Part of the community capacity building is to discuss with communities and support and facilitate processes there so that they can check: are our kids healthy? If not, why not? What are the threats to children? Which kids are not healthy? What can we do about it? Are our kids in school? If they are not in school, which kids are not in school? What can we do about it? As much as possible, we try and stimulate those kinds of processes at the community level and then to link supports for the responses to non-governmental organisations who might have additional resources for micro credit or education or to link up with services to do deals with local teachers and headmasters to try and change their hours or make adjustments; to try and strengthen capacities of coming up with local solutions to these problems. It is the greatest problem area and the greatest challenge area we have, largely because HIV is impoverishing the same families which are wanting to strengthen their capacities to care.

  Chairman: Thank you very much indeed. There is a lot more we would like to discuss with you but time will not permit it. We would like to thank you very much indeed for deepening our understanding of this extraordinarily difficult disease and the whole question of the total approach to the family and the child and the mother and what is required. Let us hope that together we can make an impact on it. Thank you very much indeed.

2   Note by witness: However, this would not represent the total UNICEF is devoting to this disease. Back

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