Select Committee on International Development Minutes of Evidence

Examination of Witnesses (Questions 400 - 412)



  400. We will have to explore that further but what I would now like to ask is whether you can direct us to any work which is being done. We are talking in most cases about very poor countries, very poor people and health systems. Has any kind of cost benefit analysis been done to say, "You have X million rand to spend on health care, what should you spend it on in terms of coping with the general health needs of the country or the HIV specific aspects of it"? For example, it might be suggested that simply providing clean water for the whole population might be more effective than a lot of expensive medical interventions. Has that kind of analysis been done on what is the most effective way of dealing with health care needs with a limited budget?
  (Mr Cochrane) The WHO and the World Bank have addressed exactly these issues and their conclusions are fairly broad indeed. Obviously, prevention is the thing that should be done because that is cost effective in the longer-term, but that does not help you to deal with the problems you have today; that will help tomorrow's problem. Their broad conclusion is that you cannot just spend your money on one particular thing, you have to have a multi-faceted approach which will deal with all of the various issues along the line.
  (Mr Walker) I think the phrase which is generally used now is that we need to think about today, tomorrow and the day after. In terms of where it is most cost effective to spend limited resources, certainly boosting primary care infrastructure in countries is important—access to clean water, as you said, but also access to a whole continuum of care for people with HIV—so access to drugs which are often much cheaper and simpler to administer to prevent opportunistic infections which are often the cause of death in people with HIV. That is often a cheaper way and often adds several years to people's lives. If you look at how the mortality rates in this country were affected, we began to see a decline in the mortality rate before the full availability of combination therapies in this country, partly because we had better management of opportunistic infections and things that generally were killing people with compromised immune systems. So there are those opportunities. There are also opportunities in areas like pain management and palliative care, so there is a continuum of care. But a lot of those things are really just going to buy you some time. One of the problems which was pointed out earlier on is that you get an initial HIV curve, which is then followed by an AIDS curve, and then if you want to think ahead of that it is followed by the orphan curve. So there are these huge surges in demand on health systems, education systems, in countries which are spread out over a period of time with HIV. So we do need to be thinking immediately about today, tomorrow and the day after, about where we can fit things into that way of thinking and that strategy of thinking, and looking at who can provide what and what the roles are of different players, whether that be state players or private sector or multilaterals, in providing the components of that longer term strategy.

  401. Perhaps this can be done in writing, but can you draw our attention to where costings have been done? Even given the preferential price for the retrovirals, what calculations have been done about how much would have to be added to what levels of care?
  (Mr Walker) I can certainly investigate that for the Committee and forward something.

  Mr Robathan: We will come on as briefly as possible to what is your specialist subject, Mr Walker, namely vaccines. I think we would all agree that the best answer obviously would be a vaccine in the long term.

  Chairman: And the next answer is the condom.

Mr Robathan

  402. The long-term answer is to vaccinate everybody but there are long-term problems with that. What is the current state of research into the development of a vaccine and how long do most people currently estimate it will take for a vaccine to come to the market?
  (Mr Walker) It is certainly better than it was. For many years vaccine research was really only a poor cousin in this area. The research which was done was generally focused on the strains of vaccine which are most prevalent in the United States and in Europe—Clade B. Only recently, again partly through the activities of IAVI, there has been a recognition that we need to start finding vaccine solutions and funding research which is going to be useful for the majority world, so that is looking at the types of virus which are prevalent in Asia and Africa. IAVI's focus has been, as I said, to fund some of that basic research itself but also to stimulate others to—

  403. What is the current state of research?
  (Mr Walker) In terms of IAVI, it has now announced four vaccine development partnerships, and those partnerships, as I have said, are built between institutions, the private sector or academic institutions in the north, paired with institutions in the south. So the most advanced one would be the partnership between Oxford University and Nairobi University which is developing a vaccine which will go to phase one trials in humans first in Oxford in August and secondly a sister trial in Nairobi in December or January of next year. Phase one is basically a safety test which is undertaken in small numbers of human volunteers. This is built on promising results in animals and promising results in other tests which suggest that the Oxford model may be one of the better candidates for a future vaccine. IAVI has also recently announced three other partnerships, one with South Africa, one with Uganda and also another partnership which uses the Oxford technology but a different mode of delivery, an oral mode of delivery, which will be with a country in East Africa. The whole point of the IAVI process, I suppose, is to make sure that we do things in parallel, not in series, that we do not try one idea, wait for that to fail, try another idea, wait for that to fail, and so extend the time in which it is going to get a solution.

  404. So we have stage one tests to find out if they are safe for one particular vaccine, but what is the timescale? If this were to work, if this were not to kill anybody, what is the timescale?
  (Mr Walker) Realistically we are looking at a timescale of at least seven to ten years. There is one phase three trial in operation and phase three trials are the large scale efficacy trials which take place to see the protective impact of a vaccine at a population level, and that is taking place in Thailand at the moment, which is run by VaxGen. Unfortunately, scientific opinion seems to think that it is unlikely that that product is going to be particularly protective. In terms of moving through the new products which IAVI and other institutions are working on, I mentioned the National Institute of Health's work which they have just announced, what is really important is that we can get those on line, but then we have an effective way of deciding what moves on to the second and third phase trials, because those are incredibly expensive, they are much, much more expensive. As I have said, the phase one trial takes one to two years to completely finish, phase two trials again the same period, but a phase three trial of 4 to 5,000 people is probably going to take three to four years to see what the results will be. But, crucially, the preparation for that kind of trial has to happen now. You have to work with the community to build its readiness for that type of trial now.

  405. Are Glaxo Wellcome involved in vaccine research?
  (Mr Cochrane) In a very small amount. SmithKline Beecham are in a huge way.

  406. So when you come together you will be very much involved?
  (Mr Cochrane) When we come together we will be very much more involved, yes.

  407. And your estimate of timescale?
  (Mr Cochrane) Is the same. A minimum of five years, and seven to ten more likely.

  408. It might be ten years onwards?
  (Mr Cochrane) Yes, ten years from now.

  409. You mentioned earlier, Mr Walker—and indeed in your written evidence—that a perceived lack of market was one reason why there was not research into a vaccine. I have to say I reckon the development of a vaccine by someone will not only make them a fortune but also probably a Nobel prize and knighthood and whatever else they might want—some people might think these are just baubles—why do you perceive there is a lack of a market for a vaccine?
  (Mr Walker) If you look at the lack of private sector interest in vaccine development over some time, it would suggest they have not thought a vaccine was something from which they would be able to recoup the kind of profits they would deem reasonable for that kind of research. I think the problem is, if you produce a vaccine which is going to be useful to the majority world, there is going to be a huge demand for that vaccine, but obviously demand is only a demand in the market sense if it can be paid for. At the moment, even if you had vaccines which were very cheap, one or two dollars as the actual cost, you would then have to have the delivery and infrastructure to be able to provide that, which means there is quite a large cost for developing countries to deliver vaccines. If, in the calculations in the private sector, that means they do not think people are going to be able to take up and use those vaccines, that means they are not going to develop a vaccine because they would be left with something which potentially makes a loss. The way forward is not to then say that you cannot develop a vaccine market, and one of the things IAVI has done is to work on a pull mechanism which basically works with the World Bank, the European Union and other multi-lateral funders, to suggest that if a vaccine does become available they will consider guaranteeing to purchase that vaccine. They will consider guaranteeing that there will be a market for the private sector to be able to provide that vaccine.[5]

  410. Let us bring in the private sector because I think they might disagree with you slightly.
  (Mr Cochrane) I do. It is a hugely complex area. If there was a simple solution to this, it would have been found; it is not an easy business and it is technically and scientifically extremely difficult to find a vaccine which will be effective against HIV. There is certainly a market for a vaccine for HIV in the first world—there are a million people in the United States who are HIV-positive, there is a huge market if this product were available, so I certainly would not say there was a lack of market. There is a tremendous market and I am sure you are right in saying there will be a tremendous incentive for companies to be finding a vaccine for this difficult area. One of the joys of HIV—"joys" is the wrong word to use—one of the good things about HIV is that it affects America, Europe, Australia as well as sub-Saharan Africa, in different degrees I know. It is still a big, big issue in the United States, a million people infected, over half a million people infected in Europe, and it is a tremendous problem in those geographies.

  411. Do you know whether or not the smallpox vaccine produced royalties forever for whoever developed it, because I suspect who developed it must have made a fortune although I do not know.
  (Mr Cochrane) I do not know.
  (Mr Walker) If I could just reinforce the point about the different clades of viruses across the world, the clade of virus in Europe and America is the Clade B virus, in Africa it is Clades C and A, and in Asia it is Clade E. We do not know at the moment whether a vaccine which is effective against B is going to be as effective against A, C and E. As I have said, the research that has been done—and it is correct to say there would be a market in the North—has been around Clade B.
  (Mr Cochrane) But we still have not found it, so it is not an easy area, in fact it is a really difficult area.
  (Mr Walker) I would also like to emphasise that IAVI's approach is not antagonistic to the private sector, it is just that we need to find ways of working with the private sector to ensure a market, to utilise the private sector's expertise. Certainly when we move into manufacturing and producing a vaccine, large companies such as Glaxo or Glaxo SmithKline or Merck or Aventis Pasteur, are going to be absolutely necessary in bringing to bear their expertise in producing vaccines.


  412. It obviously requires a combination, does it not, of public sector money through the World Bank and other government and intergovernmental agencies, together with the pharmaceutical companies making available these drugs and vaccines at a lower price, together with organisations of medical health provision overseas and particularly in the developing countries themselves, together with normal health provision which of course deals with the opportunistic diseases to which HIV sufferers are prone? Are there any other things you would like to mention, Mr Cochrane and Mr Walker in conclusion because we really do have to conclude now?
  (Mr Cochrane) I appreciate that but there is one point I would like to emphasise, and it fits in with what you have just said, Mr Chairman, which is the huge importance of the British Government and the support they can give as a partner in this process of treating today's people who are infected with HIV. It is very, very important that the British Government, either directly through DFID or indirectly through the World Bank, through the European Commission, plays its part in helping to be a very active partner in ensuring we can now with private enterprise from Glaxo Wellcome and the other companies, together with committed governments in sub-Saharan Africa, play an equal part in ensuring more is done than has been done to date.

  Chairman: Yes, I am sure that is right. I think that is a good note to end on. Thank you both very much indeed, and particularly you, Mr Cochrane, who have done the whole of the session with us.

5   Note by witness: AVI has worked with multi-lateral funders-such as the World Bank and the European Union-to raise the issue of `market failure'. IAVI has proposed the development of purchase guarantees (`pull-mechanisms') for future vaccines. These may take the form of credit lines for countries to purchase vaccines or grants for vaccination programmes. The World Bank and the EU have recognised such purchase guarantees as essential to ensure future access to HIV vaccines and hence as critical to stimulating HIV vaccine research and development by the private sector today. The Global Alliance for Vaccines and Immunisation (GAVI) has been awarded a $750m grant by the Bill and Melinda Gates Foundation to increase access to vaccination for children in the world's poorest countries. The Norwegian Government has recently donated $125 to GAVI. Back

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