Select Committee on International Development Minutes of Evidence

Examination of Witnesses (Questions 463 - 479)




  463. Dr Piot and Dr Cleves, thank you very much for coming. We know you have been en route from various places. I do not know whether this is a stop-off from somewhere else, but you have been very busy. As you know, we are doing an inquiry on HIV/AIDS and we went to Southern Africa earlier in the year and took evidence on the ground and we have been taking evidence at several sessions since then. We are very grateful to you for coming to assist us further in what I think will probably be one of the last evidence sessions we will be taking. Do you have an opening statement or shall we go straight into our questions?

  (Dr Piot) Thank you very much. If I may say just a few words. My colleague is Dr Julia Cleves who is the Chief of the Office of the Executive Director in the UNAIDS Secretariat. We have both come from the international conference on AIDS in Durban last week, which received quite some media coverage all over the world. I arrived this morning from New York where yesterday we had a second debate on AIDS in the Security Council and for the first time a Resolution was passed on AIDS, focusing on what the Security Council is supposed to do, and that is dealing with conflict, but also based on the fact that AIDS is being considered as more than a health problem and more than a development problem but as an issue of human security. I thought it was worthwhile to share with you the Resolution because it is really coming hot from the press. I would like to make three very small points to illustrate what UNAIDS is about. First, there is this Security Council debate and the Durban Conference, which are illustrations of our advocacy and political mobilisation role. Secondly, we have a major role in terms of facilitation and co-ordination, which seems all very boring but in the end you can put in motion bigger entities, and that is what our business is about—for example, negotiating a lower public sector price for the female condom, discussing with pharmaceutical companies how the price of certain HIV drugs can come down. That has been one of our major activities over the last months. Another example of our brokerage role is in countries where what we are trying to do is mobilise resources, not for us but for the country. In April we were very successful in Malawi in the Round Table where over $100 million was mobilised in two days to support a plan that we had been developing with civil society and government in Malawi. A third element of our role is knowledge creation and dissemination of best practice, monitoring of the epidemic and evaluation. I think the report that you all received is an example of that. It is not just what is in there but also the database behind it. We become a clearing house for everything that is going on in AIDS in the world and the response to that. I will just give you these facts because I think it illustrates what our three major roles are—advocacy, facilitation, and knowledge—and it also illustrates that AIDS is now very high on the agenda of all the organisations that make up UNAIDS. I think that has been, for me, a major achievement and not an easy one because dealing with this epidemic is as much as about institutional behaviour change as about behaviour change of individuals. I would like to stop there. I am very happy to be here.

  464. Thank you very much. Dr Cleves, do you want to say anything at this point.
  (Dr Cleves) Not at this point.

  465. What are the main achievements of UNAIDS to date? What would you point to?
  (Dr Piot) I think that they can be categorised along three main lines, the three main roles that we feel are for us as a Secretariat. Before answering the question I would like to emphasise that we are a co-sponsored programme. UNAIDS is not a separate agency within the UN system. We are in a sense part of a movement that we preceded, the movement of UN reform, working more efficiently and more effectively in the UN system and that is one of the reasons that we were created. When we talk about the achievements of UNAIDS we can look at the bigger UNAIDS organisation with the seven co-sponsors, from the World Bank to UNICEF and WHO and so on. As to the UNAIDS Secretariat, if we compare the situation today with what the situation with AIDS was four and a half years ago, we are four and a half years old so we are still if not a baby certainly a child. On the political front I think we have made a really major contribution. I had two major objectives when I got into this job. The first one was to bring AIDS onto the political agenda in the affected countries and the second one was in the north making sure that this remains a global issue. Five years ago what was happening was that in the north the feeling was that AIDS was over, we had not seen a major heterosexual explosion, treatment was becoming available and therefore the problem was fixed. The danger then was that AIDS would turn into another malaria, a disease in the south for the poor so that here in the West we do not have to care about it. That was my first objective and we can come back to that at some other point. My second objective was to put AIDS at the top of the institutional agenda in the UN system. We have spent a lot of time on both. This achievement in terms of political mobilisation of course is not something that UNAIDS has done on its own. What we tried to do was forge partnerships. When you are very small—and let us not forget as a Secretariat we are about 200 staff and the majority of them are based in developing countries and some in Eastern Europe, and we do not have money, we do not have the Fifth Fleet that we can send somewhere—you need to use knowledge and you need to use political strategies for that. The strategy that we are using in management terms is what I call the "judo" strategy. You have sumo wrestling and judo. In sumo wrestling you use your weight to put someone on the floor. We cannot do that, we are too small. With judo you use the weight of your opponent to make your opponent move in the direction you want them to move, and we are flexible and mobile. The idea is to put AIDS on the agenda where it is not there yet. That goes from the women's movement to ministers of finance to the World Bank, UNICEF and their constituencies and then personal advocacy showing, particularly to women in Africa and Asia, that AIDS is more than a health problem, that it is actually undermining their achievements in terms of social and economic development and is threatening the very fabric of society. So we started collecting evidence for that. It may be a big surprise but it is only slightly over two years ago that for the very first time we were able to collect and analyse data on what AIDS means in every single country in the world, with a few exceptions like North Korea and so on. That was the first time. It is very hard work. And also what kind of resources are going into a response to the AIDS epidemic. I would say overall this has been our major achievement when you look at what has happened over the last 12 months. For me it starts with what was a breakthrough of a presentation and a nearly day long debate with all the ministers of finance of Africa. They had their annual meeting in Addis Ababa in April. AIDS was there on the programme between debt relief and the strategic plan for the Economic Commission of Africa so it was not at the end like "any other business". For the first time ministers of finance were challenged and went home and some of them spoke about that with their colleagues. Secondly, several African heads of state started speaking up, as did the UN theme groups on HIV/AIDS, which bring together the representatives of various agencies making up UNAIDS as well as bilateral donors and which, have turned out to be very powerful advocacy instruments. This is the added value of speaking with one voice. I have seen it myself when I was accompanied by a full theme group on HIV/AIDS and we were meeting with the Prime Minister in a country in Africa, who said, "If you all come to see me together, this must be serious". It sounds a bit ridiculous but that is the power of doing these things together. There was a meeting called by the UN Secretary-General in December which was like a kick-off of the International Partnership Against AIDS in Africa where we have been trying to bring in civil society, NGOs and the private sector into a single endeavour. The Security Council debate on AIDS in Africa in January was an extremely powerful advocacy instrument and since then it has accelerated. At its meeting in Washington in April the Development Committee of the World Bank and IMF also had AIDS as the number one item on the agenda. Reaching out to another audience is the World Education Forum. I was also at the South Summit of the G 77 in Havana and AIDS, again, was on the agenda. On principle I try not to go to AIDS meetings where everyone is convinced this is a problem, but to those where the message has not reached them yet. There are now results in terms of more resources, and these are going up. The goal is also that AIDS should now be at the heart of the development agenda in development agencies. That is also happening in DFID. It is also happening in similar agencies as well. Secondly, I would say that in terms of co-ordination and facilitation the UN speaks with one voice when it comes to AIDS. That makes perfect sense. I can guarantee you that was absolutely not the case before we were created. Sometimes more energy was spent on fighting among colleagues on what was right and what was wrong rather than actually doing something about the problem. That is finished, both at the country level and globally. We have reached the stage now where we represent each other. Carol Bellamy from UNICEF also represented the UNDP when she was speaking in Durban. These are small things but they are the symptoms of something deeper that is happening. Thirdly, what we have achieved is bringing together the core of evidence of what works and what does not work. After twenty years with this epidemic we now have a pretty good idea of what is effective, where to put our resources and what has worked in countries that have been able to turn the tide and bring down the number of new infections. What we are doing is bringing that together in a best practice collection. It is not an academic exercise, but based on and written by people who have done work on community projects. It is then shared with others. We are also working on a new global strategy which will take into account the fact that we need a multi-sectoral response. The fourth achievement is that in many countries we have been able to go beyond the health sector, the ministries of health, although we still have a lot of work to do. What I have seen is that as long as we continue to treat AIDS only as a medical issue there is no way we can win this fight. When it comes to government departments we need to go and make sure that the Education Department is involved, the legal system, and so on. That met with a lot of resistance in many countries. As I say, we are not there yet. When you look at the number of countries that now have a National AIDS Commission, reporting either directly to the president, the vice president or the prime minister, that is certainly a result of our work. Tracking the epidemic has also been something that has now been put in place. We will continue to deliver. Sometimes people do not like us because we bring a bad message, sad news, but the facts are the facts. Lastly, we have been able to broker a number of deals. It was certainly never in the spirit and minds of our founding parents that we would be brokering a lower price for the female condom or that we would get MTV on board. MTV now produces messages on air time, which is worth more than we could ever afford. We sit down and we say, "This is the message for this year", and they translate this into a message for all of their stations. The fact that we are now into discussions and brokering arrangements with the pharmaceutical companies is also very significant, however without becoming a supplier of drugs, as that would kill us.

  Ann Clwyd: We will get on to that later. Andrew Rowe.

Mr Rowe

  466. My question follows quite neatly on from what you just said. It seems to me that a lot of your concentration is, naturally, on preventing the development of new cases. To what extent have you felt you have been successful in improving the life of those who are diagnosed as HIV-positive? Has there ever been an international conference of those who are HIV-positive?
  (Dr Piot) That is a very important question. Until recently the international community and AIDS programmes, and so on, were focusing entirely and exclusively on prevention. Prevention remains a priority. The fact you have prevention means you have less people to provide care for. We have thirty-five million infected individuals in the world. In Africa alone there are twenty-five million people with HIV without access to even basic care, and that creates not only a humanitarian problem but totally undermines the credibility of prevention programmes. What we have learned is that one needs a comprehensive approach. You cannot deal with prevention without care. Let me give you a few examples. We have learned that access to voluntary counselling and testing, knowing whether you are infected or not, is a very powerful tool for prevention. Either you start to reorganise your life because you are HIV-positive or you know that you are HIV-negative and you can really focus now and keep it that way. What is the incentive when there is no care at the end of the bad news? What is the incentive if there is a stigma, losing your job, and so on, at the end of the test? That is one of the reasons that we feel that one needs to offer some care to those who are infected. The same thing is true, by the way, for offering prevention of mother-to-child transmission. Besides the fact we can save the baby we also offer incentives for testing and counselling. We also provide hope. It is something that I feel strongly about. I believe that in any social movement, in any scientific discovery, the hope factor is extremely important. That is what we try to introduce with this care. What have we done? What has been done? Not much has been done. We have to be very clear about that. First, the actual treatment, the so-called antiretroviral therapy, the drugs that treat the HIV infection itself are very new. In our countries they have been on the market for about four or five years. The impact has been spectacular in terms of mortality and better quality of life for those who are infected. In the south we have all been paralysed by the fact that they are very expensive, they are very complicated to give, and in addition AIDS has come at a time when the health infrastructure in many countries has basically collapsed and is much worse off than five years ago, ten years ago, even 20 years ago. So we have got a very bad combination of poor supply of health care and, on the other hand, an increase in demand. So what we have been doing is to follow a plan. Firstly, we are working with countries to establish standards of care. We need to rationalise the agenda because if we do not do that, pure market forces take over. Only the rich who have access to antiretroviral therapy will have access to care, and the poor with HIV will not have access to simple treatments. This is work that is being done country to country and we are starting on it. Secondly, we are working on simpler strategies, simple drugs that can prolong life and improve quality of life, like preventing tuberculosis and preventing some of the brain and lung infections associated with HIV. Thirdly, we have started on quite an adventure which should be very positive in trying to bring the price down of pharmaceutical products by working with the pharmaceutical industry. I think the first concrete result of that is there. Last week the German company Boehringer Ingelheim announced that it would provide free for five years to all developing countries nevaripine for preventing mother-to-child transmission. If you wish, we can give you more information on that because we are working quite a lot on this.
  (Dr Cleves) Just to add one point to that which Peter Piot made. I think in 1997-98, when access to antiretroviral therapy was nowhere near the international agenda, UNAIDS took a very brave step to see whether it was even possible to provide antiretroviral drugs to people by offering them to people in two countries, Côte D'Ivoire and Uganda, as a way of testing the systems and looking at the logistics. Although not very many actual numbers were treated, only 1,000 in each instance, it nonetheless provided enormously important evidence for a subsequent scaling up and was hugely useful for this adventure, as Peter describes it, going forward. We know a little bit more than we would have done if the Secretariat had not been involved in that process.

  467. Would it be a useful thing to do and, if so, have you done it, to have an international conference of those who are HIV-positive? I would have thought to reinforce each other, to talk about what helps them practically would be an enormously powerful tool, but I do not know.
  (Dr Piot) I must say that we are more and more putting people with HIV at the centre of the response. In our work in UNAIDS we have many people who live with HIV, and we are also promoting that in the countries themselves. There are several groups now at national level in nearly all countries, although there are still some exceptions, of people with HIV who are organising that, and I will never forget what a Thai with HIV told me in Chiang Mai about five years ago before we even existed. He gave a speech and there were many politicians there and he said, "If people with HIV would unite into a political party in Thailand, we would be the biggest political party." What he was saying is, "We are going to become a political force," and I think that is what is happening in some countries. Every other year there is an international conference of people living with HIV. The last one was held in Warsaw. It is called GNP+, the Global Network of People with HIV. It attracted about 500 people out of 35 million. Of course, we cannot have 35 million together but it illustrates the difficulty that they are having to find support for that kind of idea and I would say that it is really a crucial area to work with. We are supporting on a regional or national basis networks of people living with HIV. Last year when I was in Ethiopia I went with the President and the Patriarch of the Ethiopian Church to the launch of the first association of people living with HIV called Dawn of Hope where five Ethiopians with HIV came out publicly for the first time. We did the same thing in Namibia and the interesting thing was that that was in the Catholic Cathedral. We are trying to provide some safe space for these people and I think that is one of the roles that the UN also can play. There is a place for supporting the existing organisations so that they can do more. They are always on the verge of collapsing financially.

Mr Worthington

  468. A question that has been bothering me is what percentage of people who are HIV-positive know they are HIV-positive? When you are looking at the developing world, sub-Saharan Africa, there are no testing facilities and, if there are, people do not want to use them because they do not want to hear bad news. How many people are dying never knowing they were HIV-positive? They think they are dying of tuberculosis, and they did, but they were HIV-positive. Have you got a picture of that?
  (Dr Piot) It is a very important question particularly in light of what I mentioned before about prevention, care, testing, and so on. We estimate that it is probably around five per cent of people in the developing world who are infected who know they are HIV-positive. In Africa there is basically only one country where access to testing and counselling is reasonable, and that is Uganda. It is not a coincidence that that was a part of their core strategy from the beginning. Malawi is now also making a major effort and Senegal as well. South Africa has announced that it will start with such a programme and so has Botswana. I think that is the key. As long as the problem is hidden, as long as too few people know that they are infected and even fewer people are known by the others to be infected, than the ideal circumstances exist to continue the enormous denial at the personal level and at the societal and political level, because it is at both levels. That is why we have been really paying far more attention than before in the international community to this issue of access to testing and counselling. You cannot provide care to people with HIV if they do not know they are HIV-positive and if they only find out when they are terminally ill with AIDS. You cannot generate a strong response with people living with HIV/AIDS if you do not have that.

Ann Clwyd

  469. We followed the quite extensive report in the Durban Conference, particularly the opening speech by President Mbeki and the closing speech by ex-President Mandela. What do you feel the achievements of the Conference were overall and what do you think its disappointments were?
  (Dr Piot) I think that for me it was a very different conference from all the other conferences to start with. I have been at all these conferences since 1985 and it is the first time the conference was held in the south, it was the first time in Africa. That was reflected also in the programme of speakers where there were 4,000 African participants and so to me that was very positive. Also when you look at the media coverage in the world, it was enormous. We can say this is nothing new, this has been going on for years but suddenly it hit the media circuit and in a sense the controversy generated by President Mbeki probably helped in generating more interest. When I compare it with the previous conferences, it was far more of a political conference and a conference of people than a scientific conference. There were no scientific breakthroughs as far as I know although there were very important papers presented, for example, on the prevention of mother-to-child transmission which is typically a problem for the developing world because there the main way it is spread is heterosexual. You have over half a million babies born with HIV in Africa. There were a number of things on the scientific front, mother-to-child transmission, secondly, vaccine work which got more attention than before. In the last ten years it had been written off and now there is a renewed interest. I think that is also very positive. Also, the stigma and community responses, which we have been discussing here, that people do not know they are HIV-positive, and the stigma associated with it, were discussed. The overriding theme which dominated the discussions was access to treatment and access to care. In the news that I saw it was narrowed down to one thing, and that was the price of drugs. Of course, the problem is a little bit more complex, to say the least. It is a unique combination. I do not know of any other issue in society today where you get molecular biologists, ministers, people with HIV, activists of all kinds, bureaucrats of all kinds, and so on all together and discussing and, of course, disagreeing. What I feel is in a number of areas we are reaching common ground. I may exaggerate what I am saying now, I feel we are at the beginning of what is a global movement against this epidemic. It is nothing less than such a global movement that will stop it. It is very clear to me we should not count on technology. I deeply, deeply hope that we will have a vaccine, the sooner the better. We are not going to make it with technology, it is with people.

  470. Do you feel there is real commitment amongst Africa's leadership to fight AIDS?
  (Dr Piot) Let us start with awareness. Let us try to define what commitment is. The awareness is now very high. I can see the difference. I have met nearly all heads of state in Africa, it is really the target of most of my travel. Until about a year ago I always had to start by saying, "This is such a problem, it is going to do this to you, your population here are dying and your teachers are dying", and so on. They are asking me today, "What should we do?" The awareness is very high. What to do about it is not very clear. To translate that into budgets, we need an enormous increase in resources for basic prevention, for basic care. A major part of that has to come from the governments of the countries that are affected. If something is about survival or national security that is where the money has to come from. They are struggling with that. Recently we had some very important contact with President Obasanjo. At the OAU Summit at Lomé he called for a summit of African heads of state, especially on AIDS. The OAU Summit in Lomé endorsed the International Partnership against AIDS in Africa, the framework and UNAIDS' work. These are not trivial matters. For us that was very important, however translating that into action is always the challenge. These are some more regional issues. At a national level there are countries where the president has created a National AIDS Council. In Nigeria the President himself chairs the National AIDS Council/Commission, which is a multi-sectoral body. In Malawi it is the vice president who is now spending over half of his time just on AIDS. In Kenya the National AIDS Committee is in the President's office. Uganda has had modest success but for some time the Government's response to AIDS was in limbo. It went to the Ministry of Health, then back to the President and then back to the Ministry of Health. It is now firmly imbedded in the President's office again, with a presidential AIDS adviser and a strong director-general. I can give you even more examples; with Mozambique it is the same thing. All of this happened over the last six to twelve months. What the international community has to do now is to support these efforts, because they are really country-owned. The problem with the response in the 1980s and the 1990s was often that it was felt to be imposed from the outside, that the national ownership was difficult to get. I think that is where the turning point is.
  (Dr Cleves) One of the clearest messages that came out of Durban was that leadership saves lives. In many places we are looking at AIDS as a crisis in governance. This was a headline for the closing session at Durban. I think that the statement by ex-president Mandela also underscored the point that Peter has just made about the start of an international movement against AIDS. To come back to the point that Mr Rowe was making, what is different about these International Conferences on AIDS is precisely the presence of HIV-positive people. There is quite an extraordinary blend of political activism, science and technology, and this whole leadership of governance. That came together very, very forcefully and I do not think anybody who was there will forget that sense of a real start to a global response to the epidemic that came out of Durban.

  471. What would you hope to get out of the Okinawa G8 forthcoming conference as far as AIDS is concerned?
  (Dr Piot) We have the text of Nelson Mandela's speech in Durban, which is really a very powerful one, if the Committee is interested. We can share that with you.[3] The next important step for us is the G8 Summit in Okinawa. AIDS will figure on the agenda in its own right and also as part of a discussion on poverty, together with two other diseases, tuberculosis and malaria. We have been discussing with several members of the G8 the need for the commitment of the richest countries to increase their investments in AIDS in the developing world, for a variety of reasons. There are some specific issues that can be done. What you need to roll back AIDs is people, that is the major, major commodity. The answers can only come from within the communities and it is the people who will do it. The second thing you need is knowledge. Knowledge is an international public good. Thirdly, commodities, tools, from the male or female condom, to drugs to prevent mother-to-child transmission, to treat people and to test people. That often needs to be paid for in hard currency. This is where the international community can come in and must come in. A paper was sent to the G8 members that summarises what the needs are. I would like to ask Julia, who was the author of the paper, to highlight what is in there.

  (Dr Cleves) Picking up where Peter left off, it is now the situation that in a number of African countries there is a shortage of male condoms, which in this day and age and with the epidemic at this stage is quite extraordinary. There is a shortage of basic drugs for palliative care. Many people die in Africa without so much as paracetamol, or calamine lotion for a skin rash. It seems preposterous not to have those basic commodities in place. They do not require sophisticated health systems to deliver them, they can be delivered at community level. One of the things that we have been calling on from the G8 leaders is for commodities security for all countries in sub-Saharan Africa, and no country's response should be hampered by the fact they do not have the basic commodities. The second area is also this whole business of access to drugs for opportunistic infections and, indeed, to antiretroviral therapy. We see that as a leverage to get countries more interested in the overall care agenda. That is one of the areas we have been calling on. Having done quite a lot of work recently on costing an adequate response to the epidemic, at the opening of the Durban Conference UNAIDS—Peter—went on record to call for $3 billion a year for an adequate response to the epidemic in sub-Saharan Africa for basic care and basic treatment. For the first time at this conference a number of calls for significant increases in resources were put to the Plenary and again we very much hope that Okinawa will take very seriously the level of resources needed.

  472. Would you expect debt reduction to be used in HIV/AIDS interventions in some way?
  (Dr Piot) Definitely, and we actually have a small team based in the UNICEF office in Zambia at Osaka that is supporting governments which are interested in including AIDS in their poverty reduction strategy papers. Uganda has done it, it is basically there. Mozambique is in the pipeline, as are Zambia, Tanzania, Burkina Faso, Nigeria and Mauritania. These are the countries where the Government is interested in using the money freed up by debt relief for AIDS activities, and we are just making sure that it is in the papers. We are not doing that on our own. This is of course done with some of our co-sponsors, for example in the World Bank, and, on the other hand, with some of the bilateral donors, in some cases DFID. For us it is a major strategy, not only for the money but to make it an integral part of the core development agenda.

  473. How did you arrive at the figure of $3 billion for basic care and prevention?
  (Dr Cleves) Through a fairly detailed costing exercise that we did with the World Bank, with the London School of Hygiene and Tropical Medicine, with USAID, and a consultancy company in the United Kingdom called Options, which looked at every aspect of the epidemic and looked at the needs and added it up. We have got a very detailed spreadsheet model in order to reach that figure.
  (Dr Piot) It is 1.5 billion yearly for basic prevention which includes youth-focused interventions, interventions focused on sexual behaviour, public sector condom provision, condom social marketing, strengthening services to treat sexually transmitted infections, voluntary counselling and testing, workplace interventions, strengthening blood transfusion services, the prevention of mother-to-child transmission, and mass media and capacity building. There is a whole menu that we have used and we spent a lot of time discussing this with the various institutions that Julia mentioned to make sure that there is some overall figure that is agreed by everybody.

Mr Colman

  474. Before I ask my question can I through you, Dr Piot, thank your staff in Geneva for the hospitality they offered me when I was there for the UN Social Summit. I was particularly pleased to see the way that you had entrenched yourself within the complex of the World Council of Churches and we have had evidence from other people in terms of the importance of the Faith communities in terms of the educative side of dealing with the HIV/AIDS epidemic. I think it is particularly pleasing to see how the UN Social Summit Plus 5 itself took on board (which was not taken on board in Copenhagen) the centrality of dealing with HIV/AIDS, that if you are looking at plans to deal with it you need to eradicate poverty around the world. So thank you to your colleagues for looking after me in the way they did. If I can go on to my questions which are about the linkage between HIV/AIDS and the unsafe injection of drugs. In the evidence you put forward to us in paragraphs 3.5 and 3.6 you draw attention to this. You say in Asia, particularly in India, that HIV infection in the north-east has moved rapidly through networks of men who inject drugs and spread it to their wives. In 3.6 you talk about Central and Eastern Europe where the bulk of new HIV infection is caused by unsafe injection of drugs and occurred in two countries, the Russian Federation and Ukraine. In the UNDP you quote their evidence in paragraph 5.4.28 in terms of "the most direct spread of HIV has come through needles shared by injecting drug users." Is there any estimate of the proportion of those who are HIV-positive who have been infected as a result of unsafe injection of drugs and how do the rates of infection from that compare to rates of infection through unsafe sexual activity?
  (Dr Piot) That is one of the most complicated issues. It is not only estimating what is the proportion of individuals infected through unsafe injecting practices but also what to do about it. We always tend to think that this is a problem for the industrialised world but in developing countries it is there as well. I do not know by heart the figures but it is in our report. I know that, for example, in Eastern Europe the overwhelming majority today of people with HIV have been infected through unclean needles, sharing needles. In many poor provinces and states in India, in North East India, also it is the overwhelming majority. In Thailand it is a growing proportion because they are doing a good job in terms of preventing sexual transmission, but in Bangkok there is still a lot of unsafe injecting going on, with HIV the result. In Southern China, for example, and Eastern and Western China injecting drug use is the main mode of transmission. We can provide the estimate (which is probably the best way to describe it) for that.[4] So that means that we cannot deal with HIV/AIDS, particularly in these areas, without tackling the drug use problem. Here the strategy can only be a package of demand reduction as well as harm reduction and making sure that particularly young people—because in many of these countries you have cited the age of the injectors is extremely low, particularly in Eastern Europe -do not use drugs, even in a climate of no future, of social despair, where society is in transition, where unemployment is high, and so on. In addition, we need to make sure that those who are injecting drugs do it in a safe way. That is why, if the Government allows it, needle exchange programmes are being supported by us because they have been demonstrated in scientific experiments to slow down—that is what we can see - the spread of HIV. But it is only through a very comprehensive approach that we can do it.

  475. Is there an internationally agreed policy on the provision of clean needles?
  (Dr Piot) As far as I know, there is no internationally agreed policy but last year there was a special session of the General Assembly on drugs, and AIDS was part of that. And there is a statement that came out of it which drew attention to the harm-reduction approaches. We are moving in this mine-field, particularly since UNDCP has become a co-sponsor. The UNDCP, until recently, has focussed entirely on demand reduction and supply reduction. It is now also dealing more and more with us in these countries on reducing harm on those who are injecting. There are no standards, because there is absolutely no political consensus internationally. What we are doing is we are trying to learn from positive experiences.
  (Dr Cleves) Just to supplement Peter's point, the countries reporting IDU increased from 115 in 1999 to 121 in 2000. We heard evidence at the Durban Conference that drug use is becoming more of a problem in sub-Saharan Africa; drug use, first of all, and then injecting drug use follows behind. Some evidence on that was presented. That was fairly surprising to some of the people who were there.

Mr Rowe

  476. I was reading that ten per cent of world trade is now in drugs. If it is at that scale, and going to get bigger, should we not be looking to see if we cannot deliver drugs in a less damaging way? Injecting oneself is an unattractive thing to do, speaking as an ex-asthma sufferer. Presumably you could remove a lot of the potential damage of HIV/AIDS if you could actually make the ingestion of drugs as attractive to drug users by some other method?
  (Dr Piot) That is true. That is one of the reasons—like methadone programmes, in addition to bringing the habit under control,—from an AIDS perspective, you move from injecting to oral medication. On the other hand, the logic is such that injecting is far more cost-effective and cost-efficient because you need less drugs and they have a more immediate effect. What we have seen in Asia, particularly, is that transition goes in the opposite and very damaging direction from our perspective and from many other perspectives. In cultures where drugs were traditionally smoked or inhaled they are now injecting them. In southern China they are moving from opium to more purified products, like heroin. There is a commercial logic in that. I agree with you, when we think of harm reduction it is better not to inject drugs, there is no doubt about that.

Mr Colman

  477. What has been the effect of HIV/AIDS on the provision of safe blood supplies in the developing countries' health services and thus on health care? Are testing facilities available to ensure that safe blood is available? How is the international community assisting developing countries in this area in ensuring that there are safe blood supplies?
  (Dr Piot) A lot of progress was made in the early days of the epidemic, particularly from 1985, when the first diagnostic tests for HIV came on the market. Then the WHO, the first special programme on AIDS and then the global programme on AIDS, devoted some resources to that. Also, several donors, particularly the European Commission, invested a lot in setting up blood transfusion services. In the last five years not much progress has been made. To date, I know major investments with good results, like in Uganda, were made, particularly with the European Commission. In Senegal blood is safe as well, as in most of the southern African countries, like Zimbabwe and South Africa. We have a map, but I do not have it with me here, and there are major African countries where blood is not safe. When it comes to India there is a law that makes it compulsory to test blood for blood transfusions for HIV and it also makes paid blood donors illegal. Bangladesh is now considering a similar law. The performance is very, very uneven. Some agencies in the past have said that since contaminated blood transfusions do not contribute enormously to the spread of HIV it is not cost-effective and we do not invest in it. It is an example of what I would call a technocratic approach to this problem. If you are only going to base your decision-making on what is cost-effective, how many you save by intervention, you are really missing the boat in many aspects, and this is one. In terms of safe blood transfusions, the state also has a responsibility. There are ethical, moral and legal aspects. It is something that has to be part of any AIDS programme.

  478. What proportion of HIV infection is coming through infected blood supplies?
  (Dr Piot) It is probably less than one per cent.

  479. That varies, obviously. Do you have this information you could table for us?
  (Dr Piot) Yes. That would have been more important in the early days when HIV is introduced into a country. It would be more important before you have a massive heterosexual epidemic.

3   Not printed. Back

4   Note by witness: About 5 per cent of HIV infections are the result of IDU. Back

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