Select Committee on International Development Minutes of Evidence

Examination of Witnesses (Questions 480 - 499)



  480. Can I ask whether this information on an individual country's screening of blood supplies is available freely? I think it would be important to tourists who are visiting these countries. It could be used by governments in the developing world to pressure countries from the developed world—I was thinking in terms of tour companies—to ensure that work is done on the testing of blood supplies and, therefore, is included within the AIDS policies that countries may wish to have. If you have a tour company in the United Kingdom that is promoting holidays in various countries, they might wish to ensure that information is available and that pressure is brought to bear, perhaps in this case on DFID, to ensure that clean blood supplies are available.
  (Dr Cleves) If I might add on the international response, it is the WHO that takes the lead on safe blood. Indeed, this year their world health campaign was on safe blood, under the slogan "Safe Blood Begins With Me". They have done an enormous amount of work promoting safe blood and, indeed, providing technical assistance to countries in pursuit of safe blood. There is abundant evidence that can be provided to you on their response and on the situation globally.

  481. Is this information available to tour companies?
  (Dr Piot) We will send you the information. We have it in detail for most African countries, except a few that are at war, where the situation is probably predictable.

Mr Worthington

  482. Can I ask you to talk a little bit about the places that are quoted as successes, Uganda, Senegal and Thailand. How do you demonstrate their success? What is the statistical basis for saying they are successes? What do you think have been the causes of their success? How did they achieve it? Is that in some way linked to the social and political structure of those countries? Is it possible to duplicate them elsewhere?
  (Dr Piot) Firstly, what is the evidence? The ultimate indicator of success in terms of HIV prevention programmes is you have fewer infections today than yesterday or five years ago. It is not so easy to measure but there are techniques. Certainly in Uganda, in Thailand and also in parts of Zambia we see a decline in the percentage of infected individuals in certain age groups. The basis for our statistics, for our estimates, is so-called sentinel surveillance, which means that groups of individuals, usually women, who come to ante-natal clinics are then sampled according to a sample frame that takes into account their age particularly. They are being followed all of the time, not the same individuals, for the percentage of infected individuals. It is young people who are the most important. Why is that so? When you look at the infection rate among 16 or 18 year olds that reflects fairly closely recent events. That is the situation today. What we have seen consistently in several of the sites in Thailand, and also in Uganda, since 1992/1993 is there has been a steady decline every year, less infected individuals. The question one has to ask is this, is it because everybody who was infected died? The answer to that is that the strongest decline is seen among young people. This is where prevention is the "best". Secondly, in all of these countries it is associated with dramatic sexual behaviour change. This is one of the things we are doing with a number of our partners in the countries. Estimated sexual behaviour, when young people first start to have sexual intercourse, today in Uganda on average is two years later than it was in the early 1990s, which is a dramatic change. It was not even an implicit goal of the campaign but it was one of the main results of the campaign for responsible sexual behaviour. Condom use is up. The number of sex partners is down. Numbers of sex workers are also down. That is a pattern we are seeing in Thailand, Uganda, Senegal, Zambia and also Brazil now. In Thailand much publicity was given to the One Hundred Per Cent Condom Use campaign, which was a massive campaign, saying that in commercial sex you should always use a condom. What people tend to ignore is that at the same time there was a campaign called Respect For Women, which was equally important, where the message was—now I translate—"To be a real man you do not have to go to prostitutes every Friday with your colleagues". That resulted in a major increase in condom use and a decrease in commercial sex. Many brothels had to close because of the lack of customers. It is very important that one looks at both sides of the coin. In other words, what was this campaign trying to do? A change in social norms, what is cool, as my daughter would say, and what is not cool in terms of sexual behaviour. The evidence we have is very strong. It is being confirmed year after year. The trends continue. To answer your question, why has it happened in these countries and not in others? I think you have to ask that question at the same time. We see commonalities in what is going on in countries that are so different, such as Uganda, Senegal and Thailand. Frankly, they do not have much in common in terms of social structure, and so on; it was what Julia said, the leadership, in many different ways. In 1991 Prime Minister Anand Panyarachun who had just come into power, was briefed by a group of economists who estimated how much it would cost the economy if AIDS was not brought under control. The Thai people being very pragmatic, he said, "We have to do something". He appointed a state secretary in his office, Mr Mechai who was a very well known family planning activist and also a senator, to take charge of setting up a multi-sectoral AIDS programme. The first thing they did was to make it compulsory that every day on prime time TV every station, public and privately owned, needed to spend, five minutes (it could have been less or more) of air time on AIDS messages — that was in prime time, not after midnight. Secondly, every single ministry had to create a budget line and develop a plan for what they will contribute to the fight against AIDS and how they will implement their plans. For example, most of the cases in Thailand of HIV came from northern Thailand and the sex trade in Bangkok. What they decided was to intensify education, particularly girls' education programmes and rural development programmes. You need leadership and a clear plan. It is not enough to talk about it, you need to know what you want to do. Thirdly, a multi-sectoral approach, forcing all of these departments to work on it. Openness, we have already touched on that. Testing is available. People with HIV can come out. There are events that one can point to, like in Uganda when one of the most popular singers, Philly Lutaaya came out as being HIV-positive. When he came out nobody believed it because he was a strong man but when people saw how he became thinner and thinner and thinner they said, "He has got it". It is the "Magic Johnson effect". Community involvement is very important. In all of these countries there is a very strong community-based response. The Government is in charge of the policies, making sure there is a supportive environment based also on a rights based approach but then the resources go to community groups. It is not only groups of people living with HIV, in Thailand the Pagods, the Buddhist monks, are very much involved. Museveni did a very good thing in a sense in that the first chairman of the Ugandan AIDS Commission was an Anglican Bishop. The current chairman is a Roman Catholic Bishop. Bring them on board. In Senegal the Marabouts, very powerful Islamic leaders, have really been at the forefront of the fight against AIDS. The rest, of course, involves condom promotion, messages for young people, that is the easier part. How do you do it? Can that be transposed to other societies? It requires leadership, it is a matter of governance. There is a real link between good governance, democracy, empowering communities and being able to fight AIDS. It came in Uganda after years and years of dictatorship and war. The whole country was there with hope and then there was AIDS.

Ms Kingham

  483. You mentioned about a multi-sectoral approach. I am interested in the pieces which are picked up, aspects of work you touched on, such as brothels closing down. What happens to the sex workers in those circumstances? What kind of redeployment programme is there? Is that a fundamental part of the activities or are you looking at it with tunnel vision in dealing with HIV/AIDS?
  (Dr Piot) That is a good question because in this case I have a positive answer to it. Because it was really a comprehensive programme in Thailand. They did take that into account. Thailand has a ministry for industrial investment in rural areas. They linked it to that so there were more job opportunities in the north of Thailand for women.

  484. What about the people who were in the urban areas? A lot of those sex workers move to urban areas, brothels close down and then you have the problem of total destitution and poverty and sex workers are out of jobs.
  (Dr Piot) I fully agree, however they had planned for this but then something that was not planned for happened and there was a sudden economic and financial crisis in Thailand, which led to urban/rural migration back. I think the test will be, now that the economy is starting to pick up again, what will happen there? The approach that we are taking now has been tested out in the Piaro district in Thailand. It is a really integrated approach, where you need a community response, a local response. This is how you have to deal with orphans, instead of going into the sex trade there are job opportunities for women. This is why education is important. It sounds wishy-washy when I say it but in the end this is where it has to come together. That is why the AIDS programmes cannot work in isolation from the major development policy. That is why we need the multi-sectoral approach, while at the same time, with AIDS intervention, knowing exactly where we can get the best for our money. We have documented that in Thailand. I am very interested in that question because I often see by "solving" one problem we create another one in development. That has unfortunately been inconsistent in our work. How do we avoid that? That is a model that we are trying to introduce in a number of countries now, Tanzania, Burkina Faso, Zambia, Ethiopia. It is what we call local response. That has to be brought together.
  (Dr Cleves) We have documented a great deal of what accounts for success and makes for success. Peer pressure and why it is that young people change their behaviour, is something that we can probably do well to investigate a little further. When you were asking about statistics and evidence for success, in Lusaka, for example, the rate of HIV among pregnant teenagers has fallen by half in the last six years. When you look at the behaviourial evidence it shows that sexual activity amongst unmarried girls has fallen from 52 per cent to 35 per cent in the same period. We can point to the fact that communities have been involved and religious leaders are involved. Undoubtedly, there is a tremendous amount of peer pressure and peer education going on at the same time.
  (Dr Piot) The biggest problem are the men. The driving force in this epidemic is male sexual behaviour. As long as that does not change we can empower these fifteen year old girls but when they are raped that approach is not very useful. It is the sexual behaviour of men that is really fundamental to understand this epidemic. Even for injecting drug users, the overwhelming majority of drug users are also men. We are trying to translate that concept, that knowledge, into something operational. That is why I think changing the norms is so important and also working with businesses. Reaching men is difficult. You can do that with sports events, in the work place, we have not really exploited these ports of entry enough. For the future that should be one of our major emphases. That is also why our World AIDS campaign over the next few years is focusing on men. It is not always easy or well understood.

Mr Worthington

  485. There is a tendency to say, "Here is a huge problem, we have to experiment and find out what works". The message we have been receiving overwhelmingly, is there is not much more to find out. We basically have to do the best everywhere now, instead of a small-scale project, we have to scale that up. Is that the message you would give or is there still a lot of scope for innovation or finding new methods?
  (Dr Piot) This is exactly my message. If we apply what we know works then we could save millions and millions of lives every single year. In terms of new developments we need two things, at least, a vaccine and a microbicide, a product that women can use, it is a chemical condom, that would also make a difference. If all countries could be as successful or effective as Thailand or Uganda, who are cutting the number of new infections by half, that is what we need.

  486. One of the things which has puzzled me, you referred to the behaviour of men, which is appalling probably everywhere all of the time, but we put all of the focus on condoms. We know what is wrong with condoms as a method and there seems to be extremely little attention paid to the female condom and microbicides. Am I right in that?
  (Dr Piot) What you are saying is music to my ears. The messages are a bit more complicated. As I said before, I think changing the norms, what is okay in terms of sexual behaviour, is also important. It is not only a matter of condoms but condoms must be used in all cases, which means that today woman depend entirely on the goodwill, and skills, and so on, of the men. That is why we feel that the female condom should be an integral part of any programme. The price is high and up to recently, with the exception of DFID, there was no donor who was really interested in supporting the female condom programme. As Julia said, at the moment we have countries where the demand for condoms, certainly for female condoms, exceeds the supply of affordable condoms. That is a good sign. Ten years ago that was not the case. That is an indicator that the messages are being taken. The female condom has been part of that. Our strategy has been, again based on the judo strategy, to create small projects to create a demand. In many countries people have not heard of the female condom. If they know it exists we can push and create a demand, but without subsidising, what is after all a social good, it will not happen.

Ann Clwyd

  487. Do you think that the balance of funding is right between vaccine and microbicide development?
  (Dr Piot) Between these two?

  488. Yes.
  (Dr Piot) There is hardly any funding going to microbicide development. There is probably a much higher probability of coming in with a product within the next five years.

Mr Worthington

  489. Why is that?
  (Dr Piot) From a commercial perspective what you need is an over-the-counter product which is very cheap and which does not have side effects, because women have to use it as many times as it is needed and it would have to be distributed everywhere. That does not make it very appealing for any company to invest in because you need to invest a large amount of money. Clinical trials demonstrating that it works are basically as complicated as for demonstrating that a vaccine would protect, they could be even more difficult, I think. With a vaccine you know when you give a shot in the arm, but with a microbicide you do not know exactly. The balance is not right. I think there is a case for more investment in the future.
  (Dr Cleves) Having said that, there are twenty microbicide compounds that are ready for safety trials in human volunteers at the moment and three other compounds being considered for large scale trials and thirty-six at a pre-clinical stage. There is a certain pipeline of microbicides that are ready to move forward, however that does definitely need a push.

  490. Being cynical about it, the pay-off from preventing it happening is less than the pay-off for treating the disease when you have it.
  (Dr Cleves) There is always this debate about push and pull factors. There are not very many strong forces pulling a microbicide on to the market at present, that is absolutely correct.

Ms Kingham

  491. You mentioned previously having a minimum standard of care. Presumably any minimum standard of care would provide assistance to the whole health structure of the country, a sectoral approach to the Health Service. You also mentioned a figure of 1.5 billion, is that 1.5 billion realistic? Are you envisaging that 1.5 billion to be the cost for helping to give assistance to the whole sectoral approach of health care for the country?
  (Dr Piot) This is a most complicated question.

  492. I thought it might be.
  (Dr Piot) We are really faced with an enormous complexity. We are trying to dissect the complexity and see where we can make a difference. We should be realistic, it is not because there is an AIDS epidemic that suddenly we collectively, those dealing with AIDS or the international communities, would solve problems which have been there for many years in terms of health care, access to drugs and to treatment. That has been a problem before AIDS was discovered. Today if you need renal dialysis or you have breast cancer in these poor countries, it is the same problem. That is one point. Secondly, what we have based our estimates on, as Julia mentioned before, was palliative care, treatment, the cost of treating opportunistic infections, HIV testing and treatment science, preventing opportunistic infections, particularly tuberculosis, which also has some benefits outside AIDS. It is the service delivery cost where the big problem lies. As much as I do not think that AIDS will result in beefing-up health systems I think it should provide a major incentive to invest more in health care services and to speed up what we are doing with these health sector-wide approaches. I must say that the whole approach that DFID has taken there is the model to follow. With AIDS it has to accelerate because otherwise I think we are in a situation where either we go for the full package or we can throw the money out of the window. If you do not beef-up the services that can respond to the enormous demand of people living with HIV, which is going to increase, people will vote with their feet, it is not whether we should deal with them or not, they become ill and they go to hospitals and health centres. If we continue business as usual, with health care infrastructure building or revamping, that will bring the system even more in this area than before. We need to keep pace and intensify the supply in terms of services. Can that be done? That is an answer that I do not have at the moment. This is why it is so important that the WHO and the Bank are coming in in a major way on things which are not necessarily AIDS-specific. I am not sure my answer is clear enough.

Ann Clwyd

  493. Are you saying that $1.5 billion does not include service delivery?
  (Dr Piot) It does, to a certain extent. About half of that would be service delivery. That is before we talk about antiretroviral therapy, that is not included.
  (Dr Cleves) We are not envisaging some three-layered super highway for developing HIV/AIDS care. We have the systems and we have to use the systems. As everybody knows, at the moment those systems find it very difficult to deliver treatment for TB, which is only a tiny bit as complex as other things. Nonetheless, some of the systems there are competent and can deliver much more than they are able to at the moment, with more injection of resources, both financial and human. It is also important to recognise that we have to think outside the box and think outside public sector systems. We have to find ways of engaging the private sector, the community sector and the civil society more generally. There is a great deal of interest in the WHO at the moment. We are working with them actively on thinking about how to innovate and how we can use the epidemic to really push the capacity of all sectors to deliver these basic services.

Ms Kingham

  494. In terms of funding, has there been any agreement internationally as to where funds come from, the burden sharing of funds between multilateral donors and bilateral donors and the developing countries themselves?
  (Dr Piot) No, there is no agreement in terms of percentages. What we are trying to do now is to collect figures, who is contributing what, so we have a base line. That base line tells us that, for example, at the moment in sub-Saharan Africa we estimate that about $300 million in 2000 will go to AIDS prevention programmes and about 100 million will come from national resources, domestic resources, and 200 million from international resources, half of those from the United States. Our point is that countries really need to increase their investments, the developing countries themselves. We are working out potential sources of money for each country as part of national strategic planning, with costing potential sources of money. I think the experience from ICPD Plus five was targets were set. Deciding who should contribute how much was perhaps a bit naive. What we are trying to do now is try to see what is the base line and then target who does not pay enough.

  495. Will you have some common reporting mechanisms to be able to ascertain who is paying what and how they are paying? In reality, how is it getting off the ground? We have been picking that up from numerous witnesses. Some organisations might find it impossible to say how much they are actually spending on projects that are HIV/AIDS-specific. If you are not careful it can disappear into a big pot somewhere.
  (Dr Piot) When our board was in the United Kingdom two years ago it asked that question, a very simple question, and I thought we would have the answer in a few months' time. It is very difficult. I think we have already done two rounds of it and we are getting close to, at least, an estimate of what is being spent. That is why I can give you these figures.[5] We spelt it out by donor, by country and that report will come out very soon. This is something that I feel is a service that we can provide. What we are doing is, and it is quite interesting, having a double approach. We approach it from the capitals, from the donors and also from within the country. You will see that it does not match, even for the same donor.

  496. That does not surprise me dramatically.
  (Dr Piot) I am not singling out any donor. We have major discrepancies. Then we sit down and we say, "What is it?" We can monitor the trends and what we are trying to do now, and this makes it even more complicated, is to build foundations for that. There is big foundation money coming in—Bill Gates particularly, also the Turner Fund and some of the pharmaceutical companies. I think we will be able to monitor it. It is true as you say, on the one hand we are pushing for an integrated approach or integration of HIV activities in rural development programmes, micro credit schemes and reproductive health and that makes it more difficult to track it - that is where we also have a very conflicting message. On the other hand, we are asking for more precise reporting on every single sub-item you can think of. For me the key is to collect the information, particularly at the country level.
  (Dr Cleves) It is very complex.

Mr Rowe

  497. What are the implications of HIV/AIDS for structural adjustment programmes? We have heard that you should cut back on your civil servants, and so on, and then you find that the cost of HIV/AIDS is cutting back on the Civil Service faster than anybody would have done. Are there implications in cost, recovery, health and education services and scaling down public services?
  (Dr Cleves) I think we should put the question the other way around as well, have we also been very concerned about the effect of structural adjustment on the AIDS epidemic. There was quite a lot of discussion recently at the Durban Conference on trying to track precisely what the relationship has been between the epidemic and the structural adjustment. There are some reasonably positive examples where a country like Brazil in recent years has obviously undergone a structural adjustment process but has managed to retain its investment in AIDS and, indeed, has a very successful programme, both in terms of prevention and, increasingly, in terms of the resources it is able to put into care. In other countries, and elsewhere, the picture is, perhaps, less rosy, not least because with structural adjustment programmes there tends to be this terrific urbanisation, an increase in the export market, an increase of roads and road traffic in terms of long distance lorry hauliers, which we see in sub-Saharan Africa and India as well. This always bring with it the spread of the HIV epidemic. Structural adjustment raises particular problems for governments because most of the factors which fuel the AIDS epidemic are also those factors that seem to come into play in structural adjustment programmes.

  498. That is very useful and it is interesting, because it comes from a slightly different angle than I was coming at it from. The World Bank tend to say to countries, "You have too much fat in your bureaucracy". Is there not a real danger in trying to adjust to that in a country like Malawi, where 1,000 teachers died last year? The idea that there are too many people in your education service strikes one as a bit chilling.
  (Dr Piot) I agree with that. It is crystal clear to me that the AIDS epidemic has not been integrated into longer term planning, for the public sector or the whole structural adjustment issues. When I was at the World Education Forum in Dakar in April, I was really shocked by the fact that in many countries planning for education, for expanding education in school systems, and so on, continued as if there was no AIDS epidemic, as if this was not affecting, in economic terms, the supply and demand and the quality of education. This is why it is so important that we go beyond this health sector and that we come up with credible alternatives. It is so important that AIDS is integrated in the poverty reduction strategies. That is a point of entry to counterbalance this. I would say that is a very strong recommendation. I bring that message everywhere.

  499. Given that developing countries' health budgets are so stretched, what do you think is the best strategy for such governance in terms of effective expenditure? Should they concentrate on HIV/AIDS specific programmes or on establishing sexual and reproduction health services or provide safe drinking water? If you were the chief minister where would you put your money?
  (Dr Piot) If I was the chief minister and twenty-five per cent of my adult population were HIV positive—according to UNAIDS fifty per cent or more of my fifteen year olds will die from AIDS—there is nothing more important, in terms of ensuring the continuity of the nation and also of ensuring that other development investments will pay off, than that AIDS it brought under control, it is contained. I think we need to approach AIDS more and more in a war-type fashion. We are not going to make a significant impact on AIDS if we are not really putting in all of the resources as we would in a war-type effort. You need alliances. You work with people you hate, but you go for it. You really have to take the resources where they are and we need to expand the resource base. That is one of the reasons for a multi-sectoral approach. To answer your question directly, the cost of dealing with this epidemic, in terms of government resources, can be distributed. It can be shared over several departments. One does not have to cut on clean water, one should not cut on programmes for education. We know that with education, in general, in the long-term it is one of the best things we can do to contain this epidemic. At the moment the redistribution has to come from sectors that are looking into some of the structural adjustment programmes, making sure that money that comes in is freed by debt relief operations and that would go to AIDS in the first place.
  (Dr Cleves) I think it is important not to see these sectors as competitive. You cannot look after people who have HIV/AIDS if there is no clean water for them to wash their wounds with. One of the issues that emerged strongly at Durban was military expenditure, the inordinate billions that go into military expenditure in heavily indebted countries and very poor countries. That is definitely one area where a few judicious cuts would make resources available.

  Ann Clwyd: This Committee has continually made that point.

5   See Evidence pp. 249-50. Back

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