Select Committee on International Development Third Report

Section 3 — Prevention and Care


156. In high prevalence countries where significant numbers of women are infected, transmission from a mother to child is an important route of transmission. Giving evidence to the Committee, Carol Bellamy of UNICEF said that approximately a third of children born to HIV-positive mothers will acquire HIV — approximately 500,000-600,000 children a year. Of these, "roughly two-thirds will acquire it during pregnancy and delivery, and the other third will be exposed through breast-feeding".[191]

157. As another example of disparity between rich and poor countries, transmission of HIV from HIV-positive mothers has fallen dramatically in the UK. Caesarian sections reduce the risk of infection from the birth canal during delivery and anti-retroviral drugs, which an HIV-positive mother in the UK is likely to receive on a permanent basis, appears to dramatically reduce transmissions. In addition, a programme of routinely offering HIV tests to all pregnant women has identified the small number of women who did not know their HIV status.

158. Short-courses of highly-active anti-retroviral therapy (HAART) have been shown to be effective in reducing the transmission of HIV from pregnant women to their children during birth. Studies in Thailand showed that a one-month course of zidovudine (AZT) halved the rate of transmission as long as women avoided breast-feeding. Another study in Cote d'Ivoire and Burkino Faso showed that even when women breastfed, transmission was reduced by a third.

159. Most recently, nevirapine has been shown to achieve good results with a single dose at much less than the cost of zidovudine. Compared to zidovudine, nevirapine at cost price has been judged to be cost-effective in increasing life years.[192] Boehringer Ingelheim, the German pharmaceutical company, has announced that it will provide nevirapine free of charge to all developing countries for five years to reduce mother-to-child transmission.[193] Trials are now needed to show whether sustained use can continue to be effective, in particular on women having multiple repeated treatments for subsequent children.

160. An outstanding dilemma is what advice should be given to women in resource-poor countries about breast-feeding. While there is a consensus that it can be a route of transmission, there is confusion over what advice should be given to women especially those in poor countries. It appears that exclusive formula milk is theoretically safer, at least in richer circumstances with constant access to formula milk and clean water. However, this is unrealistic for many women in the developing world, both in terms of cost and lack of clean water. Switching between breast-feeding and formula milk would appear to be more harmful than breastfeeding alone. Furthermore, there are serious risks to the health of an HIV-negative infant in the developing world who has not had the benefit of breast milk, in terms of nutrition and immunity.

161. Douglas Webb of Save the Children Fund told the Inquiry that, while "the debate is shifting backwards and forwards", overall, we would still advocate exclusive breast-feeding until four to six months. [194] Carol Bellamy said that "UNICEF's position on breast feeding continues. We think breast feeding must continue to be protected, promoted and supported in all populations irrespective of HIV prevalence rates."[195] The importance of offering testing to pregnant women has been emphasised, in order to enable an HIV-positive woman to make informed choices about anti-retrovirals during pregnancy and breast-feeding. To that end, it is as vital that women receive accurate and comprehensive information on their options. UNAIDS points out that the stigma attached to HIV and absence of ongoing treatment are a disincentive for some women to test and, in studies, a proportion of women refuse the test or do not return to find out the result.


162. In a number of countries, injecting drug use has had a major impact on HIV. In Manipur, a region of North East India, prevalence of HIV in injecting drug users rose from nothing in 1988 to 70% four years later. This was accompanied by an increase in HIV among pregnant women.[196] Similarly, parts of the former Soviet Union are experiencing drug-related HIV. For example, drug users in the various cities in the Ukraine have shown a rise from virtually zero HIV prevalence in 1994 to 31-57% two years later. Prevalence rates among injecting drug users are between 30-70% in Argentina, Brazil, India, Thailand and the USA (Puerto Rico). [197] Most injecting drug users are male and in much of China, and parts of India and Myanmar more women are infected through sex with injecting drug users than in any other way.

163. Harm reduction strategies to reduce HIV infection among injecting drug users have shown clear indications of success in many countries, including the UK. In the town of Svetlogorsk in Belarus, needle exchange programmes alongside health education have shown a dramatic fall in the number of injecting drug users reporting sharing needles and syringes from 92% in 1997 to 35% in 1999. This was helped by a change in the law in Belarus which made it legal to carry syringes. However, injecting drug use remains an illegal and highly stigmatised activity in most countries and harm reduction programmes are therefore politically sensitive. Work with injecting drug users raises questions about the role of NGOs, external funders and national governments. Jeff O'Malley said, "My big concern about India...was that DFID has perhaps put too much faith in the ability of the government of India to put money in at the top that will flow down through many levels and get out to the communities ... governments will never be very good, for example, in funding projects for injecting drug users".[198]

164. Dr Peter Piot talked about the link between drug use and social problems, pointing out that a "climate of no future, of social despair, where society is in transition, high unemployment" contributes to drug use among young people.[199] He pointed out that although there is no internationally agreed policy on needle exchange, the 1998 UN Special Assembly on Drugs drew attention to harm reduction in a statement.[200]

165. We look forward to DFID making clear how it is promoting harm reduction strategies amongst injecting drug users. This is a sensitive area where stigma and legal sanctions have meant it has been difficult to see progress in areas such as safe needle exchange. Nevertheless, injecting drug use is in a number of regions the main mode of transmission of HIV/AIDS and an internationally agreed approach is urgently needed.

Behavioural interventions


166. In the opening section of this Report we demonstrated that it is not just material poverty which exacerbates the spread of HIV/AIDS but also the denial of human rights. HIV/AIDS is a social and behavioural phenomenon as well as a physical one. The bare provision of information to everyone about the disease and how to avoid it will not necessarily alter behaviour. The persistence of many health-threatening behaviours in the UK despite well-funded health-education campaigns, such as those on smoking, drug-use and unprotected sex, proves that this is not the case. Behaviour change, whilst requiring information, also depends on such factors as the ability of an individual to control aspects of their lives, the range of other and more immediate concerns, the social cohesion and support of a community.

167. For many people in the poorest and worst-affected countries, life conditions do not empower them to place HIV prevention at the top of their concerns and then act accordingly. Other more immediate concerns take priority over avoiding a virus with a long incubation period, such as the provision of food, clean water and the avoidance of more immediately obvious health threats. People without security about their short or long-term futures are unlikely to prioritise an unseen virus which, they are told, could cause them to be ill in eight or nine years. People without the freedom to choose not to be separated from their families or without a range of activities to choose from may well use recreational or commercial sex as an antidote to loneliness and frustration. To change behaviour, people need to have a stake in their own futures. Such an outlook is difficult for the abjectly poor. The human rights to health, to education, to food and water are crucial to any change in behaviour to prevent HIV/AIDS. DFID's poverty-focussed approach, which is explicitly rights-based, is thus a vital foundation for all HIV/AIDS work.

168. We have already made specific mention of the rights of women and girls. The example previously cited of infection rates amongst high school girls in Kisumu, Kenya, highlights the need for HIV/AIDS programmes which explicitly address gender relations. We would encourage DFID to include explicitly gender rights in its HIV/AIDS programmes. Such an approach must include the education of men in less exploitative models of masculinity, the rights of women and children. Programmes need to educate young women and girls in how to negotiate sexual relations and how to be able to refuse sex with those older or more powerful than themselves. A properly designed HIV/AIDS strategy will also prioritise the protection of women from domestic violence and rape through community pressure, effective policing and a gender-sensitive courts and legal system. We request information from DFID on how many programmes it is funding which are explicitly designed to tackle HIV/AIDS and which also include such 'women's rights' components.

169. We have also mentioned the human rights of stigmatised groups such as commercial sex workers, homosexuals and injecting drug-users. These tend to be high-risk groups for HIV infection. If their existence is ignored or denied, if they are refused information and appropriate care, if they are unwilling to seek advice or treatment through fear of penalties, it is likely that the epidemic will continue unchecked at precisely that early stage when it remains possible to halt its spread. A responsible HIV/AIDS strategy must counteract stigma, acknowledge the human rights of stigmatised groups, provide information and access to prevention and treatment, survey prevalence amongst such groups and adopt strategies to reduce their vulnerability to infection.

170. The most damaging of stigmas for those attempting to halt the spread of HIV/AIDS is the stigma attached to those who are HIV-positive. The murder of the South African HIV activist Gugu Dlamini in Kwa Zulu Natal in December 1998 was an example of an extreme reaction to the shame that HIV is perceived to bring on an individual, their family and their community. People living in a society where HIV is highly stigmatised and where it leads to social ostracism have an enormous disincentive against taking an HIV test, against acquiring condoms or suggesting their use. If the rights of the HIV-positive are denied, so is HIV itself. The result, according to UNAIDS, is continuing and increasing infection, "A country in which denial flourishes is a country whose citizens are vulnerable to the silent spread of HIV."[201] Those living with HIV/AIDS must enjoy the full protection of the law, access to employment, education and appropriate care. It is a duty of donors to advocate the rights of those living with HIV/AIDS, monitor and support those rights, and argue against their abuse.

171. We were pleased to see that in the Annual Report on Human Rights for 2000 published by the Foreign and Commonwealth Office there is a section devoted to HIV/AIDS. It includes a summary of FCO intervention which include a grant to a Mexican Human Rights Centre to promote the rights of people living with HIV/AIDS and work in a Women's Crisis Centre in Malaysia.[202] There was a much smaller section on HIV/AIDS in the previous year's Human Rights Report. We welcome the work done by the FCO to promote human rights in the context of HIV/AIDS and its inclusion in the Annual Human Rights Report. We note that unlike its two predecessors the 2000 Human Rights Report is signed off only by the Secretary of State for Foreign and Commonwealth Affairs and not by the Secretary of State for International Development. If DFID is no longer to have an involvement in the Annual Human Rights Report we think it is still necessary for it to report to Parliament on what it is doing to promote human rights within its work on HIV/AIDS and we recommend that there be a section to that effect in future Departmental Annual Reports.


172. Evidence stressed the need for appropriate and effective information on HIV/AIDS to reach communities and the role of the media in such work. The Panos Institute state, "it is critical to involve the media in any response to the epidemic".[203] The aim was not that the media become an official mouthpiece for the government but rather to promote awareness and debate around the response to HIV/AIDS issues. Panos continue, "We suggest there is little prospect of improving public health in most developing countries without a major increase in the quality and quantity of informed public debate. HIV/AIDS provides the most obvious example of the link between inclusive and informed public debate and effective action on the ground. In countries such as Uganda and Thailand a combination of political leadership, a preparedness to discuss issues of sex and sexuality openly, a vibrant and plural media and a thriving civil society have greatly facilitated the creation of an environment conducive to the reduction in HIV incidence".[204] We need only recall the work of the media in the United Kingdom in bringing into open discussion such conditions as breast and prostate cancer, previously taboo, to realise how important their contribution can be.

173. The BBC World Service gave an encouraging account in their memorandum to the Committee of the work being undertaken on HIV/AIDS. This work includes general programming on HIV/AIDS, with a commitment "to telling the story of AIDS over the long term and in all its aspects, not just in occasional snapshots or sensational headlines".[205] In addition, the BBC World Service disseminates basic information on sexual and reproductive health and cooperates, through the BBC World Service Trust, with UNAIDS and DFID in HIV/AIDS work in particular countries such as India and Cambodia. Similar work is also conducted by the World Service's main competitors.[206]

174. We welcome the work done by DFID and the BBC World Service (and the BBC World Service Trust in particular) in promoting HIV/AIDS awareness through the media. We believe this is a vital aspect to effective prevention, often taking information to people otherwise inaccessible to such campaigns. We believe that the media should not simply disseminate factual information on HIV/AIDS but also encourage community debate and engagement. In other words, any HIV/AIDS media strategy must have a clear human rights dimension. One component should be the encouragement by DFID and the FCO of a plural, independent and healthy media in developing countries. Another must be the use of the media to generate grassroots involvement and activity in the fight against the disease.


175. We would also mention briefly the importance of prevention in the workplace. We were pleased to hear of the prevention work being done by, for example, Anglo American, Standard Chartered Bank and Glaxo Wellcome, all of which gave oral evidence to the Committee,[207] and by Trade Unions.[208] The TUC said, "The workplace in both formal and informal sectors is one of the most important points of focus for initiatives to tackle the disastrous effects of the HIV/AIDS pandemic as it provides access to a large, yet captive audience. Many workplaces possess the infrastructure for training and education activities which can be utilised for HIV/AIDS awareness and training campaigns".[209] We are convinced that the opportunities of the workplace provide some of the most important means of prevention, and indeed care, in the developing world.

176. A number of prevention strategies were raised in evidence. We can only list here some of the most important interventions:

  • the provision of condoms
  • the provision of health education, and in particular information on HIV/AIDS
  • the provision of voluntary testing and counselling services
  • basic care for STDs and opportunistic infections
  • the protection of the employment, legal and human rights of HIV-positive workers
  • prevention work with consumers, families of workers, and with small and medium sized enterprises linked to the company
  • the proper treatment of migrant workers, including suitable accommodation, the possibility of workers' sexual partners also living with them, the provision of leisure facilities
  • prevention work amongst commercial sex workers with whom members of the workforce might be in contact

177. This list is by no means exhaustive and the items are not in order of importance. For effective prevention and care a package of measures is necessary. Research has made clear that such interventions by business save money as sickness, absenteeism and deaths, with all their costs, are reduced. We discuss prevention in the workplace here not because it is neglected as an issue. There is now a considerable body of good practice and informative literature to draw on. We noted, however, DFID's admission that "Up to now, working directly with the large employers in developing countries has not been part of our approach".[210] We were told it was an area DFID were "beginning to explore".[211] We wish to stress the important role that DFID and other donors can play as catalysts to such workplace prevention and care. This can involve initial funding of programmes (though companies should take over beyond the experimental stage) and the provision of technical assistance.

178. DFID should also be involved in advocacy of workplace interventions. We quote Save The Children, "DFID should ... proactively work with the DTI and the FCO to use every available channel to urge large British companies operating overseas to take positive action to protect and promote the rights of people infected or affected by HIV/AIDS. In addition, as part of its anti-poverty mandate, DFID should work with foreign governments, chambers of commerce and other bilateral and multilateral donors to urge foreign companies, large and small, to do the same".[212] We recommend that DFID engage in discussions with British industry, in particular such bodies as Chambers of Commerce and the Confederation of British Industry, to promote the importance of HIV/AIDS prevention and care when operating in developing countries with high HIV/AIDS prevalence.

179. Such advocacy is also necessary within Whitehall. We recommend that ECGD only support projects where consideration has been given to the vulnerability of the workforce to HIV/AIDS and what can be done to prevent infection. There are good examples of such practice from the World Bank, amongst others. More generally, Ethical Trading Initiative members should take HIV/AIDS into account when vetting overseas suppliers. We were told this issue was currently under discussion.[213] We also recommend that DTI in promoting investment and trading opportunities overseas discuss HIV/AIDS, making clear that it does not preclude profitability but that it is vital to take the epidemic into account in workplace policies, including prevention, care and employment rights.

191   Q.187 Back

192   "Cost effectives of single-dose nevirapine regimen for mothers and babies to decrease vertical HIV-1 transmission in sub-Saharan Africa". Ellitt Marseille et al, The Lancet, 1999; 354: pp. 803-09. Back

193   Q.466 Back

194   Q.240 Back

195   Q.216 Back

196   UNAIDS June Report 2000, p.13 Back

197   UNAIDS June Report 2000, p.75 Back

198   Q.167 Back

199   Q.474 Back

200   Q.475 Back

201  UNAIDS June 2000 Report p.38 Back

202  Human Rights Foreign and Commonwealth Office Annual Report 2000 Cm. 4774 p.83 Back

203   Evidence, p.269 Back

204   Evidence, p.269 Back

205   Evidence, p.296 Back

206   Evidence, p.297 Back

207   Qq.127-237 Back

208   See Evidence p.291 Back

209   Evidence p.287 Back

210   Q.81 Back

211   Q.82 Back

212   Evidence pp.148-149 Back

213   Evidence p.72 Back

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