Select Committee on International Development Written Evidence


Memorandum submitted by Voluntary Service Overseas (VSO)

  VSO supports nearly 2,000 volunteers in 74 of the world's poorest countries. HIV/AIDS affects them all. In response to the International Development Committee's Inquiry on HIV/AIDS and Social and Economic Development, VSO would like to respond to points 1d, 2c and 2d.

1.  The impact of HIV/AIDS on developing countries

d.  the impact of HIV/AIDS on the budgets of developing country governments, including a consideration of the cost of drugs and therapies

Access to Treatment for HIV/AIDS

  VSO partners identify access to drugs and therapies as a key issue in the HIV/AIDS jigsaw. According to WHO, one third of the world's population lacks access to essential drugs, this figure rising to over half in the most impoverished parts of Africa and Asia.[5] Not having access to these medicines is undermining development: If an HIV-positive person's life is lengthened by five years through access to treatments, and during that time they are relatively well, that is five more years during which they can be breadwinners, parents and maybe skilled teachers, health workers and business people.

  AIDS treatment in the North now includes anti-retroviral drugs (ARVs) which slow the course of the whole disease. But discussions of treatment must not be limited to these drugs. VSO partners in Southern Africa have identified accessibility to treatments for opportunistic infections and symptoms as a key issue.

Treatments for symptoms and infections

    "I need medicines for my TB (tuberculosis) but the pharmacy doesn't have them every day".

    Jeremiah Mulumba, Zambian living with HIV.

  Many medicines for treating opportunistic infections and symptoms are relatively cheap, because they have passed their patent period and thus are subject to competition between "generics" companies. This process drives prices dramatically downwards once drugs come off patent. Nonetheless, these drugs are not available to those most in need. For example, a recently returned VSO pharmacist who had been working in Namibia pointed to the cost of basic drugs as the single largest barrier to treatment access. She was working at a regional hospital—a tertiary-level referral centre which was well resourced in comparison with smaller hospitals or local clinics in the country.

    "The financial year begins in April, and the medicines are beginning to run out by September . . . it depends what you mean by expensive. For example drugs to stop diarrhoea are cheap, but we still only had enough for me to give 10 to each patient. They could get through those in a day".

  In other words, even though some of the medicines are cheap, budgets do not stretch to buying adequate quantities. Not surprisingly in the above example, more expensive medicines were unavailable or in extremely limited supply.

  The figures for health service spending in some countries also indicate that health budgets are simply not adequate. The World Bank has calculated that a "minimum package" of health care (including immunisation, tuberculosis treatment, treatment for children, family planning and some health education) costs (at today's prices) US$14 per year.[6] This figure was reported in 1993, and did not allow for the massively increased demands placed on health services by HIV/AIDS. Yet, the amount available for spending on health per capita in Zambia, for example, was on average US$5.3 between 1990 and 1996. Given current health expenditure needs, this deficit means that the public health sector cannot consistently provide even the most basic treatment.

TRIPS, patents and essential drugs

  Another limiting factor to the accessibility of drugs for treating HIV/AIDS-related illnesses is the complex relationship between patented drugs, intellectual property rights and generic drugs production. The coming into force of the TRIPs (Trade Related Intellectual Property) agreement as part of WTO rules has shed light on the potential health implications of international trade rules.

  Most of the types of drugs mentioned above are not patented. But some drugs relevant to HIV/AIDS are still under patent, including for example, some antifungal drugs, some newer antibiotics (including some of those used for resistant TB) and ARVs.[7] Patented drugs are generally much more expensive than generic drugs, almost by definition, and therefore completely out of reach of most people in poor countries most of the time.

  TRIPs has the potential to undermine generic drugs production so crucial for addressing the HIV/AIDS crisis in Africa. The WHO says "the emergence of a generic drug sector in a number of developing countries represents a set of successful social policies that may be harder to duplicate under TRIPs.[8]

  The recent public-private initiative announced between UNAIDS and five pharmaceutical companies to make a limited number of HIV/AIDS-related drugs available at reduced prices demonstrates that greater price flexibility is possible under current market conditions. Certain organisations, such as Medécins Sans Frontie"res, Health Action International and the Consumer Project on Technology suggest that keeping the market open to competition from generics drugs manufacturing companies would make radical reductions in the pricing of these substances possible.

  Under current TRIPs and WTO rules, such competition should be possible through compulsory licensing and parallel importing. Reports from around the world though, indicate there are potential problems with the way in which TRIPs is being put into practice on national and regional levels. For example, the West African Bangui agreement, which implements TRIPs for 15 countries in the region, is more restrictive than necessary under TRIPs rules.[9]

  Until recently, the United States was guilty of applying bi-lateral pressure on developing countries to draft legislation that undermines the health-related clauses embodied in TRIPs. By executive order of the US President, this should no longer take place in southern Africa. To our knowledge, similar promises have not yet been forthcoming from the European Union.


c.  The human and legal rights of those living with HIV/AIDS in developing countries

  One basic and crucial right of people suffering from HIV/AIDS is the right to be HIV-positive publicly in a safe and supporting environment. The stigma attached to having HIV is undermining communities and setting back development. This is best illustrated by the experience of VSO's programme office in Zambia.

  The primary effect of stigma on VSO's work in Zambia is what is referred to as "the denial factor". People are generally unwilling to speak openly about HIV/AIDS, and to disclose one's HIV status is still almost unheard of. AIDS is widely understood to be a disease of promiscuity and people are ashamed to "admit" that they (or their family members) have contracted it. AIDS-related illnesses are identified only by the name of the actual infection (ie TB, pneumonia) and never as secondary to HIV. AIDS-related deaths are much the same—obituaries describe "death following an illness", and the death certificate purposely omits any references to AIDS. There have been no disclosures from high-ranking government or church leaders or well known sports or entertainment personalities, even through deaths "following an illness" are frequent and widely understood to be AIDS-related.

  In VSO's work in Zambia, we meet people daily whose lives are touched by AIDS: they are caring for sick relatives, they are supporting orphaned children whose parents have died of AIDS, they are attending funerals of friends who have passed away . . . But rarely is AIDS identified as the culprit. Disclosure can bring serious repercussions: people are fired from their jobs or are denied employment, they are evicted from their rented accommodation, they are shunned by their families and communities for bringing shame and dishonour.

  Denial thus becomes a coping mechanism. People who suspect themselves to be HIV+ rarely choose to be tested so do not have access to counselling and support. And the consequences are serious:

    —  they continue to infect others;

    —  they lose the opportunity to re-plan their lives, failing to make provision for the care of their children or the distribution of their property;

    —  they may be off work on several months sick leave which is never acknowledged as terminal, thus neglecting to handover of work-related responsibilities, this affects the general level of service provision across the board—in government, manufacturing, industry, service, education, agriculture, etc leading to loss of productivity and revenue as well as frustration;

    —  employers condone denial by allowing extended sick leave, placing colleague in "acting" or "temporary" positions without the training, handover or authority to plan or make decisions. This reduce efficiency, continuity and morale in workplaces across the country, and affects most VSO Zambia volunteers in their placements;

    —  children are exposed to the painful deaths of other family members at an early age, often as caregivers themselves, yet education curricula and teacher training do not include strategies for dealing with traumatised children;

    —  AIDS is thought to be the underlying cause of hospitalisation for 70 per cent of all in-patients, yet health care workers have no special training or equipment to implement universal precautions. They are more likely, out of fear and disrespect, to discharge these individuals or ignore their basic care needs. Patients are then left to their own devices, and suffer needlessly before dying a premature death.

  Thus the denial factor affects everyday life: at home, at work, in the community. People have a right to a secure social, political and economic environment that enables them to live positively with HIV and continue to make valuable contributions to the broader society.

d.  The response of the international community, and in particular DFID

  One important component of DFID's strategy for tackling the HIV/AIDS crisis in southern Africa is the VSO Regional AIDS Initiative of Southern Africa (RAISA). Through this project, VSO and the UK government are taking a two-strand approach focusing on both prevention and care. The four year initiative which began in January 2000 will place over 40 volunteers in HIV/AIDS-related posts with both government and NGOs in six countries (Malawi, Mozambique, Namibia, South Africa, Zambia and Zimbabwe). A further 700 VSO volunteers will receive specific training to enable them to address HIV/AIDS through their diverse cross-sectoral work placements. Finally, the project will develop and strengthen learning and networking at both national and regional levels. RAISA illustrates how creative approaches can be found to help governments and communities in developing countries overcome the HIV/AIDS crisis.

  VSO would recommend that governments and international agencies consider taking the following actions:

    —  encourage the use and production of generic versions of existing drugs for treating HIV/AIDS-related illnesses (in compliance with WTO rules);

    —  clarify UK and EU positions on health-related clauses and exceptions embodied in TRIPs and ensure they are not undermined by more restrictive intellectual property rights measures;

    —  provide greater technical support and advice to developing country governments to strengthen their ability to strategically plan their drugs purchasing and delivery and enable them to buy drugs at lower cost;

    —  show solidarity with HIV positive people in developing countries by pushing for greater international commitment to the rights of HIV positive people; and

    —  ensure that an HIV/AIDS strategy is integrated into projects in countries where AIDS is a priority.

Ken Bluestone
Advocacy Programme Manager

Anna Thomas
Senior Advocacy Officer

Voluntary Service Overseas

17 May 2000

5   WHO Medicines Strategy 2000-03, Framework for Action in Essential Drugs and Medicines Policy, WHO. Back

6   World Development Report, World Bank, 1993. Back

7   Patent Situation of HIV/AIDS Drugs in 80 Countries, UNAIDS, January 2000. Back

8   Globalisation and Access to Drugs, Perspectives on the WTO/TRIPS Agreement-WHO Action Programme on Essential Drugs, 1999. Back

9   Joint Mission MSF-WHO-UNAIDS, Review of Pharmaceutical Policy in Cameroon-Medicine Patents in Francophone Africa. Back

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