Select Committee on International Development Written Evidence


Memorandum submitted by the BMA Foundation for AIDS


  We greatly welcome the Select Committee's inquiry into HIV/AIDS and development and would like to thank the Committee for extending its timescale to enable us to submit evidence.

  The HIV/AIDS epidemic clearly represents the most devastating challenge to global development in recent history, as is illustrated by the graph showing how it has led to falling life expectancy in African countries. We therefore applaud the Committee's decision to examine the broader implications of HIV/AIDS for economic, political and social stability in developing regions. As a medical organisation, we have chosen to concentrate on providing the Committee with background information on some specific medical issues, but we would not wish this to be perceived as detracting from the wider impact of the epidemic.

  Specific points which we would like to draw to the Committee's attention are described below. We would be happy to supply further information on these points, including references, if requested.


  Although we have no good data, we would like to point out that developing country health services are doubly affected by HIV/AIDS. The epidemic leads to growing needs for health care, while simultaneously undermining health sector capacity through illness, mortality and loss of morale among health workers. As the Committee is doubtless aware, HIV/AIDS has a particularly serious impact on all economic sectors because it primarily affects young adults in the most productive age groups. It is also associated with prolonged or intermittent illness prior to death, leading to a substantial burden of need for formal and informal care.


  The development of effective vaccines holds out the best hope for long term control of the HIV/AIDS epidemic. We welcome the UK Government's support for research directed towards vaccines specifically suited to the needs of developing countries. However, a number of issues remain:

    —  vaccine development is a slow process. We anticipate that it will be at least five years, and more realistically 10, before an effective vaccine can be available for widespread use.

    —  although some work has been done in preparing for trials of vaccine efficacy, some ethical and methodological difficulties remain.

    —  a preventive vaccine will not help the many millions of people who will already be infected with HIV at the time when the vaccine becomes available. These people will continue to develop AIDS and need care over ensuing years.

    —  most vaccines currently in use in developing countries are given to infants or young children and are intended primarily for prevention of childhood diseases:

      —  if an HIV vaccine is given to children, there will be a long lead time before the vaccinated generation grows up and becomes sexually active. Hence any impact of the vaccine on the epidemic will be delayed.

      —  an alternative strategy, of vaccinating adolescents and young adults, would have a more immediate effect on the epidemic. However, getting the vaccine to these age groups would present a greater logistical challenge for developing countries, since adolescents and young adults do not already access other vaccine services.


  We welcome the recent announcement of dialogue between UNAIDS programme and five major pharmaceutical companies on how to broaden access to HIV-related drugs in developing countries. However, even with massive price discounts (eg 95 per cent or more), the vast majority of people living with HIV/AIDS in developing countries will not be able to benefit from antiretroviral therapies:[11]

    —  the issue is not solely one of cost. Antiretroviral therapy is complex and requires specialist monitoring. Health service infrastructures in developing countries are inadequate to deliver these treatments safely to large numbers of affected people.

    —  it is not obvious that broadening access to complex medicine represents the best health investment for developing countries. There are difficult choices to be made, but strengthening primary health care and improving access to clean water, sanitation and basic services may be a more appropriate strategy for benefiting people affected by HIV/AIDS and other diseases. Clearly, any improvement in health service provision is difficult in the face of the overall social and economic impact of the epidemic.

    —  improved primary health care could usefully include much better access to cheap, generic palliative drugs such as painkillers and antidiarrhoeals. These would benefit people with a variety of diseases, and in the case of HIV/AIDS could lead to significant improvements in quality of life and productivity.

    —  there is a particular problem in access to opiates in many developing countries. Some controls are necessary to prevent abuse of these drugs, but over-regulation and lack of understanding among health professionals lead to many people suffering severe pain unnecessarily. New regulations and guidelines and training for health professionals are needed to promote appropriate use of these cheap effective drugs.

    —  since the presence of other sexually transmitted infections (STIs) increases the risk of HIV transmission, cost-effective, evidence-based STI treatment and control programmes are particularly valuable. Also important are the promotion and distribution of condoms to prevent transmission of HIV and other STIs. There is the potential for public/private partnership in the promotion and delivery of both condoms and STI services. Some businesses are already subsidising condom provision for employees.

    —  Drugs for the prevention and treatment of opportunistic infections associated with HIV/AIDS are another important issue. The UNAIDS programme recently recommended that adults with symptomatic HIV/AIDS and children with symptomatic or asymptomatic HIV/AIDS throughout Africa should receive routine daily treatment with cotrimoxazole, a cheap antibiotic which can prevent some serious opportunistic illnesses. However, even this relatively simple treatment can have serious adverse effects and requires the advice of a trained health worker. Hence implementation of the UNAIDS recommendation will pose challenges for developing country health services.


  The one purpose for which widespread use of antiretroviral drugs may be feasible in developing countries is in preventing HIV-positive women from transmitting the virus to their babies around the time of birth. It has been known for some time that giving a course or a drug called zidovudine[12] (also called AZT) to the mother before birth and then to the baby can reduce the risk of the baby becoming infected with HIV. In some counties (especially South Africa) there has been controversy about whether this treatment should be implemented widely. Although there is some evidence suggesting it can be cost-effective compared to other health interventions, in counties where the prevalence of HIV infection is high the total cost of implementation could be prohibitive. Moreover, there are logistical difficulties in delivering this treatment in developing countries where pregnant women may not be in contact with health services before the onset of labour.

  Last year, however, a ground-breaking paper showed that a different drug, nevirapine, can also reduce the risk of mother-child transmission of HIV. This is much easier to deliver since it involves only two doses, one given to the mother during labour and one to the baby, and the cost of the drugs is only US$4 per mother-baby pair. Hence nevirapine for prevention of mother-baby transmission of HIV may be a genuinely feasible and affordable intervention for developing countries. A number of issues remain, however:

    —  there is evidence that the most cost-effective way of using nevirapine in many African countries would be to give it to all women and babies, without first testing for HIV. There are potentially ethical difficulties, however, in giving medication to healthy people who do not need it, as there could be as yet unrecognised long-term adverse effects.

    —  the alternative of offering women HIV tests and giving nevirapine only to those who test positive and their babies, can also be problematic. There are good reasons for broadening access to HIV testing in developing countries, to enable people to find out their status and plan better for the future. However, targeting testing specifically towards pregnant women potentially exposes them to a risk of stigma and discrimination including rejection by their husbands/partners (who will, in many cases, have been the source of the infection). Community education measures to combat stigma and discrimination are urgently needed in many developing countries.

    —  although nevirapine is a simple oral treatment, its administration still requires women to have access to at least basic health care around the time of labour. Fortunately, this fits well with recent thinking among international development agencies on the importance of increasing access to obstetric services in order to reduce maternal mortality from causes unrelated to HIV.

    —  neither nevirapine nor zidovudine treatment schedules prevent transmission of HIV from the mother to the baby via breast-feeding. Where formula feed is affordable and can be used safely, it is a valuable means of preventing transmission. However, in developing countries formula feed may cost more than the annual family income, water supplies may be inadequate and are often contaminated, and other diseases are common. In such circumstances, the protection of clean, balanced, antibody-rich and nutritionally appropriate breast milk makes breast-feeding the best option, even though the risk of HIV transmission is significantly increased.

    —  preventing mother-child transmission of HIV does not protect these children from the risk of later orphanhood. Death rates are likely to be higher among the uninfected children of HIV positive compared with HIV-negative mothers, because of the impact of maternal illness and death on the care they receive.

  In conclusion, although the recent research on nevirapine offers real hope for the future, HIV/AIDS will continue to have a devastating impact on child mortality. We welcome the development of trials such as PETRA looking at alternative treatment programmes to prevent mother-child transmission which are affordable and achievable in developing countries.

  Meanwhile, the international development target for a two-thirds reduction in infant and child mortality by 2015 appears severely threatened by the HIV/AIDS epidemic. Such mortality is rising in much of sub-Saharan Africa.


  The HIV epidemic is intricately linked with tuberculosis. In developing countries a high proportion of people are infected with the tubercle bacillus, but usually this remains latent and does not cause disease. Concomitant infection with HIV dramatically increases the risk of tubercule infection leading to active tuberculosis disease, which is the most common HIV-associated opportunistic illness in many developing countries. Hence the HIV/AIDS epidemic has led to a major increase in tuberculosis incidence.

  Tuberculosis is also interesting for another reason. Even when the person is co-infected with HIV, tuberculosis is curable. The WHO Directly Observed Treatment/Short Course (DOTS) approach involves taking a combination of drugs regularly for a few months. Failure to take the treatment correctly not only leads to resurgence of tuberculosis disease, it can also cause the tubercle bacillus to become drug resistant and prevent future treatment from working. The same can happen if antiretroviral treatment for HIV is not taken correctly—the virus can become resistant to the drugs. Despite the fact that tuberculosis treatment is fairly cheap, and much less complex than antiretroviral therapy for HIV, many developing countries have experienced difficulties in implementing tuberculosis treatment programmes. Although the DOTS approach helps ensure drugs are correctly taken, effectiveness is bedevilled by poor management of drug supplies, incorrect prescribing specially in the private sector, and lack of public and patient education about the need for correct and complete treatment. A country's success in implementing tuberculosis control can therefore be perceived as a barometer of the quality of its health sector management. It is hard to see how districts or countries which are failing to manage tuberculosis effectively could be ready for the much greater challenge of antiretroviral treatment for HIV (other than for prevention of mother-child transmission). Strengthening tuberculosis programmes will, however, benefit people with HIV as these are the group at greatest risk of developing active tuberculosis.

BMA Foundation for AIDS

June 2000


  We have not attempted to reference this memorandum fully, but suggest that the following source materials may be of particular interest:

  World Bank presentation on the development impact of HIV/AIDS (source of graph on life expectancy)

  Joint United Nations Programme on AIDS (UNAIDS). AIDS epidemic update; December 1999.

  UK NGO AIDS Consortium Working Party on Access to Treatment for HIV in Developing Countries. Access to treatment for HIV in developing countries; statement from international seminar on access to treatment for HIV in developing countries, London, 5-6 June 1998, The Lancet 1998; 352; 1379-80.

  Guay L A, Musoke P, Fleming T et al. Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention of mother-to-child transmission of HIV-1 in Kampala, Uganda; HIVNET 012 randomised trial. Lancet 1999; 354; 795-802.

  Marseille E, Kahn J G, Mmiro F, Guay L, Musoke P, Fowler M G, Jackson J B. Cost effectiveness of single-dose nevirapine regimen for mothers and babies to decrease vertical HIV-1 transmission in sub-Saharan Africa. The Lancet 1999; 354; 803-809.

11   Antiretroviral drugs act directly on HIV to suppress viral action and prevent development of AIDS. They have led to major improvements in health and survival for people with HIV in the UK and other developed countries. To ensure effectiveness and prevent the virus from becoming drug resistant, treatment must be monitored and a person must use more than one such drug (UK guidelines recommend at least three). Treatment should be given continuously on a long-term basis-ideally for life. Back

12   Prevention of mother-child transmission is the one circumstance in which it is acceptable to use only one antiretroviral drug at a time. Back

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