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Lord Ezra: My Lords, it is indeed satisfactory to note that a real and continuous effort is being made to

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remove the subsidies. They have been in place for many years, particularly in certain countries such as Italy and Spain. Will the noble Lord indicate when effectively the subsidies could be removed? Secondly, a problem that arose in the removal of subsidies related to the social consequences that their removal would have in those countries where alternative possibilities for employment were practically negligible. Has that problem been tackled?

Lord Simon of Highbury: My Lords, it would be wrong to say that there is a target date for the removal of all the subsidies within the system. They are coming down very quickly. Those countries which have the highest levels are under the greatest pressure at Council meetings to remove the subsidies. In Spain in particular there have been successful developments within the industry in that direction.

As to the balance between reduction of subsidy and the social impact within various countries, those are matters for national governments. They are discussed at Council level but form part of the national plan for labour market flexibility and development that has been devolved to each country to solve. That is the right approach. I do not believe it is right for the Commission to try to handle labour market flexibilities and compensations between industrial sectors in the economy as a whole. As most of us would agree, the matter can be handled more effectively at a national level with an overall target to reduce across Europe the level of subsidy.

Audiology Services

3.2 p.m.

Lord Clement-Jones asked Her Majesty's Government:

    What steps they are taking to ensure that there is an increase in hearing tests and a reduction in undiagnosed hearing loss.

The Parliamentary Under-Secretary of State, Department for Health (Baroness Hayman): My Lords, the Government are committed to the provision of high-quality audiology services that minimise the risk of undiagnosed hearing problems, and in June 1997 my right honourable friend the Secretary of State for Health helped to launch the Royal National Institute for Deaf People's information campaign for general practitioners.

In addition, the Department of Health has recently commissioned a review to look at the acceptability, benefit and costs of early screening for hearing disability.

Lord Clement-Jones: My Lords, I thank the Minister for that helpful reply. What steps are being taken by the department to iron out local variations in the waiting times for both hearing tests and the fitting of hearing

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aids, which are currently considerable? Will the primary care groups that are now being set up have a role to play?

Baroness Hayman: Yes, my Lords, the noble Lord rightly points to the fact that there are variations in the service throughout the country. In 1997 the National Health Service Executive set up a working group to examine hearing aid services. That has since been broadened to include audiology services, as the two services need to be looked at together, and to see what can be done in line with the new NHS programme for equity of access and high-quality services to improve and iron out unwarranted variation in service.

Lord Ashley of Stoke: My Lords, my noble friend's response to the Question was very helpful. Many people suffer deafness unnecessarily if it is not diagnosed or treated. Recognising, as she does, that something has to be done, does she agree that we need to improve the staffing levels in audiological services and the range of hearing aids? Does she further agree that we should also try to improve, as far as we can, all the arrangements relating to audiological services? In Britain today those services are inadequate and inconsistent. As the Minister said, they are variable--thanks to the Tory government. What do the present Government intend to do about that?

Baroness Hayman: My Lords, the noble Lord is right to recognise the problems in audiology services which he and many others have taken a great deal of effort to draw to the attention of government. I hope that when we see the results of both the hearing aid review and audiology services we can take action to implement higher quality services across the board. There are ways in which that could be done: for example, by using outreach sites and providing more access, and in promoting awareness among general practitioners. The primary care groups will be an important mechanism for ensuring that general practitioners provide a high quality of care in their localities for those people with hearing loss, who are the second largest group of people with disabilities in the country.

My noble friend referred to a range of hearing aids. As he is aware, a range of potential appliances is supplied by the NHS. More than half a million hearing aids per annum are used within the NHS at a cost of £16 million pounds. We must also examine continuing advances in technology.

Earl Howe: My Lords, to take up the point made by the noble Lord, Lord Clement-Jones, is the Minister aware that waiting times for hearing tests vary around the country from a matter of days to up to 18 months, and that having a hearing aid fitted can sometimes take several months longer? Is that not a good illustration of how bare numbers on a waiting list are a poor indicator on their own of patient need? Does she agree that a much better indicator is the length of time patients have been waiting for a consultation or treatment?

Baroness Hayman: My Lords, these are not "either/or" issues. We have to examine the whole

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provision of services. The noble Earl is right to point out that we must examine everything that is offered to a patient who requires care, not simply one small part of the process.

Referring to what I suspect underlies the noble Earl's question, as well having great success in reducing numbers on the waiting list, we are also, as he will be pleased to hear, having enormous success in reducing waiting times.

Access to Justice Bill [H.L.]

The Lord Chancellor (Lord Irvine of Lairg): My Lords, I beg to move the Motion standing in my name on the Order Paper.

Moved, That it be an instruction to the Committee of the Whole House to whom the Access to Justice Bill [H.L.] has been committed that they consider the Bill in the following order:

Clause 1, Schedule 1, Clauses 2 to 7, Schedule 2, Clauses 8 to 14, Schedule 3, Clauses 15 to 22, Schedule 4, Clauses 23 to 35, Schedule 5, Clauses 36 and 37, Schedule 6, Clauses 38 to 51, Schedule 7, Clause 52, Schedule 8, Clauses 53 to 61, Schedule 9, Clauses 62 to 75, Schedule 10, Clause 76, Schedule 11, Clauses 77 to 80.--(The Lord Chancellor.)

On Question, Motion agreed to.

HIV/AIDS in sub-Saharan Africa

3.7 p.m.

The Earl of Sandwich rose to call attention to the case for an adequate contribution to the control and prevention of HIV/AIDS in sub-Saharan Africa; and to move for Papers.

The noble Earl said: My Lords, it is a considerable honour to lead this debate today. I am grateful to everyone who is taking part, especially since over Christmas I had a terrible feeling that I might be a solitary speaker. I am relieved to see so many noble Lords present. We are discussing an issue of great importance to all of us; namely, an epidemic of the human immuno-deficiency

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virus in sub-Saharan Africa which claims thousands of lives every day, affecting 21 million, or two-thirds, of the 33 million who are infected with HIV worldwide.

If this were a war in Africa with the same death toll as AIDS, we should be discussing it every day. Someone dies of AIDS in Africa every time I finish a sentence. Nearly 2 million have died in Uganda alone. It is a topic as serious as war in terms of the loss of human life, its drain on resources and health services and its catastrophic effect on Africa's economy. In some countries in Africa this sense of urgency exists; in others, especially in rural areas, where there is less awareness, the victims are getting younger and there is a crisis still to unfold.

I intend to speak from recent experience in East Africa, mainly a rural AIDS programme supported by Christian Aid and Youth With a Mission. I shall also refer to other regions.

I salute the work of UNAIDS which, through its website, has helped to promote the cause of AIDS sufferers the world over. In Uganda, an estimated 870,000 adults and 67,000 children under 15 were infected by HIV/AIDS at the last count, roughly one in 10 Ugandan adults. One million more are orphans. Half the hospital beds in Kampala today are occupied by HIV patients.

Other parts of Africa are even more seriously affected. In South Africa, one in eight adults live with HIV infection. In Zimbabwe, one survey shows that between 20 per cent. and 50 per cent. of pregnant mothers are infected, with at least one third of them likely to pass HIV on to their babies. Botswana, Namibia and Swaziland are hard-hit, with one in five people aged between 15 and 49 living with HIV. Zaire, where HIV was first reported, continues to suffer, while many areas are afflicted by civil war. West Africa, on the other hand, seems comparatively stable, with Senegal a recognised example of successful prevention.

AIDS poses a particular threat to young people, with most new infections concentrated in younger age groups. Adolescent girls under 18 may be five times more likely to die of AIDS than women of 20 to 25, according to WHO. Save the Children is one agency that I know is especially concerned about abused and vulnerable children. Children as young as seven, it says, should be receiving education about AIDS in primary schools. Its staff are successfully using peer counselling to spread the message in countries like Mozambique.

Another sad consequence of AIDS is the number of orphans: over 7 million in Africa. In Uganda alone, the number of children who have lost their mother or both their parents was 1.1 million at the end of 1997, a larger number than the orphans from the civil war. AIDS is responsible for about 40 per cent. of all Uganda's orphans and this figure is bound to increase as an average of two-thirds of babies born to infected mothers escape infection themselves.

As a patron of the UK UWESO Trust (that is Ugandan Women's Efforts to Save Orphans), I am concerned that these children should be as high a priority for aid donors as I know they are for Uganda

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itself. Almost every family there has suffered losses, some multiple, as I soon discovered when meeting people during my visit last September. I will only mention a few personally known to me. Sam, the able young director of the Kangulumira AIDS project has lost two sisters to AIDS. Rebecca, a staff member, had lost her father, stepmother and uncle before she was 20. Fatuma, like so many other widows, was chased out of her husband's family house soon after he died of AIDS, then lost four children to the disease and related causes, besides contracting it herself. Finally, Eva, who trained as an AIDS counsellor and health worker told me:

    "Every day we heard of someone dying in my village. One night I dreamed I was helping HIV patients. So I began visiting their homes, cleaning, washing for them and listening to their problems".
In the last three years, 81 local volunteers like Eva have received basic training in community healthcare, to serve 35 villages in the area. They are primary school teachers, farmers, members of women's groups, friends of AIDS patients, ordinary people who care what happens in their community and who now complement the 45 full-time health workers.

As a result of all this, Uganda, like Thailand, is one country on the emergency list where there has been measurable success in the past few years. A progressive decline in HIV prevalence rates has been recorded in ante-natal clinics in Uganda since 1992. The number of infected pregnant women has halved. UNAIDS reported a decline from 13 per cent. in 1994 to 9 per cent. in 1997, especially among urban Ugandans in their early 20s. The Medical Research Council confirms this trend.

Elsewhere in East Africa there is some preliminary evidence of decline. For example, in urban areas of Kenya there was a reported decline between 1995 and 1996 and later figures are expected to confirm that. Tanzania is also showing positive signs.

Why has this happened? Uganda's success follows from the commitment of health workers and community leaders, and the vigorous campaign by the government, media, schools and religious bodies to bring awareness of AIDS into every family. The Churches regularly mention AIDS and safer sex, there are posters and news-sheets advertising condoms everywhere and a remarkable honesty and openness exist which would adorn a health education campaign in any society.

A network of Ugandan NGOs and others from abroad, working alongside the health services, are active in care, self-help and training. Mildmay International, which has a good reputation in AIDS palliative care, has opened a new centre outside Kampala which hopes to train health workers over a wide area. Other NGOs have deliberately chosen to work in more deprived rural areas.

Yet the conditions which help AIDS still thrive. The MRC Uganda study shows that the presence of sexually transmitted diseases greatly increases the risk of HIV infection. Genital herpes, for example, infects nearly three in every four young women under 21, yet only 5 per cent. of women and 10 per cent. of men complain of symptoms, indicating that only a small minority are aware of or admit to its presence.

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The necessity, therefore, for prompt treatment of both STDs and AIDS implies that in Uganda there is still a huge potential for containing the epidemic altogether, provided that resources can be well targeted. The training of health workers in particular is a priority in all areas where there has been a high HIV incidence.

Beyond patterns of behaviour loom larger issues of endemic poverty and the shortage of skills and resources. The AIDS epidemic has again revealed the appalling inequality in resources between our own society and the developing world. There is a scientific imbalance which has allowed patients in industrialised countries to benefit from the anti-retroviral vaccine. But more critically, in my view, there is a developmental fault line which allows us the luxury of an almost comprehensive health service and leaves national health and education budgets in Africa with only a few dollars per head. I need only quote the chairman of the local council in Kangulumira:

    "Our problem here is poverty. Good as the training is, if the people have no sanitation and clean water, and if illiteracy is as high as 60 per cent., unless we improve these services, how can we improve the people's health?"

Some will still counter this with the old chorus of corruption, political influence and inefficiency. But if we had been put off by that, we would never have conquered ill health in the 19th century. Like our Victorian forebears, we have to make a much greater world commitment to sanitation and clean water supply if we can ever hope to defeat epidemics like AIDS and cholera. As the Secretary of State said on World AIDS Day:

    "AIDS is more than a health issue, it is an issue of deepening poverty".
We have evidence from one study in Tanzania that 42 per cent. of AIDS incidence was reduced by the provision of a clean water supply. The aid agencies have other examples. Yet will our OECD leaders ever open their eyes wide enough to see poverty and not Saddam Hussein as the biggest threat to the world today?

One way for our Government is to work through trusted local community organisations and NGOs, wherever possible. Aid should be highly targeted and carefully monitored. It is often not money which is lacking but a well-designed project which truly involves and specifically reflects the local need.

Even if we do not find an affordable vaccine for AIDS in Africa, we could alter the conditions which allow it to flourish. The question is whether the risks of the epidemic will so alarm the industrialised world that it will be forced to take more action through the World Bank and the IMF.

One possible motive may be economic. The world cannot afford to allow an economy like that of South Africa to fail because of its inability to tackle the acute problems of education and health left behind by apartheid. Increased economic activity, migration and the ability of countries to trade have been a strong force behind the greater movement of labour. The habits of long-distance drivers and traders have encouraged

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prostitution and the spread of infection. This is another reason for the business community to step up its support for AIDS campaigns.

AIDS is taking a heavy toll among skilled people, and businesses are already counting the cost. One company in Zambia reported that losses through illness and death from AIDS cancelled out its entire annual profits. In Zimbabwe, insurance premiums have quadrupled. On the other hand, investment by companies in AIDS and STD prevention has been shown to save a high proportion of those losses.

I have the following question for the Minister: are the Government taking enough of a lead in the OECD to back vaccine research and attract funding which will lead most quickly to the development of vaccines?

Political endorsement for national AIDS campaigns by leaders such as Mandela and Museveni is essential. I met President Museveni just before the address to the seminar on AIDS and I was impressed by his words and his famous determination and commitment which has got Uganda where it is today. He said that Uganda needed to use activist methods to reach the widest cross-section of people and to involve the consumers of health in their own health care. President Mandela's New Year message reaffirms the ANC's pledge to end poverty and inequality. He said that every sector of civil society declared its commitment to help turn the tide against this epidemic.

Unfortunately, this tide has not yet turned in South Africa or elsewhere in the region. The Health Minister there has been criticised for preferring prevention to treatment, but at least she has helped to raise the profile of AIDS. This year's World AIDS Conference in Durban should help, but it will require more political will there, and elsewhere in Southern Africa where firm leadership is less obvious.

Governments are trying to find an effective and affordable AIDS vaccine for Africa, but the £10,000 or so a year needed for every patient to have triple anti-retroviral therapy is far beyond most families' means, and scientists have yet to agree on the best way forward. The World Bank and UNAIDS are financing an interesting scheme in Cote d'Ivoire. Expectations are being raised but it seems that disappointments are inevitable. The International AIDS Vaccine Initiative has made a start. For example, it supports Professor McMichael's research in Oxford, involving an East German company, which will be tested later this year. IAVI has another project to develop a new vaccine for South Africa.

The problems are the urgency and scale of the need, the high cost, and inadequate backing from pharmaceutical companies. I ask the Minister: is the UK response to the epidemic adequate? Is it concentrated enough on rural development--for example, primary health care, prevention and education--which will ensure that more can be helped at home in rural areas? Are resources too highly concentrated in certain countries? What co-ordination exists among the donors, especially the European Union? Are the Government satisfied with the present level of funding of £2.7 million from the Uganda budget, or are they waiting to see what needs arise

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elsewhere in Africa? Specifically, are the Government taking more action to educate younger, primary-age children about the risks of unprotected sex and HIV?

In conclusion, as deaths from AIDS in the UK fall and more and more of our patients benefit from vaccines, I am sure that we would all like a reassurance that we are doing our utmost to turn the spotlight of funding and research towards Africa and parts of Asia where the need is more acute. Surely more could be done to identify isolated communities, where a higher investment in health and education would prevent the epidemic occurring in the first place. My Lords, I beg to move for Papers.

3.23 p.m.

Lord Judd: My Lords, I am sure that the whole House will want to congratulate the noble Earl, Lord Sandwich, for introducing this important subject today. It is characteristic of his very practical and deep commitment to humanitarian issues across the world. I am sure that the Government will take very seriously everything that is said in the debate.

I hope that the noble Earl will agree with me that if we are to look at the issue of sub-Saharan Africa, it is very important that we look at that in the context of the global situation and the global challenge to governments who are trying to meet this terrible crisis.

Worldwide, more than 30 million children and adults are estimated to be living with the virus. This could be 40 million by the turn of the century if current trends continue. The principal UN agencies concerned estimate that 5.8 million people became infected in 1997 at a rate of 16,000 new infections per day. Sixty per cent. of new HIV infection is in the 15 to 24 year-old age group, underlining the vulnerability of young people. More than half of the world's population is under 25, and more than half will have had unprotected sex before the age of 16. Increasing drug abuse exacerbates the problem. Ninety per cent. of infants living with HIV contracted the virus from their mothers. More than 8 million children have lost mothers to HIV/AIDS.

In an excellent policy paper, the Save the Children Fund has summed up the situation in these words:

    "Many factors contribute to the spread of the virus. These are firmly rooted in poverty, both micro and macro economic, social deprivation, gender inequity, cultural attitudes and behaviour, under-resourced health, education and welfare services, conflict and war, the movement of people and growing urbanisation, a lack of preventative education and services to the 10-19 year old age group, discrimination and a lack of political and legal commitment".
The paper continues:

    "There is no cure for AIDS...It is anticipated that it could take another 10 to 15 years to develop a preventive vaccine. Meanwhile HIV continues to spread virtually unchecked, particularly in the poorer nations of the world where 90 per cent. of current HIV infection is located".
That, of course, is very much sub-Saharan Africa.

The noble Earl referred to the position of SCF. The SCF paper stresses that children are seldom seen as a priority for HIV preventive work, and that usually children are targeted too late. As the noble Earl has said,

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sexual experience--usually unprotected--first occurs between the ages of seven and 15. But the majority of children are denied access to the services, education and information which could help them to protect themselves from the disease.

Globally, epidemiological data are not available on HIV/AIDS for children between the ages of five and 19. Consequently, children are not prioritised for prevention. It is essential to highlight data on age of first sex, teenage pregnancy, incidence of sexual abuse and exploitation, non-consensual sex and child prostitution. It is also vital to emphasise that, although women and girls are biologically and socially more vulnerable to HIV/AIDS, preventive work nevertheless too often lacks a gender-sensitive approach. For every four men living with HIV, there are six women living with it. Obviously, the protection of women and girls from HIV is the key to the prevention of mother-to-child transmission.

The Save the Children Fund spells out three social consequences. In most societies, women and children are most vulnerable to HIV infection, yet often it is they who carry the major burden of care and support. The number of children orphaned by HIV/AIDS challenges the abilities of communities to cope. The capacity of welfare and health systems can also be challenged when children are needlessly institutionalised as a result of HIV/AIDS. SCF argues that, whenever possible, children living with the virus, or orphaned as a result of it, need to remain with family and community. That makes humanitarian, social and economic sense.

The recognition of the wider social and economic impact of the HIV/AIDS pandemic is shared by us all. The United Nations system is doing heroic work--with, as usual, far too few resources--and the Save the Children Fund is not alone as a non-governmental organisation in its courageous endeavours to grapple with the crisis. Among numerous other NGOs, Oxfam--here I should declare an interest as a former director and currently an Oxfam Association member--has repeatedly made the point that, even with the eventual development of a preventive vaccine, there will be no quick fixes. Simplistic interventions which address HIV/AIDS prevention in isolation from political, economic and social realities are doomed to prove ineffective. Like SCF, Oxfam argues that it is imperative to integrate HIV/AIDS work into national poverty reduction plans. That means that HIV/AIDS ought always to be part of policy and programme assessment, of monitoring and of evaluation. When my noble friend comes to reply, it would be good if she could reassure us that, in fact, it is.

Of course, HIV/AIDS programmes should always be part of strengthening overall health systems, social development and education programmes. The relevance of the functional approach to literacy, dealing with the responsibility of men as well as of women, with gender awareness, with health and with social hygiene, cannot be over-emphasised.

I am sure that my noble friend agrees that macro-economic policies are criminal in effect when they undermine the ability of society to cope. They are also stupid by making long-term social and economic

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viability even more difficult to achieve. Instead, macro-economic policies should invariably seek to strengthen coping capability. I would be grateful if my noble friend could reassure us on how this is being ensured.

There are four priorities to which many of us in the front line of the battle against HIV/AIDS are deeply committed. I hope that my noble friend can deal with them when she comes to reply. First, access to basic healthcare is crucial to the prevention and management of HIV/AIDS. This requires primary healthcare systems that work, with access to essential drugs, referral systems and, above all, to information and to the treatment of sexually transmitted diseases.

Secondly, policies that deal with gender inequality and the empowerment of women are indispensable if women's vulnerability to HIV/AIDS is to be decreased. That demands legislation designed to improve the status of women, including their access to education, employment and decision-making at all levels of social organisation ranging from the household to the political arena.

Thirdly, there needs to be emphasis on community participation in programme design, monitoring and evaluation which is meaningful and goes beyond simply sharing the costs of the programmes.

Fourthly, on the global stage, new trade agreements and intellectual property agreements should take fully into account the implications of patent laws on current and future access to the drugs that are needed to fight HIV/AIDS.

There must be collaboration between donors, UN agencies and national governments to promote sustainability and cost-effectiveness. Civil society, including a wide range of non-governmental organisations, has a major part to play in raising awareness and ensuring human rights in relation to HIV/AIDS. Whatever the Government can do to facilitate this deserves all possible support.

3.32 p.m.

Viscount Brentford: My Lords, I too thank the noble Earl for introducing this subject. The figures are horrendous. As he rightly said, this problem affects more people than most wars that come to mind. Two-thirds of the world's population with HIV and AIDS live in sub-Saharan Africa. Eighty per cent. of women with HIV throughout the world (8 million), 90 per cent. of children born with HIV infection, and 95 per cent. of all children who have lost their mothers through AIDS live in sub-Saharan Africa. This is an horrendous problem and that particular area suffers the most.

When my son worked in Kampala he set up a scheme to work with street children, to help them and to rescue them. He confirmed to me that quite a number of boys living on the streets (albeit only a minority) had been orphaned because both parents had died of AIDS. The extent of this problem hits one when one visits those countries. Already 11.5 million have died of AIDS-related illnesses in sub-Saharan Africa. That is an horrendous figure.

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It is important to note that not only do many people suffer because of HIV/AIDS, but economies and businesses are also hit--and that will therefore have an effect on the UK economically. Aidscap calculates that by 2005 Kenya will have lost 14 per cent. of its GDP because of AIDS. Other countries will be in a worse state. That will affect UK trade, as well as Kenya's trade. The costs to businesses in those countries (of lost productivity and of replacement training) are very high--let alone all the costs of looking after suffering people.

In that part of the world, HIV transmission arises primarily from two sources, neither of which is related to homosexual contact. The first is generally through heterosexual contact. In some countries, over 40 per cent. of women who attend antenatal clinics are HIV positive. This is true more in southern Africa rather than further north in sub-Saharan Africa. Where there is appropriate access to information and services, it appears that the age of first sexual intercourse rises, which is good news. In addition, the use of condoms, including female condoms is spreading. That helps to slow the spread of HIV. A recent survey in Kenya revealed that on average girls lost their virginity between the ages of 14 and 15 because there was no reproductive health education in schools to educate girls to avoid early sex. That is very damaging in terms of the increase in HIV.

The second means of HIV transmission is from mother to infant at birth. Preventive approaches prove to be highly cost-effective, because obviously a great deal of money is saved if babies do not suffer from HIV. I understand that Glaxo-Wellcome has produced the drug AZT which appears to reduce the spread of HIV from mother to infant. Perhaps the noble Baroness is able to confirm that that drug is proving to be effective in sub-Saharan Africa.

In conclusion, I make three points. First, I return to the problem of motherless children. Community visiting, involvement and responsibility seem to work well when in place. In Zimbabwe, for example, there are schemes under which village heads take the initiative and villages make provision for AIDS orphans. They give practical support, such as the setting aside of village land to be cultivated to provide money and practical help for those orphans, and emotional support and guidance. It is good that the local community should take that initiative, but with the possibility of the disease spreading throughout the area, will communities be able to cope? Have the Government discussed this matter with the national governments of sub-Saharan Africa? Can more help, both practical and financial, be given to them?

Secondly, I refer to education, information and training, particularly for the young. What are the Government's present plans to encourage training so that young people in particular can take control of their own sexual and reproductive health? We are very grateful to the Government for having provided £2 million for the Mildmay Centre in Uganda. What are the future plans of the Government in that respect?

Thirdly, I understand that use is being made of charities and NGOs, some of which have already been mentioned. I refer to the Mildmay Centre and to Aids

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Care Education and Training (ACET), to both of which I am indebted for up-to-date information and with which my wife and I have worked for many years. I look forward to an encouraging response from the noble Baroness.

3.39 p.m.

Baroness Miller of Chilthorne Domer: My Lords, all noble Lords are inclined to begin their speeches with statistics. I shall refrain from doing so because the statistics that have been quoted are shocking. I share the frustration of the noble Earl, Lord Sandwich, that despite the statistics we appear to have such a quiet world disaster on our hands. All of us who have worked in that part of the world for any length of time are outraged by it. Even when the UN report came out in the autumn of last year highlighting these astoundingly dreadful statistics, it was barely reported here. If this scale of death were occurring through famine or war, especially if it were occurring nearer home in Europe, we should consider it a world emergency and it would be headline news every day. Is it because the disaster is further away or is it because public response is still tinged with, "AIDS is a result of casual sex so people get what they deserve"? I certainly hope that is not the case, but let us not forget that it is not so long ago that it was highly newsworthy in Britain when the late Princess Diana shook hands with an AIDS victim to show that AIDS was not abhorrent or something to fear.

In addressing this problem, enormous efforts need to be made to keep the still healthy population healthy. In the country of which I have experience, Botswana, it is estimated that one in four adults is HIV positive. That means that three adults in four are still healthy. References have been made to the production of effective vaccines, and that is a priority, but in the short term we must concentrate hard on what should happen between now and the production of that vaccine.

The widespread provision and use of reliable condoms is vital, but the problems concealed in those few words are tremendous. Who in political circles, especially at the more local level, will raise the real problems involved in achieving widespread use? The noble Earl referred to the fact that openness is the key to this. There are very few women in decision-making political arenas, especially local ones, in sub-Saharan Africa. My own area of work in Botswana was with women at local council level. The British Council played a great role in terms of enabling that programme of empowering and trying to raise the confidence and awareness of women at a local political level. Women there have a battle to make their voices heard. They are substantially in the minority and are usually kept on the back benches. When it comes to the men, a lot of what has to be said about condom use is difficult and embarrassing. Which male politician, especially in his own local community, not in the safety of his national parliament, wants to address the real reasons why his colleagues, friends and voters will not use condoms? The fact is that men do not like using them, and one does not have to be an expert on AIDS in sub-Saharan Africa to know that. But the situation is more extreme in

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countries where there may be greater cultural resistance, where women are less able to insist upon their use and where some of the women are still girls who feel unable to insist, with older men, that they should use a condom.

I agree with noble Lords who have already spoken that among the younger age group it is crucial that AIDS education programmes address in an appropriate way what "safe sex" is and how it should be practised. Teachers, especially in the more rural areas, desperately need the material that will enable them to present a sex education programme in an effective way. The UN document on "How to use the right condom the right way" has 19 lengthy bullet points and not one diagram. I do not imply that that document is meant for use in schools, but nevertheless it is on the Internet.

Condoms need to be free and freely available. If you walk down the street in the capital of Botswana, Gaborone, you will come across boys who have bought 10 oranges and are selling them individually to make a profit. Would we seriously expect that they would spend the extremely small profit from their day's work on one condom? I think not. Nevertheless, many couples in sub-Saharan Africa have obtained and used condoms and it has been a bitter irony for some of those couples who did practise safe sex to find that the condoms they relied upon were faulty. British embassies and aid organisations in the region have been proactive in trying to insist on, and maintain, standards, but the history of condom distribution in the region makes very depressing reading. Hundreds of millions of condoms are paid for and tested by international aid agencies, but last year alone 4 million were returned to India because 48 of 200 in some test batches broke.

There has been no worldwide study of faulty condoms and I understand that there is no agreed worldwide strategy for making them more acceptable to use. National governments in the region are up to their ears in the problems of buying and distributing a sufficient number of reliable condoms. They tend to opt for a standard size and type. No wonder many men will not use them. I do not believe that a standard size is applicable. An international "comfortable condom" conference may sound like a joke, but actually it is a matter of life and death.

I should like to reinforce the following two points that were made by other noble Lords. In the rural areas a programme of home-based care is essential and a large volunteer force will be needed to help put that in place. The development of the kind of expertise needed to do this outreach work on a multi-sectoral scale will be an enormous challenge.

I should like to hear the Minister's response as to whether the department has estimated the likely number of orphans in the region by the year 2005. I gather that in Zimbabwe alone it is estimated that the figure will be about 80,000. Who will care for this generation? I am sure that other speakers will touch upon the longer term, but I should like a response on the short-term question of what we are going to do about condom provision.

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3.45 p.m.

The Lord Bishop of Wakefield: My Lords, I am grateful to the noble Earl, Lord Sandwich, for initiating this debate on the world's greatest tragedy of this generation. As yet unpublished figures from UNAIDS point to a situation even worse than had been feared. The infrastructure of countries is being decimated. I know best the countries of central Africa. In Malawi half the teachers, nurses and police are expected to be dead within 10 years and already 10 per cent. of the population are orphaned children. Yet of the global total of 2.6 billion dollars being spent on controlling and preventing AIDS only 13 per cent. is being spent in the developing world, where 92 per cent. of all cases are located.

This imbalance means that enormous responsibility for control, prevention and care continues to rest, as I and others who have visited these African countries have seen, on locally based initiatives, many of them spiritually motivated. The Islamic Medical Association, working through Imams in the mosques, is doing significant work in Uganda. The Christian Churches, strong in sub-Saharan Africa, are responsible, especially in the rural areas, for the bulk of health provision. When urban dwellers are struck by HIV, they often go back, sick and dying, to their families in the villages. As a result more than 50 per cent. of the beds in many mission hospitals are now occupied by sufferers of AIDS-related diseases such as TB. These mission hospitals now face a major funding crisis which is seriously undermining their ability to control these diseases. All over Zambia there are now health centres and hospitals with no supplies, no drugs, no gloves to protect against infection and no syringes. At one rural health centre which I visited injections have been given with one unsterilised needle.

I am grateful to the noble Earl, Lord Sandwich, for his reference to the Churches' role in preventive education work. Sixty per cent. of rural primary schools in Malawi and Zambia are now run by the Churches. But, as the noble Viscount, Lord Brentford, indicated, however hard people try with preventive education programmes, there are always huge gaps. I underline the point made by the noble Baroness, Lady Miller, about the need to emphasise condom use, and I am glad that some of the stricter Christian denominations and Moslems are now approaching this matter with reasonable pragmatism.

I hope we shall not let tragic statistics deflect us from noting the often unspectacular, small but together considerable and significant efforts at control and prevention being made at the grass roots. The Mothers' Union in Africa is doing outstanding work in prevention and care among all age groups. That body and bodies such as the Medical Missionaries of Mary and the local anti-AIDS clubs need our encouragement because there is strong evidence that such local projects help behavioural change, and prevention, and are highly cost-effective.

In no way do I wish to promote the work of Church-related bodies above the outstanding work of others. As the noble Lord, Lord Judd, said, the NGOs

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and governments need to work together and support one another, not least for the sake of better co-ordination and targeting. It is for that reason, I assure noble Lords, and not to score any points, that I say that it is astonishing that the DFID's excellent country strategy papers give little mention of the massive contribution made by the Churches in health and education, and yet workers with other NGOs tell us that those sectors could not now function in most of those countries without the Churches. I hope that that will be taken into greater account in future DFID strategy and included, where appropriate, in sector funding.

I refer also to the Jubilee 2000 campaign and the way in which world debt has so adversely affected these countries, as Oxfam and Christian Aid have so dramatically demonstrated. I repeat a point made earlier. In Africa AIDS is more a symptom of poverty than of vice.

The SAPs encouraged migration and caused low nutrition both helping the spread of HIV/AIDS. The poor countries' initiatives, well intentioned, have led unfortunately to cuts in health and education in all those countries--at the very moment when 87 per cent. of all children in the world with HIV are in Africa.

The Secretary of State made a welcome commitment at the General Synod of the Church of England to the reduction of world poverty. I know that debt relief will not magically end all poverty. I know that one cannot read off economic policies directly from the Book of Leviticus. But the ageless biblical rebuke to those who chain others in debt and poverty has in sub-Saharan Africa rarely had so pertinent a ring.

3.52 p.m.

Lord Rea: My Lords, I, too, congratulate the noble Earl on attracting such a large body of distinguished speakers. There is one snag. A few days ago one's speech was to be 12 minutes long. However, today I may speak for no longer than seven minutes, so there has had to be some last minute truncation and I apologise to noble Lords if my speech is somewhat disjointed.

The noble Earl outlined the severity and extent of the problem; others have amplified and will amplify his account. Some noble Lords may have seen a recent Channel 4 programme. It was called "The Forgotten Plague" because AIDS has slipped from the headlines in the UK. But in parts of the developing world the situation is so disastrous that no less a word than "plague" can describe it. As the noble Earl said, in some parts of southern Africa 25 per cent. of the population are known to be HIV positive. In some areas, the expectation of life has fallen from some 60 years to only 40 years, a decrease of 20 years. The impact of the epidemic has swamped already overstretched healthcare systems and is seriously disrupting development by decimating the brightest and best among the younger population, and among the professionals, as the right reverend Prelate pointed out.

It may be more appropriate for me to talk about some clinical aspects. The HIV cannot usually penetrate normal intact mucosa or skin. It passes from one host to

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another through blood products or broken, infected or ulcerated skin or mucous membranes. These lesions are often caused by another sexually transmitted disease.

In developed countries such as the UK, there is a relatively low prevalence of those "old fashioned" sexually transmitted infections because we have a healthcare system which treats most cases as they occur. In this country the main routes of transmission of the HIV have been through shared needles, contaminated blood products and anal intercourse among gay men, when a small abrasion or split in the anal skin often occurs. But in many developing countries there is a high prevalence of those "old-fashioned" sexually transmitted diseases, largely because of the lack of an effective health infrastructure to provide treatment. As the noble Earl pointed out, many carriers of those STDs are unaware of their condition because they have no symptoms. They are unaware that they are particularly vulnerable to HIV infection. That is probably the main reason why heterosexual transmission is uncommon in developed countries but is the norm in developing countries.

Because effective treatment of HIV infection is so expensive (as well as being only partially effective and difficult to administer) it is not a feasible option for sub-Saharan Africa, as the noble Earl pointed out. The accent clearly has to be on prevention and the care of affected patients, including support for their families. But prevention requires change in customs and behaviour, which is particularly difficult in traditional societies with low levels of education and literacy.

In the UK 12 years ago, a concerted programme of very explicit health education, led by a high-level Cabinet committee, was very effective. But in many developing countries, despite rhetoric, not enough priority is being given to the need for co-ordinated government action across many sectors to tackle the problem effectively.

The excellent UNDP Human Development Report for Namibia states that as well as the Ministry of Health and Social Security, the Ministries of Education, Information, Youth and Sport, Defence, Home Affairs, and Tourism should all be involved, as well as non-governmental organisations, private sector employers, parliamentarians and regional and local councillors. That across-the-board approach is necessary because, despite presidential appeals, until now it could be said that there has been denial at a high level. That does not only apply to Namibia; nor does it apply only in Africa. There is still a reluctance to accept the role of promiscuous behaviour in spreading the infection, in particular if it affects the freedom of action of the person concerned. In many communities an unjustified stigma attaches to HIV/AIDS patients instead of the compassionate attitude which would help them. In South Africa, a woman who "came out" as an HIV-positive patient to help to warn others was stoned to death by other members of her village. The human rights of those afflicted with HIV/AIDS are frequently abused. Last year that matter was the subject of a UN-sponsored consultation on HIV/AIDS and human rights.

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The noble Earl and other noble Lords described the home care programmes which have developed in Uganda and other countries in Africa. There is simply not room in the hospitals for all the AIDS patients, but their terminal days can still be made more comfortable through home care. It is not a cheap or easy option. Good home care requires trained and dedicated people, as has already been pointed out. It is important that those who have TB as part of their AIDS--and there are many--should be treated. Although they developed the infection due to their immune defence system being weakened, they can nevertheless pass it on to others. Often, the TB infection may be due to a multiple drug resistant organism.

Perhaps I may say a final word on vaccine development. I know that DFID was a pioneer in funding vaccine research and intends to provide more resources. Can my noble friend give any news on that front, both about the progress of research to date and future funding? Can she also give any information on the development and use of a very useful new idea: a vaginal antimicrobial preparation which kills the HIV virus in the vagina before it can cause an infection? This is extremely useful for women to use where condoms are not acceptable or available. I know that there are currently trials of this antimicrobial preparation.

4 p.m.

Baroness Masham of Ilton: My Lords, I thank my noble friend for bringing this horrific problem of HIV/AIDS in sub-Saharan Africa to the notice of your Lordships today. In recent years there has not been so much publicity about HIV/AIDS; but to the individual who loses a loved one from this dreaded condition, wherever it may be across the globe, it is devastatingly tragic and sad.

As education is so important, perhaps I may list what the initials HIV/AIDS stands for. Human--it only affects humans; immuno-deficiency--enters and takes over the immune system; virus--capable of entering a body's cell and making new viruses; acquired--cannot be caught passively; immune--prevents immune system working effectively; deficiency--body becomes easy target for illnesses; syndrome--collection of illnesses. No one dies from AIDS. They die because their body cannot cope.

There are 7.8 million AIDS orphans in sub-Saharan Africa. One of the dilemmas is that HIV can be transmitted from an infected mother to her child during pregnancy, during delivery and in breast milk; but in most countries the risk from not breast feeding is greater than the risk of HIV infection.

I commend to your Lordships the work that NGOs are undertaking in some of the African countries. ACET, which stands for AIDS Care, Education and Training, has been working in Uganda since 1990. One in eight people is already infected, with the figure rising to a staggering one in three in high-density urban areas. Though the numbers are very high, HIV infection in Uganda seems to be being contained. Health education campaigns across Uganda are cited as being responsible for this. ACET's Uganda health education programme

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has been awarded major new funding by the United Nations Development Programme. In 1996 it was given £100,000 to duplicate its education programmes and support income-generation projects in the north of the country.

ACET's team sees thousands of children and students face to face to give them education on HIV, and have trained over 100,000 community AIDS workers. ACET is a Christian organisation and finds that, even with large-scale health education campaigns, there is still a place for simple acts of Christian compassion when they are called to help by an individual family. I had the pleasure last year of meeting some of ACET's Uganda team at a reception at Lambeth Palace. It is important that these dedicated and splendid people continue to have our support.

The HIV/AIDS pandemic is threatening Botswana's development. The introduction of drug cocktails to prevent pregnant women from passing HIV/AIDS to their unborn children, home-based care, orphan care and feeding schemes for destitute patients are desperate measures that add to welfare costs. Kenya has been placed among six countries with the world's highest infection rate, along with Botswana, Zimbabwe, Namibia, Zambia and Swaziland. Migration and rape, linked to Rwanda's 1994 genocide, increased the cases of HIV in that country sixfold.

HIV/AIDS is a changing picture in many of these countries. It is thought that some 2 million people in South Africa are unaware that they carry the virus. In recent years tuberculosis cases have rapidly increased. In Zambia it was found that between 50 and 70 per cent. of TB patients were also infected with HIV.

In Zimbabwe governmental organisations are calling on the country's rural communities to end the tradition of men taking over the wives of their late brothers, in an effort to stem the spread of HIV. The practice of wife inheritance, which was originally expected to provide continuity of responsibilities and security for a widow, has been cited as a prime source of HIV transmission.

During 1998 Africa held 5,500 funerals a day for people dying from AIDS, but the death rate is set to increase. At a conference I attended I heard a missionary doctor tell of a grandmother who had buried 19 of her family. My Lords, education in African villages is vital. There may be suspicions that children orphaned due to AIDS are helped by bad spirits--spirits which prevent those who try to help from doing so. Good schemes for the children need encouragement and education is vital.

Back here in England, over three-quarters of the residents presumed to have been infected with HIV heterosexually acquired their infection whilst in Africa. Denial is still a problem amongst African men living in the UK. There is a reticence to be tested and to be treated. African men tend to keep working until they become very seriously ill or even die. There is a need for both prevention and care to be targeted at the African community in Britain. The women can be left holding the baby.

There are some wonderful people helping. I hope the Minister will visit to see the work being done in Great Ormond Street--not the hospital--by a small voluntary

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organisation called Body and Soul. They give day-to-day support to many African women and children.

Many of your Lordships have mentioned the vaccine. Could the Minister tell us what progress there is on this? It must be the solution for world-wide prevention.

4.7 p.m.

Lord Ponsonby of Shulbrede: My Lords, I too should like to thank the noble Earl, Lord Sandwich, for introducing this extremely important debate. It is difficult to exaggerate the devastating effects of AIDS, particularly as regards sub-Saharan Africa. Africa continues to dwarf the rest of the world on the AIDS balance sheet.

Like a number of the noble Lords, I have been searching through the Internet and have come up with probably the same documents as a number of other noble Lords. I shall resist the suggestion of the noble Baroness, Lady Miller, not to repeat statistics, as I think it is worth repeating some of the enormous statistics with which we are dealing.

Seven out of 10 newly infected people live in Africa. Among children under 15 the proportion is nine out of 10. Of all AIDS deaths since the epidemic started, 83 per cent. have been in sub-Saharan Africa and 95 per cent. of all AIDS orphans are African children. The sheer numbers involved are overwhelming. Thirty-four million people living in sub-Saharan Africa have been infected by HIV; of these some 11½ million have already died, and a quarter of them are children.

When I was preparing for my contribution to today's debate I was very conscious of how we must seem worlds away from the problems which we are debating tonight; and how each of those statistics which we repeat, and I have repeated again, represent individual human tragedies on a scale which I for one find quite impossible to comprehend.

For some outside this House, this debate may be seen as an exercise in hand-wringing with no real purpose. I believe that that impression would be wrong and I hope that three central messages will emerge from this debate. First, the Government's response has been appropriate in that the types of programmes which the Government are supporting are having an impact and their support for the various multilateral agencies is appropriate, although there is undoubtedly a need for a greater sense of urgency.

The second message which I hope will come from the debate is that there are examples of countries in Africa which have contained the growth of AIDS. The key to their success has been early and vigorous action in education campaigns. The third message which I hope will come from the debate is that the time to act is now in order to stop that epidemic spreading through eastern Europe and central Asia.

The noble Earl, Lord Sandwich, referred to Uganda. That is a good example of a country which has gone a long way towards combating the crisis. When President Museveni became president in 1986, he literally flooded the country with leaflets about AIDS. He forced

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government departments to take the issue seriously and to implement their own plans to fight the virus. Most significantly, he gave free rein to the various internationally-financed NGOs to educate people about the consequences of risky sex.

One story which I read in the Economist magazine was that a group of AIDS workers visited Uganda from South Africa and Zimbabwe. They were astonished to find that the NGOs in Uganda were distributing extremely explicit sex education material which had the approval of the Ugandan government. The implication of that is that both South Africa and Zimbabwe have been slow to act by comparison.

Another country where firm government action has led to stable and relatively low infection levels is Senegal. There, brothels have been regulated since the early 1970s. A vigorous education programme has led to soaring condom sales which have increased from 800,000 in 1988 to 7 million in 1997. Most significantly, homosexual behaviour is not denied as is the case in so many other countries. There is a denial among many African men in relation to that fact within their own societies.

In the successful education programmes about which I have heard and been briefed in the past few days, one theme is recurrent; that is, the position of young women in African society. That was a point referred to by my noble friend Lord Judd. One voluntary sector worker said to me that the most dangerous thing that a young woman can do in Africa today is to get married. That exposes her to the risk of infection which is very difficult to control. The key to that is empowerment through education but in the general context of broad reproductive health. Certainly from the reports which I have read, there is nothing to be gained from dithering and prudishness.

However, while this debate is looking at sub-Saharan Africa, it is worth reminding ourselves that AIDS is still an emerging epidemic in eastern Europe and central Asia. The virus appeared in those regions only in the late 1980s, 10 years after Africa and Western Europe. The reports that I have read are pessimistic. They say that it is only a matter of time before AIDS increases in those regions. Most alarming is the global rise in TB referred to by my noble friend Lord Rea.

I hope that those reports are unduly pessimistic and that the lessons of Uganda and Senegal can be learned in other regions of the world. I am a rapporteur for the Migration and Refugee Committee of the Council of Europe. I am currently working on a report which looks at the health implications of migration in Europe. While that is wide of the theme of today's debate, my report will make it clear that the uprooting and displacement of people has a tremendously detrimental impact on their health, both for the migrants themselves and their host communities. The growth of AIDS is perhaps the starkest example of that phenomenon. As a result of today's debate, I shall ensure that the examples of Uganda and Senegal are included in my report so that that information can be more widely circulated within Europe.

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This has been an important debate. I do not believe that it has been an exercise in hand-wringing. The Government should take heart because they have addressed the issue in a constructive and methodical way. In particular, I hope that the lessons learnt in sub-Saharan Africa can be applied elsewhere in the world.

4.15 p.m.

Lord Hardinge of Penshurst: My Lords, I too would like to thank my noble friend Lord Sandwich for initiating a debate on this crucial subject. One of the few advantages of slow catastrophes over sudden catastrophes is the possibility of planning for their consequences, and in this case there will be no excuse if we fail to do so. This debate is an excellent opportunity to investigate the possibilities open to us.

In a real sense, the catastrophe has already happened. Only the consequences remain largely in the future. This is not to say that action now cannot ameliorate those consequences, or that lack of action will not permit them to become even worse. But events that have already occurred make terrible results extremely likely.

Others can speak--and have spoken--far more knowledgeably and eloquently than I of the immediate effects. I want to concentrate on the secondary, economic consequences, and on what can be done to ameliorate them. First, I should say that I do not for a moment suggest that the factors I am about to discuss should take precedence over simple humanitarian imperatives. I simply wish to illustrate the nature of the economic effects, which we need to address at the same time.

Those effects are very much accentuated by the fact that AIDS kills people slowly rather than quickly, so that illness becomes a direct and indirect drain on social and administrative networks. Ill people inevitably consume more resources than they can generate. In relation to subsistence agriculture, for example, the sectoral AIDS brief on the University of Bordeaux website draws attention to the domestic-farm interface--the way in which totality of activity in a household or group is far more closely intertwined than in a wage economy. The extended family in sub-Saharan Africa has proved an extraordinarily resilient institution, but it is not infinitely resilient. Family disintegration is clearly an increasing problem: noble Lords have mentioned the 8 million orphans. The pressure on those who are still well will obviously be very great indeed.

Again, national infrastructure in even the poorest countries is quite complex by historical standards, and AIDS attacks its maintenance in a variety of ways. In most countries it is over-stretched already, and may quite possibly collapse.

For other sectors of the economy, the prognosis is equally gloomy. For example, manufacturing is threatened in three main ways: first, illness and death will affect production, training will become an increasing burden and absenteeism an increasing problem; secondly, the same factors, together with the pressures on people looking after, or anticipating looking after, the ill will reduce demand; thirdly,

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taxation is likely to rise, as a result of pressures, generated by the pandemic, on the exchequers of the countries concerned. All of these factors will tend to depress investment and will affect competitiveness.

So what can be done? I think it evident that any extra resources that can possibly be spared should be thrown at the front line of AIDS care, which has been described by a number of noble Lords, and AIDS education. The suggestions I shall now make are, therefore, aimed largely at the reordering of priorities within other existing programmes, to make them more responsive to the situation created by the level of infection, to reinforce the effects of direct intervention, and to help people deal as well as possible with the secondary effects of their situation.

First, structural adjustment and related programmes often impact significantly on health spending. It is doubtful whether this now makes any sense, even in the narrowest economic terms, and it is critical that such programmes take full account of the impact of HIV infection when looking at the control of spending. Formal mechanisms for this would be desirable.

Secondly, priorities can be adjusted in aid programmes aimed at poverty. Programmes which save on labour will move up the scale of importance, and here I point particularly to the provision of ready access to clean water. Significant amounts of time are spent fetching water in many societies, and this time competes with other demands, including those created by the epidemic. It may also be important to give special assistance in countries or regions with a short sowing season, or other labour peaks in the agricultural cycle.

Thirdly, high risk sectors should be targeted. Migrant labourers are an important example. More intensive education for them and their dependants should be a high priority. Supporting them in bringing their families to live with them will, apart from the humanitarian benefits, repay the investment many times over. Employers can be helped and encouraged to provide or support counselling for both infected and affected individuals, and to encourage them to continue working if possible.

Fourthly, the maintenance of public provision will be critical. The health sector will require particular attention as it will be weakened by illness and mortality at the same time as demands on it increase. We need to aim at over-provision of qualified personnel to deal with the double effect I mentioned. Finally, the introduction and encouragement of intermediate labour-saving technologies in agriculture, manufacturing and the home will be important.

Disaster tends to strike hardest at the most vulnerable, and never more so than on this occasion. The challenge is very large. The resources available to wealthy societies have proved more or less sufficient, so far, to contain the spread of the disease in their own populations. The proposition before us now is to assist in repeating this partial success on a far larger scale, and among our far poorer neighbours, with far less educational, communications, and health care infrastructure available, and with the pandemic already quite far advanced. There is no time to be lost if we are to have any chance at all.

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4.22 p.m.

Baroness Gould of Potternewton: My Lords, I too express my appreciation to the noble Earl, Lord Sandwich, for initiating what is a crucial debate. For too many years AIDS was an invisible epidemic, HIV spreading silently. It is only now, after two decades, that the repercussions of AIDS are stripping off the cloak of invisibility. But not absolutely. Silence continues to reign, even when people with HIV are ill or dying.

Nor has the epidemic been overcome anywhere. During the course of today 16,000 people will be infected--10 per cent. more than a year ago. That does not include those people who will not acknowledge or who are unaware that they are actually suffering from HIV/AIDS infection. The figures have been quoted so I shall not repeat them. They all show, when one looks at them in detail, that in all countries women appear to be heading for equality with men and there is no indication that that trend will reverse, the majority of infections being the result of the sexual behaviour of their husbands or partners, through exploitation, coerced sex, often with older men, or because poverty has driven them to engage in commercial sexual transactions in order to survive.

But children are the saddest victims of all, as the noble Earl said in his opening address. As has been said, there are now around 8 million orphans, many of whom are themselves infected. However, some communities are rising to the challenge. In Zimbabwe community leaders and church groups are providing for them so that they can stay in the community and not be institutionalised. But, overall, the number of children with HIV is up to 1.2 million; one tenth of newly infected people are under the age of 15. Most of them acquired the virus from their mother before or at birth or through their mother's milk.

Breast feeding is protective against some diseases but does not protect against AIDS, leaving African women faced with a terrible choice: do they continue breast feeding with the related risks or do they consider feeding formula to their babies after years of being warned of the dangers from possibly mixing the formula with unclean water? And water is something of a luxury. Formula feeding can also send mixed messages about the value of breast feeding to uninfected women.

A further problem is that too many women do not know whether they are infected or not; they have never had prenatal care, nor had a blood test. While considerable progress has been made in the development of anti-retrovirals which would help to reduce mother-baby transmissions, the high costs--£10,000 per patient per year--put them outside the reach of the poorer countries in the region. For instance, drugs for 25 per cent of all HIV infected people in Malawi would use 84 per cent. of GDP. It must therefore be worthwhile to find appropriate ways of introducing short-course ARV for pregnant women. However, this relatively cost-effective intervention requires to be accompanied by well developed health systems as well as breast milk substitutes which can be expensive.

In those circumstances, prevention has to be the top priority, be it the accessibility of condoms and family planning services, education of school children or

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projects to change behavioural patterns. And although HIV infection does not respect the artificial boundaries between "high" and "low" risk groups, targeted interventions for high risk behaviour groups can work.

Young people are especially at risk. A recent study in Zambia showed HIV infection is more prevalent among young girls, being reported in 12.3 per cent. of girls and 4.5 per cent. of boys. But prevention can also have a greater chance of success among younger people. While the majority are still engaging in unprotected sex, education campaigns and condom promotion in Uganda and Tanzania have resulted in dramatic declines in infection among teenagers. Perhaps the Minister could indicate what support DFID is specifically giving to NGOs and others working on such projects and to the already over-stretched health systems of the hardest hit countries.

But, the long-term hope has to be the development of a preventive AIDS vaccine. Praise must be given to the Government for being the first country to give financial support to the International AIDS Vaccine Initiative and to the World Bank for its 1 million dollar donation. But it is not enough. Other countries have to be mobilised to put money into vaccine development and research. It would be useful to learn from the Minister what progress is being made in persuading other countries to follow our example.

One of the major problems to prevention is the stigma of being identified as being infected. It is hard to measure stigma but it is a real obstacle to both prevention and care. While it affects both sexes, for women exposure can have severe consequences, given their social and economic dependence on men. They risk being beaten or even thrown out of their homes or being blamed for the death of their children, even when the husband is the source of infection. Adjoa, a Ghanaian woman with HIV, a mother of two, lives in fear of her family finding out. She believes--I paraphrase--that if her sister discovered her state she would poison her. She is adamant she will tell no-one. She sees the example of another woman in her village, Abena, whose husband and family abandoned her and her children while she was in hospital.

Fear of acknowledging HIV can stop a man from using a condom or his wife from giving her baby replacement feeding. And so the disease spreads. Few remain unaffected, either directly or indirectly. While the Government have to be commended for budgeting £100 million directly to support sexual health and HIV/AIDS activities in many of the African countries, the urgency of the epidemic requires us to do more, more quickly and more effectively. But we cannot meet that challenge alone. Global co-operation is essential to free Africa of this horrendous disease.

4.30 p.m.

Viscount Hanworth: My Lords, perhaps I too may express my appreciation of the noble Earl, Lord Sandwich, for raising this issue in the House. An excellent book on the subject of AIDS and the HIV virus by the geographer Peter Gould was first published in

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1993. It is remarkable not only for its clarity and the quality of its research, but also for its passionate nature. Its title is The Slow Plague. One might well startle at such a title in view of the speed with which the devastation of AIDS has swept through the world and the continent of Africa in particular.

When I visited Zimbabwe in 1982, there was still no hint of the impending disaster. That was the year in which the discovery of the human immunodeficiency virus, HIV, was first made public. It has taken only 15 years to reach a stage where, in many parts of central and southern Africa, the proportion of the sexually active population which is infected by the virus equals or exceeds 30 per cent. over wide geographical areas. In the continent at large, there may be as many as 40 million infected people. The number of deaths to date probably exceeds 10 million--and there is little sign of any abatement.

If this is a slow plague, by what standards is its speed being judged? The answer must be by the standards of other pandemics which have hit the human race in recent years. We are inclined to think of the influenza pandemic of 1918-1919. It is estimated that some 30 million people died in that short period as a result of the influenza, but the eventual mortality from AIDS will far exceed that figure. The flu epidemic was highly contagious. However, the world-wide plague was brief and only two years were necessary for the human population to produce an immunological response.

The HIV virus, by contrast, is only weakly infective. It can be passed from one person to another only by the interchange of bodily fluids: by blood, by semen or by vaginal secretions. It is doubtful even whether it is transmissible by saliva. However, once the disease has been contracted, there is no immunological response which will save the victim from eventual death. In the absence of drug therapy, the victim has at most 10 years to survive before dying of AIDS. In conditions of poverty, such as characterise most of Africa, they are more likely to be granted only six or eight years.

There is no medical cure for AIDS and there is unlikely to be one in the foreseeable future--certainly not one which will be affordable on a wide scale. In the absence of an immunological response to HIV, the only thing which can defeat it is a sociological or behavioural response in the populations which are at risk. Such a response is already under way in many parts of Africa. However, its speed is comparable to the so-called demographic reaction of family limitation, which is a universal but highly variable response to the survival of increasing numbers of children. Measured against the speed of a "slow plague", this is too slow to avert widespread suffering and disaster.

It is not entirely idle to wonder why Africa is so affected by the disease; nor to ask why the response appears to be markedly less rapid than in other parts of the world. It helps in combating the disease to know the answers in detail. We might ask, for example, whether there is something in the cultures of Africa or in the sexual mores of its populations which is conducive to sexually transmitted disease.

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I raise those cultural allusions only to dispose of them. I do not believe that one needs to give a very detailed exposition in order to do so. It is perhaps enough to remind ourselves that in the absence of penicillin the war-ravaged Europe of the late 1940s would have been devastated by epidemics of gonorrhoea and syphilis. That threat was the natural outcome of the concomitance of men without social constraint and women without any means of support for themselves or their families except prostitution or something close to it. Rape would also have played a part.

Africa continues to be ravaged by war, by drought and by the displacement of large numbers of people. Many parts of the continent have been afflicted by bands of marauding soldiers. For years, there have been congeries of migrant labour passing up and down the length of the Rift Valley. Throughout the century, there has been a rapid migration of displaced people into urban slums, seeking refuge from war or drought or simply leaving a countryside which cannot contain them. The rate of this migration has increased.

Among the principal vectors of the infection have been the migrant workers, the truckers and the prostitutes; but the disease knows no occupational or class boundaries. Particularly affected have been the African urban elites and the military personnel--those who have the disposable income to demand the services of prostitutes. Untold harm is done to the economic prospects of Africa by the decimation of its urban elites. As Gould remarks, we know very well what tends to happen when armies, depleted of their leadership, are taken over by corporals.

It is not upon exhortation and advice that we must rely primarily in the struggle against AIDS. The one device which can most effectively block the transmission of the HIV virus is the condom. Condoms should be included in pay packets by every Western firm operating in Africa. They should be freely available in bars and shabeens, in bus depots and railway stations and in prostitutes' parlours. They should even be made available via schools.

The solution to the problem of the AIDS epidemic and the solution to the problem of birth control are one and the same thing. There is a hopeful example which suggests that a country undergoing a rapid demographic transition can quickly and effectively counteract the AIDS epidemic. The country in question is Thailand, where it once seemed that the circumstances were optimised to assist the spread of the HIV virus. Now there is the expectation that it will be held in check.

It is exactly 200 years since the Reverend Thomas Malthus published his dismal Essay on the Principle of Population. In it, he classified the checks to the growth of population as either preventive or positive. He would, no doubt, have classified the AIDS epidemic as a positive check in the company of the other checks of war, famine and pestilence. Malthus doubted whether the preventive checks which he envisaged, such as the deferment of marriage and the abstinence from sexual activity or resort to prostitutes, were ever likely to be effective in stemming the growth of population; and he foresaw widespread misery.

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The pessimism of the Malthusian doctrine and its moralising tone invoke a strong aversion in many of us. We like to think that there is a far greater scope for human amelioration than Malthus allowed. Nevertheless, the Malthusian spectre is one which confronts us today in Africa no less than it confronted an English clergyman in this country 200 years ago. To people of goodwill and optimism, it is surely clear that there are immediate actions which demand to be taken if we are to help in defeating the spectre of AIDS in Africa.

Last week the Government announced a budgetary provision of £100 million for combating AIDS in Africa and elsewhere. We on these Benches are proud of that, and I personally hope that it is only the first tranche of an ongoing subvention to combat this deadly disease.

4.36 p.m.

Lord St. John of Bletso: My Lords, I have just returned from a month's visit to South Africa, where the AIDS epidemic continues to spread at a horrifying rate of around 1,600 new infections every day. With well over 3 million South Africans living with HIV and with nearly 50,000 new infections a month, South Africa has one of the fastest growing HIV epidemics in the world. Even though medical science has come up with several drug therapies that offer some hope of arresting the virus's programme, South Africa is sitting on a pandemic that threatens explosive consequences for the country and its economy, as well as being a major burden on the health service and the welfare system.

Like other noble Lords, I am extremely grateful to my noble friend Lord Sandwich for having given us this opportunity to debate this most topical and critical subject today. I personally commend my noble friend for all the work that he has done on trying to promote the development of awareness of what is happening concerning many problems affecting southern Africa. The harsh reality, which was highlighted in a recent article on 2nd January in the Economist, headed A Global Disaster, is that in most of the rich countries AIDS is no longer a death sentence. Expensive drugs keep HIV positive patients alive and healthy, perhaps sometimes indefinitely. But in most of the developing countries the disease is spreading, in the words of the Economist,

    "like a nerve gas in a gentle breeze".

The poor cannot afford to spend the 10,000 dollars a year on these wonder pills. Certainly the World AIDS Day in December last year, as well as the recent reports from the joint United Nations programme on HIV and AIDS together with the World Health Organisation, has raised public awareness of the problem. However, there certainly needs to be a lot more government support. Many of the reports point out that few political leaders treat the global disaster of AIDS as a priority.

I wish to focus my few remarks on a number of the positive initiatives taking place in South Africa to help reverse the tide of AIDS spreading throughout the country. With the general election in May this year, the South African Government will need to show how they are tackling not just the escalating unemployment and

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crime in the country, but also how they are addressing the social and health needs of the nation. The fights against disease and poverty are inextricably interlinked.

In 1995 the South African Government adopted the widely hailed National AIDS Plan, but unfortunately bungles and lost opportunities made them lose sight of the larger picture. However, in October last year, Deputy President Thabo Mbeki formally launched the Partnership Against AIDS initiative, hailed by the Health Minister, Dr. Zuma, as the turning point in the country's new phase of the struggle.

The objective has been to promote a mass mobilisation campaign to encourage all sectors to come together to combat HIV. In his speech to the nation, when he launched the initiative, Thabo Mbeki admitted,

    "For far too long, we have closed our eyes as a nation, hoping that the truth was not so real".
He referred to the partnership as being a partnership between,

    "Youth, women and men, business people, workers, religious people, parents and teachers, students, healers, farmers and farm workers, the unemployed and professionals, the rich and the poor".
In brief, he referred to it as a problem of all of us.

The Partnership Against AIDS initiative has specified what each sector of society can do, not just to raise awareness of the problem but also to assist those infected with the disease and those many thousands and millions of orphans who have been left without their families and often without any home.

Clearly, if this initiative is to have any success, it needs on-going government and financial support. So far the South African Government have committed their support in launching the initiative but have not given much financial support. Certainly, in South Africa, NGOs and community-based organisations which command a high level of credibility in the country have played a major role over the years in assisting the cause.

The South African Government have also promoted another initiative called "Beyond Awareness Campaign" targeted specifically at the youth in South Africa. My noble friend Lord Sandwich referred to the NGO International AIDS Vaccine Initiative, based in New York, which has so far invested over 9 million dollars in promoting a vaccine development initiative led by an immunologist in Oxford in conjunction with an immunologist in Kenya, as well as the medical department of Cape Town University. All those initiatives desperately require international support.

In conclusion, there is no doubt that the HIV/AIDS epidemic represents one of the greatest threats to South Africa and, indeed, the world, while at the same time offering unique challenges and opportunities to recognise and address the inequities found in South Africa. For the campaign to be successful, it needs broad-based and multi-sectoral support. Following the Prime Minister, Tony Blair's, recent visit to South Africa and his announcement that Her Majesty's Government have increased their aid package to the country, I hope that the Minister, when she winds up the debate, can elaborate on what plans Her Majesty's

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Government have to promote and assist the initiatives in South Africa to stem the HIV epidemic, not just in that country but in all other countries in the region.

4.44 p.m.

Lord Graham of Edmonton: My Lords, like other noble Lords, I feel that it is right and proper to pay tribute to the opportunity created for us by the noble Earl, Lord Sandwich, in initiating the debate. The noble Earl has not been active in the House for as long as myself, but from the moment he arrived he brought with him rich experience of this subject. One of the great assets of this House is that we can benefit from the experiences of practitioners in various areas. The noble Earl has also stimulated a number of his colleagues in all parts of the House to contribute to the debate.

Stunning statistics have been quoted by the noble Earl and others. There is no need for me to repeat them. If one wants to be depressed by the enormity of the task in hand, one simply has to watch television or read Hansard on this subject. I become very depressed indeed. I hope that the Minister will be able to tell us, when she replies, not only that the Government are well aware of their responsibilities, but that to the extent that it is possible when balancing budgets and allocating resources, they recognise that Britain in 1999 has a part to play.

The noble Lord, Lord Judd, made a powerful speech based on his own experiences. My noble friend Lord Hanworth told us of his experiences, which enlightened and enlivened the debate. In debates such as this, one finds out about the background of one's colleagues in the House of which perhaps one was not previously aware. I respect people who can tell it as it is from where they have been.

I do not have solutions or very much experience on this subject. For a period, I assisted the Prison Officers' Association in getting its case heard in this place. In that capacity I visited many prisons. Throughout the 1980s and 1990s, I saw the rise of this disease and its manifestation in the tiny communities and estates which form our penal institutions. Fortuitously, in comparison to the staggering and calamitous statistics of other countries, the problem in this country is minute. However, we know that at one time the problem was minute in those other countries yet the powers that be failed to stimulate, legislate, encourage and educate--especially children--early enough. We know of the enormous cultural and religious difficulties which have to be overcome in communities and nations. The Minister should recognise that there is not only an understanding of the problem but a willingness on the part of those who have spoken and among the British people to provide more assistance to tackle this scourge--and it is a scourge. The Government should recognise that this issue is not a vote-winner. It is not one of those issues about which one can say to the people of this country, "Vote Labour and we will spend more money on tackling the AIDS crisis". It is not "sexy"--I can see noble Lords opposite correcting me--as an attractive political proposition or something that people will willingly want to tackle. A major responsibility rests on the Government and Ministers to

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recognise that a lead must be taken and encouragement given. When I force myself to listen to the statistics and to watch television programmes on this, I ask myself, "What on earth can we do to assist?".

I make no party point in saying that this country has politicians, a government and a people who recognise their responsibilities to others. Such remarks as, "Am I my brother's keeper?", "What does it mean to me?" and, "Why should I spend my hard-earned cash to educate and to elucidate?" may come to mind, but I believe that the British people would respond to encouragement by the Government to provide even more financial support in the future than they have in the past. All that I can say to my noble friend the Minister is that I wish her well when she reports on this debate to her colleagues in government.

4.50 p.m.

Lord Redesdale: My Lords, I should like to begin by thanking the noble Earl, Lord Sandwich, for initiating this timely debate. I shall talk about something which is now taken for granted by looking back at how our first experience of AIDS came to this country. Listening to the debate today, I feel that it is probably a debate which could not have taken place 10 years ago. Indeed, if it had been held 10 years ago, I believe that it would at least have caused a sensation in the press.

Today's debate shows that our attitude to AIDS has changed remarkably. Many of the taboos that we held quite dearly 10 years ago have since disappeared. That is due to a great extent to the lead taken by the previous government in actually publicising AIDS and taking the bold step of going forward and drawing to people's attention the dangers associated with it. However, I should perhaps remind your Lordships of some of the images that were used then because they were so insensitive. I have in mind the crashing icebergs; indeed, that is an image which I still do not understand.

The reason I mention the latter is that, from my own experience in Africa, it was something which did not happen. Many noble Lords have talked about the stigma attached to the discussion of AIDS. My first awareness of discussion on AIDS in Africa was in Zimbabwe. I walked into a local police station and read a rather interesting article which discussed how one could contract AIDS. The point of the article was that you actually contracted AIDS from sleeping with foreign travellers. That was the main source of infection and worry. Of course, it seems quite incredible now.

The silent spread of AIDS was mentioned by the noble Lord, Lord Ponsonby, and that is one of the reasons why it has spread so quickly. I found the stigma attached to having AIDS to be incredible. I went to visit a hospital in Malawi back in 1990. There was a women in the hospital and it was quite obvious she was dying from AIDS, but no one was willing to admit that fact. Indeed, if anyone in public life died of AIDS, no mention of that fact was ever made. A code was developed, especially in the Zimbabwe press, which would state that the person had died "after a long illness". One could read into that the fact that AIDS was the cause of death.

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The spread of AIDS has been commented upon, but one of the most effective ways of transporting AIDS around the sub-Saharan continent was the truck/trade route. The trucks went from South Africa to Zaire and visited all points in between. They were very effective in the promotion of AIDS. I remember travelling to Malawi from Zimbabwe. The cheapest way to get there was to hitch a ride for about 25 Zim dollars on a thing called the "gun run", which was a convoy route which went through the Tete corridor. It was usually made up of about 100 trucks with an armed Zimbabwe escort because it used to get fired upon on a fairly frequent basis by Renamo rebels. However, the image that has always stayed with me was of a particularly uncomfortable night which I spent on the border in incredibly hot conditions watching prostitutes going from one truck to the next right down the line. They did so because the truck drivers had money. Of course, some of those truck drivers would then travel to Malawi, but others would go all the way up to the former Zaire. Studies carried out later on infection rates in communities on the truck routes revealed an incredibly high percentage of infection--indeed, sometimes as high as 90 per cent. or 100 per cent.--in people living close to the truck corridors.

Mention has been made of the two lines of defence against AIDS. The first line has to be education. I have seen some of the effects of education in the form of drama projects in Zimbabwe. I have in mind particularly fine groups of actors. In one case, I remember a quite frightening character which portrayed death. Considering the illiteracy in many villages, that was a very effective form of education. I should also like to mention the work carried out by the Churches. As the right reverend Prelate pointed out, some attention should be drawn to that fact.

The second line of defence is condoms and prevention. The free distribution of condoms in Uganda has been one of the reasons why the latter has had some success in turning the tide on the AIDS epidemic. However, it also has to be linked to education. I remember walking along a road in Malawi and being asked by a young Malawian how he should avoid contracting AIDS. I said, "The answer is you must use a condom". He replied, "Oh, that's alright then; I used one of those once". Unfortunately, that attitude was quite prevalent.

While considering prevention, another measure would be the use of AZT for pregnant mothers. However, the cost of the drug in Africa is prohibitive. I very much doubt that it is a measure which could be used on a wide scale. The noble Baroness, Lady Gould, mentioned the issue of mothers changing back to bottled milk, with all the inherent risks that that involves. However, the prevalence of AIDS means that it is almost a preferable option, which is quite frightening. The cost to the African countries is staggering because the first groups affected by the HIV virus have tended to be the intelligentsia, those with enough money and those with training.

I remember being in Zimbabwe and talking to a woman who worked for the Standard Chartered Bank. She had come from the north of the country but had had

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training in Britain. That was back in 1991. She said that the worst thing about the epidemic was that she very much doubted that she would actually see her children grow up. What I found so frightening about that comment was the assumption she made that she would contract the disease because it was so prevalent.

It is difficult to see whether this epidemic can be reversed. I believe that inroads can be made through education and prevention. However, when such a high proportion of the population has contracted the virus, it is difficult to believe that major inroads can be made in the future just through education and prevention. I speak bearing in mind the rather frightening statistics which have been put forward. I remember being in Lilongwe when a study was published which revealed that 34 per cent. of the population were HIV positive. It showed just how risky things could be if you were a young person looking for a wife or a husband. The only really effective cure for the disease would be a cheap cure, or, more appropriately, a cheap vaccine. Many noble Lords have spoken about the latter, including the noble Baronesses, Lady Masham and Lady Gould.

One of the diseases prevalent last century which led to some of our social attitudes towards sex was syphilis. It is worth remembering that syphilis wiped out a large proportion of Europe's population during the last century. That is probably why the Victorians developed such attitudes. It was only the discovery of penicillin that countered that threat. A sexual revolution has been mentioned. However, the advent of AIDS in Africa has reintroduced stigmas and the idea that sex cannot be taken for granted and is not the safe option that we would like to believe it is.

I have an important question to ask the Minister. How much money is being spent on the development of a vaccine? This is a major problem in the making. Pharmaceutical companies are prepared to spend enormous sums of money on treatments for AIDS. It is easy to understand the economics of this matter as it has been estimated that it costs up to £10,000 a year to treat someone in this country who has HIV or AIDS. I know that last year the Government contributed £200,000 to the development of a vaccine but that constitutes only the treatment for one year of 20 people with AIDS with the drugs that are now available.

The noble Lord, Lord St. John of Bletso, mentioned initiatives that are being taken to find a vaccine. Can the Minister give some indication of how much money will be allocated to try to develop a vaccine? This is an area which is being neglected by private companies as there is no profit motive involved. I very much hope that the Minister can give us some good news on that matter.

5.1 p.m.

Lord McColl of Dulwich: My Lords, I, too, wish to thank the noble Earl, Lord Sandwich, for calling our attention to this great tragedy in Africa. At the outset I should declare an interest in that I am chairman of the board of governors of Mildmay Hospital in the East End of London, which was the first hospice in Europe devoted solely to the care of those dying of AIDS--men, women and, unfortunately, children.

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We have also become heavily involved in many countries abroad, particularly Uganda. As has already been pointed out, Uganda was the first African country to acknowledge publicly in 1985 that the HIV epidemic was causing serious problems in that country. This was due to President Museveni, who first realised the seriousness of the situation when some of his troops were sent abroad and were routinely tested. Some of the armies in Africa have an infection rate of up to 70 per cent. As soon as he realised the seriousness of the problem he made sure that the government took the threat seriously. The Ugandan AIDS control programme was developed and supported many effective educational preventative programmes. It appears that the mortality rate is beginning to plateau and even to fall in certain key areas.

However, prevention must always go hand in hand with care if it is to be effective. The Ugandan Ministry of Health therefore invited Mildmay International to set up a centre for AIDS palliative care and training in Kampala. The noble Baroness, Lady Chalker, was instrumental in providing funding from the British Government through ODA. Later this support was continued by Clare Short through DFID. That is a great credit to them. The Mildmay Centre was opened recently by Princess Anne. It is worth noting that when she arrived at the centre at 11 a.m. she had already completed four previous engagements that morning. I ask those who criticise the Royal Family to take note of that.

The patron of the project, President Museveni, in his keynote address said something which I do not think has been mentioned today. He is an honest and, in my opinion, a great leader in Africa. He said,

    "There is no cure for AIDS, therefore it must be prevented. This means no sex before marriage, no sex outside marriage and those who cannot keep to this policy need to take precautions realising that precautions are not always successful".
I have not heard any other national leader spell out the matter in those clear terms because I suppose that is not politically correct. However, this directness and honesty has paid off in that country and there are now signs that the mortality is beginning to fall in some places, as I said.

The tragedy of this epidemic is that there may never be a cure for AIDS. The virus keeps changing its nature, making the production of a vaccine well nigh impossible. This makes even more relevant President Museveni's courageous statement. I do not wish to repeat all the statistics, but I want to draw attention to the fact that of the 12 million people who have already died since the beginning of the epidemic, 25 per cent. were children. The number of those orphaned since the beginning of the epidemic amounts to more than 8 million. One of the problems in controlling this epidemic is the totally inadequate data, and much more money needs to be put into research in this field urgently.

Heterosexual contacts and mother-to-infant transmission of HIV account for the majority of infection, but injectable illegal drugs, such as heroin, and infection through unscreened blood transfusions are severe problems. I shall give noble Lords some idea of the statistics. In 1995, 2.5 million blood transfusions

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were given, most of them to women and children, and 25 per cent. of these had not been screened for HIV antibodies. Funds are desperately needed for this essential and simple screening technique.

Canada's High Commissioner to Zimbabwe, Ann Charles, has been doing her bit in the preventative field. She has stressed the need for preventative measures and has urged high school students to start to make choices that will keep them safe from HIV infection and give them the chance to live a normal life. I think it has already been mentioned that Zimbabwe has become the centre of the world's AIDS epidemic. It is probable that it may have the highest AIDS infection rate in the world. The evidence is that the virus is still spreading rapidly in Africa, despite already high levels of infection. In Botswana the proportion of adults living with HIV has doubled over the past five years: 43 per cent. of pregnant women tested HIV positive in 1997 in Francistown. As I think has already been mentioned, in Zimbabwe one in four adults in 1997 were thought to be infected. In a major commercial farming centre in Harare HIV prevalence in pregnant women rose rapidly from 32 per cent. in 1995 to 59 per cent. the following year.

As regards prevention, perhaps the most effective course is President Museveni's honest educational approach. We should be honest and open about the whole thing. Further changes in attitude and behaviour are essential. In case anyone is inclined to be critical of the sexual behaviour of Africans, perhaps we should remember that in California the AIDS epidemic spread like wildfire due to the fact that some people were having a thousand different partners per year. Changing that behaviour was crucial in reducing the incidence of the disease there. In this country as many as 10 per cent. of children may be subjected to sexual abuse. A change in moral standards would make a very great contribution to this whole subject.

I have witnessed in Africa attempts to educate children in schools and adults in the villages. It was interesting that when the thought was put forward at a conference in Africa that people had to change their attitude, many of those attending laughed their heads off. But that was some years ago. They have now learnt better ways. I have witnessed attempts to put on plays in schools, villages and prisons. A common technique is to use professional actors, but also to get the children themselves, and in prisons the prisoners, to act in the play. The plays were performed with great professionalism and humour. I found them very moving indeed.

Both the Conservative government and the present Government are to be congratulated on their support for all the efforts being made in Africa, especially through NGOs. We very much hope that that will continue.

5.11 p.m.

Baroness Amos: My Lords, first, perhaps I may join other noble Lords in thanking the noble Earl, Lord Sandwich, for introducing this important debate. The noble Earl's commitment to development issues is well known in this House. I should also like to thank all other

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noble Lords who have made such valuable contributions. I shall seek to respond to all the questions raised, but will write to any noble Lords whose questions I am unable to address in detail in the time available.

HIV/AIDS represents a human tragedy, particularly in sub-Saharan Africa, where a number of factors continue to influence the shape of the epidemic. My noble friend Lord Hanworth made reference to some of the factors, as did the noble Lord, Lord Redesdale, the main ones being migrant labour, and people in conflict and refugee situations, who have little control over their exposure to HIV. But poor public health systems and the widespread existence of untreated sexually transmitted infections are also major contributors.

HIV/AIDS is playing a significant role in reversing many of the gains made in development since the Second World War. And it is jeopardising the achievement of some of the international development goals to which Britain has committed itself. For example, it is impacting on life expectancy. The decline in life expectancy is due not only to the deaths of adults, but also to child deaths. In Zimbabwe, life expectancy will fall from 61 years to 39 years by the year 2010.

Unfortunately, rapid advances in treatment in rich countries have switched political and media attention away from HIV/AIDS. That has masked the growing seriousness of the epidemic in many parts of the developing world. While there is sporadic evidence of a slowing down of the epidemic in some countries, few have succeeded in developing a sustained national response.

A number of noble Lords made reference to the scale of the problem. The statistics defy belief. As we are on the cusp of the new millennium, five young people every minute are being infected with HIV, and half of all new infections are to young people between the ages of 15 and 24. We need to pause and consider what that means for the first generation of adults in the new millennium.

The situation in Africa is appalling. Of the nearly 34 million people in the world living with HIV/AIDS, 70 per cent.--or 22.5 million--are in Africa. One million of that total are children. There are about 11,000 new infections in Africa every day. The noble Baroness, Lady Masham of Ilton, made reference to the number of people in South Africa who do not know that they have the virus. A staggering nine out of 10 people are unaware that they have the virus. Health and demographic data show clearly that HIV/AIDS represents a massive addition to the global disease burden which is concentrated, and flourishing, in poverty and inequality. As usual it is the poor who suffer most. In the worst affected countries of southern and eastern Africa infection has reached levels of one in four of the adult population. And it will get worse before it gets better.

A number of noble Lords made reference to the costs to business. They were mentioned by the noble Viscount, Lord Brentford; the noble Lord, Lord Hardinge of Penshurst, focused on economic effects; and the noble Lord, Lord Redesdale, made reference to

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the cost to African countries. The impact goes far beyond health. It is the single biggest threat to the prospects for reducing poverty and improving living conditions in developing countries. It is having an enormous impact on economic development and sustainability. The most productive members of the population are dying. It has cut a swathe through a generation of Africa's brightest and best in government and industry. It is killing the prospects for a better future as it kills the generation of skilled people on whom that future depends. In Malawi, between one-quarter and one-half of urban-based teachers and health workers will die by the year 2005. AIDS is denting agricultural output and company profits as skilled human resources spend long hours ill at work or off sick and eventually die. A study in Kenya in 1995 showed that over the period of the next 20 years the gross domestic product would be 14.5 per cent. smaller than it otherwise would have been had AIDS not occurred.

The noble Lord, Lord St. John of Bletso, spoke in particular about South Africa. There, UNAIDS estimates that one in seven civil servants is infected with HIV. South Africa needs all its skilled capacity to maintain the momentum of economic and social transformation. HIV/AIDS has increased poverty and malnutrition. It has reduced access to schooling as children are obliged to work. And AIDS orphans have increased beyond the ability of most communities and countries to care for them.

HIV/AIDS has reduced the ability of individuals, communities or governments to save and invest for a better future as resources are absorbed in caring for the sick now and replacing lost income. For example, the annual cost to African health systems of caring for someone with an AIDS-related illness could have paid for 10 years' primary schooling.

We must stop seeing HIV/AIDS only as a health issue. It is a most serious issue of development. The response must be multi-sectoral and it must be long-term. As my noble friend Lord Judd mentioned, HIV/AIDS must be mainstreamed through national strategic planning into ongoing development interventions and must feature prominently in policy and programme discussion. DFID is seeking to do that.

So what practical action needs to be taken? Perhaps I may start by repeating the words of the noble Lord, Lord McColl of Dulwich: there is as yet no cure for HIV/AIDS. Until one is found that is affordable and feasible in developing countries, the key to arresting the epidemic has to be to prevent HIV infection.

So, first, and perhaps most importantly, as part of a long-term strategy, we need better information. Lifestyle behaviour change is the key to cracking this problem. To change behaviour, the right information needs to be communicated through the right channels which is persuasive enough to change behaviour, particularly of young people, and particularly of young girls.

The noble Baroness, Lady Miller of Chilthorne Domer, and the noble Lord, Lord McColl, made particular reference to what is happening to young women and girls. Armed with the knowledge, means

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and a supportive community, people with high risk behaviour do act to reduce their risk of contracting or spreading HIV. But transferring the knowledge to make sustainable change is very difficult. The message is not yet getting through clearly enough in sub-Saharan Africa. We need to develop prevention campaigns that are targeted and relevant to the local environment. It is here that civil society has a particularly key role to play. Churches, community based organisations, NGOs and youth groups are often best at organising prevention programmes which reach their target groups most effectively. I shall say more about their role later.

Secondly, we need condoms. That was mentioned by a number of noble Lords. Thirdly, we need treatment for sexually transmitted infections. Greater understanding of the connection between HIV transmission and STIs has been a major boost to efforts to reduce transmission. That point was made by the noble Earl, Lord Sandwich, and my noble friend Lord Rea.

Fourthly, and perhaps most obviously, we need safe blood. I agree with the noble Lord, Lord McColl, that reliable, safe and uncontaminated blood supplies are essential to prevent accidental transmission of HIV.

Of course, there is the overarching issue of leadership and in particular the key role which political leadership has in relation to the HIV/AIDS issue. Strong leadership and commitment of those with political power and responsibility--mentioned by a number of noble Lords--is critical to sustain the reduction in the incidence of HIV/AIDS.

In some countries with severe AIDS epidemics, politicians and policy makers have often denied that the behaviours that spread HIV exist in their culture and they have tended to blame the epidemic on others. HIV/AIDS has become a disease of denial and blame. This must change. Denial robs society of precious time during which early and focused action can avert an epidemic.

Uganda was mentioned by a number of noble Lords as an excellent example of a country which has shown that it is possible to reduce infection rates by a well targeted campaign of prevention. It has been critical that this has been led by the highest level of government. My noble friend Lord Ponsonby also mentioned Senegal where 40 per cent. of women under 25 and 65 per cent. of men used condoms with non-regular partners in 1997, compared with less than 5 per cent. for both sexes at the start of the decade.

The noble Earl, Lord Sandwich, also mentioned the issue. Last year's World AIDS Campaign which focused on Young People--A Force for Change, was an important campaign in relation to that. We recognise the absolute importance of addressing children as a cohort, as one of the only effective ways of slowing down the epidemic.

We have learnt from Uganda and Senegal and from other success stories that strong leadership of people in power really makes a difference. We can also learn from our experience in Asia where we must not forget the epidemic is still emerging. Among certain populations in India, for example, it is spreading as rapidly as it did

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in Africa early on. Thailand is another good example where concerted action taken by the government to promote total condom use and to remove the stigma attached to HIV infection had a major impact on the transmission of the virus. Incidence rates in Thailand are falling.

But too few African governments have taken a strong lead on the issue. We must call on all political leaders to accept responsibility and to show strong and committed leadership.

Many noble Lords mentioned the British response and my noble friend Lord Graham asked about the Government's response. I start by saying that we see it as a global problem which requires a global response. Britain has a responsibility to contribute and we wish to contribute as part of a bigger, more effective international effort.

When he visited an AIDS hospice in Cape Town last week, the Prime Minister announced that Britain would be spending £100 million on HIV/AIDS activities in the next three years. The bulk of the money will be spent in sub-Saharan Africa.

Overall, DFID is spending between £30 million and £35 million of its annual health spend of £200 million on sexual health. We are supporting national responses directly through STI/HIV/AIDS activities in 39 countries, intensively in eight sub-Saharan African countries. Programmes focus on ensuring that information, condoms and sexual health services are available for all those who need them. We are also helping governments to implement programmes which develop sustainable forms of care. A key element of our work is to lead co-ordination in all health sector work.

More generally, the Government are increasing their level of assistance to Africa and working with others to increase its impact. In July 1997, the Prime Minister announced that we would commit 50 per cent. more for basic education, basic health and clean water in the first three years of this Government than in the last three years of the previous government. We are well on the way to doing that. I hope that that addresses the points made by my noble friend Lord Judd in relation to basic health care and the noble Lord, Lord Hardinge, who mentioned access to clean water.

We are also making a significant contribution to the work of the UN co-ordinating body, UNAIDS. We believe that the international community has a vital role to play in combating HIV/AIDS. We also have high hopes for the role of a re-vitalised World Health Organisation and want to help UNICEF and the UN Population Fund to do more. Our influence with wider international agencies--the World Bank, the International Monetary Fund and the UN--has never been greater.

On the point of co-ordinating international activity, I add that we used our presidency of the G8 last year to raise the issue of HIV/AIDS among our OECD partners. We will continue to encourage Germany in its current presidency, both of the G8 and the EU, to emphasise the importance of a developed country response.

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Research too is important and DFID supports work by the UK Medical Research Council on the development of AIDS vaccines. The work conducted by the London School of Hygiene and Tropical Medicine and specific research projects such as those on the relationship between HIV and TB and on paediatric AIDS have been supported.

I wish to make particular reference to the issue of an AIDS vaccine. Many see the development of an AIDS vaccine as a long-term hope. We agree. A vaccine is scientifically within our grasp, but the best estimate is that we are at least five to 10 years away from one which is effective, available and affordable to people in poor countries. One problem in working towards this is the lack of industrial investment.

A number of noble Lords mentioned that Britain has taken a lead in the development of a vaccine. We were the first and so far only government to have contributed to the international AIDS vaccine initiative. We made a modest contribution in 1998, as mentioned by the noble Lord, Lord Redesdale, but we are building a long-term strategic partnership with IAVI to which we expect to contribute substantially more in the future. I shall write to noble Lords who have asked specific questions about the amount when decisions have been taken in relation to it.

IAVI is not only doing the science but is also helping to establish the vital support mechanisms to take vaccines onto the market in a way in which developing countries can afford them.

Mention was also made of AZT, particularly by the noble Viscount, Lord Brentford. I do not have time to go into it in detail. Not only is the cost a deterrent but also using it effectively requires a well developed health system to deliver the treatment safely. It also requires the use of breast milk substitutes for at least three months. Some of the problems associated with that have already been raised by my noble friend Lady Gould of Potternewton.

We are also particularly concerned about the impact of HIV/AIDS on women and girls. We know that women and girls are increasingly affected by the HIV/AIDs pandemic. Research, prevention and care activities for women have been slow to develop, and more is needed. Socio-cultural factors increase the risk by promoting behaviours which favour the sexual transmission of HIV and constrain women's ability to adopt HIV preventive behaviours.

Many noble Lords made reference to the important work of NGOs. I echo that. The role of civil society is particularly important in the work which is being done on the ground. I would like to pay particular tribute to the work of the churches, a point which was raised by the right reverend Prelate, the Bishop of Wakefield. I will of course take back his concerns about the country strategy papers and the need to more fully reflect the partnership element in those.

Of course we are keen to promote partnership, not only with NGOs but with the private sector. It has an important role to play. Many companies have grant-aided NGOs to assist with counselling, AIDS awareness and prevention work to assist people living with HIV/AIDS to help themselves.

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In closing, I reassure noble Lords that Britain is playing its part in the global effort to respond to the human tragedy which is HIV/AIDS. But we all need to do more, far faster and far more effectively. We need to keep the spotlight on the crippling burden of HIV/AIDS in poor countries. We all have a role to play in this. I hope that all noble Lords will keep this issue high on the agenda. Strong political leadership and commitment is essential to reverse the appalling trend we are seeing and, ultimately, to remove the threat which HIV/AIDS continues to pose to the developing world.

5.33 p.m.

The Earl of Sandwich: My Lords, when I first came to this House a few years ago I was advised that every debate should have the essential ingredient of good humour. In this debate I despaired of this ingredient arriving until the noble Lord, Lord Graham, supplied the most magnificent tribute and the best joke about this being an unsexy debate, for which we were all grateful. I thank all noble Lords who have taken part. I must mention that others would have put their names down to speak if they had been able to be present. We have had a splendid attendance and support for this subject. I hope that we will commit ourselves to that again in the future, because no subject can be encapsulated in 150 minutes, let alone in 15 minutes.

I acknowledge that I have a strong bias towards NGOs. I was therefore grateful to the Minister for correcting the bias by reminding us that governments are there to look after this problem and that they are doing something. We are all encouraged by the amount that she is doing on behalf of her Government. We heard from the noble Lord, Lord McColl, about work that had been started a few years ago. It is encouraging to hear that, for example, spending is increasing and that clean water and sanitation is now a bigger priority than before.

I would like to thank in particular the noble Baronesses for introducing the ingredient of family decisions and the difficulty of making decisions when one of the family has contracted this terrible virus. I am sure that that brought a real sense of immediacy to the House. The question of gender and equality in Africa is one of the major problems, as the noble Baroness, Lady Miller, mentioned.

I also thank the right reverend Prelate the Bishop of Wakefield, who has experience of Africa. The fact that only 13 per cent. of the money for controlling AIDS is being spent in the developing world where 92 per cent. of the problem exists remains with me. He was kind enough to mention the work of the mosques. Certain aspects have been left out of this debate. We have not covered what is being done in Islamic Africa and francophone Africa, although the noble Lord, Lord Ponsonby, gave us that splendid example from Senegal. There is plenty that has not been said, but I am grateful to those who have said what they have. I beg leave to withdraw the Motion.

Motion for Papers, by leave, withdrawn.

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