Examination of Witnesses (Questions 463
TUESDAY 18 JULY 2000
463. Dr Piot and Dr Cleves, thank you very much
for coming. We know you have been en route from various places.
I do not know whether this is a stop-off from somewhere else,
but you have been very busy. As you know, we are doing an inquiry
on HIV/AIDS and we went to Southern Africa earlier in the year
and took evidence on the ground and we have been taking evidence
at several sessions since then. We are very grateful to you for
coming to assist us further in what I think will probably be one
of the last evidence sessions we will be taking. Do you have an
opening statement or shall we go straight into our questions?
(Dr Piot) Thank you very much. If I may
say just a few words. My colleague is Dr Julia Cleves who is the
Chief of the Office of the Executive Director in the UNAIDS Secretariat.
We have both come from the international conference on AIDS in
Durban last week, which received quite some media coverage all
over the world. I arrived this morning from New York where yesterday
we had a second debate on AIDS in the Security Council and for
the first time a Resolution was passed on AIDS, focusing on what
the Security Council is supposed to do, and that is dealing with
conflict, but also based on the fact that AIDS is being considered
as more than a health problem and more than a development problem
but as an issue of human security. I thought it was worthwhile
to share with you the Resolution because it is really coming hot
from the press. I would like to make three very small points to
illustrate what UNAIDS is about. First, there is this Security
Council debate and the Durban Conference, which are illustrations
of our advocacy and political mobilisation role. Secondly, we
have a major role in terms of facilitation and co-ordination,
which seems all very boring but in the end you can put in motion
bigger entities, and that is what our business is aboutfor
example, negotiating a lower public sector price for the female
condom, discussing with pharmaceutical companies how the price
of certain HIV drugs can come down. That has been one of our major
activities over the last months. Another example of our brokerage
role is in countries where what we are trying to do is mobilise
resources, not for us but for the country. In April we were very
successful in Malawi in the Round Table where over $100 million
was mobilised in two days to support a plan that we had been developing
with civil society and government in Malawi. A third element of
our role is knowledge creation and dissemination of best practice,
monitoring of the epidemic and evaluation. I think the report
that you all received is an example of that. It is not just what
is in there but also the database behind it. We become a clearing
house for everything that is going on in AIDS in the world and
the response to that. I will just give you these facts because
I think it illustrates what our three major roles areadvocacy,
facilitation, and knowledgeand it also illustrates that
AIDS is now very high on the agenda of all the organisations that
make up UNAIDS. I think that has been, for me, a major achievement
and not an easy one because dealing with this epidemic is as much
as about institutional behaviour change as about behaviour change
of individuals. I would like to stop there. I am very happy to
464. Thank you very much. Dr Cleves, do you
want to say anything at this point.
(Dr Cleves) Not at this point.
465. What are the main achievements of UNAIDS
to date? What would you point to?
(Dr Piot) I think that they can be categorised along
three main lines, the three main roles that we feel are for us
as a Secretariat. Before answering the question I would like to
emphasise that we are a co-sponsored programme. UNAIDS is not
a separate agency within the UN system. We are in a sense part
of a movement that we preceded, the movement of UN reform, working
more efficiently and more effectively in the UN system and that
is one of the reasons that we were created. When we talk about
the achievements of UNAIDS we can look at the bigger UNAIDS organisation
with the seven co-sponsors, from the World Bank to UNICEF and
WHO and so on. As to the UNAIDS Secretariat, if we compare the
situation today with what the situation with AIDS was four and
a half years ago, we are four and a half years old so we are still
if not a baby certainly a child. On the political front I think
we have made a really major contribution. I had two major objectives
when I got into this job. The first one was to bring AIDS onto
the political agenda in the affected countries and the second
one was in the north making sure that this remains a global issue.
Five years ago what was happening was that in the north the feeling
was that AIDS was over, we had not seen a major heterosexual explosion,
treatment was becoming available and therefore the problem was
fixed. The danger then was that AIDS would turn into another malaria,
a disease in the south for the poor so that here in the West we
do not have to care about it. That was my first objective and
we can come back to that at some other point. My second objective
was to put AIDS at the top of the institutional agenda in the
UN system. We have spent a lot of time on both. This achievement
in terms of political mobilisation of course is not something
that UNAIDS has done on its own. What we tried to do was forge
partnerships. When you are very smalland let us not forget
as a Secretariat we are about 200 staff and the majority of them
are based in developing countries and some in Eastern Europe,
and we do not have money, we do not have the Fifth Fleet that
we can send somewhereyou need to use knowledge and you
need to use political strategies for that. The strategy that we
are using in management terms is what I call the "judo"
strategy. You have sumo wrestling and judo. In sumo wrestling
you use your weight to put someone on the floor. We cannot do
that, we are too small. With judo you use the weight of your opponent
to make your opponent move in the direction you want them to move,
and we are flexible and mobile. The idea is to put AIDS on the
agenda where it is not there yet. That goes from the women's movement
to ministers of finance to the World Bank, UNICEF and their constituencies
and then personal advocacy showing, particularly to women in Africa
and Asia, that AIDS is more than a health problem, that it is
actually undermining their achievements in terms of social and
economic development and is threatening the very fabric of society.
So we started collecting evidence for that. It may be a big surprise
but it is only slightly over two years ago that for the very first
time we were able to collect and analyse data on what AIDS means
in every single country in the world, with a few exceptions like
North Korea and so on. That was the first time. It is very hard
work. And also what kind of resources are going into a response
to the AIDS epidemic. I would say overall this has been our major
achievement when you look at what has happened over the last 12
months. For me it starts with what was a breakthrough of a presentation
and a nearly day long debate with all the ministers of finance
of Africa. They had their annual meeting in Addis Ababa in April.
AIDS was there on the programme between debt relief and the strategic
plan for the Economic Commission of Africa so it was not at the
end like "any other business". For the first time ministers
of finance were challenged and went home and some of them spoke
about that with their colleagues. Secondly, several African heads
of state started speaking up, as did the UN theme groups on HIV/AIDS,
which bring together the representatives of various agencies making
up UNAIDS as well as bilateral donors and which, have turned out
to be very powerful advocacy instruments. This is the added value
of speaking with one voice. I have seen it myself when I was accompanied
by a full theme group on HIV/AIDS and we were meeting with the
Prime Minister in a country in Africa, who said, "If you
all come to see me together, this must be serious". It sounds
a bit ridiculous but that is the power of doing these things together.
There was a meeting called by the UN Secretary-General in December
which was like a kick-off of the International Partnership Against
AIDS in Africa where we have been trying to bring in civil society,
NGOs and the private sector into a single endeavour. The Security
Council debate on AIDS in Africa in January was an extremely powerful
advocacy instrument and since then it has accelerated. At its
meeting in Washington in April the Development Committee of the
World Bank and IMF also had AIDS as the number one item on the
agenda. Reaching out to another audience is the World Education
Forum. I was also at the South Summit of the G 77 in Havana and
AIDS, again, was on the agenda. On principle I try not to go to
AIDS meetings where everyone is convinced this is a problem, but
to those where the message has not reached them yet. There are
now results in terms of more resources, and these are going up.
The goal is also that AIDS should now be at the heart of the development
agenda in development agencies. That is also happening in DFID.
It is also happening in similar agencies as well. Secondly, I
would say that in terms of co-ordination and facilitation the
UN speaks with one voice when it comes to AIDS. That makes perfect
sense. I can guarantee you that was absolutely not the case before
we were created. Sometimes more energy was spent on fighting among
colleagues on what was right and what was wrong rather than actually
doing something about the problem. That is finished, both at the
country level and globally. We have reached the stage now where
we represent each other. Carol Bellamy from UNICEF also represented
the UNDP when she was speaking in Durban. These are small things
but they are the symptoms of something deeper that is happening.
Thirdly, what we have achieved is bringing together the core of
evidence of what works and what does not work. After twenty years
with this epidemic we now have a pretty good idea of what is effective,
where to put our resources and what has worked in countries that
have been able to turn the tide and bring down the number of new
infections. What we are doing is bringing that together in a best
practice collection. It is not an academic exercise, but based
on and written by people who have done work on community projects.
It is then shared with others. We are also working on a new global
strategy which will take into account the fact that we need a
multi-sectoral response. The fourth achievement is that in many
countries we have been able to go beyond the health sector, the
ministries of health, although we still have a lot of work to
do. What I have seen is that as long as we continue to treat AIDS
only as a medical issue there is no way we can win this fight.
When it comes to government departments we need to go and make
sure that the Education Department is involved, the legal system,
and so on. That met with a lot of resistance in many countries.
As I say, we are not there yet. When you look at the number of
countries that now have a National AIDS Commission, reporting
either directly to the president, the vice president or the prime
minister, that is certainly a result of our work. Tracking the
epidemic has also been something that has now been put in place.
We will continue to deliver. Sometimes people do not like us because
we bring a bad message, sad news, but the facts are the facts.
Lastly, we have been able to broker a number of deals. It was
certainly never in the spirit and minds of our founding parents
that we would be brokering a lower price for the female condom
or that we would get MTV on board. MTV now produces messages on
air time, which is worth more than we could ever afford. We sit
down and we say, "This is the message for this year",
and they translate this into a message for all of their stations.
The fact that we are now into discussions and brokering arrangements
with the pharmaceutical companies is also very significant, however
without becoming a supplier of drugs, as that would kill us.
Ann Clwyd: We will get on to that later.
466. My question follows quite neatly on from
what you just said. It seems to me that a lot of your concentration
is, naturally, on preventing the development of new cases. To
what extent have you felt you have been successful in improving
the life of those who are diagnosed as HIV-positive? Has there
ever been an international conference of those who are HIV-positive?
(Dr Piot) That is a very important question. Until
recently the international community and AIDS programmes, and
so on, were focusing entirely and exclusively on prevention. Prevention
remains a priority. The fact you have prevention means you have
less people to provide care for. We have thirty-five million infected
individuals in the world. In Africa alone there are twenty-five
million people with HIV without access to even basic care, and
that creates not only a humanitarian problem but totally undermines
the credibility of prevention programmes. What we have learned
is that one needs a comprehensive approach. You cannot deal with
prevention without care. Let me give you a few examples. We have
learned that access to voluntary counselling and testing, knowing
whether you are infected or not, is a very powerful tool for prevention.
Either you start to reorganise your life because you are HIV-positive
or you know that you are HIV-negative and you can really focus
now and keep it that way. What is the incentive when there is
no care at the end of the bad news? What is the incentive if there
is a stigma, losing your job, and so on, at the end of the test?
That is one of the reasons that we feel that one needs to offer
some care to those who are infected. The same thing is true, by
the way, for offering prevention of mother-to-child transmission.
Besides the fact we can save the baby we also offer incentives
for testing and counselling. We also provide hope. It is something
that I feel strongly about. I believe that in any social movement,
in any scientific discovery, the hope factor is extremely important.
That is what we try to introduce with this care. What have we
done? What has been done? Not much has been done. We have to be
very clear about that. First, the actual treatment, the so-called
antiretroviral therapy, the drugs that treat the HIV infection
itself are very new. In our countries they have been on the market
for about four or five years. The impact has been spectacular
in terms of mortality and better quality of life for those who
are infected. In the south we have all been paralysed by the fact
that they are very expensive, they are very complicated to give,
and in addition AIDS has come at a time when the health infrastructure
in many countries has basically collapsed and is much worse off
than five years ago, ten years ago, even 20 years ago. So we have
got a very bad combination of poor supply of health care and,
on the other hand, an increase in demand. So what we have been
doing is to follow a plan. Firstly, we are working with countries
to establish standards of care. We need to rationalise the agenda
because if we do not do that, pure market forces take over. Only
the rich who have access to antiretroviral therapy will have access
to care, and the poor with HIV will not have access to simple
treatments. This is work that is being done country to country
and we are starting on it. Secondly, we are working on simpler
strategies, simple drugs that can prolong life and improve quality
of life, like preventing tuberculosis and preventing some of the
brain and lung infections associated with HIV. Thirdly, we have
started on quite an adventure which should be very positive in
trying to bring the price down of pharmaceutical products by working
with the pharmaceutical industry. I think the first concrete result
of that is there. Last week the German company Boehringer Ingelheim
announced that it would provide free for five years to all developing
countries nevaripine for preventing mother-to-child transmission.
If you wish, we can give you more information on that because
we are working quite a lot on this.
(Dr Cleves) Just to add one point to that which Peter
Piot made. I think in 1997-98, when access to antiretroviral therapy
was nowhere near the international agenda, UNAIDS took a very
brave step to see whether it was even possible to provide antiretroviral
drugs to people by offering them to people in two countries, Côte
D'Ivoire and Uganda, as a way of testing the systems and looking
at the logistics. Although not very many actual numbers were treated,
only 1,000 in each instance, it nonetheless provided enormously
important evidence for a subsequent scaling up and was hugely
useful for this adventure, as Peter describes it, going forward.
We know a little bit more than we would have done if the Secretariat
had not been involved in that process.
467. Would it be a useful thing to do and, if
so, have you done it, to have an international conference of those
who are HIV-positive? I would have thought to reinforce each other,
to talk about what helps them practically would be an enormously
powerful tool, but I do not know.
(Dr Piot) I must say that we are more and more putting
people with HIV at the centre of the response. In our work in
UNAIDS we have many people who live with HIV, and we are also
promoting that in the countries themselves. There are several
groups now at national level in nearly all countries, although
there are still some exceptions, of people with HIV who are organising
that, and I will never forget what a Thai with HIV told me in
Chiang Mai about five years ago before we even existed. He gave
a speech and there were many politicians there and he said, "If
people with HIV would unite into a political party in Thailand,
we would be the biggest political party." What he was saying
is, "We are going to become a political force," and
I think that is what is happening in some countries. Every other
year there is an international conference of people living with
HIV. The last one was held in Warsaw. It is called GNP+, the Global
Network of People with HIV. It attracted about 500 people out
of 35 million. Of course, we cannot have 35 million together but
it illustrates the difficulty that they are having to find support
for that kind of idea and I would say that it is really a crucial
area to work with. We are supporting on a regional or national
basis networks of people living with HIV. Last year when I was
in Ethiopia I went with the President and the Patriarch of the
Ethiopian Church to the launch of the first association of people
living with HIV called Dawn of Hope where five Ethiopians with
HIV came out publicly for the first time. We did the same thing
in Namibia and the interesting thing was that that was in the
Catholic Cathedral. We are trying to provide some safe space for
these people and I think that is one of the roles that the UN
also can play. There is a place for supporting the existing organisations
so that they can do more. They are always on the verge of collapsing
468. A question that has been bothering me is
what percentage of people who are HIV-positive know they are HIV-positive?
When you are looking at the developing world, sub-Saharan Africa,
there are no testing facilities and, if there are, people do not
want to use them because they do not want to hear bad news. How
many people are dying never knowing they were HIV-positive? They
think they are dying of tuberculosis, and they did, but they were
HIV-positive. Have you got a picture of that?
(Dr Piot) It is a very important question particularly
in light of what I mentioned before about prevention, care, testing,
and so on. We estimate that it is probably around five per cent
of people in the developing world who are infected who know they
are HIV-positive. In Africa there is basically only one country
where access to testing and counselling is reasonable, and that
is Uganda. It is not a coincidence that that was a part of their
core strategy from the beginning. Malawi is now also making a
major effort and Senegal as well. South Africa has announced that
it will start with such a programme and so has Botswana. I think
that is the key. As long as the problem is hidden, as long as
too few people know that they are infected and even fewer people
are known by the others to be infected, than the ideal circumstances
exist to continue the enormous denial at the personal level and
at the societal and political level, because it is at both levels.
That is why we have been really paying far more attention than
before in the international community to this issue of access
to testing and counselling. You cannot provide care to people
with HIV if they do not know they are HIV-positive and if they
only find out when they are terminally ill with AIDS. You cannot
generate a strong response with people living with HIV/AIDS if
you do not have that.
469. We followed the quite extensive report
in the Durban Conference, particularly the opening speech by President
Mbeki and the closing speech by ex-President Mandela. What do
you feel the achievements of the Conference were overall and what
do you think its disappointments were?
(Dr Piot) I think that for me it was a very different
conference from all the other conferences to start with. I have
been at all these conferences since 1985 and it is the first time
the conference was held in the south, it was the first time in
Africa. That was reflected also in the programme of speakers where
there were 4,000 African participants and so to me that was very
positive. Also when you look at the media coverage in the world,
it was enormous. We can say this is nothing new, this has been
going on for years but suddenly it hit the media circuit and in
a sense the controversy generated by President Mbeki probably
helped in generating more interest. When I compare it with the
previous conferences, it was far more of a political conference
and a conference of people than a scientific conference. There
were no scientific breakthroughs as far as I know although there
were very important papers presented, for example, on the prevention
of mother-to-child transmission which is typically a problem for
the developing world because there the main way it is spread is
heterosexual. You have over half a million babies born with HIV
in Africa. There were a number of things on the scientific front,
mother-to-child transmission, secondly, vaccine work which got
more attention than before. In the last ten years it had been
written off and now there is a renewed interest. I think that
is also very positive. Also, the stigma and community responses,
which we have been discussing here, that people do not know they
are HIV-positive, and the stigma associated with it, were discussed.
The overriding theme which dominated the discussions was access
to treatment and access to care. In the news that I saw it was
narrowed down to one thing, and that was the price of drugs. Of
course, the problem is a little bit more complex, to say the least.
It is a unique combination. I do not know of any other issue in
society today where you get molecular biologists, ministers, people
with HIV, activists of all kinds, bureaucrats of all kinds, and
so on all together and discussing and, of course, disagreeing.
What I feel is in a number of areas we are reaching common ground.
I may exaggerate what I am saying now, I feel we are at the beginning
of what is a global movement against this epidemic. It is nothing
less than such a global movement that will stop it. It is very
clear to me we should not count on technology. I deeply, deeply
hope that we will have a vaccine, the sooner the better. We are
not going to make it with technology, it is with people.
470. Do you feel there is real commitment amongst
Africa's leadership to fight AIDS?
(Dr Piot) Let us start with awareness. Let us try
to define what commitment is. The awareness is now very high.
I can see the difference. I have met nearly all heads of state
in Africa, it is really the target of most of my travel. Until
about a year ago I always had to start by saying, "This is
such a problem, it is going to do this to you, your population
here are dying and your teachers are dying", and so on. They
are asking me today, "What should we do?" The awareness
is very high. What to do about it is not very clear. To translate
that into budgets, we need an enormous increase in resources for
basic prevention, for basic care. A major part of that has to
come from the governments of the countries that are affected.
If something is about survival or national security that is where
the money has to come from. They are struggling with that. Recently
we had some very important contact with President Obasanjo. At
the OAU Summit at Lomé he called for a summit of African
heads of state, especially on AIDS. The OAU Summit in Lomé
endorsed the International Partnership against AIDS in Africa,
the framework and UNAIDS' work. These are not trivial matters.
For us that was very important, however translating that into
action is always the challenge. These are some more regional issues.
At a national level there are countries where the president has
created a National AIDS Council. In Nigeria the President himself
chairs the National AIDS Council/Commission, which is a multi-sectoral
body. In Malawi it is the vice president who is now spending over
half of his time just on AIDS. In Kenya the National AIDS Committee
is in the President's office. Uganda has had modest success but
for some time the Government's response to AIDS was in limbo.
It went to the Ministry of Health, then back to the President
and then back to the Ministry of Health. It is now firmly imbedded
in the President's office again, with a presidential AIDS adviser
and a strong director-general. I can give you even more examples;
with Mozambique it is the same thing. All of this happened over
the last six to twelve months. What the international community
has to do now is to support these efforts, because they are really
country-owned. The problem with the response in the 1980s and
the 1990s was often that it was felt to be imposed from the outside,
that the national ownership was difficult to get. I think that
is where the turning point is.
(Dr Cleves) One of the clearest messages that came
out of Durban was that leadership saves lives. In many places
we are looking at AIDS as a crisis in governance. This was a headline
for the closing session at Durban. I think that the statement
by ex-president Mandela also underscored the point that Peter
has just made about the start of an international movement against
AIDS. To come back to the point that Mr Rowe was making, what
is different about these International Conferences on AIDS is
precisely the presence of HIV-positive people. There is quite
an extraordinary blend of political activism, science and technology,
and this whole leadership of governance. That came together very,
very forcefully and I do not think anybody who was there will
forget that sense of a real start to a global response to the
epidemic that came out of Durban.
471. What would you hope to get out of the Okinawa
G8 forthcoming conference as far as AIDS is concerned?
(Dr Piot) We have the text of Nelson Mandela's speech
in Durban, which is really a very powerful one, if the Committee
is interested. We can share that with you.
The next important step for us is the G8 Summit in Okinawa. AIDS
will figure on the agenda in its own right and also as part of
a discussion on poverty, together with two other diseases, tuberculosis
and malaria. We have been discussing with several members of the
G8 the need for the commitment of the richest countries to increase
their investments in AIDS in the developing world, for a variety
of reasons. There are some specific issues that can be done. What
you need to roll back AIDs is people, that is the major, major
commodity. The answers can only come from within the communities
and it is the people who will do it. The second thing you need
is knowledge. Knowledge is an international public good. Thirdly,
commodities, tools, from the male or female condom, to drugs to
prevent mother-to-child transmission, to treat people and to test
people. That often needs to be paid for in hard currency. This
is where the international community can come in and must come
in. A paper was sent to the G8 members that summarises what the
needs are. I would like to ask Julia, who was the author of the
paper, to highlight what is in there.
(Dr Cleves) Picking up where Peter left
off, it is now the situation that in a number of African countries
there is a shortage of male condoms, which in this day and age
and with the epidemic at this stage is quite extraordinary. There
is a shortage of basic drugs for palliative care. Many people
die in Africa without so much as paracetamol, or calamine lotion
for a skin rash. It seems preposterous not to have those basic
commodities in place. They do not require sophisticated health
systems to deliver them, they can be delivered at community level.
One of the things that we have been calling on from the G8 leaders
is for commodities security for all countries in sub-Saharan Africa,
and no country's response should be hampered by the fact they
do not have the basic commodities. The second area is also this
whole business of access to drugs for opportunistic infections
and, indeed, to antiretroviral therapy. We see that as a leverage
to get countries more interested in the overall care agenda. That
is one of the areas we have been calling on. Having done quite
a lot of work recently on costing an adequate response to the
epidemic, at the opening of the Durban Conference UNAIDSPeterwent
on record to call for $3 billion a year for an adequate response
to the epidemic in sub-Saharan Africa for basic care and basic
treatment. For the first time at this conference a number of calls
for significant increases in resources were put to the Plenary
and again we very much hope that Okinawa will take very seriously
the level of resources needed.
472. Would you expect debt reduction to be used
in HIV/AIDS interventions in some way?
(Dr Piot) Definitely, and we actually have a small
team based in the UNICEF office in Zambia at Osaka that is supporting
governments which are interested in including AIDS in their poverty
reduction strategy papers. Uganda has done it, it is basically
there. Mozambique is in the pipeline, as are Zambia, Tanzania,
Burkina Faso, Nigeria and Mauritania. These are the countries
where the Government is interested in using the money freed up
by debt relief for AIDS activities, and we are just making sure
that it is in the papers. We are not doing that on our own. This
is of course done with some of our co-sponsors, for example in
the World Bank, and, on the other hand, with some of the bilateral
donors, in some cases DFID. For us it is a major strategy, not
only for the money but to make it an integral part of the core
473. How did you arrive at the figure of $3
billion for basic care and prevention?
(Dr Cleves) Through a fairly detailed costing exercise
that we did with the World Bank, with the London School of Hygiene
and Tropical Medicine, with USAID, and a consultancy company in
the United Kingdom called Options, which looked at every aspect
of the epidemic and looked at the needs and added it up. We have
got a very detailed spreadsheet model in order to reach that figure.
(Dr Piot) It is 1.5 billion yearly for basic prevention
which includes youth-focused interventions, interventions focused
on sexual behaviour, public sector condom provision, condom social
marketing, strengthening services to treat sexually transmitted
infections, voluntary counselling and testing, workplace interventions,
strengthening blood transfusion services, the prevention of mother-to-child
transmission, and mass media and capacity building. There is a
whole menu that we have used and we spent a lot of time discussing
this with the various institutions that Julia mentioned to make
sure that there is some overall figure that is agreed by everybody.
474. Before I ask my question can I through
you, Dr Piot, thank your staff in Geneva for the hospitality they
offered me when I was there for the UN Social Summit. I was particularly
pleased to see the way that you had entrenched yourself within
the complex of the World Council of Churches and we have had evidence
from other people in terms of the importance of the Faith communities
in terms of the educative side of dealing with the HIV/AIDS epidemic.
I think it is particularly pleasing to see how the UN Social Summit
Plus 5 itself took on board (which was not taken on board in Copenhagen)
the centrality of dealing with HIV/AIDS, that if you are looking
at plans to deal with it you need to eradicate poverty around
the world. So thank you to your colleagues for looking after me
in the way they did. If I can go on to my questions which are
about the linkage between HIV/AIDS and the unsafe injection of
drugs. In the evidence you put forward to us in paragraphs 3.5
and 3.6 you draw attention to this. You say in Asia, particularly
in India, that HIV infection in the north-east has moved rapidly
through networks of men who inject drugs and spread it to their
wives. In 3.6 you talk about Central and Eastern Europe where
the bulk of new HIV infection is caused by unsafe injection of
drugs and occurred in two countries, the Russian Federation and
Ukraine. In the UNDP you quote their evidence in paragraph 5.4.28
in terms of "the most direct spread of HIV has come through
needles shared by injecting drug users." Is there any estimate
of the proportion of those who are HIV-positive who have been
infected as a result of unsafe injection of drugs and how do the
rates of infection from that compare to rates of infection through
unsafe sexual activity?
(Dr Piot) That is one of the most complicated issues.
It is not only estimating what is the proportion of individuals
infected through unsafe injecting practices but also what to do
about it. We always tend to think that this is a problem for the
industrialised world but in developing countries it is there as
well. I do not know by heart the figures but it is in our report.
I know that, for example, in Eastern Europe the overwhelming majority
today of people with HIV have been infected through unclean needles,
sharing needles. In many poor provinces and states in India, in
North East India, also it is the overwhelming majority. In Thailand
it is a growing proportion because they are doing a good job in
terms of preventing sexual transmission, but in Bangkok there
is still a lot of unsafe injecting going on, with HIV the result.
In Southern China, for example, and Eastern and Western China
injecting drug use is the main mode of transmission. We can provide
the estimate (which is probably the best way to describe it) for
So that means that we cannot deal with HIV/AIDS, particularly
in these areas, without tackling the drug use problem. Here the
strategy can only be a package of demand reduction as well as
harm reduction and making sure that particularly young peoplebecause
in many of these countries you have cited the age of the injectors
is extremely low, particularly in Eastern Europe -do not use drugs,
even in a climate of no future, of social despair, where society
is in transition, where unemployment is high, and so on. In addition,
we need to make sure that those who are injecting drugs do it
in a safe way. That is why, if the Government allows it, needle
exchange programmes are being supported by us because they have
been demonstrated in scientific experiments to slow downthat
is what we can see - the spread of HIV. But it is only through
a very comprehensive approach that we can do it.
475. Is there an internationally agreed policy
on the provision of clean needles?
(Dr Piot) As far as I know, there is no internationally
agreed policy but last year there was a special session of the
General Assembly on drugs, and AIDS was part of that. And there
is a statement that came out of it which drew attention to the
harm-reduction approaches. We are moving in this mine-field, particularly
since UNDCP has become a co-sponsor. The UNDCP, until recently,
has focussed entirely on demand reduction and supply reduction.
It is now also dealing more and more with us in these countries
on reducing harm on those who are injecting. There are no standards,
because there is absolutely no political consensus internationally.
What we are doing is we are trying to learn from positive experiences.
(Dr Cleves) Just to supplement Peter's point, the
countries reporting IDU increased from 115 in 1999 to 121 in 2000.
We heard evidence at the Durban Conference that drug use is becoming
more of a problem in sub-Saharan Africa; drug use, first of all,
and then injecting drug use follows behind. Some evidence on that
was presented. That was fairly surprising to some of the people
who were there.
476. I was reading that ten per cent of world
trade is now in drugs. If it is at that scale, and going to get
bigger, should we not be looking to see if we cannot deliver drugs
in a less damaging way? Injecting oneself is an unattractive thing
to do, speaking as an ex-asthma sufferer. Presumably you could
remove a lot of the potential damage of HIV/AIDS if you could
actually make the ingestion of drugs as attractive to drug users
by some other method?
(Dr Piot) That is true. That is one of the reasonslike
methadone programmes, in addition to bringing the habit under
control,from an AIDS perspective, you move from injecting
to oral medication. On the other hand, the logic is such that
injecting is far more cost-effective and cost-efficient because
you need less drugs and they have a more immediate effect. What
we have seen in Asia, particularly, is that transition goes in
the opposite and very damaging direction from our perspective
and from many other perspectives. In cultures where drugs were
traditionally smoked or inhaled they are now injecting them. In
southern China they are moving from opium to more purified products,
like heroin. There is a commercial logic in that. I agree with
you, when we think of harm reduction it is better not to inject
drugs, there is no doubt about that.
477. What has been the effect of HIV/AIDS on
the provision of safe blood supplies in the developing countries'
health services and thus on health care? Are testing facilities
available to ensure that safe blood is available? How is the international
community assisting developing countries in this area in ensuring
that there are safe blood supplies?
(Dr Piot) A lot of progress was made in the early
days of the epidemic, particularly from 1985, when the first diagnostic
tests for HIV came on the market. Then the WHO, the first special
programme on AIDS and then the global programme on AIDS, devoted
some resources to that. Also, several donors, particularly the
European Commission, invested a lot in setting up blood transfusion
services. In the last five years not much progress has been made.
To date, I know major investments with good results, like in Uganda,
were made, particularly with the European Commission. In Senegal
blood is safe as well, as in most of the southern African countries,
like Zimbabwe and South Africa. We have a map, but I do not have
it with me here, and there are major African countries where blood
is not safe. When it comes to India there is a law that makes
it compulsory to test blood for blood transfusions for HIV and
it also makes paid blood donors illegal. Bangladesh is now considering
a similar law. The performance is very, very uneven. Some agencies
in the past have said that since contaminated blood transfusions
do not contribute enormously to the spread of HIV it is not cost-effective
and we do not invest in it. It is an example of what I would call
a technocratic approach to this problem. If you are only going
to base your decision-making on what is cost-effective, how many
you save by intervention, you are really missing the boat in many
aspects, and this is one. In terms of safe blood transfusions,
the state also has a responsibility. There are ethical, moral
and legal aspects. It is something that has to be part of any
478. What proportion of HIV infection is coming
through infected blood supplies?
(Dr Piot) It is probably less than one per cent.
479. That varies, obviously. Do you have this
information you could table for us?
(Dr Piot) Yes. That would have been more important
in the early days when HIV is introduced into a country. It would
be more important before you have a massive heterosexual epidemic.
3 Not printed. Back
Note by witness: About 5 per cent of HIV infections are
the result of IDU. Back