Table Of Content

molex moym mG e) sala area): International Development Committee HIV/AIDS: DFID’s New ‘Strategy Twelfth Report of Session 2007-08 Volume Il HC 1068-II IONIC 22503058384 House of Commons International Development Committee HIV/AIDS: DFID’s New Strategy Twelfth Report of Session 2007-08 Volume Il Oral and written evidence Ordered by The House of Commons to be printed 25 November 2008 Weed . ; ICE RINE SDE WCE, AS HC 1068-II Published on 30 November 2008 by authority of the House of Commons London: The Stationery Office Limited International Development Committee The International Development Committee is appointed by the House of Commons to examine the expenditure, administration, and policy of the Department for International Development and its associated public bodies. Current membership Malcolm Bruce MP (Liberal Democrat, Gordon) (Chairman) John Battle MP (Labour, Leeds West) Hugh Bayley MP (Labour, City of York) John Bercow MP (Conservative, Buckingham) Richard Burden MP (Labour, Birmingham Northfield) Mr Stephen Crabb MP (Conservative, Preseli Pembrokeshire) Daniel Kawczynski MP (Conservative, Shrewsbury and Atcham) Ann McKechin MP (Labour, Glasgow North) Jim Sheridan MP (Labour, Paisley and Renfrewshire North) Mr Marsha Singh MP (Labour, Bradford West) Sir Robert Smith MP (Liberal Democrat, West Aberdeenshire and Kincardine) Powers The Committee is one of the departmental select committees, the powers of which are set out in House of Commons Standing Orders, principally in SO No 152. These are available on the Internet via www.parliament.uk. Publications The Reports and evidence of the Committee are published by The Stationery Office by Order of the House. All publications of the Committee (including press notices) are on the Internet at www.parliament.uk/indcom Committee staff The staff of the Committee are Carol Oxborough (Clerk), Ben Williams (Assistant Clerk), Anna Dickson (Committee Specialist), Chl6e Challender (Committee Specialist), lan Hook (Senior Committee Assistant), Sarah Colebrook (Committee Assistant), Miguel Boo Fraga (Committee Support Assistant) and Alex Paterson (Media Officer). Contacts All correspondence should be addressed to the Clerk of the International Development Committee, House of Commons, 7 Millbank, London SW1P 3JA. The telephone number for general enquiries is 020 7219 1223; the Committee's email address is [email protected] Witnesses Tuesday 28 October 2008 Page Lucy Chesire, HIV-TB Advocate, ACTION Project Kenya Ev 1 Dr Kent Buse, Health Policy Analyst, and Alvaro Bermejo, Executive Director Ev 4 of the International HIV/AIDS Alliance, Ms Fionnuala Murphy, Campaigns and Policy Officer, ActionAid; Stuart Kean, Chair of the Working Group on Children Affected by AIDS, and Carol Ev 12 Bradford, Chair of the UK Network for Sexual and Reproductive Health Rights, UK Consortium on AIDS and International Development Thursday 30 October 2008 Ivan Lewis MP, Parliamentary Under-Secretary of State, Malcolm McNeil, Team Leader, AIDS and Reproductive Health Team, and Alastair Robb, Ev 18 Senior Health Adviser, DFID Uganda, Department for International Development, List of written evidence Department for International Development Ev 31; Ev 44 ActionAid Ev 45 All-Party Parliamentary Group on AIDS Ev 49 Business Action for Africa Ev 51 Lucy Chesire, ACTION Project-Kenya Ev 54 Consortium for Street Children Ev 57 Interact Worldwide Ev 58 C=BO OUWN YDInNte rnational HIV/AIDS Alliance Ev 68 Malaria Consortium Ev 7/7 tOi =) Médecins sans Frontiéres Ev 78 National AIDS Trust Ev 81 Results UK Ev 84 STOP THE TRAFFIK Ev 88 Tearfund Ev 89 UK Consortium on AIDS and International Development Ev 94 eSem=BM WeN World Vision Ev 102 —_f op) —; — woe Fe _ « q 7 e _ <:‘ 1ar i 7 i&r©z%i s )e ~~: 7: ty + m © : 1 ¢ a8 C . be fr F * Py A 4 ‘ ¢< *% rn is br x snp: rl = ea 1 A eee aamater one y : > ; y . w Ot a britey e 7. aei 4 ihre wae Ai L / d aL Wy Pa AR we] mi,p Hs 9 4 sepeubcy yt OTA steno¥bA at: feng ie awe |p itepearits Were: ‘indAs ohana ercelth 2ce et eee ae re i im iy Ovo ihe Sap eR ee Me nay na’ f . ETN Vie rss iA oe baht, ryt one) OFA as ; ar eRi) el t P, i) eataa Daes eyODMsT!a. Wy vk 1sgt iwea + 0} h#rs0: avCOaRnA.t OMeU, a. h 1 Bgl RO area eho Dee: ey M ieteM ler 14 (e9 haenebatls Nee a: pe Mhiyit erate vy, ie tie avian bow Ont hersH e fw er AM JB m Led eee aT eT 3 ‘ ? ye? i se annabive, 1: , ; vnif + FWes y ‘ j 4 ue eee Lee , a el > ta 2P RC etwas as eae rh by ayejenl pS taciatisah K y, é ‘ ears! eo" ve) yGattA nhs Se ae o saa.a n Sei a IE om ; ot te em iy i “gphatetirt a Ps 7 t ssoutetiya oo. ; ‘ ah . pa; y eyer. ‘hy ’ or; d —,aml oslat . bo Manta: iy Vinh eg‘para ito i ‘ie or es “angel teb ien, Sabet hen nna ‘ esl YANG sa Wie Corum ints ed — International Development Committee: Evidence Ev 1 Oral evidence Taken before the International Development Committee on Tuesday 28 October 2008 Members present: Malcolm Bruce, in the Chair John Battle Daniel Kawezynski Hugh Bayley Mr Marsha Singh Richard Burden Sir Robert Smith Mr Stephen Crabb Witness: Ms Lucy Chesire, Kenyan HIV-TB Advocate, ACTION Project Kenya, gave evidence. Q1 Chairman: Good morning, Lucy. Can you hear can understand me, to follow that up: are you, and see us? therefore, saying that you would like to see priority Ms Chesire: Yes, | can hear you loud and clear. Can given to improving the diagnosis and then also you hear me? giving people with HIV routine screening with better techniques? Q2 Chairman: Yes, we can hear you. That is fine. Ms Chesire: In relation to that, I think it is pretty Thank you very much. First of all, can I say thank clear what the demand for interaction activities is. you very much for coming into the DFID office to When you look at the TB and HIV collaborative talk to us. Some of us met you when you were in activities (inaudible) it states very clearly what London in June and, obviously, we felt that you programmes are supposed to do. Something that would be a very good person to share your they need to do is establish mechanisms for co- experiences with us. I just wondered if you would infection, because here we have a_ reasonable perhaps start by saying, as somebody who has been ambition and, therefore, the programmes need to living with HIV and TB, what are the biggest cognate together. The issue is around decreasing the challenges that you face, and feel free to express burden of TB among people living with HIV/AIDS what you think are the most important issues for and, of course, decreasing the burden of HIV among you? TB patients. What basically programmes are Ms Chesire: Okay. Thank you very much. It is supposed to do is be able to create each and every excellent of you. First of all, the challenges and part. When you look at TB/HIV co-infection— experiences of people living with HIV are very clear. Are you able to hear me? Q5 Chairman: Lucy, can I stop you? Ms Chesire: Yes. Q3 Chairman: Yes, we can hear you now. There was a slight scramble, but carry on. Q6 Chairman: The sound quality is variable and Ms Chesire: Okay; cool. What I wanted to say was what they are suggesting is it might be better if we that some of the challenges that people with HIV redial and see if we can establish a better connection. face in relation to TB/HIV, co-infection is the issue We are getting quite a lot of what you say, but it is around the main diagnosis. The challenges are very difficult to get a complete record. So if we can around diagnosis because, if I can give my own stop and see if we can re-establish the connection, I experience, what basically happened is that I was think it would be better for all of us. already living with HIV and I went for a chest x-ray Ms Chesire: That is fine. but the truth was that none of them were actually showing that I had TB. So that is the biggest one. Q7 Chairman: Hopefully we will see and hear you The kind of techniques that are being used should more clearly in a minute or two. actually be updated. If you look at the chest x-ray, it Ms Chesire: Okay. has been used for over 100 years (inaudible), and Chairman: I am sorry about this, but I am assuming that technically means that if you want to see a that people are all having difficulty with the sound. diagnosis for having HIV, for TB, it means, despite The Committee paused whilst a new video link being in an area of (inaudible) it becomes very connection was established difficult for the patient to be able to survive. Q8 Chairman: Hello, can you hear us? Q4 Chairman: It is very difficult; I do not know Ms Chesire: Yes, we can. whether we can get a better sound quality. While that is being done, can I say I certainly understood Q9 Chairman: Okay. I think that is better. We will the main point you were making, which is that you certainly try. I am sorry about that. Technology is believe that the diagnosis for TB is inadequate and great when it works but it is a problem when it does outdated. I can perhaps ask you the question, if you not. You were saying to us that you find the Ev 2 International Development Committee: Evidence 28 October 2008 Ms Lucy Chesire techniques for diagnosing TB are primitive. Perhaps Ms Chesire: Absolutely. For those who are you would just say it again. Are you really saying symptomatic, they are being screened, but the more should be invested in improving the techniques screening is not done for the generalised population. for diagnosing and are there particular problems That is one thing we need to understand. What I am with people who are HIV positive? Do they require also trying to say is that when you look at the TB/ dedicated diagnosis? HIV co-infection activities, when it comes to Ms Chesire: | do not think they necessarily require decreasing the volume of TB among people living dedicated diagnosis. The issue is that the diagnoses with HIV, one requirement is each of us, for that are currently available are not all sufficient to be example, living with HIV should be screened for TB. able to detect micro-bacterial problems with HIV, Currently that is not happening. That is why I was and what that basically means is that it calls for more trying to give examples of countries that are even research into TB/HIV co-infection with regard to implementing co-infection activities, we still see that diagnostic provision and co-ordinating bodies. it is just not happening. Now, on reflection (inaudible) whereby it takes over six hours to be able to get a conclusive test. Of Q12 Chairman: DFID are targeting a lot of their course, the challenge here is that the current funding over the next few years to strengthening diagnosis is not able to pick up the micro-bacteria health services. Do you think this will help or do you and that is why we have to look at the global TB side. think the HIV/TB at-risk patients will kind of get They are trying to see what can be done in relation to lost in the general service? In other words, do you advancing the diagnostics for TB/HIV so that every think you need to continue to have a targeted person who has HIV is screened for TB, but, equally, service, and, if you have a targeted service, can you antiretroviral therapy is continuing. When you look deliver it if you do not have an effective health at the three basic donors for HIV, which is service? PEPFAR, ! Global Fund and the World Bank, none Ms Chesire: That is very interesting, because I of them are actually charting how many people always look at it as you have to do both—you living with HIV are being screened, and to me that is cannot have one and not have the other—and so, at a crisis, because we cannot have over seven or eight the end of the day, what we have seen in the past is hundred thousand people who are already infected that because of the burden of TB, HIV and malaria and only less than 2% of them are being screened, actually this whole area is a symptom of our current and that shows that even the global donors are not healthcare standards, and it shows everybody it really able to adopt and address co-infection as means how do each work together so that at the end being a problem. of the day even specific programmes are actually contributing to health system strengthening. If you Q10 John Battle: I wonder if I could ask whether the look at the health system strategy, screening states problem in detection of TB is an issue of screening that one of the clear components is the issue around personnel staff and clinics, or is it a scientific the whole of the health strategy. How do we look at problem that once a person has HIV scientifically the six blocks in relation to that? You are talking the bacterial infections make it more difficult for about healthcare workers having adequate even the best doctors to detect TB? What is the basic healthcare providers, healthcare financing, issue here? Is it scientific detection or is it lack of monitoring and evaluation in place—all these staff, medical personnel actually physically components are really significant, so we know that screening people? we cannot have one without the other because we Ms Chesire: The problem is actually both. It is both have got to have both of them working in tandem so scientific and also it is medical. Why I say it is both that at the end of the day the strengthening means scientific and medical is because all the TB/HIV that we have an efficient service so that at the end of programmes that are currently implementing the co- the day somebody is able to actually get adequate infection activity, only less than 1% of persons living services. with HIV around the world are actually being screened for TB, which to me is a disaster. We Q13 Sir Robert Smith: On that point, how do you cannot afford to delay diagnostics. Programmes are think DFID should measure the effectiveness of its not even doing the actual screening and at the same strategy? What sort of outcome should it be looking time, not even for the very few that are doing it, like for to see if it has made a difference? in Kenya, Malawi and Rwanda, they are recording Ms Chesire: One of the things that DFID needs to and reporting a problem, and that is why when you do is that when you look at the current AIDS look at the countries’ plans they do not even have a strategy there is not really much on what they are specific indicator for TB/HIV, which to me is a going to do specifically on TB/HIV, and that disaster. provides an opportunity, so it is important that it is clear-cut in terms of how much of DFID’s money is Q11 John Battle: Could I follow that up? Are the actually going even to contribute to addressing the health authorities screening for 7B for people who issue of the co-infection alongside the health system. are not yet diagnosed as HIV positive? In other Then, of course, the issue of monitoring, which is words, is there a general anti TB campaign and really critical. It is pretty clear that if DFID wanted screening running? to go that way, one of the indicators we will be looking at is how many persons are being screened ' US President’s Emergency Plan for AIDS Relief. for TB? How many TB/HIV co-infected patients are International Development Committee: Evidence Ev 3 28 October 2008 Ms Lucy Chesire benefiting from prophylactics, which is Isoniazid Ms Chesire: Y ou are pretty right in that, but I do not preventive therapy, and then at the same time how think your figure is right because when it comes to many of these are being started on HIV multi-drug resistant TB the issue of making the antiretroviral therapy? So these are inherently difference becomes also another greater challenge, difficult to look out for, and I think they are pretty because when you look at XDR and MDR, most well spelt out when you look at the TB/HIV co- countries do not even have the laboratory facility to infection activities but it is important that through be able to screen that, and that is why now the World the AIDS strategy, which is lacking currently, there Health Organisation has been trying to see if it can is no allocation of funding that is going to address set up a laboratory within Africa, so that patients the co-infection, despite (inaudible), or people living can get better services with the screening being done with HIV around the world, and then, of course, the so that it does not become an impediment. issue of monitoring and evaluating to see what progress is being made at the country level and Q16 Chairman: I was going to ask you, because within the country plan. really this is an opportunity for you to provide from your experience your thoughts, as to how DFID could better deliver on HIV/TB; so do you have a Q14 Chairman: Is the problem that not only are you specific point or points that you would like DFID to not screening and diagnosing people who are take on board if they are spending, as they are, or vulnerable to TB and are HIV positive, but if you do offering, substantial amounts of money that would not actually have the health infrastructure, you meet your concerns and objectives? In other words, cannot treat it? It is almost worse to be told you have if you were writing DFID policy, what would your got TB but there is no valid treatment available. So priority be? is access to treatment at least as big or bigger a Ms Chesire: | think my priority would be one of problem than diagnosis? accommodation in terms of a financial commitment Ms Chesire: | think we have seen the issue of access within the HIV strategy to be able to address the co- to treatment being much more available to many infection, and then, of course, secondly, ‘the people. It was a big challenge actually when starting opportunity for DFID to be able to track the antiretroviral therapy for many people, and today amount of money that it is spending on some of the we have over 280,000 people who have been started diseases, which is currently not happening, and then, on treatment. So we have come a long way in of course, most importantly, the issue of monitoring relation to that, but the thing is we have also got to and evaluation. be able to address the challenges that are coming up today, and that is why TB/HIV co-infection as a Q17 Chairman: Do you have a view, then, about the challenge has been very, very important in one area Global Fund, because that clearly is designed to try where we are having multi-drug resistant TB and and deliver that, but you feel that it is falling short? also XDR,? and so, with resistance to most of the Ms Chesire: The Global Fund has played its role, drugs, it becomes much more scary because it is but it has also had its challenges along the way. I was becoming more expensive to be able to treat it. The going through some of the proposals from the first cost is $5,000 to treat one person for multi-drug round of funding to the seventh round. It is pretty resistant TB over a period of two years, and this is sad, in as much as it is either the fault of the something where we have drawn on the South countries. When they are putting in either HIV or African experience whereby the very first people TB proposals, they should be able to incorporate a who were diagnosed to have MDR-TB were actually TB/HIV indicator. Most countries actually do not people living with HIV, and so it means that we have do that. So we are seeing HIV proposals falling to got to look back and say what are the challenges and the ground, particularly TB/HIV co-infection being the plusses, think where (inaudible) has exposed the addressed, and I think in the up and coming Global takeover healthcare and what can be done in order Fund meeting, which is taking place on the seventh to be able to bring progress so that we are actually and the eighth, part of the recommendation is to able to contribute to a period where we can offer our make sure that when they have a net core of _ services, which will become an impediment if the proposals which are coming up, one of the challenges that are coming along are not being requirements would be that all countries when submitting HIV proposals should specifically have a addressed as we go by. dedicated allocation for TB/HIV and also specify the type of activities that should be undertaken to be Q15 Chairman: If I am right, the incidence of multi- able to address that. drug resistant TB has got a lot to do with not having early diagnosis. So clearly for a developing country Q18 Chairman: Thank you very much. I am sorry we finding $5,000 for a patient is extremely challenging, had a problem with the line and the sound. It was but presumably you can find a smaller amount of actually much better the second time. We are very money to actually catch them before they develop grateful to you. I think it would have been nice for multi-drug resistant TB. Am I right in that you to be here, because I think you are a very good judgment, and is that really one of the things you are witness, and the technology has slightly got in the focusing on? way of us. Nevertheless, I think we have had a useful exchange and you have had an opportunity, I think, ? Extensive Drug Resistant TB. to give us some food for thought. I sincerely hope Ev4_ International Development Committee: Evidence 28 October 2008 Ms Lucy Chesire our report will reflect some of the things you have much indeed for coming in and can I wish you very said. DFID, of course, are listening, both given that well with your campaign and your own personal you are in the DFID offices in Kenya they are health too. listening, but here as well. Can I thank you very Ms Chesire: Okay. Thank you. Witnesses: Dr Kent Buse, Health Policy Analyst and Mr Alvaro Bermejo, Executive Director of the International HIV/AIDS Alliance, gave evidence. Q19 Chairman: We can resume on our second set of whether it is a laboratory strengthening, or witnesses. Just to comment on the last session, I whatever. I think DFID is trying to address or think Lucy Chesire is a real campaigner. Those of us redress a past imbalance in its support. Chairman, who have met her in person know what kind of you talked about a balance, but actually it is not, it personality she has got and I do not think the is £6 billion into health system strengthening versus technology completely communicated _ that, £1 billion towards the Global Fund, and I think that although I do think she said some very important that is, in part, trying to rectify some of the problems and useful points. I wonder, first of all, if Ic ould ask that were inherent in the tight earmarking of funds. you both to introduce yourselves for the record and, I suppose my position is coming through that I obviously, for the benefit of the whole committee? would see it to be a very reasonable decision to have Dr Buse: Certainly. My name is Kent Buse, I am a taken for a number of reasons, and I would be happy political economist, I taught at Yale for a number of to expand on those unless we want to come back to years and taught at the London School of Hygiene that question but I wanted to provide some general and Tropical Medicine. I have worked for a number food for thought. of UN organisations. For the past three years I have Mr Bermejo: { would like to add a couple of things. been with the Overseas Development Institute here One is whether that is the right question. I would in London and I am about to join UNAIDS next agree that the answer we need to do both is true, but week. I have done a fair amount of work on global the first big issue, I think, is to understand (and there health initiatives, but my real interest is in the are lots of studies that have shown that) that the politics of decision-making in the health sector. efficiency of health systems increases Mr Bermejo: My name is Alvaro Bermejo; I am the proportionately to amount per capita investment Executive Director of the International HIV/AIDS until you reach $40—60 per person per year. We are Alliance UK charity, working on _ supporting not here having a discussion on what is the best community responses, the responses of people like investment in countries that have $9-14 per year per Lucy in developing countries. capita. That is not the right question. The question is how do we take it to a level where these systems can be effective? Because if not, you can talk more Q20 Chairman: Thank you for that. I think the point about the macro numbers, but from the that emerged from that exchange is obviously how communities where the HIV/AIDS Alliance comes best to deliver funds in ways that actually really meet from, I remember in Mozambique hearing from a the needs. Clearly what is happening at the moment community activist like Lucy who was HIV positive does not do it. The debate really is about the role of and had a TB infection—who said, with the current direct vertical funding targeted at specific diseases as investment we have, why do we not stop the opposed to horizontal funding building up the discussion and just invest it in cemeteries, because we capacity of the health service. In one sense it is are spending much more time discussing what to do obvious that you need both, but the question is the with $14 per person per day, and money and priority. DFID appears to be focusing more on the resources and studies and meetings, than we are horizontal, although they also contribute to the seeing how we take that amount further up? How Global Fund. Do you have a view, both of you, on can you really create an efficient health system? It whether they have got that balance right in terms of does require more money. So I think that is one what they are doing or how they should balance element that we need to remember. While I would those two approaches? agree that we need both—and that certainly has Dr Buse: First of all, I think that a lot of people in been the experience in different countries who need the last year have started to object to those terms— different balances to achieve the best health the horizontal, vertical and diagonal—but just to be outcomes—it is a useful discussion, but we need to clear, there are clear differences in terms of vertical remember, within $14 a day it does not matter too being tightly earmarked and horizontal being much what approach you take, it just is not enough unearmarked. Unearmarked being towards a to reach the Millennium Development Goals and budget support sort of approach or systems the objectives that we have set ourselves. approaches and looking at what is broken in the system. I just want to define the terms so we are all talking about the same thihg. Diagonal has Q21 Mr Crabb: Given that there is research that something to do with trying to achieve those disease- suggests that certain vulnerable groups, for example, specific outcomes with the vertical funding but also sex workers, are much less likely to access to be achieving other kinds of health systems government provided treatment and services, what outcomes, whether it is more health workers or does that say about the system strengthening