HIV Treatment: Low and Middle- income Countries

Anas Sarwar Excerpts

Wednesday 11th March 2015 Westminster Hall

[Anas Sarwar (Glasgow Central) (Lab)]

It is a pleasure to serve under your chairmanship, Mrs Main. I start where my hon. Friend the Member for Dumfries and Galloway (Mr Brown) ended, by congratulating my hon. Friend the Member for Airdrie and Shotts (Pamela Nash) on securing this important debate. I also recognise her unflinching commitment and her leadership on this important issue, and the tremendous work she and the all-party group have done on the “Access Denied” report. We can tell from her contribution that she has a genuine passion and commitment on the issue, which she has championed in Parliament for the past five years, and which I hope she will be championing here for many years to come.

The previous Government and this Government have done constructive work on this important issue, and we require a reaffirmation of that commitment on HIV/AIDS as we move forward, but I start by mentioning a few things from the report that shocked me. Two thirds of adults with HIV do not have access to treatment or are not on treatment. Three quarters of children with HIV do not have access to treatment—that is completely unacceptable in the modern day, and something must be done about it. Children and adults in low and middle-income countries have seen support from the international community fall and prices from pharmaceutical companies rise, which is a stain on the international community. By 2030, 55 million people are expected to need HIV treatment. Last year, 1.5 million people died of HIV when that disease can be managed, although we do not have a cure. Again, that figure is a stain on the international community.

My hon. Friend the Member for Airdrie and Shotts said some thing that struck me—people need to come before profits, which is a powerful phrase. Treatments are available to help to manage conditions, but people do not receive them because they are too expensive, there is no health care system or stigma is attached to HIV/AIDS. That is completely unacceptable. We must remember that behind the statistics are real people, who have the basic human rights that we all share. They have the right to life, health, and dignity, and to contribute positively to their family and society.

It is easy to focus on doom and gloom, and obviously there is much that is negative, but there are also things to welcome. According to data, last year, for the first time, more people gained access to HIV drugs than were infected with the virus; the ONE campaign has called that the tipping point. In 2013, the most recent year for which data are available, 2.3 million people gained access to HIV treatment programmes, compared with 2.1 million people with new infections. That is a welcome statistic, but we cannot be complacent.

We do not want such progress to be reversed. The ONE campaign’s recent report noted that the US, France and the UK in particular have carried what it calls an “unsustainable” share of the burden in the international community. It is incumbent on the Government and their international partners to press donor countries, and indeed those developing countries able to provide support to those who need it, to do more. I look forward to hearing more details about that from the Minister.

The November 2014 UNAIDS report talked of a fast-track approach to end the AIDS epidemic by 2030, with a target to be reached by 2020, called 90-90-90. The target is that 90% of people living with HIV should know their status, 90% of those who know it should have access to treatment and 90% of those being treated should have suppressed viral load. That is a difficult but positive target, achievable if there is the will in the international community. It has been said that turning the target up to 95-95-95 would be tantamount to ending the epidemic.

A further report, “Fast track: Ending the AIDS epidemic by 2030”, also said that nearly 28 million new infections and 21 million AIDS-related deaths could be averted by 2030 if the target were met. However, it also warned that “business as usual” could mean missing the opportunity to end the epidemic for a long time to come. UNAIDS estimates that, by June 2014, 13.6 million HIV-positive people around the world had access to antiretroviral therapy, but an estimated 35 million need it. It will be interesting to hear the Minister’s response to the UNAIDS 90-90-90 target, what partnership work the Department for International Development is doing with it towards that aspiration, and what global leadership we are showing to get our bilateral partners and multilateral funding agencies to reflect those priorities.

It is important to talk about funding and to recognise the responsibility of the UK and the global community to support HIV and AIDS treatment. In 2012, the UK Government contributed 10.7% of all bilateral aid for HIV. That statistic is welcome, and so is the fact that between 2008 and 2013 DFID’s overall spend, including bilateral and multilateral funding, averaged £300 million a year. At the time of the recent global health fund replenishment, a commitment was given to provide £1 billion for 2014-16, which means that the annual contribution will increase significantly to £500 million. I am sure the Minister will confirm those figures.

I wonder, following the UNAIDS report, whether that funding and support have been reflected on. We have heard today, in the context of DFID funding, about budget spending that has been committed and unallocated funding. Might there be scope to look again at the funding and support we give to the global health fund, particularly given our withdrawal of funding for the International AIDS Vaccine Initiative, which my hon. Friend the Member for Airdrie and Shotts pointed out? I welcome the fact that we spend £300 million annually, and the £500 million commitment for 2014-16, but cutting by up to 80% our support to IAVI—the fund trying to find a cure and a vaccine—is unacceptable.

I look forward to hearing the Minister’s explanation for that cut. We should not give up on the dream and hope of finding a cure and a vaccine for HIV and AIDS. I would like to think that we could find those things in my lifetime and bring an end to a global injustice.

Although the UK has come in for praise from the ONE campaign, as have the US and France, there is still a hell of a lot of work to do. Global funding for anti-HIV programmes reached an all-time high of $19.1 billion last year, but that is still an estimated $3 billion a year short of the annual $22 billion to $24 billion that the UN says we need to spend.

By 2020, low-income countries will need $9.7 billion, lower-middle-income countries $8.7 billion, and upper-middle-income countries $17.2 billion for the fight to bring the epidemic to an end. However, the report says that if the money is forthcoming and enough effort is made to reach the 2020 targets, the need for more funds will decline. That is an interesting point: the fund could decline if we matched the UNAIDS aspiration. By 2030, the funding needed globally could drop from $35.6 billion in 2020 to $32.8 billion. If we make an initial big investment—not taking any wasted route, in terms of value for money, but investing in genuine care and treatment to help to save lives—the long-term positive effect will be not only those lives saved and a reduction in the proliferation of the condition, but money saved that can be used to fund other areas of work.

The hon. Member for Brighton, Kemptown (Simon Kirby) and my hon. Friend the Member for Airdrie and Shotts noted the important point made in the report about middle-income countries. There are many issues related to extreme poverty besides HIV and AIDS, including access to education and other health care, such as drugs and treatment for TB and malaria. We still have a lot of work to do in middle-income countries: 50% of people in extreme poverty live in those countries, so the international community, and particularly the UK, cannot afford to ignore or pass by their challenges. We must still engage with them, and consider need, as my hon. Friend said, rather than classification.

We need to support people as those countries graduate from the low-income to the middle-income group, rather than thinking that that means our job is done. Quite the opposite: sometimes in those cases, even more support is needed, particularly when there is a lack of governance, although some people might think that the graduation to middle-income status means Government officials can think less about their obligations to the poorest citizens.

I have in mind two examples raised by my hon. Friend and in the “Access Denied” report, which have been the subject of much discussion and negotiation. South Africa and India, with their continuing struggles, still need our support—particularly technical assistance and help with strengthening health care systems. Currently, 58% of people who are HIV positive live in middle-income countries. By 2020, the proportion is expected to rise to 70%. We cannot ignore that 70%; we need to engage and work with them.

There are a couple of other issues. First, 52% of people suffering from HIV and AIDS in low and middle-income countries are women. One young woman contracts HIV every minute. The report also found that in sub-Saharan Africa the proportion of young women aged 15 to 24 living with HIV is twice that of young men. There are also cultural issues. Given that carers and people with caring responsibilities when loved ones are unwell are often women and girls, we have a responsibility to support people with conditions and to support people who support those with conditions. Perhaps the Minister will respond to that, too.

My hon. Friend the Member for Dumfries and Galloway rightly mentioned child treatment and transmission. When I read some of the stats in preparation for today’s debate, the stat that got me most was that, across the world, there are 3.2 million children with HIV and that 20,000 children a month are still being infected. Up to half of all new paediatric HIV infections occur during breastfeeding, which is a heartbreaking tale: a mother trying to do her very best to give her child the best possible start in life has, through breastfeeding, transmitted HIV and AIDS to that child.

In many cases, perhaps, the mother had to choose whether to breastfeed her child, knowing that the child would suffer because of her condition. That is heartbreaking indeed. More work needs to be done to ensure that we are giving adequate treatment to women and girls to prevent the transmission of the disease to children in the first place. If children contract the condition, they should get the support, medicine and treatment they need.

I have two further points in relation to women and girls. First, education is crucial. There should be education for all, and we should ensure that people know about the risks of HIV and AIDS. Secondly, we must address violence against women and girls. The Minister and I have talked about the important issue of female genital mutilation and violence against women and girls more generally, particularly in conflict. We have talked about putting women and girls at the heart of development, and putting women and girls at the heart of support for HIV and AIDS is also crucial and must be considered much more carefully.

Another issue raised in “Access Denied” that has perhaps been mentioned less in the debate is the support given to people who inject drugs. If we are to follow the “no one left behind” principle, we must ensure that we give adequate support to people who inject drugs, which means access to clean syringes, opioid substitute treatment and naloxone to prevent overdose and the spread of infections.

We have two good cases where treatment has helped to make a difference. Tanzania and Kenya have demonstrated good practice on those issues, but we must scale that up and ensure that we give them and other people in the region the same adequate support and treatment. UNAIDS estimates that $2.3 billion is needed annually to fund preventive measures for those who inject drugs, but all global donors combined spend only $160 million—that is $160 million when we need $2.3 billion every single year. How can we ensure that those issues are more fully considered?

We have heard colleagues talk about the obstacles faced in licensing and about companies putting profits before people. I welcome the progress that has been made on relaxing intellectual property rights to produce low-cost generic drugs for first-line treatment. I welcome the coalition of five big pharmaceutical companies that is granting licences for generic production to the UN-backed medicines patent pool, but more can and must be done.

Second-line drug combinations are far more expensive than the basic cocktail, which costs no more than $100 per person per year, although we have heard that in South Africa people are being charged exponentially even for first-line treatment. Granting licences for second and third-line drug combinations must be implemented much more efficiently than in previous decades. We must reduce the price of front-line drugs to a much more manageable level. That is the responsibility of the UK Government, working in partnership with the international community and other key development agencies, whether in country or through multilaterals. It is also for the drug companies to ensure that second and third-line drugs are available and affordable for all, irrespective of the income or the affluence of a person or a country. I emphasise the 80% cut to IAVI.

We can all get wrapped up in one fundamental issue, and I say that particularly in the climate of the discussions on sustainable development goals, which are ongoing and will continue—hopefully, they will conclude later this year. We see a lack of strong universal health care systems in developing countries. We see clinics popping up for tuberculosis, malaria and HIV and AIDS, but what we need is holistic care so that people, whatever conditions they turn up with, receive adequate support and the care they need.

There is no better example than our own national health service. We have a system that is based on people’s need, not their ability to pay. If we have that great system in the UK, it is incumbent on us to work with the international community to help to promote such a system of universal health coverage globally. That is why we have already said that we would set up a universal health coverage institute within the Department for International Development to provide technical assistance using the expertise of the Department, of the people who work with and for the Department, and of the NHS.

The institute would bring together the expertise of people who put together tax systems to help to create and build models in developing countries so that those countries may have universal health care systems that have the support they need, but are sustainable and able to raise their own funds. There is no greater example than the Ebola crisis. In Nigeria, where money has been spent on the health care system, Ebola was brought reasonably under control, which helped to save lives, and in Sierra Leone, which did not have such a system, the Ebola crisis worsened and up to 10,000 people lost their lives. I encourage the Minister to move forward with universal health care systems and access to health for all.

Today, let us resolve to do as my hon. Friend the Member for Airdrie and Shotts and the wider all-party group on HIV and AIDS have done and put this important issue at the forefront by talking about it, discussing it and debating it. We must put the solutions at the forefront, too, so that in my lifetime, and in the Minister’s lifetime, we can bring HIV and AIDS to an end.

--- Later in debate ---

[Mr Swayne]

The commitment of an average of €60 million per year for 20 years has been and will be met, but it is an average. There was a reduction, and my understanding is that it was made good with a €40 million contribution. The contributions are being met and we are fulfilling the requirements.

HIV treatment is linked to broader issues of health development, the strengthening of health systems, gender equality, and stigma and discrimination. All those things have to be addressed. We have to have a rights-based prevention and treatment regime. That remains a key policy objective in tracking how our contributions and investments deal with those issues. We need to be much better informed, and we must understand how to tackle stigma. Only when that happens will more people be able to access preventive programmes, get tested, and initiate and adhere to treatments.

The product development partnerships model has been very successful in bringing forward new drugs to the market. It has brought forward 43 new drugs in the past 10 years, and there are 350 under development. The Department for International Development is a strong supporter of PDPs; indeed, we were the first Government donor to them. I congratulate the Labour party on its initiative in 2008 and on driving forward that innovative agenda. It was an important contribution. We remain a globally significant player in that field, having committed £154.2 million between 2013 and 2018.

I was asked any number of questions. Let me start with those about vaccines and the International AIDS Vaccine Initiative. There has been no cut. We fulfilled the contract that we had with IAVI. All the money that we had committed was paid. We have a new contract now for £5 million, for which it competed, for a slightly different programme.

Let us be clear about what has happened. It is quite right that we have withdrawn from something that we were previously involved in, just as any organisation continually reviews its operations and does what it does best. I understand that some six vaccines went for field trials and we were funding that process. The results were disappointing, so it was back to the laboratory. We do not consider laboratory work as part of our comparative advantage. There are organisations in the world that are much better at dealing with that sort of scientific funding and do that work. Frankly, I believe that our funds are better expended elsewhere, where we have a comparative advantage.

Remember that we have not made a saving; we are spending more than we were spending before. We are spending it differently and I believe that we are spending it effectively, although we are not funding IAVI to the extent that we were in the past. That is a perfectly reasonable position to have taken, given the change in the situation.

[Anas Sarwar]

The Minister mentions the six vaccines that went to field trials and the “disappointing” results. He does realise that we only need success once, but we need to fund that programme to be able to get that one success.

[Mr Swayne]

Absolutely, but the difference is this. Funding field trials is one thing but going back to the laboratory and working there is a different field of endeavour, one where we have no comparative advantage. [Interruption.] I think we will just have to agree to disagree about this one, but there has absolutely been no cut in our funding of IAVI. We fulfilled our contracts and entered into a new one—a quite different one—with IAVI.

Now we come to the big question of the middle-income countries. I accept entirely that, when a country becomes a middle-income country, it hits a double whammy: one, the funding is withdrawn; and, two, all the prices go up. But hey—they are middle-income countries, and we are trying to encourage people to invest properly and to step up, as they are richer countries, and fund their health systems properly and have properly integrated health systems. That is an important part of the deal.

I accept entirely that that is a bit like falling off a cliff. Perhaps we should have some system akin to, say, universal credit, where there is a taper, as countries move from low-income status to middle-income status. I accept that there is an argument—a case to be made here. I am open to that discussion. It is something that we would have to agree with our international partners; I do not think we would have leave to change the system ourselves. Hon. Members have drawn attention to a very clear problem. The way we get around it at the moment is through the funding of the Robert Carr network, to which we have committed £4 million until the end of this month, and then we will have to replenish it. That is underfunded; there is a £13 million funding gap in respect of the Robert Carr network. We have to work with our donor partners to try to see how that gap can be filled.

I agree entirely with the hon. Member for Airdrie and Shotts that viral load testing is the top end. It is exactly what we should be pursuing. I am glad that the price has fallen significantly as a consequence of the market shaping; it is down to a cap of $9.40, which is down some 40% in low-income and middle-income countries. The problem is, as she rightly pointed out, that that requires a developed network of laboratory testing. Again, I entirely share her view that we have to continue investing in alternative point-of-care technology, and in research and development in that area. I know that there have been more than 924,000 CD4 tests at point of care, but she is right that load testing is a much better and much more valuable tool. The way the Global Fund works is that it asks countries that are capable of supporting the network with laboratories for viral load testing to apply for that funding, and it asks other countries that are not able to support that to apply, certainly for the moment, for funding to deal with CD4 and whatever else may be brought forward. The work of UNITAID and the Clinton health foundation has been instrumental in reducing the price of viral load testing, which was one of the principal problems with it.

I come on to the Transatlantic Trade and Investment Partnership and the impact of any trade negotiations. I was asked whether we have formal input into the process. The reality is that, as a consequence of decisions taken in 1975—decisions that might be reviewed if the election result turns out the way I want it to—trade policy is a European Commission competency. Within the UK Government, the Department for Business, Innovation and Skills is the lead Department in relation to that, but DFID successfully ensures that issues such as access to medicines and intellectual property rights lead to joint discussions between our Departments. It is physically in BIS but it is actually staffed by DFID officials. Therefore, we do that.

On the issue itself, my own view is that it is down to the negotiations at the time, on a case-by-case basis. When we make a trading agreement, we have to ensure that we are absolutely certain that we are not compromising ourselves on intellectual property and that we are not going to restrict access to drugs as a consequence of the decisions we make. That is just down to being vigilant when we come to make these arrangements.

I was specifically asked about research and development. That agenda has been driven forward largely by civil society, rather than by nation states and Governments. Nevertheless, it is important. Frankly, it is unlikely that there will be a legally binding instrument for health research and co-ordination. The Government’s view is that any agreement needs to be built on existing mechanisms, such as that proposed by the expert working group.

The background to the issue is that for the past 10 years the World Health Organisation has convened a number of working groups to discuss and suggest solutions to the issues that the hon. Lady has raised, namely, funding flows, innovative funding mechanisms and co-ordination of health research. The latest of these groups—the consultative working group—suggested that we should establish a WHO global R and D observatory and a pooled fund for product R and D, together with a co-ordinating mechanism to support the fund.

The World Health Assembly is due to discuss that matter later this year. My concern is this: will countries wish to put more into this pool than they are putting in at the moment to contributions to R and D, particularly when the pool will be controlled by a mechanism other than the countries themselves? My estimate is that most countries would want to put research funding into a direct contribution that they control and to know where it is going. I will not go any further than that, because I was asked about 90-90-90 and I have one minute left to respond. It is a very interesting thing. It is far too soon to tell. My concern is that it adds a very substantial burden to the funding that already exists, and the emphasis must be on the poorest and the sickest first. I would want to see a little more about how the UNITAID proposals are brought forward before committing myself irrevocably to the 90-90-90 strategy.