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MEMORANDUM TO INTERNATIONAL DEVELOPMENT COMMITTEE INQUIRY INTO HIV/AIDS
AND SOCIAL AND ECONOMIC DEVELOPMENT
21 JUNE 2000
Introduction
We greatly welcome the Select Committee's inquiry into HIV/AIDS
and development and would like to thank the Committee for extending its
timescale to enable us to submit evidence.
The HIV/AIDS epidemic clearly represents the most devastating challenge
to global development in recent history, as is illustrated by the graph
showing how it has led to falling life expectancy in African countries.
We therefore applaud the Committee's decision to examine the broader implications
of HIV/AIDS for economic, political and social stability in developing
regions. As a medical organisation, we have chosen to concentrate on providing
the Committee with background information on some specific medical issues,
but we would not wish this to be perceived as detracting from the wider
impact of the epidemic.
Specific points which we would like to draw to the Committee's attention
are described below. We would be happy to supply further information on
these points, including references, if requested.
Impact of HIV/AIDS on the health sector
Although we have no good data, we would like to point out that
developing country health services are doubly affected by HIV/AIDS. The
epidemic leads to growing needs for health care, while simultaneously
undermining health sector capacity through illness, mortality and loss
of morale among health workers. As the Committee is doubtless aware, HIV/AIDS
has a particularly serious impact on all economic sectors because it primarily
affects young adults in the most productive age groups. It is also associated
with prolonged or intermittent illness prior to death, leading to a substantial
burden of need for formal and informal care.
Vaccine development
The development of effective vaccines holds out the best hope
for long term control of the HIV/AIDS epidemic. We welcome the UK government's
support for research directed towards vaccines specifically suited to
the needs of developing countries. However, a number of issues remain:
- Vaccine development is a slow process. We anticipate that it
will be at least five years, and more realistically ten, before an effective
vaccine can be available for widespread use.
- Although some work has been done in preparing for trials of vaccine
efficacy, some ethical and methodological difficulties remain.
- A preventive vaccine will not help the many millions of people
who will already be infected with HIV at the time when the vaccine becomes
available. These people will continue to develop AIDS and need care
over ensuing years.
- Most vaccines currently in use in developing countries are given to
infants or young children and are intended primarily for prevention
of childhood diseases:
If an HIV vaccine is given to children, there will be
a long lead time before the vaccinated generation grows up and becomes
sexually active. Hence any impact of the vaccine on the epidemic
will be delayed.
An alternative strategy, of vaccinating adolescents and young
adults, would have a more immediate effect on the epidemic.
However, getting the vaccine to these age groups would present
a greater logistical challenge for developing countries, since
adolescents and young adults do not already access other vaccine services.
Pricing and access to drugs
We welcome the recent announcement of dialogue between the UNAIDS
programme and five major pharmaceutical companies on how to broaden access
to HIV-related drugs in developing countries. However, even with
massive price discounts (eg 95% or more), the vast majority of people
living with HIV/AIDS in developing countries will not be able to benefit
from antiretroviral therapies.
- The issue is not solely one of cost. Antiretroviral therapy is complex
and requires specialist monitoring. Health service infrastructures
in developing countries are inadequate to deliver these treatments safely
to large numbers of affected people.
- It is not obvious that broadening access to complex medicine represents
the best health investment for developing countries. There are difficult
choices to be made, but strengthening primary health care and
improving access to clean water, sanitation and basic services may be
a more appropriate strategy for benefitting people affected by HIV/AIDS
and other diseases. Clearly, any improvement in health service
provision is difficult in the face of the overall social and economic
impact of the epidemic.
- Improved primary health care could usefully include much better
access to cheap, generic palliative drugs such as painkillers
and antidiarrhoeals. These would benefit people with a variety of diseases,
and in the case of HIV/AIDS could lead to significant improvements
in quality of life and productivity.
- There is a particular problem in access to opiates in
many developing countries. Some controls are necessary to prevent abuse
of these drugs, but over-regulation and lack of understanding among
health professionals lead to many people suffering severe pain unnecessarily.
New regulations and guidelines and training for health professionals
are needed to promote appropriate use of these cheap, effective drugs.
- Since the presence of other sexually transmitted infections (STIs)
increases the risk of HIV transmission, cost-effective, evidence-based
STI treatment and control programmes are particularly valuable.
Also important are the promotion and distribution of condoms to prevent
transmission of HIV and other STIs. There is the potential for
public/private partnership in the promotion and delivery of both condoms
and STI services. Some businesses are already subisidising condom
provision for employees.
- Drugs for the prevention and treatment of opportunistic infections
associated with HIV/AIDS are another important issue. The UNAIDS programme
recently recommended that adults with symptomatic HIV/AIDS and children
with symptomatic or asymptomatic HIV/AIDS throughout Africa should receive
routine daily treatment with cotrimoxazole, a cheap antibiotic
which can prevent some serious opportunistic illnesses. However, even
this relatively simple treatment can have serious adverse effects and
requires the advice of a trained health worker. Hence implementation
of the UNAIDS recommendation will pose challenges for developing country
health services.
Mother-child transmission of HIV
The one purpose for which widespread use of antiretroviral drugs
may be feasible in developing countries is in preventing HIV positive
women from transmitting the virus to their babies around the time of birth.
It has been known for some time that giving a course of a drug called
zidovudine (also called AZT) to the mother before birth and then to the
baby can reduce the risk of the baby becoming infected with HIV. In some
countries (especially South Africa) there has been controversy about whether
this treatment should be implemented widely. Although there is some evidence
suggesting it can be cost-effective compared to other health interventions,
in countries where the prevalence of HIV infection is high the total cost
of implementation could be prohibitive. Moreover, there are logistical
difficulties in delivering this treatment in developing countries where
pregnant women may not be in contact with health services before the onset
of labour.
Last year, however, a ground-breaking paper showed that a different drug,
nevirapine, can also reduce the risk of mother-child transmission of HIV.
This is much easier to deliver since it involves only two doses, one given
to the mother during labour and one to the baby, and the cost of the drugs
is only 4 US$ per mother-baby pair. Hence nevirapine for prevention
of mother-baby transmission of HIV may be a genuinely feasible and affordable
intervention for developing countries. A number of issues remain,
however:
- There is evidence that the most cost-effective way of using nevirapine
in many African countries would be to give it to all women and babies,
without first testing for HIV. There are potentially ethical difficulties,
however, in giving medication to healthy people who do not need it,
as there could be as yet unrecognised long term adverse effects.
- The alternative, of offering women HIV tests and giving nevirapine
only to those who test positive and their babies, can also be problematic.
There are good reasons for broadening access to HIV testing in developing
countries, to enable people to find out their status and plan better
for the future. However, targetting testing specifically towards pregnant
women potentially exposes them to a risk of stigma and discrimination
including rejection by their husbands/partners (who will, in many cases,
have been the source of the infection). Community education measures
to combat stigma and discrimination are urgently needed in many developing
countries.
- Although nevirapine is a simple oral treatment, its administration
still requires women to have access to at least basic health care
around the time of labour. Fortunately, this fits well with
recent thinking among international development agencies on the importance
of increasing access to obstetric services in order to reduce maternal
mortality from causes unrelated to HIV.
- Neither nevirapine nor zidovudine treatment schedules prevent transmission
of HIV from the mother to the baby via breast-feeding. Where formula
feed is affordable and can be used safely, it is a valuable means of
preventing transmission. However, in developing countries formula feed
may cost more than the annual family income, water supplies may be inadequate
and are often contaminated, and other diseases are common. In
such circumstances, the protection of clean, balanced, antibody-rich
and nutritionally appropriate breast milk makes breast-feeding the best
option, even though the risk of HIV transmission is significantly increased.
- Preventing mother-child transmission of HIV does not protect these
children from the risk of later orphanhood. Death rates are likely
to be higher among the uninfected children of HIV positive compared
with HIV negative mothers, because of the impact of maternal illness
and death on the care they receive.
In conclusion, although the recent research on nevirapine offers real
hope for the future, HIV/AIDS will continue to have a devastating impact
on child mortality. We welcome the development of trials such as PETRA
looking at alternative treatment programmes to prevent mother-child transmission
which are affordable and achievable in developing countries.
Meanwhile, the international development target for a two-thirds
reduction in infant and child mortality by 2015 appears severely threatened
by the HIV/AIDS epidemic. Such mortality is rising in much of
Sub-Saharan Africa.
HIV and tuberculosis
The HIV epidemic is intricately linked with tuberculosis. In developing
countries a high proportion of people are infected with the tubercle bacillus,
but usually this remains latent and does not cause disease. Concomitant
infection with HIV dramatically increases the risk of tubercle infection
leading to active tuberculosis disease, which is the most common HIV-associated
opportunistic illness in many developing countries. Hence the HIV/AIDS
epidemic has led to a major increase in tuberculosis incidence.
Tuberculosis is also interesting for another reason. Even when the person
is co-infected with HIV, tuberculosis is curable. The WHO Directly Observed
Treatment/Short Course (DOTS) approach involves taking a combination of
drugs regularly for a few months. Failure to take the treatment correctly
not only leads to resurgence of tuberculosis disease, it can also cause
the tubercle bacillus to become drug resistant and prevent future treatment
from working. The same can happen if antiretroviral treatment for HIV
is not taken correctly - the virus can become resistant to the drugs.
Despite the fact that tuberculosis treatment is fairly cheap, and much
less complex than antiretroviral therapy for HIV, many developing countries
have experienced difficulties in implementing tuberculosis treatment programmes.
Although the DOTS approach helps ensure drugs are correctly taken, effectiveness
is bedevilled by poor management of drug supplies, incorrect prescribing
especially in the private sector, and lack of public and patient education
about the need for correct and complete treatment. A country's success
in implementing tuberculosis control can therefore be perceived as a barometer
of the quality of its health sector management. It is hard to see
how districts or countries which are failing to manage tuberculosis effectively
could be ready for the much greater challenge of antiretroviral treatment
for HIV (other than for prevention of mother-child transmission). Strengthening
tuberculosis programmes will, however, benefit people with HIV as these
are the group at greatest risk of developing active tuberculosis.
Further reading
We have not attempted to reference this memorandum fully, but suggest
that the following source materials may be of particular interest:
World Bank presentation on the development impact of HIV/AIDS (source
of graph on life expectancy) http://www.worldbank.org/aids-econ/board/index.htm
Joint United Nations Programme on AIDS (UNAIDS). AIDS epidemic update:
December 1999. http://www.unaids.org
UK NGO AIDS Consortium Working Party on Access to Treatment for HIV in
Developing Countries. Access to treatment for HIV in developing countries;
statement from international seminar on access to treatment for HIV in
developing countries, London, June 5 and 6, 1998. Lancet 1998; 352: 1379-80.
Guay L A, Musoke P, Fleming T et al. Intrapartum and neonatal single-dose
nevirapine compared with zidovudine for prevention of mother-to-child
transmission of HIV-1 in Kampala, Uganda: HIVNET 012 randomised trial.
Lancet 1999; 354: 795-802.
Marseille E, Kahn J G, Mmiro F, Guay L, Musoke P, Fowler M G, Jackson
J B. Cost effectiveness of single-dose nevirapine regimen for mothers
and babies to decrease vertical HIV-1 transmission in sub-Saharan Africa.
Lancet 1999; 354: 803-809.
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