HIV Treatment: Low and Middle- income Countries

Desmond Swayne Excerpts

Wednesday 11th March 2015 Westminster Hall

[The Minister of State, Department for International Development (Mr Desmond Swayne)]

It is always an enormous pleasure to follow the hon. Member for Glasgow Central (Anas Sarwar), particularly when he makes such a helpful and thoughtful contribution. I congratulate the hon. Member for Airdrie and Shotts (Pamela Nash) not only on securing this debate and on introducing it so well but on the enormous impact that her all-party group has achieved with its two publications. It is extraordinary for an all-party group to be able to inform the public and the legislature in that way. I commend the other Members who have contributed: the hon. Members for Paisley and Renfrewshire North (Jim Sheridan) and for Dumfries and Galloway (Mr Brown) and my hon. Friend the Member for Brighton, Kemptown (Simon Kirby). I owe my hon. Friend a particular debt because he drew my attention to this subject and engaged and interested me in it. He has worked very hard on HIV and AIDS in his constituency, where he rightly says that they have been a significant issue. I pay tribute to him.

I have been asked a large number of questions, so I will race through putting the Government’s position on the record, and then I will deal with the questions as expeditiously as I can. The hon. Member for Airdrie and Shotts said that there are 35 million HIV-positive sufferers, but I think that one of the most worrying statistics is that 19 million of them do not know that they have the disease. We have to draw attention to that. Only 34% of those who are eligible for treatment under the World Health Organisation’s 2013 treatment guidelines have access to antiretroviral treatment.

We remain the second biggest donor in the world. We set out our approach in the document “Towards zero infections” in 2011, and we updated it in “Towards zero infections: two years on” at the end of 2013. In those documents, we clearly laid out a pathway for withdrawing from bilateral funding and transferring to a multilateral approach to this problem. Principally, we are going to work through the Global Fund, which represents about one fifth of the entire world’s contribution.

We have changed the way we operate, but we have not reduced it at all. I looked at the figures extensively this morning. From 2006-07 to 2009-10, we spent £849 million on HIV/AIDS, and from 2010-11 to 2013-14 we spent £1,070 million. The highest years for expenditure were last year and one a couple of years before that. Therefore, quite properly, we are maintaining the pressure on this important issue. We are not slacking or suffering from donor fatigue. The measure of that—the hon. Members for Glasgow Central and for Airdrie and Shotts referred to this—is our commitment of £1 billion to the Global Fund from 2014 to 2016, subject to a 10% burden share.

We see ourselves as the voice of the affected populations. I will return to that point, because a number of hon. Members have expressed concern about it. We are driving forward improvement and integrating HIV treatment with health systems in the countries where people are affected. The hon. Member for Glasgow Central drew attention to that important agenda. We are driving forward the centrality of women and girls. He was entirely right when he said that, every hour, 50 young women between the ages of 15 and 24 are affected. That is twice the infection rate of young men, and it represents 22% of new infections. In sub-Saharan Africa, 57% of sufferers are women.

We want to use market shaping to ensure that drugs are available at affordable prices, so we have committed £35 million between 2012 and 2015 to the Clinton Health Access Initiative. That money has been used effectively to shape the market and to bring about £1 billion of savings to the purchasing countries, which translates to 2.5 million more people being treated and getting drugs, so it is an important part of the agenda.

The hon. Members for Dumfries and Galloway and for Airdrie and Shotts spoke about children. I recognise that there is a gap in the market for paediatric care. The United Kingdom and France are the major funders of UNITAID, to which we made a 20-year commitment. As part of that agreement, we have committed an average of €60 million per year. UNITAID provided 400,000 children with fixed-dose combinations last year, and was instrumental in reducing the price of those doses from $252 per child in 2006 to $130 in 2011. Those actions contributed to the 52% reduction in child infections since 2001. That reduction has been accelerating in recent years.

UNITAID also funds the medicines patent pool, which has been performing well. I know that the hon. Member for Airdrie and Shotts has an interest in it because she raised it with my noble Friend Baroness Northover. That model was designed specifically for AIDS, but it is reasonable to ask whether it can be expanded and used to deal with other diseases. It is an effective way of operating and it has been a success, so I hope it is going to be part of the agenda in future.

[Pamela Nash]

I am extremely grateful to the Minister for making that point, which will be good news not only for the all-party group but for the organisations that support us. I want to make one small point, which I have raised informally with the Department. The minutes of the UNITAID board meeting in December state that there was a reduced contribution from the UK Government. Can the Minister clarify that or seek advice from his colleagues?

[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.