HIV Treatment: Low and Middle- income Countries

Pamela Nash Excerpts

Wednesday 11th March 2015 Westminster Hall

[Pamela Nash (Airdrie and Shotts) (Lab)]

It is a pleasure to serve under your chairpersonship, Mrs Main. I and the other members of the all-party group on HIV and AIDS are extremely grateful to be granted this debate to discuss access to HIV treatment in low and middle-income countries. The debate is based on the findings of our “Access Denied” report, which our group has been working on for a long time, so we appreciate the chance to bring it to Westminster Hall today.

I am grateful to the members of the group who have come to join us today. They have shown great dedication to this issue, which has not been riding high in the public agenda in recent years. Nevertheless, it is still extremely important and I am grateful for their support. It is notable that the group has extremely active members from all political parties represented in the House of Commons, and we have many active members of considerable experience from the other place, too. The cross-party consensus has been consistent for the four years that I have been chair of the group, as I understand it was before my chairpersonship, and I hope that that will long continue.

The debate is about access to HIV treatment in low and middle-income countries, but many issues that we will cover today, and which were covered in the report, are relevant to various diseases of poverty. I hope that we are able to discuss some of those later in the debate.

Our report outlines the findings of almost one year of research conducted by the all-party group, which included visits to South Africa and India, and also many written and oral evidence sessions here in Parliament.

Despite the incredible progress that has been made in the battle against HIV, there remain many barriers to accessing medicines and treatment in low and middle-income countries. The latest estimates from UNAIDS—the joint UN programme on HIV/AIDS—show that there are around 35 million people infected and living with HIV globally. There are encouraging figures, too. New infections have reduced from a peak of 3.4 million in 2001 to 2.1 million in 2013, the most recent year that we have complete figures for. However, 2.1 million is still a staggering number of people, so we must continue to do everything we can until we reach the ultimate goal of zero infections.

AIDS-related deaths have fallen from a peak of 2.3 million in 2005 to 1.5 million in 2013. In the past three years alone, deaths have fallen by a huge 19%. The statistics show that incredible progress is being made, but those huge numbers also show that more must be done. Behind the statistics are real people trying to live fulfilling lives. Mothers and fathers are trying to provide for their families, and young people are facing the prospect of a lifetime living with a currently incurable, although treatable, disease. If they are to have any chance of a high quality of life, they must be able to access treatment.

We now have almost 14 million people across the world accessing ARV—antiretroviral therapy—compared with fewer than 1 million 10 years ago. That is a tremendous, unprecedented achievement, which is the result of the global community coming together and a campaigning movement unlike anything the world has seen before. Many of the people who access treatment are able to do so thanks to the work of the Global Fund to Fight AIDS, Tuberculosis and Malaria. I commend the Government for their significant commitment of £1 billion to the fund, and also for the utilisation of the UK’s influence on convincing other donor countries to contribute.

So, 14 million people on treatment is clearly a significant number, but that leaves us around 21 million people in the world still unable to access treatment. That is equivalent to three out of every five people living with HIV unable to access ARVs. If 60% sounds high, the figure is even higher and even worse when we consider paediatric care. Of those children and adolescents living with HIV, 80% are unable to access treatment; we covered that in depth in the report. We have reached a crossroads in the AIDS response. Progress has been made, but international aid and public interest in HIV and AIDS is no doubt diminishing.

According to figures from UNAIDS, international donor funding for the HIV response is stagnating, with funds remaining largely the same since 2008, despite the fact that we now have an increased scientific understanding of HIV. We now know, for example, that starting treatment earlier saves lives, and, thanks to groundbreaking research, we have proof that treatment is highly effective at preventing transmission of the virus in the first place. That new tool, combined with improved targeting of a range of effective prevention interventions, means that we could significantly reduce the number of new cases of HIV by scaling up our response.

To sum up my introduction, we have the tools at our disposal to end AIDS in a generation, so this is not the time for us to walk away from that important issue. This is the time when we have to scale up the response. The Government have been at the forefront of that so far, and I want that to continue.

[Simon Kirby (Brighton, Kemptown) (Con)]

The hon. Lady is absolutely right. We need renewed political commitment to keep the momentum going so that we do not lose it and undo much of the good work that we have achieved to date.

[Pamela Nash]

I thank the hon. Gentleman for that intervention. He is an active member of the all-party group, and I appreciate his support in the work that we do.

I want to move on to the barriers to accessing treatment, which we have drawn attention to in our report. Various barriers were obvious to us at the beginning of our inquiry, but the impact of many came as a surprise. Barriers include the continued high cost of second and third-line treatments. The cost of first-line treatments has come down considerably, particularly due to the fantastic impact of the medicines patent pool. Indeed, the full impact that that will have is yet to come to fruition. However, second and third-line treatments remain very expensive for the poorest people living with HIV.

In our inquiry, we also found that there is completely inadequate access to the most effective testing and diagnostic tools, especially viral load testing. We found that continued weak and unsupported health systems in low and middle-income countries were having a direct impact on people living with HIV. Poor supply chain management is having an impact, although it is avoidable with technical support. Lack of investment in research and development is still having an impact. We found that particularly in lower priority areas and in less profitable treatment areas such as paediatric medicines.

In many countries there is still no political prioritisation of key populations most at risk, unlike here in the UK with our development work. We still see men who have sex with men, sex workers, injecting drug users and transgender people not getting the prioritisation that they need. They are being left behind, even in countries that are otherwise doing well in creating access to medicine. We also continue to see severe stigma and discrimination with respect to all people who live with HIV. That stops people accessing not only treatment, but advice on prevention and testing. That is causing people to contract HIV; it is not just affecting their treatment.

Sharp reductions in support—financial, technical and otherwise—to countries becoming classified as middle income are having a direct impact on the treatment of people living with HIV. To be clear, that is a much bigger debate in international development, but it is a clear example of the impact that is happening.

I will discuss some of those barriers in more depth, but I will start with the cost of treatment. Treatment prices remain one of the biggest barriers to accessing ARV treatment. From my experience in the all-party group and otherwise, the justification that we have often heard for high prices of medications has been the extremely high cost of research and development. Although that is a considerable cost and investment for many pharmaceutical companies, it was enlightening to hear, in one oral evidence session for the report, a pharmaceutical company representative admit that it is not the case that that determines the price. He was clear in saying that the price of treatments is primarily driven by licensing costs and decisions by pharmaceutical companies about what the market will bear.

Intellectual property rights grant exclusive rights to manufacture drugs without competition, and that lack of competition leads to high prices. That said, there is a globally accepted principle that IP rights and patents do not interfere with public health. That was not always the case, however, and in my experience threats to that principle have been overcome only by huge public campaigns.

Governments can bypass IP rights if there is a public health need by imposing compulsory licences. Alternatively, innovator drug companies can agree voluntary licences. Both those ways allow generic pharmaceutical companies to produce quality-assured generic treatments. We saw that first hand during our inquiry, when we visited India and South Africa. We visited generic companies and saw the work that they were doing, and we went to clinics to see the people who were being treated with those drugs, who otherwise would not be receiving any medication. We now have affordable first-line treatments that are available as a result of the voluntary licences, and that has been instrumental in increasing access to treatment.

We now have a price for first-line treatments of around $100 per person per year, whereas 10 years ago it was $10,000 per person per year, so there has been a huge drop in price. Unfortunately, however, if a patient’s first-line treatment is failing and second and third-line treatments are required, the cost of those treatments still remains high.

[Jim Sheridan (Paisley and Renfrewshire North) (Lab)]

I genuinely congratulate my hon. Friend on securing this extremely important debate. Will she expand on the role of the pharmaceutical industry? On page 21, the report mentions that

“a leaked document outlining a lobbying plan for the Innovative Pharmaceutical Association South Africa (IPASA)—the representative body for pharmaceutical companies in South Africa—highlighted the industry’s plans to delay reforms.”

What does that mean?

[Pamela Nash]

We met the South African Government and lobby groups in South Africa on that issue. There was a war between the pharmaceutical companies and Médecins sans Frontières and other smaller groups about this, and it was part of a wider campaign from some pharmaceutical companies to prevent any legislation that might reduce their power to have higher prices. That included such things as “evergreening”, which we have seen in other countries, when patents are granted for a drug because there is a slight change in its chemical composition. Drugs are designed to have a new patent and therefore get round some of the existing patent legislation.

There has been a lot of experience of those companies trying to dodge that, but there are good examples of companies such as Gilead, which have been willing to be at the forefront of being part of voluntary licences and of the medicines patent pool. I do not want to stand here and paint the pharmaceutical companies as the bad guys, because without them we would not have those drugs, but we want to encourage responsible behaviour from them and ensure that they realise what a fantastic contribution they can make to the public health of the world and of people living with HIV.

As I said before the intervention from my hon. Friend the Member for Paisley and Renfrewshire North (Jim Sheridan), there is still a clear problem with second and third-line medication being much more expensive than first-line treatment. In relation to the points that my hon. Friend made, issues have been raised about free trade agreements, in the inquiry and since with the all-party group.

The Transatlantic Trade and Investment Partnership will certainly not be a stranger to the inboxes of most Members in Westminster Hall today. TTIP and the Asia-Pacific Trans-Pacific Partnership—free trade agreements that are under negotiation—seem to pose the risk of introducing additional property rights restrictions or extending patent exclusivity. Although TTIP and TPP do not have a direct impact on the low and middle-income countries that we are discussing, an impact will be felt by them. There is a reasonable fear that the precedent set by those trade agreements will have an impact and shape future agreements.

Any introduction of more onerous patent rules would hinder the ability of generic manufacturers to operate and reduce competition and drive prices back up. That would be disastrous for access to treatment, and our Government must do all they can to protect global public health within these and future agreements. I would be grateful if the Minister clarified today whether the Department for International Development shares any of those concerns and if he put on record his Department’s formal input into free trade agreements. I appreciate that some of that is private, but I am asking how the Department does that and whether he feels that has an impact on the Government’s view as they go into these negotiations.

I shall move on to middle-income countries. During the inquiry, I was particularly struck, more than ever before in my involvement in international development, by the squeeze on middle-income countries and particularly by the impact on the poorest people living in those countries. As I said, this is part of a much bigger debate in international development—it is not confined to HIV—but access to medicine is a clear example of where we might be going wrong.

In providing HIV treatment, middle-income countries in particular are facing a crisis of increased prices combined with reduced financial support. Many of those countries are excluded from the licensing deals that I just mentioned for first-line treatments that allow generic production and supply, forcing them to purchase from innovator pharmaceutical companies at market prices. Those prices are prohibitive and inconsistent. For example, prices for second-line drugs in Argentina are $2,570 per person per year, and the price in Mexico is similar. That is over 12 times the price that South Africa pays at $204 per person per year, which is double the price that I mentioned earlier of $100, which is available for first-line drugs in many low-income countries.

At the same time as they face increased prices, many middle-income countries are having their official development assistance withdrawn from bilateral and multilateral donors. As far as I can see, that has been this Government’s policy, not only in bilateral support, but in using the UK’s influence on the expenditure of multilateral donors to which we contribute, such as the global fund. In addition, we are, in my view, using outdated country classifications and pushing more and more countries prematurely into middle-income status.

When those factors combine, national Governments in middle-income countries are unable to provide services, leading to a treatment crisis. Classification of countries must move away from the current gross national income to a more nuanced analysis. Further support needs to be given to countries, as they graduate through classifications. Decisions about the provision of aid need to be based on need, not just country classifications, although it is completely correct that resources should be prioritised to those who need them most.

Of course, we should expect countries to take on an ever-increasing responsibility for their own development as they become wealthier, but we should not assume that a country with a label of middle-income status has the resources or the technical capacity to cope with aid being withdrawn. The inequality within middle-income countries must be kept in mind. Increasing GNI does not instantly equate to improved living standards or fantastic new health systems, particularly for the poorest and hardest to reach. In relation to access to treatment, funding decisions should be based solely on evidence.

As bilateral donors such as us are withdrawing funding from middle-income countries, so the burden falls on multilateral donors to plug the gaps until countries in transition can fund their services from domestic resources. However, we have seen multilateral organisations following the lead of bilateral donors and reducing support for middle-income countries.

I repeat to the Minister that we should not underestimate the influence that the UK has globally. I say that not with a conceited British ego, but from the experience of speaking to multilateral donors and the people who run those organisations and to people from donor countries and from countries that benefit. When we speak to them, they beg us to bring to DFID the view that this is a huge problem. If a solution to it is to be found, it will require political leadership from the British Government and DFID and a concerted effort to make this issue a priority to ensure that it receives the necessary political attention. Will the Minister tell us whether that is recognised by the Government and whether there is any change in the Government’s thinking on how we look at middle-income countries and their support, particularly on this issue but also more generally?

As I said, the current models of research and development are not delivering all the treatments necessary to meet public health needs. R and D is not prioritised based on need; it is prioritised according to the most profitable products. In our report, we found that there is a gap in relation to treatment for many HIV co-infections, paediatric treatment and diagnostics for small children. Existing models for R and D rely on pharmaceutical companies securing patents that grant exclusive rights to sell the drugs that they develop. If a potential market does not exist, there is currently no incentive to develop products. The need for market advantage reduces collaboration between researchers and increases delays in research into potential vaccines and cures and more effective treatment regimes.

At this point, I want to highlight the fact that in the report we note the disappointment in the UK Government for withdrawing 80% of the funding for the International AIDS Vaccine Initiative and research into an HIV vaccine. Will the Government reconsider that? If not, can the Minister explain why not?

On treatment, a key recommendation in the report is for DFID to play a role in developing new R and D models that are delinked from profits, based on open data sharing and reward people for the development of new clinical technologies, rather than exclusive sales rights being granted. We have recent examples of where what I have described could be a continued problem and where the solution that we have proposed could work. The Ebola crisis is a good example of the failings of the current global model, whereby a vaccine is developed only after a crisis has developed because there was no market incentive to develop one before. Médecins sans Frontières estimates that a vaccine for Ebola will emerge not from a private laboratory, but from publicly funded research.

Models for encouraging innovation in relation to HIV and neglected diseases can broadly be divided into push and pull mechanisms. Push mechanisms reduce the risks and costs of investment in R and D. They include direct funding of research and tax credits, both of which have already been used by the UK Government. The main drawback to push mechanisms, such as direct funding, is that they require funders to make a judgment about which research bodies are most likely to achieve the needed results. Clearly, more research is needed into who would be the best people to make that judgment.

Pull mechanisms, in contrast, create an extra incentive to achieve the result, such as a new medicine, with the benefit delivered only on achievement. Examples of such mechanisms include prizes for the first researchers to come up with a specified innovation, advance market commitments or tax credits on the sale of a certain product that has yet to be developed. There are examples of that already.

We have seen success in delinking R and D costs in relation to the meningitis A vaccine initiative. That developed an adapted meningitis A vaccine through collaborative research, which included the National Institutes of Health and the Serum Institute of India, a private vaccines company. The cost of the vaccine is approximately 50 cents a dose. Furthermore, delinked models of R and D are under consideration for the development of new antibiotics, particularly because there are no incentives for industry to develop products that are meant to be both affordable and conserved or tightly managed.

Our research findings show that the Government could be doing much more to explore the benefits of alternative research models, and I urge them to commission a paper analysing the costs and benefits of alternative R and D models. I ask the Minister whether the Department is considering that. It was a key recommendation of the “Access Denied” report and was previously communicated to the Department.

I want to touch on another finding of the report—the lack of access to viral load testing. We need effective diagnostic tools if we are to provide quality care, but we are seeing very limited investment in that area of research and provision. Viral load testing is the gold standard of diagnostic testing, with increases in viral load indicating treatment failure. If any of us in this Chamber were living with HIV in the UK, we would be undergoing regular viral load testing to ensure the effectiveness of our treatment. The idea is that if the treatment is not effective, people are moved on to second-line or third-line treatment as soon as possible.

In low and middle-income countries, however, viral load testing is limited, which leads to lower standards of care and delays in identifying treatment failure. There have been recent moves to reduce prices, but the tests are carried out only in specialist centres with limited capacity. When I was in India, we went to a clinic and saw the situation at first hand. There was very limited capacity to provide viral load testing. When someone was suspected of having a treatment failure, they had to go in front of a board. There were layers and layers of bureaucracy for such a person. The only justification that I can give is that people there just did not have the capacity and were trying to limit the number of individuals going for viral load testing because they could not afford to send any more. When we met representatives of organisations that were lobbying the Government and, indeed, us on this issue, they told us horrific stories of people who had died waiting to get a test to know whether their treatment was failing. That is something that we do not need to live with in this country, and we have the technology to stop it happening. I feel that we have a responsibility to try to increase the capacity for viral load testing across the world as soon as possible.

Even as the tests are becoming more affordable, there remains a challenge to ensure that these systems are in place. There is a need to develop affordable, accurate point-of-care testing to increase available testing and to reduce delays. That would avoid the need for patients to travel hundreds of miles to testing centres far from their homes and would significantly improve the quality of care received by patients.

Diagnostics are just one area where we see a disparity in treatment between rich and poor countries. We also see that across the spectrum of clinical settings. Distribution networks and health systems in low and middle-income countries are far behind where they need to be. Supply chains are vulnerable to a number of issues, resulting in poor access to treatments. Those challenges include significant delays in registering new drugs, poor demand forecasting and ordering, inadequate storage facilities, stock-outs, corruption and poor patient record management. I would be grateful if the Minister outlined what his Department is doing to address those issues and to support health system strengthening to improve access to treatment, particularly in terms of what we can do to encourage investment in making viral load testing cheaper and more accessible to low and middle-income countries.

The final issue that I will consider is that key populations are being left behind. That has been much debated in the main Chamber and in this room by the all-party group on HIV and AIDS and by our friends among other all-party groups. In addition to the practical, scientific and economic barriers that have been outlined, there are definite social barriers to treatment. The UNAIDS report on the global AIDS epidemic demonstrates that key populations are being left behind when it comes to access to treatment across the globe. The problem is not confined to low, middle or upper-middle-income countries, but it is particularly acute in some upper-middle-income countries—such as former Soviet Union states and countries in central Asia—because HIV epidemics are growing rapidly among key populations.

As MSF pointed out in its submission to our inquiry, the problem of pricing in such countries is compounded by the fact that the epidemics are not generalised but concentrated in marginalised populations. For the avoidance of doubt, I am talking about injecting drug users, sex workers, men who have sex with men, and the transgender population. As I outlined earlier, many global funders actively restrict funding to such countries. That inevitably creates barriers to access for the most vulnerable groups, because there is no political will in those countries to help the key populations that are most affected.

The UNAIDS report highlighted the barriers to treatment created by punitive and discriminatory legislation in many countries:

“As of 2013, 63 countries have in at least one jurisdiction, specific provisions that allow for the persecution of HIV nondisclosure, exposure and/or transmission. Criminalisation of key populations also remains widespread, and 60% of countries report having laws, regulations or policies which present obstacles to effective HIV prevention, treatment, care and support for key populations and vulnerable groups.”

Stigma and discrimination must be challenged wherever they are encountered, whether at a community or a state-wide level. If we do not remove social barriers to accessing testing and treatment, scientific advances will be ineffective. The thing I find most painful about this section of the report is that the position of key populations is not improving but getting worse. There have been many debates in this Chamber about the situation in Uganda and the change in its laws, and there has been much interest in what has happened in Russia. There is cross-party support in the House for fighting discrimination, and I am proud of our country’s record of working to do so. I hope that that will continue.

In conclusion, I am grateful to have had the opportunity to debate this important subject. Hon. Members may think that I have gone on a bit, but I could speak for hours about the detail of the report. It was born out of the huge impact of the report on access to medicines that our predecessor group published in 2009, which I have seen on shelves across the world in countries that I have had the privilege of visiting as chair of the all-party group. A huge amount of progress has been made in the past five years, and a great deal has changed, so I felt that it was time to look at these issues again. As I said at the start of my remarks, despite that progress, so much more can be done. We need to ensure that that happens by working together to tackle the barriers that are outlined in the report.

--- Later in debate ---

[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.