HIV Treatment: Low and Middle- income Countries

Simon Kirby 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.

--- Later in debate ---

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

I want briefly to reinforce four of the many excellent points that the hon. Member for Airdrie and Shotts (Pamela Nash) has made. First, I want to talk about access to medicine. Fifteen years ago, 70% of people living with HIV were located in low-income countries. Estimates now show that, by 2020, about 70% of people living with HIV will be located in middle-income countries. That dramatic shift means that a fresh approach is required to the AIDS response.

Recently, Governments and multilateral donors have withdrawn funding from middle-income countries, at the very moment when they are faced with increasing treatment costs. Outdated classifications of countries based on simplistic gross national income calculations need to be replaced with evidence-based approaches to ensure that the response to HIV/AIDS, and to other diseases such as tuberculosis, malaria and hepatitis C, is as effective as possible. The focus should be not on low-income countries versus middle-income countries, but on ensuring that the most vulnerable and marginalised in society receive the services that they require.

Secondly, we need to keep going. It is now possible to end the HIV epidemic as a public health threat, but at the very moment when that has become possible, HIV has fallen off the political radar as a matter that requires urgent attention. There is an ever-decreasing window of opportunity to bring HIV under control, and that can be achieved only with a renewed political commitment. Without such a commitment, we face losing momentum and seeing a reversal of the progress that we have made. We must not let that happen.

Thirdly, I want to mention HIV transmission. Access to treatment is a significant problem that we must solve, and we must consider what more we can do to prevent new HIV transmissions. Social factors play a significant role in reducing HIV transmission. If people know how the virus is transmitted, they can often take action to protect themselves—often, but not always, because social factors such as stigma, discrimination and inequality can reduce the options available to vulnerable and marginalised groups. Fear and lack of knowledge about how HIV is transmitted can lead to stigma and discrimination, which make people afraid to get tested or to reveal their status.

Fourthly, we must consider social barriers. Women and girls face a disproportionate risk of HIV, and it has a disproportionate impact on them, because of gender power imbalances that result in economic disempowerment, gender-based violence and the denial of their human rights. Others at high risk of contracting HIV—including those who use drugs, sex workers, prisoners and people from LGBT communities—often cannot access evidence-based prevention services because of punitive laws, stigma and discrimination. Young people are denied access to information on their sexual and reproductive health and rights, including information on HIV prevention. Those social barriers to accessing HIV services such as testing, counselling and prevention services, alongside the freedom to control life choices, must be addressed as part of a holistic approach. I joined the all-party group on HIV and AIDS nearly five years ago, because it is a considerable issue in my constituency. It is still a big issue, but there is a realisation that we need to continue to do all we can around the world to end the HIV epidemic. I welcome the report.