From the Department for International Development

Gareth Thomas's Speech to the UK Forum for Hospice and Palliative Care Worldwide. 

What is the global situation of HIV/AIDS and its impact on development?

HIV/AIDS is an unprecedented challenge to development. 40 million people are currently living with HIV/AIDS. In 2002 5 million people worldwide were newly infected with HIV and 3.1 million people died of AIDS. 71% of those infected are in Sub-Saharan Africa, but in Asia and Central Europe infection rates are rapidly escalating. Low prevalence rates in Asia mask the fact that large numbers of people are living with HIV. In China for example the prevalence rate is the same as the UK at 0.1%, but this translates into 850,000 infections, set to rise as high as 10 million by 2010. 

In short HIV/AIDS is reversing many of the development gains of the last 50 years, and is threatening the achievement of many of the Millennium Development Goals. The epidemic has some stark messages for us all:

• In Africa life expectancy now stands at 47. Without AIDS it would have been 62. In Botswana it has dropped even further to 37. 
• Young people, women and girls are being hit hardest. HIV/AIDS is undermining the future workforce, and carers of the next generation.
• The epidemic is placing colossal strain on health systems. In the worst affected countries in Africa over half the hospital beds are taken by people with HIV infection. Despite falling drugs prices treatment remains a distant hope - only 5% of the 5 million people who currently need it have access, and that figure is only 1% in Africa. 
• There are now 15 million children orphaned by HIV/AIDS, 11 million in Sub-Saharan Africa. And the numbers are projected to rise sharply. Extended families take in the majority of orphans who lose both parents, placing pressure on scarce household resources. But wherever they are, orphaned children are vulnerable to exploitation, including physical and sexual abuse. In turn they are made more vulnerable to HIV/AIDS themselves.
• The impact on economic development is devastating. Recent World Bank research has suggested the total collapse of the South African economy within four generations.

The UN Secretary General, in this year's review of progress on the UNGASS Declaration of Commitment says that we are all falling short of the targets. We will not meet basic prevention and care goals unless efforts are scaled up dramatically. UNAIDS described his report as a 'wake up call to the world' - its imperative that we hear the alarms and act on them now. 

The UK is committed to maintaining its role at the forefront of the fight against AIDS. We are the second largest bilateral donor of HIV/AIDS assistance. Our investments in HIV/AIDS assistance in 2002/03 amounted to more than £270m. In addition we have already pledged $280 million to the Global Fund over 7 years. We are backing research into vaccines and microbicides. And palliative care has been a central part of DFID's support to HIV/AIDS in countries from Uganda to China. 

What is an effective response to HIV/AIDS?

An effective HIV/AIDS response requires the full range of approaches, including prevention, care and alleviation of the social and economic impacts of the epidemic on communities. DFID has been a champion of prevention programmes. 

We know also that an effective response requires more than prevention. We welcome the WHO "3 by 5" target to get three million people on treatment by 2005, and will work with our development partners to ensure that progress towards this ambitious target is equitable and leads to quality services.

Drug prices are falling but demand for treatment is growing and it is crucial that in extending access we ensure that drugs reach the poorest communities, and particularly women.

But antiretroviral treatment programmes are on their own not enough. Gaps in coverage and barriers to treatment will remain for some time. Many people will be unable to maintain treatment. For some it simply won't work.

So a comprehensive package of care is needed, including home based care, psychosocial support, promotion and widescale acceptance of self help, treatment for opportunistic infections and pain management. All elements that are often overlooked. DFID is committed to a poverty and equity focused response to HIV/AIDS. Effective palliative care has an important part to play in the response. And that's why this meeting is particularly important. 

I am clear that palliative and home based care must be an important part of our response

Indeed important lessons have been learned from the development of effective palliative care. In Zambia and elsewhere volunteers in the community have been extremely effective in providing care for people in their homes, acting as an important community based platform and entry point from which other services - including treatment - can be delivered, linking hospices and hospitals with communities and families and helping to reduce pressure on health systems. Good quality care provided at home or in the community is not only welcomed by many people living with HIV but also allows for better allocation of resources throughout health systems, and can therefore improve standards of care overall.

Palliative care has the potential to strengthen the synergy between prevention and treatment. By involving families and communities and helping them to confront their attitudes about HIV it can increase knowledge and reduce the fear and stigmatisation which in many countries have made people unwilling to listen to information about AIDS. It can also allow families to consider and put plans in place to prevent further infections. 

By putting the emphasis in communities it also allow people with HIV to plan for their futures, and the future of their families. It allows families to consider how to look after surviving members if deaths do occur, or how to provide for family members whilst people are too sick to work. Understandably, it is difficult to think about and plan for the possibility of death, but where this can be done sensitively it has enormous benefits, including helping avoid the destitution of widows and orphans we have seen when they have been deprived of property and livelihoods and which compound the tragedy of AIDS.

Crucially palliative care is relatively inexpensive. Research in Zambia found that community initiated care was effective and less costly than hospital based care, with six months care averaging $26. And when measured against savings at the hospital or clinic as well as the overall impact on the family and community in terms of education, reduction in stigma and discrimination, the benefits begin to more than stack up. 

We need to consider what opportunities there are for expanding palliative care, and what challenges remain.

The Declaration of Commitment on HIV/AIDS, which calls for access to quality care, including palliative care, is a good starting point. As Hilary Benn said at the UN General Assembly in September, we need now to turn that commitment into action. We should take the lead from countries like Uganda and make palliative care part of national plans on HIV/AIDS. 

There are increasing resources available for work on AIDS. There still remains a large resource gap, but there is also a gap in the ability of countries to spend increasing resources effectively and of donors to coordinate their resources well. We are committed to helping improve the capacity of poor countries to put resources into effective prevention, care and impact mitigation programmes. 

And, increasingly we have the knowledge of what works. Programmes in Zambia have shown us how to provide care in the community, linking to health centres where needed. In Uganda, programmes have shown us how to provide palliative care which places emphasis on rehabilitation and the promotion of independence. We need to make sure these best practises are adequately communicated and taken up elsewhere. 

Inevitably, challenges remain. Many countries constrain the use of opiates which are essential for reducing the pain experienced by people with HIV. In Indonesia, for example, only four hospitals can prescribe morphine in the entire country, and often stocks are limited. But there are good examples, again from Uganda, that it is possible to use opiates for pain relief without these drugs being diverted from their intended use. We need to promote South-South learning and to help publicise these good models and advocate in other countries for policies that will support their implementation. 

We also need more evidence and knowledge in some key areas. We need to know:

• How to meet the needs of women infected by HIV, and how to ensure that they receive as much care as they give?
• What supports are needed by children, and what treatments are appropriate for them? and 
• How to provide other forms of social and emotional care?

What will DFID do to meet the challenges?

DFID will continue to support comprehensive responses to HIV/AIDS that include the full range of activities including prevention, care and impact mitigation. We are committed to maintaining our position as the second largest bilateral donor of HIV/AIDS assistance and where more funding is required, we will work with others to make that money available. We must also work with developing country governments to ensure spending is effective and efficient.

We will support the scaling up of treatment and care programmes - including the 3 by 5 initiative of the World Health Organisation - and will push for this treatment to be made more accessible to the poorest and to be scaled up in a way that maximises the synergy with prevention work, and works to build up functioning health systems.

DFID will also play its part in the international community seeking to better coordinate the response on the part of other donors, multilateral institutions, NGOs, the private and public sectors and with research institutions. We need to accelerate our response to enable developing country governments to ensure the best quality of life for men, women and children who are affected by HIV.