IDC C19 Secondary Impacts Inquiry STOPAIDS Submission

Introduction to STOPAIDS and our reason for submitting evidence

STOPAIDS is a network of 70 UK agencies fighting to secure an effective response to HIV and AIDS since 1986. 

We were pleased to be invited to give oral evidence to the International Development Committee as part of this Inquiry on Tuesday 13th October. This submission mirrors our contribution to that session.

Even before the COVID crisis we knew that despite having the tools we need, due to underfunding and political neglect we were unlikely to meet the 2020 targets set by UNAIDS and that we were off track to hit the overarching SDG target of ending AIDS as a public health threat by 2030.  Early Imperial College COVID-19 response team modelling set out that AIDS, TB and Malaria deaths related to the impacts of COVID-19 could overtake the number of direct COVID-19 deaths if mitigation measures were not put in place.[1] We don’t have the data to be definitive but early indications show that the COVID-19 response so far has mitigated additional deaths, but that we are likely to see an increase in HIV acquisitions. It is clear that all elements of the HIV response are being affected by COVID –19 and it's likely that this trend will continue, potentially exponentially. If we do not protect the gains made in the HIV response over the last 20 years, many of which UK funding has delivered, COVID-19 will cause significant, irreversible, disruption and begin to turn back the clock.

The impact of COVID-19 on the global HIV response

The disruption of healthcare provision

1. The latest data has not yet been published by key agencies but it would appear that the impact of COVID-19 on the global HIV response has been significant. However, it has not been as devastating, as yet, as the worst projections originally laid out at the start of the pandemic.
2. WHO projected that a six-month disruption of antiretroviral therapy could lead to more than 500,000 extra deaths from AIDS-related illnesses, including from tuberculosis, in sub-Saharan Africa in 2020–2021. Thankfully, we have been able to avoid such disruption[2].
3. Early indications show that the response so far has mitigated many additional deaths, but that there has been an increase in HIV acquisitions.
4. According to a WHO survey conducted in July, between April and June, 36 countries reported disruptions in the provision of HIV treatment services - affecting 11.5 million people - 45% of the global population of people living with HIV accessing treatment.[3]
5. The Global Fund to Fight AIDS, TB and Malaria (Global Fund) reported in October that  75% of programs reported moderate to high levels of disruption to HIV service delivery and that for all three diseases (HIV, TB and malaria), community based services remain the most impacted[4].
6. At a more micro level, in August and September, the International Treatment Preparedness Coalition (ITPC), Salamander Trust and Making Waves interviewed 30 women in 10 counties in Southern and East Africa and found that they were not able to get viral load testing[5].

The impact of COVID-19 and response to HIV and the extent to which this is different or the same as that for other diseases such as TB or Malaria

1. The response to COVID-19 must be in partnership with and mutually supportive of the continued response to other key health issues otherwise we risk undermining all the progress we have made so far.
2. The COVID-19 response must build on the substantial infrastructure, evidence and approaches of the three diseases to improve performance over time and effectively identify and reach communities at risk of being left behind.
3. One aspect all pandemics underline is the critical importance of access to medicines and technologies.
1. STOPAIDS hopes the UK will support all necessary measures to facilitate technology transfer - i.e the know-how around how to manufacture COVID-19 health technologies - so that we are able to meet global demand.
1. This includes championing the COVID-19 technology access pool where Intellectual Property, research data and manufacturing know-how can be shared[6]; supporting the TRIPS (Trade Related Aspects of Intellectual Property Rights) waiver put forward by the governments of India and South Africa at the TRIPS council[7]; and reaffirming the right of all World Trade Organisation members, including the UK, to actively use the Public health safeguards within the TRIPS agreement.

The impact of COVID-19 on people’s behaviour in relation to health-related / health service-seeking behaviour

1. The ITPC, Salamander Trust and Making Waves study referenced above found that the women living with HIV they interviewed particularly feared attending services in hospitals because of lack of clarity whether living with HIV classes as an underlying health condition and that they may be immunocompromised if they contracted COVID-19.[8]
2. For key populations, HIV testing and prevention services were often already facilitated through peer outreach services but as bars and meeting places are closed down this has been made a lot more difficult.
3. There also has been the huge impact of isolation and lockdown on mental wellbeing.

The positive and negative impacts COVID-19 has had on civil society and community health responses

1. Community based services remain the most impacted.
2. Continued or renewed lockdown is of significant concern for people who are care dependent, including older people and people with disabilities and HIV comorbidities.
3. Civil society and communities have not been actively included in many national COVID governance mechanisms.
1. STOPAIDS has been co-leading work to ensure civil society representation in the ACT-Accelerator. There are still no Civil society representatives in the Covax Facility. We urge the Foreign Commonwealth and Development Office (FCDO) to use its voice to support civil society and particularly marginalised communities, to be at the table of all global and national COVID governance mechanisms

How the FCDO should approach the secondary impacts

1. There are significant negative pressures on the UK, as with many countries, due to COVID-19 and the cuts to ODA linked to the recession[9].
2. To maintain progress, FCDO must show a continued commitment to leaving no one behind.
3. FCDO should also build upon the Foreign and Commonwealth Office’s strengths on diplomacy and human rights to build political leadership on global health issues, including the rights of key populations (such as LGBTIQ individuals, people who use drugs and sex workers), and sexual and reproductive rights. 

What should be guiding the FCDO response

1. STOPAIDS encourages the FCDO to continue to collaborate closely with UK civil society to hear what is happening on the ground and co-ordinate effectively through the joint task forces and the CS-FCDO steering committee but also ensure funding continues for critical COVID and broader health work.
2. STOPAIDS believes a cross-government Global Health Strategy is required. This would implement a cross government approach to global health overseen by a strengthened Global Health Oversight Group, and a Government Minister responsible for delivering the government’s manifesto commitment of Ending Preventable Deaths.

How ODA cuts could impact for HIV and broader health

1. The only public indications of the priorities for the new FCDO were described in the response by Secretary of State Dominic Raab MP in the DFID-FCO Merger Parliamentary Debate on the 18 June[10]. It was notable that while COVID-19 was listed as a priority, broader global health was not and even the Conservative Manifesto commitment of Ending Preventable Deaths was not included. 
2. We haven’t seen substantial cuts to health as yet but we remain vigilant. Especially as individual health or disease specific investments often have interconnected gains and a cut to one could have significant wider impacts.
3. We have had welcome assurances that the UK’s 2019 pledge to the Global Fund will be disbursed as planned.
4. Unfortunately additional investment in the Global Fund is now needed by all donors to protect the response to the three diseases and the Global Fund’s role in responding to COVID. We hope the UK can make an additional contribution to this highly effective organisation.
5. The Prime Minister’s suggestion of using the G7 to agree a 5-point plan on Global Health Security is notable[11]. We need to make sure this places health systems and UHC at its centre.

What the future may hold

1. We are clearly still in the middle of the crisis and are in no sense post-COVID. The number of variables make predictions extremely difficult. Many localities and countries are facing a second wave. Where we might be in 6-12 months in terms of HIV, health and life will really depends on three critical factors:
1. Financing:

■        Debt relief efforts and global financial support against recession;

■        Financing for the COVID-19 vaccines certainly but also therapeutics and diagnostics 

■        Ongoing funding for non-COVID-19 health issues - for HIV TB and malaria this means ongoing and additional funding for the Global Fund

2. Access and availability:

■        We will not be able to afford or create enough vaccines, diagnostics and therapeutics unless we share IP and know-how and take a global commons approach to production and distribution

■        The poorest and most marginalised have to be guiding decision-making at national and global level to ensure they are not the last in line yet again

2. Global solidarity and political leadership: We welcome the leadership shown by the UK to date and hope it will use its G7 presidency to galvanise collective action
3. By unlocking financing, guaranteeing access to new COVID-19 tools and shepherding global political leadership the UK can and should use its global positioning strategically and play a crucial role in the fight against COVID-19.

Key lessons from the response to date

1. There are some lessons we are relearning from the HIV response. In light of these the COVID-19 responses should:
1. place affected communities at the centre of the response.
2. be grounded in human rights and equality
3. uphold SRHR.
2. More broadly, from COVID-19 we have learnt that we don’t necessarily need to be in the same room as others to provide support and services - whether health or broader support. For those who have communication mechanisms such as phones and computers, we have been able to create new ways of engaging. However, this is a significant danger for the poorest and most marginalised since without this access they risk becoming even further isolated.