Foreign Affairs Committee Global Health Security Inquiry

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STOPAIDS Submission (supported by Harm Reduction International) (GHS0018)

Introduction to STOPAIDS and our reason for submitting evidence

1. STOPAIDS is a network of 70 UK agencies fighting to secure an effective response to HIV and AIDS since 1986. 
2. 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. 
3. 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]
4. We do not 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.
5. 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.
6. 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 on the progress to date.
7. Ending AIDS by 2030, especially now, with the added complication of COVID-19, will require a comprehensive approach to global health security. To protect and advance global health, we believe the UK Government must commit to:

1. Maintaining the UK Aid budget at 0.7% of Gross National Income.
2. Supporting the international community to overcome COVID-19 and helping provide equitable access to all effective new COVID-19 tools including diagnostics, therapeutics and vaccines.
3. Ensure greater coherence across Her Majesty’s Government’s investments in global health, through creating a cross-government global health strategy, which is centred around achieving Sustainable Development Goal 3: Healthy Lives and Well Being for All and universal health coverage (UHC) by 2030.
1. This strategy should also outline a multisectoral approach to tackling the determinants of health or access to healthcare, for example across education, water and sanitation, nutrition, climate change,  agriculture, tax, trade and arms sales.
4. Ensure all investments in global health contribute towards achieving UHC and strengthening health systems, especially through building capacity for primary health care.

What lessons has the COVID-19 pandemic taught us about the importance of international collaboration in securing global preparedness and resilience against biosecurity threats?

1. The past 10 months have fostered a spirit of cooperation between leading global health actors, governments and the pharmaceutical industry that should be similarly adopted for HIV.
2. The ability to move so swiftly against COVID-19 has been built on the existing collaborative shoulders and structures of past responses to AIDS, tuberculosis, malaria and Ebola.
3. The mobilisation of the global health architecture, the multiple different institutions coming together and the mass pooling of funding at a global level all demonstrate what we are capable of if we choose to coordinate and work together and support each other in solidarity.
4. The response to COVID-19 gives renewed hope that the international community is capable of ending AIDS by 2030, if we have sufficient political will and financial resources to do so.
5. The pandemic has reaffirmed that solutions that collaborate to uphold feminist, community-led responses, and interventions focused on key populations should continue to be prioritised in order to help address the increasing inequalities stemming from the impacts of COVID-19.
6. On this theme, the pandemic has also affirmed that effective collaboration to uphold sexual and reproductive health and rights (SRHR) is essential. We need to continue to ensure that provision of SRHR and HIV services during a pandemic are not negotiable or interrupted, and do this in ways that feel safe for women and girls living with, and vulnerable to HIV.
7. As with the HIV response, we have learnt that the COVID-19 response efforts should place affected communities at the centre of the response so that they can be at the heart of collaborative efforts: in governance and planning, direct service delivery and community monitoring and accountability.
8. We have additionally learnt that, again as with the HIV response, the COVID-19 response efforts should be grounded in human rights and equality, with particular attention being paid to creating an enabling environment and removing punitive, arbitrary and discriminatory legal and policy measures that increase marginalization and undermine access to essential prevention and treatment services.
9. Lessons learned from the HIV response provide critical insights for countries to reimagine systems for health that are optimally effective, accountable, inclusive, equitable, rights-based and sufficiently resourced and COVID-19-relevant services should be accessible, integrated, tailored and people-centred.
10. To be effective, the COVID-19 response must be multisectoral and address social and structural inequalities that increase vulnerability and slow service uptake.
11. We have also learnt of the importance of balanced investments in new tools between collaborators. We have seen many donors step up to invest in the Access to Covid-19 Tools Accelerator (ACT-A) COVAX partnership but less investment in the diagnostic and therapeutic pillars. We must encourage collaborators to invest equally across the tools we need in order to not put the global community’s eggs all in one basket when so much hangs in the balance.
12. Collaborative by nature, multilaterals are essential and well placed to respond rapidly and at scale. For example, The Global Fund to Fight AIDS, TB and Malaria (Global Fund) has responded rapidly to COVID-19. In March, it made US$500 million available through grant flexibilities to support its efforts in the response. In April, it announced an additional US$500 million of funding to supplement this and continue to fight COVID-19,mitigate the impact of COVID-19 on HIV, TB and malaria, and deliver activities and resources to strengthen critical health systems. The Global Fund has been one of the only global health institutions able to respond at this speed by being flexible within the existing systems and structures it’s established over many years. The Global Fund has also become a founding partner of the ACT-A, a global collaboration to accelerate the development, production and access to Covid-19 tests, treatments and vaccines.
13. Finally, we have learnt about the fragility of health systems and how quickly they can deteriorate in the face of crises, emphasizing the need for further collaborative health system strengthening efforts. Some examples of fragility can be seen in the impact of the pandemic on the HIV response.
1. When the pandemic emerged the World Health Organisation (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[2].
2. Early indications show that the response so far has mitigated many additional deaths, but that there has been an increase in HIV acquisitions.
3. 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]
4. 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].
5. 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].

How effective is the UK’s current approach to global health security?

14. The 5 point global health security plan that the Prime Minister unveiled at the 2020 United Nations General Assembly is almost entirely focused on dealing with another future pandemic and omits any plans or intentions for mitigating the secondary health impacts of COVID-19 or a further pandemic.
15. The UK’s approach to global health security for existing global health threats is not articulated or published and scrutinising its effectiveness is a challenge.
16. 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.
17. STOPAIDS would suggest that rather than using a narrative of security, the UK moves to an approach of solidarity in it’s global health reach. Our concern is that when the government refers to Global Health Security it is really referring to prevention and treatment against diseases that might kill UK Citizens which is neither moral, sustainable or practical. This concern echoes those articulated in a recent article from Global Fund Executive Director Peter Sands[6].
18. A narrative of Global Health Security could lull us in to believing that once a disease, like for example HIV, no longer threatens the lives of those living in our borders it becomes a development or humanitarian issue, rather than a ‘health security threat’, and then this often dismantles the response architecture and resourcing surrounding it. We have seen this phenomenon first hand in the global HIV response.

What role should the FCDO play in bringing about a resolution to the COVID-19 pandemic and preventing future pandemics?

19. The FCDO should adopt an approach which allows the UK to continue to play a leading role in the epidemics that we had failed to eradicate before the advent of COVID-19, as well as COVID-19 itself.
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. The capabilities and infrastructure required to prevent future epidemics are largely the same as those that need to defeat diseases like AIDS, TB and malaria.
2. The COVID-19 response must build on the substantial infrastructure, evidence and approaches of the three diseases (HIV, TB and malaria) to improve performance over time and effectively identify and reach communities at risk of being left behind.
3. The FCDO should help size on synergistic opportunities to further and better the responses to the pre-existing epidemics when responding to COVID-19, for example by supporting additional HIV testing at future COVID-19 vaccination sites.
20. 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. 
21. 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.
22. As with the above recommendation that the FCDO publish a cross Government Global Health Strategy we also recommend that they finalise and publish both the Foreign, Commonwealth and Development Office’s Health Systems Strengthening position paper, in collaboration with civil society partners and the Ending Preventable Deaths Action plan, again in collaboration with civil society partners.
23. Finally we recommend the FCDO take forward the commitments of the 2019 UN HLM on UHC by:
1. Supporting countries to develop their own transparent and accountable UHC national roadmaps, engaging stakeholders across civil society, communities and youth in the process.
2. In line with national UHC roadmaps, supporting countries to decrease maternal mortality and under 5 mortality, eliminate diseases of existing epidemics  such as malaria, AIDS, tuberculosis and neglected tropical diseases, significantly reduce premature mortality from non-communicable diseases and increase access to sexual and reproductive health services.
3. Supporting countries to develop strong taxation systems to fund UHC.

Has the UK effectively used its position in multilateral organisations to promote international collaboration in response to COVID-19 and the global health security agenda?

24. The UK has and should continue to utilise its position on global health multilateral boards, such as the Global Fund, Unitaid and GAVI, to ensure that health systems strengthening and achieving UHC remains a primary objective both within the COVID-19 response and beyond.
25. The UK should also utilise key global ‘moments’, such as the UK’s G7 2021 presidency, to establish clear objectives and prioritise UHC and health systems strengthening as well as the opportunity of the upcoming United Nations General Assembly High-Level Meeting on Ending AIDS and its Political Declaration.
26. The UK Government must also learn from the mistakes made in the HIV response where  protecting intellectual property rights on health technologies have been prioritised above the human right to access medicines leading to a huge loss of life.
27. The UK should therefore use its position on multilaterals that are involved in the Access to Covid Tools Accelerator (ACT-A) as well as its role as a donor to the ACT-A, to ensure that this new partnership is contributing to equitable access to all Covid-19 tools.
28. To achieve this the UK Government should impose conditions on all UK funding committed to developing vaccines and treatments for COVID-19. These should ensure:
1. An open innovation approach achieved through the mandatory sharing of know-how, clinical trial data and health technologies via the Covid-19 Technology Access Pool (C-TAP) to maximise innovation and collaboration in a diverse pharmaceutical and life sciences sector.
2. Any new COVID-19 vaccines and treatments should be considered a ‘public good’ meaning they are affordable for all countries and free at the point of use for those who need them, including in countries that do not have the benefit of a publicly funded health service such as the NHS.
3. Universal, non-exclusive licenses on any vaccine or medical product.
4. Full transparency of all licensing agreements made between research institutes and pharmaceutical companies and other actors. This transparency would include making available information about the R&D costs; and final product prices and ‘step-in’ rights for the UK government to issue non-exclusive licenses if a licensing partner fails to comply with the requirements of providing the health technology at an affordable and fair price. Transparency is important in order to prevent practices that are against the public interest and ensure that the government has the information it needs to make informed decisions.

December 2020