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Global Fund: AIDS, Tuberculosis and Malaria

Volume 738: debated on Wednesday 4 July 2012

Question for Short Debate

Asked By

To ask Her Majesty’s Government what plans they have for helping the development of the Global Fund to Fight AIDS, Tuberculosis and Malaria.

My Lords, first, I very much welcome the number of speakers who have put their names down for this short debate, which I think speaks volumes for the importance of making progress in this area.

I speak as an enthusiastic supporter of the Global Fund. I saw it in its early stages, when Richard Feachem was director, and I pay tribute to all the pioneering work that was done then. The fund has already done vast good. It has an enormous canvas: HIV/AIDS, tuberculosis and malaria. Without exaggeration, it is one of the most ambitious health programmes that the world has ever seen. The lives of millions of people have been saved, but the bleak fact is that much, much more needs to be done. The challenge remains immense.

With HIV/AIDS, the world death toll is still 1.8 million a year, 30 or 40 years after the virus began its deadly sweep, first through sub-Saharan Africa and then through so much of the rest of the world. With TB, the latest figures show a death toll of 1.7 million, with the highest number of deaths in the Africa region. With malaria, there were an estimated 655,000 deaths in 2010, of which 91% were in Africa. Of course, these diseases do not fit into neat, separate boxes. Together, HIV and TB form a lethal combination, each speeding the other’s progress.

There is no question of the size of the death toll, but the added tragedy is that we are not being held back by a lack of knowledge of what needs to be done or what measures are necessary to save lives. When I was Health Secretary, dealing with HIV at the beginning of the crisis, there were no drugs to prolong life. I remember visiting a hospital in San Francisco, where there was a large ward full of young men simply dying from AIDS, with nurses being able to do absolutely nothing. Of course, the same was true here in London. Today is the exact 30th anniversary of the death of Terrence Higgins, the first person in the UK to be publicly identified as dying from AIDS, who has given his name to one of Europe’s most effective civil society organisations working in this field.

That was the 1980s, but today we have anti-retroviral drugs that are easy to take and able to ensure that a man or woman can live a long life. The means are there to tackle the disease, just as they are with TB and malaria. What is lacking in the world today are the resources that are necessary to take full advantage of the medical advances, and the political will to bring this about.

In its brief life, the Global Fund has done wonders. It has approved grants worth $22 billion for 150 countries. It has provided anti-retroviral therapy for an estimated 3 million people. It has detected and treated almost 8 million cases of TB between 2002 and today. It has enabled the treatment of 170 million cases of malaria. Of course, I acknowledge that there have been some problems in resources reaching the people for whom they were intended, although frankly these should not be exaggerated. When they have arisen, they have been tackled, and they continue to be tackled very effectively by the Global Fund and its excellent new general manager, Gabriel Jaramillo. The real characteristic is that money donated to the Global Fund has reached its target; that is not the problem.

The real problem lies with Governments. Some do not give anything at all and simply ignore the problem that is on their doorstep. I will give one example from the area I know best, HIV. One of the fastest growing epidemics in the world today is driven by injecting drugs. It is a problem in eastern Europe and many other countries. It is certainly fuelled by criminally imported drugs, but also by deadly home-made combinations. According to UNAIDS, only eight of every 100 people who inject drugs have regular access to sterile injecting equipment. Half the countries with epidemics centred on injecting drug users have no needle and syringe programmes at all. Yet all the evidence is that programmes such as clean needle exchanges work in reducing and almost eliminating infection. In Britain we started such a policy in 1986-87 and the result is that only 2% of new cases now come that way. I hope that the Minister will take the opportunity to underline the continuing support of the Government to this policy, given the comments that have been made outside this House.

That brings me on to a specific issue concerning the Global Fund. Ukraine, where I spent a week recently looking at the issues, has a massive problem of drug users injecting themselves. There are no government-run needle exchanges and no substitution programmes, but a great deal of discrimination and stigma. All prevention work is carried out by civil society organisations, notably the excellent International HIV/AIDS Alliance. It, in turn, is financed by the Global Fund. It has limits on its financial resources, so has decided to concentrate help on the poorest nations. We can see the reasoning behind that, but it means that help for poor, middle-income countries such as Ukraine will reduce and eventually be eliminated. The effect is to throw responsibility back on the Government of Ukraine, but frankly there is no sign whatever that they are ready to pick up the challenge and give that policy priority. We face the real prospect that the progress that has been made will be reversed.

That is the underlying fear in all three areas that we are debating tonight. Massive advances have been made by the Global Fund but the danger is that the potential to do more good and save more lives will be ignored as we walk on the other side of the road. In that respect, let me say this about the Government’s response. Like the previous Government, the coalition has been a firm supporter of the Global Fund. We are the third biggest contributor and no one can doubt the commitment of DfID and the Secretary of State, Andrew Mitchell—I would expect nothing less from the MP for Sutton Coldfield. However, the general position is not remotely as encouraging. We are going through the most difficult period in the fund’s history. At the end of last year it cancelled its 11th round of grant-making, which would have involved spending of $1.5 billion. It did that because of fears of inadequate funding. The result is that no new grants will be approved until 2014, although existing contracts will obviously be continued.

That position has caused dismay among civil society organisations. Again, it needs to be stressed just how much is done in all these areas by non-government organisations. They have filled a gap and without their work millions of lives would have been lost. In these circumstances what can this country do? The answer is that we should seek to take a lead to give an example that others might follow. The Secretary of State has made it clear that he is prepared to increase very substantially the Government’s contribution to the Global Fund for 2013 to 2015 by up to double—in other words, double the current amount of £384 million. That is a very significant promise that I wholeheartedly welcome. I urge that the occasion should now be found to make the pledge a firm commitment. By itself, the increased contribution will save lives but the hope must be that an announcement of that kind will unlock other funds from around the world. The Global Fund has already shown what it can achieve. The aim must now be to allow it to achieve its full potential.

My Lords, I thank the noble Lord, Lord Fowler, for securing this debate and for introducing it so well. Since he has provided a large number of relevant statistics, I am spared the trouble of having to rehearse them.

I think that the Global Fund has been doing excellent work, largely because of its overall strategy. It is innovative and engages in demand-driven financing. Its funding is based on performance, it engages local communities, and it receives contributions from the private sector as well as voluntary organisations and the Government. All that gives it a certain strength. As it is in the process of revising its strategy for the next few years, I want to propose three or four important ideas that it might like to consider.

First, the fund used to do a little more than it has done so far to negotiate with manufacturers to reduce drug prices, which eat into its funding and limit its capacity to help the 150-odd countries that are its members. Secondly, it needs to concentrate a little more than it has done on strengthening health systems. Currently it allocates about 36% of its investment to that. I feel that it needs to do a little more in this area and to reconsider its priorities. In terms of strengthening health systems it needs to pay more attention to raising public awareness of the three major pandemics with which it is concerned, concentrating as much on prevention as on cure, making sure that the nursing staff and others are well trained and that there is an international exchange of experts from developed countries to the poorer countries. It has almost completely ignored that area and my experience is that there are a lot of people who could be persuaded to go to developing countries and help to train staff.

Thirdly, regional results are uneven. Grants for TB were achieving between 82% and 100% of their targets, but for malaria the figure fell to between 59% and 82%. Why are the malaria-related grants performing less well than those for TB? One could say that in some parts of the world there has been a growth of parasites that are resistant to artemisinin—for example, in south-west Asia. That by itself would not explain it and one would like to see some monitoring of those uneven results. Finally, although the Global Fund has been involving civil society organisations, as the noble Lord, Lord Fowler, pointed out, perhaps there is scope for greater civil society intervention in terms of planning strategy, putting pressure on Governments and monitoring the harmful industrial activities that resulted in these three pandemics in the first instance. That kind of work can be done only by civil society organisations, because the Global Fund by itself is seen as an external body and cannot be seen to be interfering in the internal politics and activities of the receiving countries.

My Lords, I, too, congratulate the noble Lord, Lord Fowler, on initiating this debate and on his long-term commitment in this area. I declare non-financial interests as a trustee of the Sabin Vaccine Institute and vice-chairman of the Parliamentary All-Party Group on Malaria and Neglected Tropical Diseases.

The noble Lord, Lord Fowler, said that these diseases tackled by the Global Fund do not form neat, separate boxes. Indeed, they do not. Tonight, I want to concentrate on the connectivity and co-morbidity between neglected tropical diseases and the diseases covered by the Global Fund. Recent evidence, published in the New England Journal of Medicine in an article by Peter Hotez, the director of the Sabin Vaccine Institute, Jeffrey Sachs, and others has shown that there is a widespread geographical overlap between the prevalence and severity of HIV/AIDS, tuberculosis, malaria and NTDs. In the brief time tonight, I wish to highlight some of the opportunities that the cheap and effective treatments available for NTDs bring to that fight against HIV/AIDS, malaria and TB.

Investment in mass drug administration programmes were given a great boost at the London summit on NTDs, partly by, as the noble Lord, Lord Parekh, will be pleased to hear, the vastly increased donations of drugs from pharmaceutical companies and the very welcome additional funding from DfID. Sustained effort in this field would not only diminish the suffering and increase the educational and economic prospects of some of the world’s poorest people but, beyond that, additional resources and support from the global fund for integrated programmes could prove highly potent in the fight against the major killers that we are discussing tonight.

The scientific evidence for such an approach is, I believe, growing more potent by the day. For example, we know that those poor children infected by helminths—horrible worms which debilitate and stunt their lives and which can be treated for 50p per child per year—are more likely to acquire TB, and the acquisition of TB will make for more expensive and problematic treatments. Similarly, when hookworm overlaps with malaria, as it does throughout sub-Saharan Africa, the result is profound and debilitating anaemia, especially in young children. The association between schistosomiasis and HIV prevalence and susceptibility is becoming clearer all the time. Research has shown that treating girls and women regularly for schistosomiasis can help to protect them from HIV infection, and that women with female urogenital schistosomiasis, which causes genital lesions, are three or four times more likely to have HIV infection.

It is difficult to deal with some of these complicated interactions in the short time available but I should like to make it clear tonight that, by investing in research into possible vaccines for some of these diseases, bundling together treatments for NTDs and the Global Fund diseases, we do not lose focus; rather, we prevent ourselves putting on blindfolds that could stop us getting great value for money and alleviating much suffering.

My Lords, I apologise for intervening. I know that what noble Lords have to say is extremely important. However, they will appreciate that this is a time-limited debate and that there is very little spare time in the budget. Every noble Lord who goes over his three minutes is therefore eating into the time of noble Lords who speak after him.

My Lords, my noble friend Lord Fowler has done this House another profound service by bringing before us this evening the state of this important and ambitious Global Fund on the anniversary of the death of Terrence Higgins. I repeat some of the astonishing figures that he gave.

By the end of last year, the fund’s work had given more than 3 million people access to antiretroviral drug treatments to combat HIV, almost 8 million people had been treated for tuberculosis, and more than 230 million mosquito nets had been distributed to help to combat malaria. These are truly impressive figures, and they underline the importance of securing effective solutions to the fund’s recent administrative and internal problems. As the International Development Select Committee of the House of Commons noted, donor contributions fell as the fund attracted some negative reports about the misappropriation of some limited funds. A body which has come to be regarded, in the committee’s words, as,

“an effective international financing institution”,

and which has helped to save 7.7 million lives in over 150 countries was forced to cancel its latest round of funding applications, as we heard from my noble friend, anticipating significant shortfalls as a result, in part, of growing doubts among donors about the organisation’s management.

The pace of reform at the fund has been significant. My right honourable friend the Secretary of State for International Development said recently that,

“strong leadership is now in place and action is being taken to begin a process of robust reform”.

He made it clear that the Government are,

“prepared to agree a significant increase”,

in their contribution to the fund if the reforms succeed. If the British contribution is increased, a clear signal will surely be sent to other donors that Britain believes that the fund has established itself firmly as a strong and efficient organisation capable of providing the continuity of care which millions in the world’s poorest countries need so much. As the Bill and Melinda Gates Foundation stressed at the height of the allegations over fraud, while,

“dealing with these hard-to-reach places is challenging ... not trying to save these lives is unacceptable”.

Now that the fund is committed to,

“better financial and risk management”,

and to delivering the best possible returns on taxpayers’ money, Britain should prepare itself to lead a global recommitment to support an institution upon which so many depend.

This coalition Government pledged at the outset to strengthen our country’s contribution to tackling the problems of the developing world. It is to the Government’s credit that, even during a time of severe economic stringency at home, they have held fast to that pledge. Compassionate conservatism is in fruitful alliance with liberal democracy. In Milton’s words from Paradise Lost:

“good, the more

Communicated, more abundant grows”.

My Lords, the noble Lord, Lord Fowler, has, as usual, chosen a topic which urgently needs to be addressed. In three minutes I shall try to cut to the quick.

The Global Fund has been an overall success, as everyone has said. DfID has played a major part in this, recognising its transparency and accountability. In fact, the Global Fund itself recently detected and put right a minor accountability problem within its organisation. It was a small fraudulent diversion of funds, I believe, but that was seen to.

The Global Fund is a very focused organisation which funds vertical targeted programmes. However, subsidiary aims are to assist and strengthen national healthcare systems and support civil society. Many, like the noble Lord, Lord Parekh, feel that this should have greater emphasis, as only then will the programme initiated by the Global Fund be sustainable. These aims need to be integrated into the general healthcare provision of the countries concerned. HIV, TB and malaria are a heavy burden but they are only part of the whole infectious diseases picture, let alone the increasing role in the developing world of non-communicable diseases.

In April, the Secretary of State for International Development, Andrew Mitchell, said that, following up its already substantial grant to the transitional funding arrangements to take the place of the missing funds from the cancelled round 11, the UK could increase its contribution to the Global Fund very substantially, as the noble Lord said, in 2013, 2014 and 2015 by up to double the current £384 million pledge. Can the noble Baroness give us some indication of how much it will be and when the amount will be announced? What occasion will the Secretary of State choose to make that statement? The money is urgently needed, as already several programmes have had to be either contracted or postponed. I am worried in particular by the postponement of plans to address emerging threats such as resistance to artemisinin combination therapy, in Myanmar—Burma. That of course is the main, if not the only, weapon against the malaria parasite. I hope that, if a donation is made, other countries will be encouraged to contribute to the fund, as the noble Lord suggested will be the case.

My Lords, the worldwide emergence of multidrug-resistant tuberculosis is a major and most important threat to global tuberculosis control. The continued spread of extensively drug-resistant tuberculosis throughout Asia, eastern Europe and southern Africa is an ominous sign. There are two issues regarding multidrug-resistant TB. There is a lack of diagnostic tests, and new diagnostic technologies for detecting drug-resistant TB are now available but are expensive and constrained by round 11 of the grant of the Global Fund. There is lack of access to second-line TB drugs for drug-resistant TB and the Global Fund should invest more in provision of adequate TB drugs. In Africa, 70% of TB patients are co-infected with HIV. A large percentage of TB and HIV cases remain undiagnosed. More proactive routine screening needs to be introduced at all points of care. All receiving countries should account for their funds so there is no malpractice.

Decades of the use of anti-TB drug treatments have resulted in the growth of multidrug-resistant tuberculosis strains. The highest ever prevalence in the world of MDR TB was found in Minsk, Belarus. MDR TB was found in 35.3% of new cases and in 76.5% of those previously treated. In addition, extensively drug-resistant TB was found in 14% of MDR TB cases. This is much higher than the global average. We must not be complacent. I think of the unfortunate 15-year-old girl who died of TB in Birmingham having not been diagnosed by her GP or four different hospitals. She had had TB in 2009 and was struck down again in 2010. I hope lessons will be learnt from this tragic case. Eastern Europe has the highest level of infection, but London has the highest TB rate in any European city. I am pleased that WHO has praised the UK’s Find and Treat service, which uses a mobile X-ray van to screen homeless people and drug addicts in London for TB. I too think that it does a splendid job: its vital work must always be supported.

My Lords, I join with others in the heartfelt plaudits for my noble friend and welcome the vital work of the Global Fund. For more than 10 years it has been saving lives, saving families and sometimes saving entire communities that might have been ravaged by TB, malaria or HIV. However, the fine work that the fund undertakes will only ever be part of the solution unless we do much, much more across the world to tackle the stigma which is so often the engine which drives the transmission of these diseases.

This issue is at its starkest in the battle to bring HIV and AIDS under control in the developing world. In much of Africa, particularly in those countries ravaged by HIV, it is still regarded as a great taboo, with sufferers marginalised by society. Far too many of them continue to be driven underground, their conditions untreated, allowing the virus to flourish, often on the margins of society.

Decriminalisation of homosexuality in countries where it is still illegal—some 80 of them worldwide, which is a shocking figure—would be a major step forward in breaking this vicious cycle of stigma. I commend the work of the Human Dignity Trust in this field. Its efforts to ensure the application of international human rights laws in countries where they are ignored is groundbreaking and will do a huge amount to complement the vital work of the Global Fund. They must work hand in hand. I hope this House may be able to debate the subject of decriminalisation at some point.

TB too suffers from stigma which can make it difficult to tackle. It is all too often seen as a disease of the poor and disfranchised, of those living on the fringes of society. Although it can be treated quite easily, many do not get the therapy they need—including a long and expensive drug programme—because of the fear of marginalisation. One of the principles of the Global Fund is to,

“pursue an integrated and balanced approach to prevention and treatment”.

That should include the provision of carefully formulated and informed education programmes to ensure that those societies and communities most affected or at risk have a better understanding of these diseases, for it is only understanding that will lead to a reduction in stigma. Schools and a free media have an absolutely fundamental role to play in ensuring that, over time, those who suffer from HIV and TB in particular are treated not as pariahs but as ordinary people who, through no fault of their own, have contracted illnesses which, if left untreated, will kill them.

My Lords, the whole House—and, indeed, the wider world—owes the noble Lord, Lord Fowler, a debt of gratitude, not only for this debate but for his leadership on this issue. The Global Fund is a unique and special model for development in that it is a partnership between donor Governments, civil society and the private sector. That is a very special partnership and I declare an interest, serving as I do on the global health advisory board of a major pharmaceutical company led by Sir Richard Feachem, the founder of the fund.

I seek, this evening, to draw attention to one particular aspect of that partnership in the fight against malaria that urgently needs additional resource if the momentum is to be maintained. The reality is that the funds committed to malaria are expected to peak this year at just under £2 billion. They will remain substantially lower than the resources required to achieve the global targets under the millennium development goals, which are estimated at just under £5 billion for 2010 to 2015. We will not be able to build on the real gains that have been made in combating malaria globally, and in sub-Saharan Africa in particular, without added momentum being given by additional, concrete pledges to the Global Fund. The fund has been described by our own multilateral aid review as having given “very good value” to the taxpayer and,

“very high standards for financial management and audit”.

That is where the Global Fund is now, after the reforms, and we should back it. I commend the Secretary of State for International Development for the excellent work that he and the department have done in supporting development generally and healthcare in particular. However, we now have to concretise that support in terms of pledges if we are to see the gains already made consolidated.

I will make five quick points in relation to malaria. We know that interventions on it are cost-effective, saving more lives per dollar spent than interventions for most other diseases. We also know that it requires long-term financing commitment for country-implementation activities and, importantly, for research and development. From my own experience of a childhood lived under bed nets—and with ready access to drugs, because of the fortune of my parents’ financial situation—in a country which was first colonial, then newly independent, and where there was an effective public health system able to promote spraying as part of a unified response to the challenge of malaria, I know that it works. It is something where you can see real gains made and we have seen them in Swaziland, Namibia and South Africa.

In Swaziland there is a blessing: “Pula! Pula! Pula!”—let it rain, three times. Let the demonstrated largesse and compassion of the British taxpayer rain on the Global Fund.

I too am grateful to the noble Lord, Lord Fowler, and to the all-party group which has very helpfully briefed us. My experience comes from the voluntary sector in east Africa with Christian Aid and other local church partners working on HIV/AIDS. On these visits, I am always impressed by the resilience of the individuals who often suffer—as the noble Lord, Lord Black, says—in isolation and the critical role of the family and the community around them, on which the hope and investment of outsiders must always be based. I also admire their ability to put up with the ignorance and incompetence of outsiders coming in—even health professionals—who may be the victims of larger issues such as corruption in their department. On a parliamentary visit to Kenya a few years ago it was clear that the extent of graft in the procurement of pharmaceuticals was such that the health ministry had been simply split in two, and no one could even rely on the safe supply of drugs on the WHO list; they were still stuck in warehouses.

Today, we are primarily concerned with the shortfall in funding but, as we go along, we have to recognise the frailty of human beings and systems. Families are so often left to cope alone. We need to train more local health auxiliaries. As the noble Lord, Lord Parekh, has said, we need to give much more support to civil society. It is always easy for aid agencies to throw money at poverty through ineffective bureaucracy rather than working closely with the people most concerned. This is how the World Bank and other large organisations came a cropper in South Sudan two years ago. We know that the Global Fund itself has suffered from serious fraud, although I am glad that that has been addressed. I join others, including the International Development Committee, in again asking Her Majesty’s Government whether and why DfID’s funding is being held up, and if they are delivering on their promises.

I find that I can trust the voluntary agencies to work closely with the local community. Agencies like Save the Children are expanding their HIV and AIDS programmes all the time. Save the Children is in 16 countries. In 2010 it reached more than 194,000 children in Ethiopia and Mozambique. My main question for the Minister is whether DfID is adequately committed to working closely with the voluntary sector. Are the IPAPs—the international partnership agreement programmes, whereby DfID ensures continuity and funding over a given period—still in place?

The Global Fund has a remarkable record and DfID has been one of its leading advocates. Can the Minister say what proportion of Global Fund funding has been through the non-governmental agencies? I know that that is a difficult figure to arrive at but, if it could be as high as 20%, that would be an amazing achievement for the voluntary sector.

My Lords, the Global Fund to Fight AIDS, Tuberculosis and Malaria is a truly worthy cause which has transformed the lives of many since its creation in 2002. Programmes supported by the global fund have provided AIDS treatment for 3.3 million, anti-tuberculosis treatment for 8.6 million and 230 million mosquito nets for the prevention of malaria. It has also approved over £14 billion for programmes in 150 countries. The global fund works in collaboration with other bilateral and multilateral organisations to supplement existing efforts in tackling the three diseases. The factors I find most appealing about the global fund model are the concept of country ownership and performance-based funding. It is making a direct contribution to the fulfilment of three millennium development goals, which cover child health, maternal health and combating HIV/AIDS.

Noble Lords will be aware that the global fund was plagued by scandals involving corruption and the misappropriation of funds which caused some countries to temporarily suspend payments. It was necessary to implement structural and management reforms. The global fund has recognised the need for there to be transparency and the need to root out corruption and malpractice.

The global fund has now made efforts to achieve greater efficiency by streamlining its operations through creating small departments with particular remits. Disease management committees meet once a month, including partner countries, to assess progress. The global fund also monitors the results of its direct investments in the 150 countries. I sincerely hope that this will provide comfort to some taxpayers who are doubtful about the merits of international aid.

The UK is the global fund’s third largest donor. Last March, DfID’s multilateral aid review rated the fund as one of the highest-performing multilateral organisations, which gave “very good value” to the taxpayer and had,

“very high standards for financial management and audit”.

It is for this very reason that I feel Britain should increase its contribution to the global fund over and above the current £384 million pledge over three years. If we increase our contribution, it will also help to attract greater financial support from other countries. I therefore ask the Minister to tell your Lordships’ House whether there are any plans to increase our contribution to the global fund.

My Lords, I, too, thank the noble Lord, Lord Fowler, for this characteristically excellent debate. My contribution is essentially a statistical appendix to some of the earlier statements, particularly those of the noble Baroness, Lady Hayman. I also declare a professional interest: my contribution is an attempt at a three-minute précis of my one-hour opening keynote to the International Congress of Parasitology in Glasgow six years ago.

We all know that the better understanding of biomedical things has lengthened lives in both the developed and developing worlds, but what actually is the pattern? A recent study shows that in rich countries about 7% of mortality is associated with infectious diseases. Only one of those seven percentage points is covered by TB, HIV and malaria. In the developing world, by remarkable contrast, 57% of mortality and morbidity arises from infectious diseases, and 16 of those 57 percentage points—two in seven—are the big three that are currently centre stage.

The neglected tropical diseases that my noble friend Lady Hayman referred to have many manifestations. First, a study of research in the four major medical journals shows that something like 12% of papers deal with diseases of the tropics; the British journals are better than the American ones, I would say. Not surprisingly, perhaps, of the 1,233 new drugs licensed world wide from 1975 to 2000, only 13—less than 1%—were for tropical diseases. Of those, five were accidental by-products of veterinary studies; only four were actually targeted deliberately.

Why is that? Only 1% of the global expenditure on drugs and vaccines comes from Africa. Only another 1% of it comes from the Middle East. Even south-east Asia and China account for only 7%. We are focused on diseases of the rich. We need to change that perspective.

In conclusion, not everything is biomedicine. The millennium development goals focus on maternal health and infant health. It is increasingly clear that smaller families work towards delivering both those goals. We are seeing declining birth rates as more women are educated, and we see more demand for access to non-coercive fertility control. Against that background, it is obscene that US legislation forbids any advice on contraception under work sponsored by government funds. It is even more obscene that the Vatican has an arm explicitly dedicated to communicating untruths about the inefficiency of condoms against HIV. In short, we are doing well but we could do a hell of a lot better.

My Lords, it is a great pleasure for me to wind up for the Opposition on this very important Question. In the unavoidable absence of my noble friend Lady Kinnock, I, too, congratulate the noble Lord, Lord Fowler, on his commendable efforts tonight and on his long-standing and excellent record in this area.

We heard a very important contribution from the noble Lord, Lord May, which I hope that the Minister will be able to respond to. I also commend the noble Baroness, Lady Masham, for the remarks that she made. She reminded us that, although tonight we debate the global challenge of HIV, TB and malaria, we have a challenge in this country. She mentioned my own city, Birmingham, and a very tragic TB case. The trust that I chair runs one of the clinics involved. I want to tell her that I very much take her point to heart. Just as tonight we support the Global Fund in its worldwide efforts, it is very important in Birmingham that all of us get our act together to make sure that we deal with issues in relation to HIV and TB in an effective way.

The previous Government gave tremendous support to the fund and I echo my noble friend’s remarks on that matter. But so, too, we commend Mr Mitchell for the work that he has done. I hope that in the spirit of all sides of the House coming together, the Minister will be able to give us good news when she comes to wind up the debate.

As the noble Lord, Lord Fowler, said, much has been done by the fund but much more needs to happen. There is real concern about the decision that the fund had to take to cancel Round 11 of the funding grants in November 2011. There were various reasons for that, which we have heard about, such as the global economic downturn and the issue about fraud, which was exposed in part, as Aidspan has argued, because the fund has a commendable commitment to anti-corruption and transparency. As the Minister will know, the fund has moved swiftly to implement a programme of reform. Her noble friend has already told the International Development Select Committee that his department would announce new funds as soon as they were confident that the money would be well spent.

Clearly the Global Fund has to do more, but it has moved very quickly in the past few months. I simply ask the Minister whether she will prevail on her right honourable friend Mr Mitchell to be able to make an announcement very soon. That would be a fitting conclusion to this excellent debate.

My Lords, I thank my noble friend for securing this debate on the Global Fund to Fight AIDS, TB and Malaria. My noble friend’s record in this area is second to none, as the noble Lord, Lord Hunt, indicated, and he introduced this debate very powerfully. I, too, pay tribute to the Terrence Higgins Trust on this, the 30th anniversary of Terrence Higgins’ death.

As many noble Lords have said, the Global Fund has accomplished much, but there is still much to do. It was founded to increase funding on a massive scale to change the course of AIDS, TB and malaria, and in its first decade results have been dramatic. The fund has become the largest multilateral funder of programmes addressing the health-related MDGs. It has approved more than $23 billion for more than 150 countries.

The UK Government—this and the previous one—have been a major supporter of the fund. In 2007, they pledged up to £1 billion between 2008 and 2015. They have consistently brought forward and increased their commitments to live up to this pledge. Recently my right honourable friend the Secretary of State for International Development confirmed that the Government would commit £128 million this year, next year and the year after. That means that we will meet in full, and a year early, the 2007 pledge to make the UK the fourth largest donor to the fund.

More than 3.3 million people in the world's poorest countries are receiving life-saving and life-prolonging antiretroviral treatment through the fund. Ten years ago, there were almost none. The fund has helped to detect and treat more than 8.6 million new cases of infectious TB and has delivered 142 million malaria drug treatments and more than 230 million insecticide-treated bed nets, saving an estimated 6.5 million lives.

Prices for first-line HIV treatment have fallen dramatically, from approximately $10,000 per patient per year in 2000 to $125 in 2009. The fund has played a major role in shaping the market. New research suggests that treatment can also play an important role in prevention, and we have the opportunity to eliminate the transmission of HIV from mothers to children and to eliminate malaria in many endemic countries.

More than 33 million people live with HIV. There were 2.7 million new infections in 2012. Globally, the number of new infections is falling, but that hides regional disparities and, for every person put on treatment, two others become newly infected. According to the WHO, fewer than half of the 19 million people who need ARV treatment receive it.

Over the past few years, there has been significant progress in reducing deaths and illness due to TB, and 187 countries implement the WHO treatment guidelines. That has resulted in a decline of one third in deaths associated with TB since 1990. But the global burden remains significant and TB caused the deaths of 1.7 million people in 2009. There remain challenges: getting people to complete the long course of treatment; responding to drug resistance, as emphasised by the noble Baroness, Lady Masham; and HIV/TB co-infections. On drug-resistant TB, through DfID’s support, 13 low-income countries with a high burden of TB now have state-of-the-art testing laboratories to detect multidrug-resistant TB. We also know that the issue is increasingly important within the United Kingdom.

Malaria is preventable and treatable. Insecticide-treated bed nets, indoor residual spraying and new artemisinin combination therapies (ACT), together with better diagnostic technologies and new vaccines under trial potentially give us powerful tools to combat this disease. Improvements in child and maternal health have been achieved. But there are many hard-to-reach people in fragile and conflict-affected regions, and drug and insecticide resistance pose real challenges for the future. That is an area where DfID is investing. I assure the House that that is a significant investment. Those were issues raised by the noble Lords, Lord Rea and Lord Boateng.

The fund remains critical to the fight against the three diseases. The UK's Multilateral Aid Review, as noble Lords have said, assessed the fund as providing very good value for money, but identified the need for serious reforms. My noble friend Lord Fowler and others referred to some of the issues that have arisen in recent times. In September 2011, a high-level independent review panel recognised the achievements of the fund but identified significant areas for improvement and reform. It argued that the fund needed to transform from an emergency to a more sustainable response to the three diseases. There is cross-over between these three diseases and others such as the so-called neglected tropical diseases to which the noble Baroness, Lady Hayman, referred. We have seen a knock-on benefit from investment in the three diseases in bringing down other diseases as well.

The Government have strongly advocated reform of the fund: a DfID official, in his personal capacity, chairs the board, and the UK continues to take a close interest in the fund and to lobby others to achieve the necessary changes. In November last year, a new strategy for the fund was approved. This challenges the fund to invest more strategically, in the way that the noble Lord, Lord Parekh, referred, and to provide better support to improve implementation at country level, to promote and protect human rights, and to raise money.

At the same time, there was considerable uncertainty over the financial position of the fund, which noble Lords mentioned. The board decided that it could not move forward with round 11, but in response to concerns that people then flagged up—that people would suffer as a result—it agreed transitional funding. I am pleased to tell the noble Lord, Lord Fowler, that the fund board has decided to accelerate funding decisions to spring 2013 and it still plans to spend between $9 billion and $10 billion during 2012-2014. The board also decided to bring in new, interim leadership to transform the organisation, and we are pleased that significant and rapid progress has been made. I note with interest what the noble Lord, Lord Parekh, said about strategically sharing expertise. He is right to look at the fund’s activities in that strategic sense.

The fund also needs to think about where it works. Much remains to be done in low-income countries but there are particular challenges elsewhere. Nowhere is the spread of HIV/AIDS more rapid and aggressive than in eastern Europe and central Asia. As my noble friend Lord Fowler said, Ukraine has done almost nothing to address the challenges of HIV spreading among injecting drug users. Civil society organisations, often funded by the global fund, play a crucial role, as he emphasised.

In responding to a number of other points, I assure my noble friend Lord Fowler that the UK’s drug strategy 2010 acknowledges the value of needle and syringe programmes. I am very happy to emphasise that. The noble Lord, Lord Black, and other noble Lords are quite right about the importance of addressing stigma, an issue on which the noble Lord, Lord Fowler, has been at the forefront throughout his own work. The noble Lord, Lord Black, may wish to note the commitment to human rights in the fund’s strategy.

In response to the noble Earl, Lord Sandwich, the noble Lord, Lord Parekh, and other noble Lords, I say that 33% of the fund’s disbursements are to civil society. The noble Lords, Lord Rea, Lord Fowler, Lord Lexden, and Lord Sheikh, and other noble Lords, asked about the uplift in commitment. The Government are looking for clear evidence in key reforms so that they can make sound judgments in early 2013 on future funding increases in 2013 and 2014. I have given the commitments that are already in place, so I am talking here about that increase.

I thank noble Lords for their tributes to DfID for its support in this area but also for making sure that money will be well spent, as the noble Lord, Lord Hunt, and other noble Lords pointed out. The noble Lord, Lord May, focused on the absence of research into new drugs for neglected tropical diseases. It is certainly very important in the control of neglected topical diseases, and others, that research is carried out. I think he will be aware of the initiative that DfID announced, putting £21.4 million into that up to 2013.

In conclusion—I know noble Lords are desperate to get back to the Crime and Courts Bill—I emphasise that the Government will continue to support and monitor progress in the Global Fund. We have already confirmed that the UK will live up to its financial commitments. I confirm again that a significant uplift is also possible, subject to continued progress. We are optimistic in terms of the reforms that have been taken through. We recognise how the Global Fund, in 10 years, has transformed the prospects of millions around the world who were suffering from these three terrible diseases. However, we and the fund know how much more there is to achieve, which is why this debate is so timely.