China steps up AIDS response

It is estimated that there are 840,000 people currently living with HIV in China, according to official government statistics. This number, which may be an underestimate due to previously inadequate efforts to provide HIV testing, is not exceptionally high considering the country's 1.3 billion inhabitants account for one fifth of the world's population. But the epidemic's spread has worsened in recent years and the United Nations now warns that China is one of five countries predicted to experience the largest number of new infections over the next five years. The number of HIV-infected Chinese could swell to more than 10 million by 2010.

At that rate Asia could overtake Africa as the continent with the highest number of HIV infections in only 25 years time. Experts familiar with China's AIDS epidemic warn that a narrow window of opportunity now exists for the Chinese government to ensure that a much larger epidemic is averted. "There needs to be resources behind the rhetoric," says William Hsiao, professor of economics at the Harvard School of Public Health. And by most accounts the political commitment necessary to avoid this explosion of HIV infections is finally mobilizing.

"The policy is clearly heading in the right direction, but it will take a long time to fix," says David Ho, Chief Executive Officer of Aaron Diamond AIDS Research Center (ADARC) in New York.

This policy shift is partially the result of new leadership. Since President Hu Jintao succeeded Jiang Zemin, the Chinese government has shown greater concern for the health disparities between the rich and poor. China has experienced great economic growth in recent years. This prosperity has caused an even greater gap in the social and economic status of the country's citizens and furthered the spread of HIV, mainly among the rural poor. The new government is cooperating with health authorities to develop HIV/AIDS prevention and treatment programs in the hardest hit areas.

The lessons Asia learned from the outbreak of Severe Acute Respiratory Syndrome (SARS) in 2003 are also fueling China's response to AIDS. Ho refers to SARS as the wake-up call. "It had a profound impact on how China viewed its healthcare infrastructure," he adds.

With the Chinese leadership engaged, treatment and prevention resources are finally reaching China's two most affected communities: blood donors and injection drug users (IDUs). The national government is also investing heavily in AIDS vaccine research and the country's first vaccine trial recently began enrolling volunteers in Guangxi province.

"It's very clear that there is a level of engagement that is new and unexpected," says Sarah Schlesinger, research associate professor at ADARC. "Nobody should underestimate the ability of the Chinese authorities to make a change when they put their mind to it."

Despite the response at the national level, the local governments must also get involved. Provincial governments play an essential role in providing education and outreach programs, and the response at this level varies greatly. In some provinces active local governments are providing outreach to vulnerable populations, including needle-exchange, drug-treatment, and extensive HIV-testing programs. In other regions there is little coordination between the local governments and the healthcare providers.

Joan Kaufman, of the Schneider Institute for Health Policy at Brandeis University, notes that most local officials still regard the AIDS response as the work of the health sector, which is under-funded and has limited power at the provincial level. "Despite the strengthening of the government's response there remains a real lack of understanding at the local level. For example, there is little attention paid to maintaining confidentiality during HIV testing." Kaufman emphasizes that China must act quickly at all levels of government to check the epidemic's spread.

A tale of two epidemics

China is a country with two distinct AIDS epidemics. The first began in Henan province in the early to mid 1990's due to flawed blood collection practices. This province in eastern China is one of the most densely populated in the country. It is estimated that hundreds of thousands, perhaps even millions, of rural Chinese were infected while donating blood. The infections in this population soared for two reasons. Blood collectors often re-used blood collection equipment without sterilization and also re-infused red blood cells from donated blood back into donors to prevent anemia, allowing donors to sell blood more often. These practices were a devastatingly efficient way to spread HIV infection.

A report issued by Human Rights Watch in 2003 urged an investigation into these blood collection practices. Even now not much is known about the disease burden in this community. "China is still restricting scientific and medical access to the community of blood donors," says Chris Beyrer, director of the Johns Hopkins Center for Public Health and Human Rights.

According to Beyrer, the epidemic among blood donors in Henan province is not expected to reach beyond rural areas. But China's other HIV epidemic is spreading rapidly. More than half of China's HIV infections are in IDUs. This epidemic started in the southern provinces of Yunnan and Guangxi, along the border with Myanmar, Laos, and Viet Nam. Myanmar is one of the world's main producers of heroin and it is easily transported across the border into China. The number of IDUs in the country is still on the rise and drug use is now extending to other provinces.

The epidemic is also affecting other communities, though to a lesser extent. Communities of men who have sex with men and commercial sex workers are not as well studied as blood donors or IDUs. According to Shen Jie, director of China's National Center for AIDS Prevention and Control, the rate of HIV infection among commercial sex workers is expected to escalate in the coming years as heterosexual transmission becomes a major route for the spread of HIV in the country. Sex workers are considered the "bridge" population because they could further the spread of HIV within the general population. The HIV epidemic in China is now beginning to move outside the concentrated pockets of infections among blood donors and IDUs.

Outreach for drug users

"China, until recently, was a very hard place to work with IDUs," says Beyrer. "Now there is a pragmatic and serious response." This response includes providing drug users with more education about HIV prevention and the establishment of harm reduction programs that treat drug addiction. These include needle exchange programs where IDUs can exchange used needles for clean ones to reduce the risk of transmitting HIV.

Unfortunately the harm reduction efforts are tremendously variable within the provincial governments, according to Beyrer. In some regions the police are not cooperating with the healthcare authorities and are stopping needle exchange programs.

China is also starting to allow drug treatment programs for the first time. Heroin users are treated with the drug methadone as a substitute so they can slowly overcome the withdrawal symptoms associated with addiction. Previous drug rehabilitation programs in China required IDUs to enter camps where they were forced to stop taking drugs without any treatment and were required to do hard labor as a means of detoxification.

There are also some advocacy groups and non-governmental organizations springing up in China to support efforts to treat and prevent HIV infection among drug users. But their role is limited. "The non-governmental organizations in China play a much more circumscribed role than anywhere else in the world," says Kaufman, who is also the team leader on vaccine preparedness in China for IAVI.

Moving ahead with vaccine trials

The national government is also investing in vaccine research and development. Many groups are interested in running vaccine trials in China. The country recently started its first preventive AIDS vaccine trial. The European Union, the HIV Vaccine Trials Network (HVTN), ADARC, and CIPRA (a US National Institutes of Health program in cooperation with China's Centers for Disease Control) are all looking to start testing vaccine candidates in China over the next few years.

The current trial is taking place in Guangxi province and is a Phase I safety study of a DNA vaccine candidate with a modified vaccinia Ankara (MVA) vector developed at Johns Hopkins University in the US and produced in China. Vaccine trials in China will seek to enroll IDUs because there is such a high incidence in this population. A study by the HIV Prevention Trials Network found an incidence of 8%. This study had good participation and retention of volunteers, even in the absence of drug treatment programs.

ADARC is also preparing to conduct vaccine trials in IDU populations. The vaccine candidate that ADARC is currently studying is based on a strain of HIV isolated from an infected individual from Kunming in Yunnan province. This makes it the ideal place to test the candidate in clinical trials. The candidate is a DNA vaccine followed by an MVA booster vaccination. A workshop on vaccine preparedness was conducted in Kunming earlier this year. "There is a general enthusiasm to organize the ethics committees, community advisory boards, and vaccine education materials," according to Schlesinger.

Preparations for vaccine trials are an important part of outreach to communities at high-risk for HIV infection because they facilitate the introduction of education and prevention programs. "Vaccine preparedness activities must be paired with other prevention strategies," says Schlesinger.