Citation: Wen-yuan YIN, Zun-you WU. Challenges and Opportunities: the Expanded Government-led HIV/AIDS Programs in China .VIROLOGICA SINICA, 2007, 22(6) : 493-500.

Challenges and Opportunities: the Expanded Government-led HIV/AIDS Programs in China

  • Corresponding author: Zun-you WU,;;
  • Received Date: 24 July 2007
    Accepted Date: 10 October 2007
    Available online: 01 December 2007

    Fund Project: China International Clinical, Operational, and Health Services Research and Training Award with NIH U2R TW006918

  • HIV/AIDS has posed an increasingly serious issue in China. In recent years, Chinese government has taken further intensified efforts to combat HIV/AIDS with high-level political commitment, supportive policy development, increased financial allocation, large-scale of government- led initiatives, expanded international cooperation and great involvement of non-governmental organizations. Meanwhile gaps and challenges coexist impacting the implementation and the results of national HIV/AIDS programs. Thus, further government efforts are needed to improve and tailor the actions to meet the requirement of HIV/AIDS control in China.

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    Challenges and Opportunities: the Expanded Government-led HIV/AIDS Programs in China

    Fund Project:  China International Clinical, Operational, and Health Services Research and Training Award with NIH U2R TW006918

    Abstract: HIV/AIDS has posed an increasingly serious issue in China. In recent years, Chinese government has taken further intensified efforts to combat HIV/AIDS with high-level political commitment, supportive policy development, increased financial allocation, large-scale of government- led initiatives, expanded international cooperation and great involvement of non-governmental organizations. Meanwhile gaps and challenges coexist impacting the implementation and the results of national HIV/AIDS programs. Thus, further government efforts are needed to improve and tailor the actions to meet the requirement of HIV/AIDS control in China.

    • Since China's first indigenous outbreak of HIV infection was identified among injecting drug users (IDUs) in Yunnan Province in 1989 (6), HIV has spread exponentially and geographically throughout the country (10). By the end of 2007, it was estimated that approximately 700 000 people were living with HIV/AIDS, of which 50 000 were the newly infected cases in the year. HIV/AIDS is being primarily transmitted through sexual contact and injecting drug use (9).

      Chinese government has been increasingly priori-tizing the importance of HIV/AIDS prevention and control, particularly within the recent years, linking it with national security, economy growth and social development. With high-level political commitments, a series of policies and regulations have been issued and implemented, a great many of pragmatic strategies and international best practices have been adapted to the government-led HIV/AIDS responses, and a growing number of financial allocation has been made accordingly in this regard. Though there still remain numerous and complicated challenges and gaps, many significant achievements have been made thus far in the context of HIV/AIDS prevention and control in China (9). This article is intended not only to review the progress of government-led actions in fighting against HIV/AIDS over the past years but also to identify those potential challenges and opportunities lie ahead with the purpose to better understand the situation of curbing HIV/AIDS epide-mic in a more effective way.

    • China has undergone a complicated evolution of policy and regulation development from conservative to innovative roadmaps. In the earlier stage of HIV/AIDS epidemic, regulations were made focusing on the measures of isolation and quarantine along with other contagious diseases, which had less or fairly limited impact on HIV/AIDS prevention and control. Based on the worldwide experiences of combating HIV/AIDS and evidence-based national pilot pro-grams, Chinese government recently has taken signi-ficant strides by making high-level political commi-tments and setting forth a series of pragmatic policies and regulations to expand and deepen the efforts to reduce further HIV/AIDS spread.

      In the year of 1998, the Chinese State Council issued the China's Medium-and Long-Term Plan for the Prevention and Control of AIDS (1998-2010) (7), which although bold has since served as the blueprint for the HIV/AIDS prevention and control strategy in China until now.

      In 2001, China's Action Plan for Containment and Control of HIV/AIDS (2001-2005) was issued by the State Council (11). This policy was significant because for the first time it highlighted effective strategies for the control of HIV, including condom promotion, community based drug maintenance treatment and social marketing of needles for injecting drug users, but in the absence of strong national leadership and enforcement, programs were difficult to implement in local.

      In 2003, a new administration led by President Hu Jintao, Premier Wen Jiabao, and Vice Premier and Health Minister Wu Yi substantially accelerated the commitment to and implementation of evidence-based HIV/AIDS policies and strategies. Under this admini-stration, a number of initiatives have been introduced: the China Comprehensive AIDS Response (China CARES), which assists 127 high prevalence counties in providing care and support to people living with HIV/AIDS and prevention servies to high risk groups; In late 2003, China introduced the "Four Frees and One Care" policy to provide free ART, free education for children orphaned by AIDS, free voluntary HIV counseling and testing (VCT), free services to prevent mother-to-child transmission (PMTCT) of HIV for infectec pregnant women, and care and financial assistance to the households of PLHA needing financial assistance (10). With this policy the govern-ment weighed heavily the need of prevention, treatment and care, not only as a means of improving the quality of lives of individuals and functioning of communities affected by HIV/AIDS but also as a means of preventing further spread of the disease to general population; In addition, the State Council AIDS Working Committee was formulated respon-sible for the development of a comprehensive policy framework and coordinate the multi-sectoral coo-peration at all levels.

      Furthermore, the Law on the Prevention and Treat-ment of Infectious Disease revised in 2004 included not only language to protect the identity and disease status of those with an infectious disease, but also disciplinary action recommended for those individuals or institutions that violate these laws. Although there had been language in previous regulations to protect the rights of people living with HIV/AIDS, these new laws give such individuals and their families a stronger basis from which to defend their rights (8).

      In September 2005, the President Hu Jingtao, attended the General Assembly of the United Nations and reaffirmed China's commitment to the Millen-nium Development Goals (MDGs). On 14th March 2006, the 4th Session of the tenth National People's Congress approved the Eleventh Five Year National Strategic Plan on Economic and Social Development. Section 2 of Chapter 40 of it clearly states that HIV/AIDS is among the priority infectious diseases to be controlled.

      The most notable breakthrough arrived in March 2006 when the State Council of the People's Republic of China officially promulgated the first legislation directly aimed at controlling HIV/AIDS, namely the Regulations on AIDS Prevention and Treatment (12). This regulatio, together with the second Five-Year Action Plan to Control HIV/AIDS (2006-2010) (13), which provide the overall framework for the response to HIV/AIDS in China, elevating the importance of this issue and laid substantial foundation for HIV/ AIDS prevention and control. The needle exchange program (NEP) has been included in the second 5-year action plan (13). Methadone maintenance treatment was also reinforced by this legislation to establish broad cooperation among multi-sectors of health, public security and drug administration at different levels (12). Furthermore, it is highlighted that leaders are held accountable and their work in relation to HIV/AIDS will be assessed as part of their job performance. Annual monitoring and evaluation will be conducted and those who are responsible for misconduct will be brought to account. The AIDS Regulations have made it illegal to discriminate against people living with HIV/AIDS and their families in terms of their rights to schooling, employment, receiving health services, and partici-pation in community activities (12).

      High-level political commitments have supported efforts to launch government-led large-scale HIV/ AIDS prevention and care programs, help to fight HIV/AIDS related stigma and discrimination in the whole. There has been gradually formulating an environment of government-led, multisectoral coo-peration and society participation in China.

    • In 1998, the previous State Council Coordinating Committee for AIDS/STD was formulated to coo-rdinate and mobilize all government sectors to put froth a national response against to the HIV/AIDS epidemic in China. Since mid-2003 the national res-ponse has become significantly more aggressive and open, resulting in important policy and program initiatives, one of them was the establishment of State Council AIDS Working Committee (SCAWC) in early 2004, chaired by Vice Premier and Minister Health Wu Yi as director. The Working Committee comprises the Vice-Ministers of 23 key ministries and mass organizations, together with the Vice-Governors of the seven most affected provinces. It created a multi-sectoral working group on HIV/AIDS and this group has taken the lead in directing and coordinating national efforts to curb the epidemic. Subsequently, AIDS Working Committees (or AIDS Prevention and Control Leading Groups) have been established in all provinces, autonomous regions and municipalities to coordinate local HIV/AIDS responses across all sectors. The State Council has outlined 9 key mea-sures for HIV/AIDS prevention, treatment and care work. Each level of government has established prevention, treatment and care coordinating mec-hanisms, and mobilized strong societal and multise-ctoral supports for the HIV/AIDS response (9).

    • The first large-scale national program to expand access to HIV/AIDS treatment, care and support was the China Comprehensive AIDS Response (China CARES) Program, launched in 2003 that covers 127 sites in priority provinces most affected by HIV/ AIDS.

      Under the supportive political environment and after several successful pilots, China has been rapidly scaling up its prevention programs to high-risk popu-lations since 2004, including methadone maintenance treatment, needle exchange programs, condom promo-tion and peer education, etc.

      The NEP programme was substantially scaled up in 2006, from 93 sites to 729 by the year's end (16). Scale-up has been focused in rural areas, and in many places additional services are offered to IDUs, including condom distribution, voluntary counseling and testing, anti-retroviral therapy, and educational information about drug use and HIV. In acknow-ledgment of the first 8 pilot MMT clinics successful practices in China and worldwide MMT practices (2, 3, 5, 14), in 2004 the Chinese government innovate-vely called for the use of such practices to prevent HIV transmission even though there exist some contradictions within certain law enforcements historically in some extent. The government shifted their attitudes and position weighing much heavier of the efficacy of MMT in reducing HIV/AIDS spread among the injecting drug users than the contradictions. Immediately, under the jointly governance of the Ministries of Health and Public Security and the State Food and Drug Administration, China expanded the number of clinics to 320 at the end of 2006 (16) and planed to reach to 500 by the end of 2007. The intro-duction and expansion of methadone clinics are supposed to make a substantial contribution to China's effort to control the HIV/AIDS prevalence among the intravenous drug-using population.

      In order to make evidence-based sound policies, Chinese government realized the urgency of streng-thening the previous weak national surveillance system throughout the whole country. The surveil-lance system has gradually been expanded to 845 national sites and now also includes pregnant women and men who have sex with men, and a web-based disease real-time reporting system has been establi-shed (16). As client-initiated testing was failing to identify most infected individuals, campaigns to screen high-risk groups, including drug users, com-mercial sex workers, prisoners, and former plasma donors, were commissioned to link patients to free treatment services. The campaigns have resulted in a substantial increase in the number of individuals who know their HIV status, with an additional 60 000 people living with HIV/AIDS identified (17). Around the same time, the number of screening laboratories has been expanded to 6061, and there are now 145 laboratories able to do confirmatory HIV tests. HIV voluntary counseling and testing has been made available, and expanded from 365 counties in 15 provinces in 2002 to over 2300 counties, with 4293 sites, in all provinces in 2007 (9).

      With the provision of free antiretroviral therapy for rural residents and the urban poor became policy in 2003 under the Four Free and One Care Policy, the National HIV/AIDS Clinical Taskforce took the lead in establishing the program, and set up a database to monitor it. As of the end of 2007, more than 40 000 patients have been treated in 1190 countries in all 31 provinces (7). Prevention of mother-to-child trans-mission has been further reinforced by the AIDS regulation. Scale-up is being prioritized to the most heavily affected areas. By the end of 2005, more than 500 000 pregnant women in high-risk groups or in high-prevalence areas had been tested for HIV in 271counties in 28 provinces (16). Services are now planed to scale up to cover at least 85% of infected pregnant women by 2007 and to reach at least 90% by 2010 (15).

      The provision of condoms at entertainment estab-lishments is now an official requirement under the AIDS regulations, and condom promotion and edu-cation campaigns that target youth and migrant workers are gradually being scaled up.

      Furthermore, management of blood donation and collection has been further consolidated by the government in order to eradicate illegal blood collection activities. Social campaign for reducing stigma and discrimination against the HIV/AIDS infected from national down to community level. Without the supportive political environment, these efforts and achievements would have been hardly to make and achieve.

    • The central government has established a clear framework for allocating resources under the HIV/ AIDS program, with the population, social and economic status, as well as magnitude and trend of HIV/AIDS epidemic carefully weighed in allocating HIV/AIDS budget resources to provinces. Over the period 1999-2003, the three priority components of government HIV/AIDS spending were blood safety (27.4%), health education and intervention (25.9%) and surveillance and testing (24.8%).

      During the last few years, the central and provincial governments of China have significantly increased their investments in a comprehensive response to HIV/AIDS (9). In 2003, the central government augmented the initial US$14.5 million allocated for HIV/AIDS programs by adding US$33.7 million to provide free ART, care and support in areas hard-hit by the disease. In 2005, the central government allo-cated approximately US$100 million for a compre-hensive response to HIV/AIDS. Provincial and local governments have also increased dramatically their investment in HIV/AIDS response, from US$12.5 million allocated in 2003 to approximately US$34.7 million in 2005. A significant increase is expected from the central government in 2008, with US$90 million expected for prevention programs.

    • The Chinese government has been working closely with international society to integrate the worldwide best practice into the practice of HIV/AIDS prevention and control in China. International cooperation, tech-nical assistance and scientific research have grown to support China's HIV/AIDS response.

      Governmental cooperation with UNAIDS, WHO and other UN agencies as well as with the United Kingdom, the United States, Australia and other countries have been extended and deepened interactively over the past years through governmental dialogue, situation analysis, strategic planning, moni-toring and evaluation, program development, etc., In addition, private foundations and the philanthropic arms of pharmaceutical firms have also joined the donor community in China to help support HIV/AIDS programs. In 2003 and 2004, approximately 700 million RMB (US $87.5 million) was infused to the resources pool to back-up the effort of HIV/AIDS prevention and control in China.

      Chinese government also conducted extensive coo-peration with the international society. For example, scientific research has been conducted jointly with other countries focusing on ARV treat-ment, vaccine development, surveillance and drug addiction, etc. The government also seeks the cooperation with neighboring countries to reduce poppy cultivation by replacing other economic plants for economic purpose, meanwhile joint action have been made in region to crack down drug smuggling and trafficking.

      China has set up a large HIV/AIDS prevention, treatment and care scientific research project, estab-lishing a platform for HIV/AIDS prevention, trea-tment and care research in Henan and Yunnan provinces (9). Protocols have been launched in the areas of clinical care, treatment drugs, vaccines, diag-nostic testing, and epidemiology. Significant progress has been made in strengthening clinical research into traditional Chinese medicine (TCM) for AIDS treatment. The government has also commissioned research on harm reduction strategies, such as MMT and NEP programs, etc.

    • As stigma is recognized as a major barrier to HIV control because it prevents people from seeking services for testing and treatment and discourages people from practicing safer behaviors (4, 18, 19). To address this issue, senior political leaders have demonstrated themselves in anti-discrimination cam-paigns for the public. This has been best exemplified by for example, on World AIDS Day, Dec 1, 2003, Premier Wen Jiabao publicly shook hands with AIDS patients in Beijing Ditan Hospital. The day before the 2004 World AIDS Day, President Hu Jintao and other senior government leaders visited patients living with HIV/AIDS and called for the elimination of bias against this group. During the Chinese New Year celebrations in 2005, Premier Wen Jiabao visited the homes of HIV-infected villagers in Henan province. These actions had a tremendous effect throughout the whole country, and have now been backed up by policy changes, and the public gestures and announce-ments have been widely publicized and recognized both at home and abroad.

    • Despite China has made significant progress in development of supportive policies and implemen-tation of pragmatic intervention strategies, there still remain numerous and complicated gaps and chal-lenges that need to be well addressed in the future.

      Although policies and regulations have been made in place strongly calling for multi-sectoral coope-ration, the action still lags behind the demand of disease control, especially when combating HIV/ AIDS are viewed as a task that thought to be primarily taken by health sector rather by the whole society. Though China has a powerful central government and administrative system, each government sector operates its function within its own vertical system, mitigating the interactive impact on HIV/AIDS control. Besides, response to HIV/AIDS has been attenuated from the top central level down to the prefecture level which might result in a vary response and inconsistent enforcement of HIV/AIDS policy. For example, the "Four Free and One Care" policy has been implemented unevenly throughout the whole country with concern of social inequity and health access for all (16). Besides, conflicts of interest between departments, such as those responsible for health and public security, have also made coordi-nation of services to reach high-risk groups, like drug users and commercial sex workers that engage in illegal behavior difficult (1). Concretized and practical assessing protocol is fundamental to examine and fuel the pragmatic collaboration across the sectors and levels in light of the requirement of HIV/AIDS prevention and control.

      The combination of insufficiently trained and qualified staff, inadequate technical resources, and a largely remote, poorly educated, rural population affected by HIV/AIDS represents a remarkable challenge to the implementation of effective programs. While in these areas where hardly hit by HIV/AIDS, human recourses and the capacity to deliver health services are typically poor and dysfunctional in some extent, whereas social stigma and lower awareness of HIV/AIDS are always coexist seriously, making it a major bottleneck on China's ability to deliver HIV prevention and care. Chinese government should place much emphasis on prioritizing the rural health system strengthening, optimizing the recourses distribution to the poorer area, building the human and institutional capacity thus to increases the access to health service and meet the demand of HIV/AIDS prevention and care in whole.

      Although impressive progress has been made in HIV/AIDS intervention and treatment, there are still many issues need to be addressed technically and administratively with the supports from government. For instance, researches on increasing the adherence of ARV treatment is very crucial to prevent drug-resistant strain from emerging to infringe the public good, while maintaining the retaining rate of MMT is largely worthy of further scientific attentions to reduce the risk behaviors among the drug users. Informed policy need evidence-based scientific results, thus made the policy more adaptable to the situation.

      Using the HIV/AIDS resource needs estimation software recommended by UNAIDS, a panel of Chinese and international experts estimated that the resources needed for an effective HIV/AIDS response in China are between US$387 million and US$650 million per year, in 2004 currency. The estimation took into account the objectives from "China's Medium and Long-Term Program for Prevention and Control of AIDS (1998-2010), " recent progress against these objectives, and an assessment of implementation capacity in 2004. In a low-cost scenario, the annual resource need was estimated at US$387 million, while the estimated annual resource need in a high cost scenario was US$650 million, in 2004 currency.

      Recognizing the ever-increasing roles of civil society in the national response to HIV/AIDS over the past years, Chinese government has cooperated with NGOs and grass root organizations through inter-national programs, like Global Fund programs, even though there is no matured working mechanism being clearly established. According to the international experience, GO and NGO' should cooperate in a large extent, complementary and synergize the roles of each other. Chinese government could make the full utilization of the social resources by collaborating with the NGOs in the future.

    • China has formulated a supportive political environ-ment at the height of policy and legislation level, government-led initiatives have been conducted in a large scale pragmatically and impressive progresses have been made thus far, but challenges and oppor-tunities coexist significantly, impacting the future outcome of HIV/AIDS prevention and care programs in some extent. Tailored and immediate measures should be encouraged to take by government and the whole society to better response the challenges and fill the gaps to fight against HIV/AIDS in a more efficient way.

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