Anti-AIDS Effort in Central China Focuses on Former Plasma Donors

http://www.prb.org

by Drew Thompson

China has focused much of its fight against HIV/AIDS on former plasma donors — villagers in roughly seven central provinces who contracted the virus at blood collection centers that operated prior to a government crackdown in the late 1990s. The flagship national effort that was specifically designed to address the needs of these former plasma donors who contracted the virus is the China Comprehensive AIDS Response or "China CARES" program, which aims to provide free and subsidized HIV testing, counseling, and antiretroviral treatment to affected communities and individuals. The program operates through clinics run by the China Center for Disease Control and Prevention (CDC) at the provincial, county, and township levels. However, responding to the problems in Central China presents unique challenges for local governments.

The epidemic in Central China took root between the late 1980s and the late-1990s when entrepreneurs paid poor farmers in Henan province for plasma — the liquid portion of blood that provides critical proteins for blood clotting and immunity. The farmers, who were not tested for HIV, hepatitis B, hepatitis C, or other blood-borne infections, gave blood to collection centers, which pooled the blood of several donors of the same blood type, separated the plasma, and injected the remaining red-blood cells back into individual donors to prevent anemia. Farmers often would remain for weeks at the centers, making repeated donations for cash.

The risky practice of pooling and transfusing blood back to donors meant that infection from just one person could spread to many others on a single visit. Collection centers eventually opened in surrounding provinces and spread to some northeastern areas as well.

Impact of HIV/AIDS in Central China

As many as 230 plasma collection centers existed in Henan province prior to a government crackdown between 1995 and 1997.¹ In some villages in the province, some 60 percent of the former plasma donors now have HIV. Many of these people have progressed to AIDS and thousands have died, according to the proposal for the China CARES program to the Global Fund to Fight AIDS, Tuberculosis and Malaria.²

The government places the total number of people with HIV in Henan at about 35,000,³ but other estimates are much higher. The Aizhi Health Education Institute, for one, estimates some 34,000 HIV infections and up to 3,000 AIDS-related deaths in just one county in the province.⁴ These levels of infection help illustrate the extent of the problem in rural areas where plasma Alternative Treatments occurred.

While China's national prevalence of HIV is estimated at less than half a percent, the high prevalence in these hard-hit areas, presents unique challenges for local governments. The economic and social impact is significant. Farmers become too sick to tend their fields and travel to market, or they migrate to cities to work in factories, leaving family members without financial support. AIDS ravages the social fabric of villages, forcing extended family members to care for orphans when relatives have died or become incapacitated.

Orphans present a major problem in many affected areas. The number of children affected by HIV through the loss of one or both parents is difficult to pin down. The United Nations estimates that throughout China, living AIDS orphans — children under age 15 who have lost at least one parent to AIDS — numbered about 76,000 at the start of 2002.⁵ Without a social security system, health insurance, or life insurance for the majority of Chinese peasants who have HIV, affected families depend on the government to provide care and support, creating immense pressure on local governments.

Government Approach at Local Levels

Local officials in the most-affected areas face multiple challenges in providing medical treatment, orphan care, and preventing the spread of HIV from former plasma donors to the rest of the community.

Dealing with HIV at the local level requires mobilization of numerous government departments to treat the disease and to address the social and economic impacts of the epidemic. Similar to the national-level State Council AIDS Prevention Working Committee, coordinating committees at the provincial and county levels of government meet regularly to coordinate plans to control and prevent the spread of infection. To qualify as a China CARES site and to be eligible for funds from the Global Fund and from the Chinese CDC, each county must set up a coordinating committee and must develop short-term and long-term plans.

Effective implementation of the China CARES plan requires the participation and coordination of numerous bureaus. Some pilot sites have provided useful models for other counties, and the CDC-operated China CARES clinics act as focal points for a number of services:

• Family planning officials provide free condoms to the clinics for distribution to patients with HIV.
• County officials maintain lists of children who have at least one parent with HIV, and they coordinate with schools and education bureaus to ensure that students receive free education.
• The civil affairs bureau and the Chinese Red Cross provide subsidies to affected children and operate orphanages for children whose parents are incapacitated or dead.
• Public security officials play a role in facilitating outreach and counseling for commercial sex workers, including permitting the implementation of campaigns calling for "100 percent condom use" at entertainment establishments.

While local governments in heavily affected areas are under pressure to deliver comprehensive services and administer programs, many lack adequate capacity and support. The central government therefore provides some support for pilot sites to train doctors, build medical infrastructure, and help local governments develop management systems and programs to distribute drugs and condoms and educate family members of infected people.

International organizations have also trained government officials and funded programs to support comprehensive care. The United Nations Development Program convened a seminar in February 2004, to help various levels of government in Hubei province increase coordination between departments in addressing HIV/AIDS. Officials from provincial, municipal, and county governments participated with representatives from local coordinating committees, including from the health, public security, judicial, civil affairs, and tourism sectors.⁶

WHO also provided funding to China CARES sites in Hubei to establish "Warm House" centers at CDC clinics in counties and townships. These centers are meeting rooms for HIV patients to gather and support one another, share health education, and discuss home care options. This model is expected to increase family involvement in prevention activities and ensure greater adherence to antiretroviral treatment regimens.⁷ Efforts such as these contribute to the capacity of local officials to create an effective, broad response to HIV/AIDS in central China.

China CARES program

The China CARES project grew out of China's increasing willingness to openly address the AIDS crisis, and it benefited from the formation of the Global Fund. The program initially sought to establish treatment and care in 51 counties hardest hit by HIV. However, the target grew to more than 120 counties, as estimates of the numbers and distribution of former plasma donors in rural areas increased. Through the program, patients receive subsidized clinical tests, free domestically manufactured antiretroviral drugs and other medication to treat opportunistic infections.

Officially launched in the spring of 2003, the program trained three doctors from each of 56 counties from May to August. Following the training, provincial, county, and township clinics received domestically manufactured antiretroviral drugs. Each county also received a quota of patients, as the program sought to identify and begin treating 5,000 people by the end of September 2003.⁸ By the end of October, Chinese CDC officials reported they had indeed met the quota, with 5,289 persons initiating treatment. However, officials note that more than 1,000 of these patients have since died or have left the program because of adverse effects of the antiretroviral treatment.⁹

Treatment Programs Carry Benefits and Risks

With patients in the China CARES program dropping out of treatment and unknown numbers taking their medicine without adequate counseling, the risk of spreading drug-resistant strains of HIV that defy treatment is significant.

Established treatment programs with affordable life-prolonging drugs provide entry points for voluntary testing and counseling. Without access to treatment, individuals lack motivation to get tested. The availability of treatment provides an incentive for people to know their status and creates opportunities for health officials to counsel and train individuals and families in HIV prevention and care.

At the same time, the provision of complex HIV treatment presents a number of risks, particularly when few doctors, nurses, and lab technicians have been trained to respond to the epidemic and when vital equipment is not available. A significant concern about the China CARES program is that the initiation of antiretroviral treatment without adequate medical and social counseling will increase the risk of patients developing and spreading drug-resistant strains of the virus.

The WHO notes that while drug resistance can be considered a natural response to the selective pressure of the drug, the process could be exacerbated by abuse, under-use or misuse of the treatment regimen, poor patient compliance, and poor quality of available drugs.

Relationship Between Center and Provinces

Effectively implementing a national program such as China CARES also requires purposeful coordination between the central government and the provinces. But the steady devolution of power from Beijing to the provinces since 1979 has led to significant autonomy among the provinces. For example, while the constitution mandates that primary school is compulsory and free for all students, the law is rarely implemented in provinces. However, the central government does have the ability to ensure that selective policies — such as the country's one-child policy-are carried out nationally.

The difference between success and failure often depends on the central government's involvement. Sustained top-level leadership in Beijing creates incentives for local and provincial authorities to carry out policies, even when implementation requires locally raised funds. Recently, the actions of President Hu Jintao, Premier Wen Jiabao, and Vice Premier Wu Yi have signaled the government's full support for implementing HIV/AIDS programs — the kind of support that would give local officials increased impetus to heighten their own response.

At the same time, the level of interest and capacity to implement a national policy varies at the local level. In Henan, officials have fielded accusations that they are resisting efforts to help people living with HIV/AIDS and that they are trying to cover up reports of the extent of the epidemic. However, continued pressure, both from the international community and from political authorities in Beijing have created an improved environment for implementing treatment and care programs in rural areas that have large numbers of farmers with HIV.¹⁰

In February 2004, Chinese media widely reported a program in Henan that involves posting teams for one year to 38 villages with 10 or more HIV/AIDS sufferers. The teams would include two provincial-level officials from various bureaus, including health and finance and from the provincial party committee. Two city- and county-level officials from the affected areas will complete the working teams in each village.¹¹ These teams are expected to improve strained relations between the affected villages and provincial officials.

Other provinces such as Hubei are employing creative approaches to prevention, treatment, and care. Programs involve family participation to increase adherence to medicine regimes and to prevent transmission within the family. Program also include social support for orphans and children affected by HIV/AIDS.

Financial Demands of China CARES Is High

The China CARES program benefits from international support that increases the government's capacity to provide treatment and counseling for patients and their families. Support is coming from organizations such as the Global AIDS Program of the U.S. Centers for Disease Control and Prevention. More support is also expected as a result of China's five-year, $98 million application to the Global Fund. Some $32 million dollars of the total was approved in 2003 for the first two years.¹² These funds will go toward procurement of medicine as well as equipment and vehicles for the Chinese CDC.

While the combination of financial and technical support from international sources should boost the potential effectiveness of the China CARES program, the financial demands of the treatment program present a long-term burden to the government. Current international financial support will provide primarily medical infrastructure and short-term supplies of drugs, not the lifetime supplies needed to ensure that patients are able to adhere to treatment for the remainder of their lives. If financial commitment drops off over time and patients are increasingly forced to shoulder the burden of medication and associated treatment expenses, significant numbers of people are likely to drop out of treatment, increasing the likelihood that resistant viruses will spread.

Long-term success of the national treatment program will therefore be predicated by sustained, top-level political support and dedication of resources to the HIV/AIDS issue in general and the China CARES program in particular.

Drew Thompson is a research associate with the Freeman Chair in China Studies at the Center for Strategic and International Studies (CSIS) in Washington, DC. Mr. Thompson has traveled extensively throughout China and speaks, reads, and writes Mandarin.

References

1. "On an Odyssey to Help AIDS Orphans," Shenzhen Daily, Nov. 28, 2003.
2. China's Country Coordinating Mechanism, "China CARES (Comprehensive AIDS Response): A Community Based HIV Treatment, Care, and Prevention Program in Central China," Round 3 HIV Proposal to the Global Fund to Fight AIDS, Tuberculosis and Malaria, June 2003, accessed online at http://www.theglobalfund.org/en/, on May 7, 2004.
3. "Henan Officials to Fight AIDS," China Daily, Feb. 18, 2004. See also: "HIV Carriers Estimated at 35,000 in Henan," Xinhua, Nov. 16, 2003.
4. "Children/orphans and HIV/AIDS in China," Beijing AIZHIXING Institute of Health Education
   (Beijing: AIZHIXING Institute of Health Education, April 2003).
5. Joint United Nations Programme on HIV/AIDS (UNAIDS), UNICEF, and WHO, "Epidemiological Fact Sheets by Country," accessed online at www.who.int/emc-hiv/fact_sheets/All_countries.html, on May 5, 2004.
6. "Chinese local leaders attend UN training on AIDS," People's Daily, Feb. 3, 2004.
7. World Health Organization (WHO), "Partnership Work: The Health Service-Community Interface for the Prevention, Care and Treatment of HIV/AIDS: Report of a WHO Consultation, 5-6 December 2002, Geneva Switzerland" (Geneva: WHO, 2003).
8. "AIDS Care and Treatment in Xiangfan, Hubei Province, May-December 2003" (Brussels: Doctors Without Borders, 2003).
9. Presentations by Chinese CDC officials, Beijing, Nov. 7, 2003.
10. "Top Chinese leader met with country's most famous AIDS activist," AFP, Feb. 18, 2004.
11. "76 officials sent to high-AIDS prevalence villages," People's Daily, Feb. 18, 2004.
12. China's Country Coordinating Mechanism, "China CARES (Comprehensive AIDS Response): A Community-Based HIV Treatment, Care, and Prevention Program in Central China," Round 3 HIV Proposal to the Global Fund to Fight AIDS, Tuberculosis and Malaria, June 2003.