Statement Presented to the Congressional-Executive Committee on China

By Kevin Robert Frost
October 20, 2003

Introduction

My name is Kevin Robert Frost and I am Vice President for Clinical Research and Prevention Programs at the American Foundation for AIDS Research (amfAR).

amfAR was founded in 1985 and is the nation's leading nonprofit organization dedicated to the support of HIV/AIDS research, AIDS prevention, treatment education, and the advocacy of sound AIDS-related public policy. I am also the director of amfAR's international initiative, Therapeutics Research, Education, and AIDS Training in Asia, or TREAT Asia. TREAT Asia is a cooperative venture designed to help Asia and the Pacific region - which is expected to become the next epicenter of the pandemic - prepare for the safe and effective delivery of HIV/AIDS treatments as they become more widely available. The program pairs the resources and experience of clinical centers in Asia with amfAR's education, training, and clinical research expertise.

The goals of TREAT Asia are to:

Develop the skills of the health care workforce in the safe and effective delivery of drug treatments for HIV/AIDS;

Enhance existing health care infrastructure and formulate strategies for capacity building to prepare for expanded access to HIV/AIDS drug treatments;

Develop a framework for regional collaboration on a therapeutics research agenda that is responsive to the needs of patient populations in the region;

Define and address the national and regional policy issues that impede expanded access to drug treatments for HIV/AIDS and, by working with regional and in-country NGOs, strengthen civil society's preparedness for treatment programs.

Size and Scope of the Epidemic in China

China's HIV/AIDS epidemic has been gaining momentum and the Chinese government estimates that currently 840,000 persons are infected with HIV/AIDS. Intravenous drug use and contaminated blood have been the two primary routes for infection in China, representing two distinct and separate epidemics. However, HIV infection is increasingly spread through sexual transmission, with rising rates of infection among commercial sex workers in several provinces. Among those who acquired infection through tainted blood collection practices in central China during the 1990s, large numbers are now falling ill and have minimal access to care and treatment in China's under funded rural health care system. Relative to many developing countries with severe AIDS epidemics in Africa and Southeast Asia, China has a functioning health care infrastructure, and antiretroviral therapy is starting to be offered through public hospitals and clinics at the county, township, and village levels in severely affected communities. However, healthcare providers at these levels have little training or experience in counseling and treating AIDS patients, compounding the problem of side effect management and drug compliance. The lack of healthcare provider capacity to administer antiretrovirals is one of the biggest obstacles to treatment preparedness in China.

Though by all accounts China has become more open in dealing with HIV/AIDS, denial of the full extent of the epidemic persists. Unfortunately, there are no reliable data that accurately assess the scope of the epidemic. Chinese doctors privately suggest that the epidemic is at least five times - and possibly even 10 times - the official estimates.

The HIV epidemic in China's central province of Henan is instructive. With an estimated population of 110 million, Henan is China's largest province. If only one percent of this population was infected through the "blood trade," more than a million people would be HIV-positive in Henan alone. Yet a recent survey showed that the prevalence rate among commercial blood donors in rural eastern China was 12.5 percent and 2.1 percent among their non-donor spouses. In January 2002, the Henan Health Department reported that 80 percent of Houyang village residents were HIV-positive. Of its 4,000 residents between the ages of 16 and 55, some 90 percent participated in blood donation programs. More than 400 villagers have developed AIDS, and 150 died between November 2000 and November 2001. In December 2002, former Health Minister Zhang Wenkang acknowledged that 23 provinces, autonomous regions, and municipalities were affected by unhygienic blood collection. And this is to say nothing of the epidemic among injecting drug users in the south and northwest provinces of Yunnan, Sichuan, and Xinjiang among others.

When asked by amfAR recently about the size and scope of China and India's epidemics in an article published in amfAR's quarterly newsletter for the TREAT Asia Report, Dr. Richard Feachem, Executive Director of the Global Fund for AIDS, TB, and Malaria, had this to say:

"There has been this strange collusion between Western experts, international organizations, and the Chinese and Indians to first say that the HIV epidemic is not seriously going to affect China and India at all, then to say, well, maybe they're going to have a small epidemic, and then to say, well, maybe they're going to have a rather larger epidemic.

But only very recently has there been anything approaching a consensus that China and India are set for very large epidemics. Because of this history of minimizing the epidemics in China, India, and in Asia more generally, I would go with the higher-end estimates now being produced."

China's Response

Recently there have been promising signs of an increasing willingness in China to confront its HIV/AIDS epidemic. China has just been awarded a grant from the Global Fund to carry out voluntary counseling and testing (VCT) and treatment programs in seven provinces where many infected through blood donation during the 1990s are falling ill. Prior to this, the Chinese government had initiated a treatment program in four of these provinces that offers antiretroviral therapy to about 3,000 persons now, with a target of 5,000 by the end of 2003. The Global Fund support will be used to scale up treatment, including antiretrovirals, to 40,000 AIDS patients in 56 counties in these seven provinces by 2008. Many experts believe even the 40,000 target is a significant underestimate of the number of patients in these communities who will require treatment in the next five years.

While the Chinese government's goal of extending free antiretroviral treatment to rural AIDS patients is laudable, many problems exist with China's current treatment policy program beyond the issue of the numbers of sick persons who will have access to free treatment. One significant problem has to do with the affordability of state-of-the-art antiretroviral therapy that is both easier for patients to tolerate and for health care providers to supervise (i.e., fewer doses, less complicated regimens with fewer side effects). As a new member of the World Trade Organization, China has been careful to respect international trade agreements and only manufacture drugs that are off patent. Two Chinese pharmaceutical companies have begun to produce generic versions of 4 off-patent drugs that the government has acquired for their public treatment program. Patented drugs, such as combivir (AZT + 3TC), are imported but considered too expensive to use routinely and are only used in a handful of patients when domestically manufactured drugs are not tolerated. The treatment protocols currently being used are not optimal and have not been well tolerated by patients, resulting in severe side effects which local health care providers have no training or experience in managing.

Because of these side effects, the treatment options currently available in China in many ways represent the worst possible choices and offer the potential for disaster. Yet China is taking the approach that most developing countries are forced to take when it comes to choosing treatment regimens. Rather than developing public health strategies for delivering treatments to the population of HIV-infected individuals, China is left in the undesirable position of having to settle for what it can get, rather than what it needs. Unless serious attention is paid to acquiring better combination treatments, the failure rate of the current regimens is likely to be enormously high and could have dire consequences in terms of diminished long-term efficacy of treatment programs in China and widespread development of HIV drug resistance, with implications for the rest of the world. Similar lack of access to imported reagents for HIV and CD4 testing has constrained the ability of the health system to do the necessary voluntary counseling and testing, and to properly monitor those patients on treatment.

The mix of insufficiently trained medical staff with poor counseling skills, poorly tolerated drug regimens, and lack of testing and laboratory monitoring capacity is a worrisome combination of factors. In an editorial published in The South China Morning Post in August 2003, Drew Thompson of the Washington DC-based Center for Strategic and International Studies wrote: "To safely treat HIV sufferers with powerful antiretroviral drugs, it is crucial to have trained physicians with access to laboratories which can carry out advanced blood testing… By jumping the gun and beginning treatment before doctors and counselors are properly trained, a drug-resistant disaster is waiting to happen."

Now that China has been granted a big infusion of funds through the Global Fund mechanism, it will quickly be scaling up its treatment program. It is imperative that education and training programs are rapidly expanded and accelerated in order to ensure that the best available drugs are being provided by trained medical professionals, with proper counseling and rigorous monitoring and follow-up testing.

At amfAR, and within the TREAT Asia program, we believe that it is here the United States has much to offer. China desperately needs (and there is growing evidence of China's willingness to seek), international support for rapidly developing and scaling up education and training programs for healthcare providers in the delivery of HIV/AIDS drugs. It is my sincere hope that we will find the necessary resources to provide precisely that support.

Thank you.