HIV Care and Treatment in China

1. HIV Care and Treatment in China

2. OutlineHIV Care and Treatment in China • Overview of HIV/AIDS in China • China’s Free ART National HIV Treatment and Care Program • International Cooperation and Support for HIV Control in China • Clinton Foundation HIV/AIDS Initiative’s China Cooperative Programs • Regional Treatment and Care Scale-Up: Yunnan • Regional Treatment and Care Scale-Up: Xinjiang • National Partnerships: Lixin Clinical Training Center, Pediatrics Treatment, Early Infant Diagnosis

3. HIV/AIDS Situation in China

4. China in Context: Regional and Domestic Influences on the Development of an HIV Epidemic

5. 1995 1998 1989 Spread of HIV/AIDS epidemic in China 1985

6. HIV/AIDS Context in China • HIV/AIDS Context in China • Estimated 700,000 PLWHAs in 2007. • Primary mode is now sex transmission (41.2%); IVDU (28.4%). • Overall prevalence 0.06%. • Estimated 3% of PLWHAs are children (21,000). • By mid 2008: reported 253,748 HIV/AIDS cases, just over 1/3 of estimated epidemic. • 3/4 of the epidemic concentrated in Yunnan, Henan, Guangxi, Xinjiang and Guangdong. • Rural vs. urban distribution of epidemic -- 4:1. • Now more than 50,000 patients on ART, • 85% increase since 2005. • 1,500 children on treatment. FPD Regions IVDU Regions • HIV/AIDS Care and Treatment • China’s treatment goals by 2010 include providing: • ART/TCM to 80+% of all patients; • OI treatment to 90+% patients; • PMTCT to 90+% HIV+ pregnant women.

7. HIV/AIDS Epidemic in China General Population Family Bridge Population Sex Workers Source Population Drug Users Children

8. China’s “Free ART” HIV Care and Treatment Program

9. On December 1st, 2003, Premier Wen Jiabao and Vice Premier Wu Yi went to Beijing Ditan Hospital to meet AIDS patients, doctors and nurses. From December 18th to 20th Vice Premier Wu Yi went to Henan province to visit AIDS patients and their families as well as village health workers.

10. HIV/AIDS Epidemic and National ART in China Comparison Between Cum. Reported Cases of HIV and Patients on ART • In 2008 there were > 50,000 adult patients and 1,400 pediatric patients enrolled in the National ART program • Despite the scale-up of the National ART program, the gap between patients on treatment and patients needing treatment has widened

11. China’s National Free ART Program: Outcomes Analysis Zhang FJ, et al: Effect of HAART on Mortality in HIV-Infected Former Plasma Donors in China. XVII International AIDS Conference, Mexico City, 2008.

12. China’s National Free ART Program: Outcomes Analysis Zhang FJ, et al: Four Year Outcomes of the China National Free Antiretroviral Treatment Program. XVII International AIDS Conference, Mexico City, 2008. Change over time by mortality and survival following treatment initiation for previously ART-naïve adult AIDS patients

13. International Cooperation and Support for HIV Control in China • UN Sector • WHO, UNAIDS, UNICEF, UNDP • Bilaterals • US CDC, AusAID, DIFD (UK) • NGOs • Clinton Foundation • Gates Foundation • MSF, Project Hope, Others • Coordination under Ministry of Health

14. Clinton Foundation in China

15. Clinton HIV/AIDS Initiative (CHAI) China Cooperation Partners Clinton Foundation Ministry of Health China CDC NCAIDS Department of Int’l Cooperation NCTB Bureau of Disease Control NCWCH Department of Comm., M&C Health CAMS Department of Hospital Admin. ARC Yunnan BOH Ministry of Civil Affairs Xinjiang BOH Bureau of NGO Management Anhui CDC CMU No.1 Hospital

16. CHAI Global Structure & Services Access Services Country Operations Programs • Pharmaceuticals • Global Diagnostics • UNITAID liaison • Malaria • Nutrition • Africa • Asia • Latin America & the Caribbean • Eastern Europe • Pediatric Initiative • Rural Initiative • PMTCT • Special programs • Clinical training • “Products” that CHAI can offer across all of our partner countries • Approach is to apply basic business principles to lower cost and improve quality of care and treatment – maximizing output per $ • Teams placed on the ground working directly with Ministries of Health • Approach is to identify key bottlenecks in the healthcare system and to fill gaps as required to meet treatment targets • Resources and support provided in areas that require special attention • Approach is to provide direct support to accelerate pediatric care, to create replicable models of rural healthcare, and support specialized in-country programs

17. CHAI Regional Meeting 2007 Continuum of C &T: CF China Partner Support Strategy CHAI Cooperative Support Strategy in China Containment Care & Treatment • Bringing targetpopulation into Treatment • Identifying and providing access to C&T for targeted HIV+ populations such as: • Pediatric patients • Former/current IVDUs • Women identified as HIV+ during pregnancy • TB patients • Plasma donors • MSM • CSWs/clients • Nat’l Policy, Planning & Program Coordination • Provide platform / framework to enable a continuum of C&T nationwide through: • Laws/Protocols/Guidelines • Procurement • M&E • Research • Retaining patients in treatment • Development / implementation of models to ensure retention of HIV+ individuals in successful C&T and other interventions, through: • Treatment education • Adherence support • Family care pilot • Engagement of PLWHAs • Delivering high-quality care and treatment • Development/establishment of sustainable health systems models for HIV/AIDS, including: • Clinical capacity • Reliable laboratory performance • Affordable & accessible drugs & related supplies Partner Support Strategy Continuum of C&T

18. Regional Treatment & Care Partnerships

19. Regional Treatment & Care Partnerships 18

20. Background on Regional Treatment & Care Programs Yunnan Xinjiang • Locations: • Dehong Prefecture (Luxi, Ruili, Yinjiang) • Honghe Prefecture (Kaiyuan, Gejiu, Mile, Jianshui) • Baoshan Prefecture (Baoshan, Tengchong) • Dali City • Lincang Prefecture (Lincang, Cangyuan) • Wenshan County • Pu’er City • Xishuangbanna Prefecture • Total 15 program counties • Supported by: • Norway Government and Pangaea • Locations: • Urumqi City (5 districts) • Yili Prefecture (3 counties/cities) • Kashgar City (4 neighborhoods and 2 counties) • Kuche County • Total 16 treatment sites. • Supported by: • AusAID 19

21. Yunnan Province Bureau of Health - Clinton FoundationCooperative HIV / AIDS Treatment and Care Program

22. HIV / AIDS Epidemic: National Overview2007 estimates indicate that there are 700,000 PLWHA’s in China.Yunnan is among the provinces with the largest number of cases of HIV. Geographic distribution of cumulative reported HIV cases in China (as of October 2007) IVDU Regions Source: People’s Republic of China Proposal Form, Rolling Continuation Channel (RCC) to the Global Fund, November 2008

23. Yunnan Program Background • Program goals: • The Yunnan BOH – Clinton HIV / AIDS Initiative Cooperative Program was initiated in 2005 to scale-up care and treatment in a comprehensive and standardized way to assure sustained, high-quality care and treatment for as many people with HIV / AIDS as possible; • Objectives (2005-2008): • Put 3,000 patients on ART (including 50 children) • Train 180 physicians and 300 health professionals • Strengthen laboratory capabilities (HIV diagnosis, CD4 and VL testing, and quality control) • The cooperative program met and surpassed its original objectives by working with local partners to develop and implement an effective model; • New funding support from Government of Norway (MFA) since late-2007 has allowed: • Further development of comprehensive local treatment services which are now integrated with prevention and harm reduction services for IVDU; • Demonstration of scalability as a province-wide treatment model

24. Yunnan Program Outcome: EnrollmentWith support from the Government of Norway since late 2007, the program has supported the enrollment of ~4,600 patients on treatment, including 128 children. Number of patients enrolled on ART Figures at YE, 2005 - 2008 No. of patients enrolled on ART Source: Analysis using SIMCLIN and Patient Information System data Note: Slight discrepancies in patient enrollment figures (by <1%) may occur between figures displayed here and Aids Care China Reports. This is due to ongoing improvements in the Patient Information System; patients may be re-classified between analyses.

25. Yunnan Program Outcome: Site Scale-upOne important focus of the program has been on accessing hard-to-reach patients in closed facilities. Key achievements By March 31, 2009 County-level site locations • Cumulative 5,345 patients on ART • 4,380 active patients on ART • 1,652 new in 2008 • 495 newly enrolled in Q1 2009 • 15 Sites • 4 new in 2008 • Comprehensive HIV treatment and care programs established through the local government at these key rural epidemic sites • Trained • 400 physicians • 200 nurses • 180 lab technicians • ART in 9 closed facilities • 7 detention centers • 1 RETLC • 1 prison • Linked services into integrated system serving IDU-based PLWHA communities

26. Clinical Capacity Building Laboratory Capacity Building • Builds upon existing health system to deliver HIV treatment • Long-term expert clinical support to train and mentor HIV doctors at each site; develop sustainable local clinical leadership • Training workshops for ART physicians and nurses, as well as Methadone and Detention Center health workers • Core technical support to develop capacity and quality system of CD4 and VL labs • VL pilot to demonstrate feasibility and successful treatment outcomes; donation of test reagents • Training and guidelines for Early Infant Diagnosis (EID) pilot with Yunnan CDC and Honghe sites Peer-Based Community Treatment Support Program Management / Local HIV Care Coordination • In partnership with NGO AIDS Care China (ACC) • Red Ribbon Center (RRC) teams support patients in community-based treatment • Electronic patient information system at each site for medical info and case management • RRCs build linkages with networks for prevention, harm reduction and community-based services; patient-centered integration of the comprehensive response • Led by YN BOH, support and mentoring for county-level HIV program management builds capacity and assures programmatic efficiency • Targeted patient support encourages ART enrollment and retention, and reduces financial barriers to quality HIV treatment Components of the Comprehensive Care and Treatment ModelThe four key components of support:

27. Yunnan Program Outcome: RetentionPatient retention in the program is remarkable, with lost-to-follow-up rates below 2% across mature sites, and mortality rates at approximately 3.2% across all sites. Impact of the program on lost-to-follow-up rates1 Annual LTFU rate2 Impact of the program on mortality rates3 • Mortality rate of PLWHA enrolled on ART has declined • 3.24% at YE2008 • 5.88% mortality in 2006 when program in initial stages • In comparison, the nationwide annual mortality rate is approximately 5% Annual LTFU rate These rates demonstrate the efficacy of the comprehensive continuum of care model, with especial emphasis on peer-based community treatment support 1 ACC Analysis of the 9 sites that had ACC presence for more than one year as of YE 2008 2 Lost-to-follow-up after program start refers to “patients who cannot be contacted or who exited the program without medical advice and will no longer return to receive medicine or for check-up”; LTFU before program start follows national guideline definitions of ““lost” if patient has not come in for follow up in 3 months” 3 Analysis includes all program sites

28. Yunnan Treatment Outcome: Viral Load SuppressionViral load suppression among patients who have been on treatment for more than 6 months is 89%, indicating positive treatment outcomes. Viral load suppression as indicator for treatment success • Viral load undetectable = successful ART outcome • VL outcomes in Yunnan sites have consistently been ~90%, placing them among the best in nationwide surveys Percent of patients who have undetectable VL results in last 6 mo. = 89% Patients as of YE2008 Undetectable 1 Analysis includes adults and children 66% of all patients on who have been on treatment for more than 6 months have received a VL test in the last 6 months 89% of monitored patients who have been on treatment for more than 6 months have undetectable VL results (Recent defined as w/in last 6 mo.; Undetectable defined as 400 or less)

29. Yunnan Sustainability Planning: Historical costsAnalysis of historical costs shows that the program focuses on 4 major elements to deliver a comprehensive continuum of care model. Early investments in capacity building was crucial to program success. It will remain significant as the program continues to expand to new sites and enroll more patients.

30. Xinjiang Uyghur Autonomous Region Bureau of Health – Clinton Foundation Cooperative HIV / AIDS Treatment and Care Program

31. More photos . . . The end.

32. HIV / AIDS Epidemic: National Overview2007 estimates indicate that there are 700,000 PLWHA’s in China.Xinjiang is one of the frontline regions, ranked 4th in reported cases, and is estimated to have > 60,000 PLHIV Geographic distribution of cumulative reported HIV cases in China (as of October 2007) IVDU Regions Source: People’s Republic of China Proposal Form, Rolling Continuation Channel (RCC) to the Global Fund, November 2008

33. Xinjiang Program Background • Context: • By 2006 ART services were still very limited in XJ and most PLHIV had no access to treatment or HIV care. • AusAID-supported programs with Xinjiang BoH for prevention, harm reduction, community mobilization and care - but lacked a treatment component • CHAI was engaged by AusAID and MOH to partner with Xinjiang BoH to support development and scale up of HIV treatment and care services • Goal: • The Xinjiang BOH – CHAI cooperative program was established in 2007 to build capacity in Xinjiang to treat increasing numbers of HIV/AIDS patients at a high standard of quality, within a continuum of supportive services that retain patients in care. • Objectives: • Increase the number of patients in care and on ARV treatment • Maximize the number of patients who are treated successfully and retained in care • Create sustainable replicable models for comprehensive HIV/AIDS treatment and care

34. Xinjiang Program Outcome: EnrollmentSince 2007, the program has supported enrollment ~1760 patients on treatment, and initiated pediatric ART now providing treatment for 62 children. Number of active patients enrolled on ART No. of patients enrolled on ART Source: Xinjiang Regional BoH and CHAI

35. Xinjiang Program Outcome: Site Scale-upImplementing comprehensive HIV treatment/care services through local BoH management County-level site locations Key achievements by YE 2008 • 1,441 active patients on ART • 798 new in 2008 • 14 sites • 4 sites at start in Mar 2007 then 6 sites new at end 2007 (Yili & Urumqi) • 4 new in 2008 (Kashgar & Kuche) • Implemented practice-based training models building treatment capacity • Established local expert teams in program areas for mentoring • Scaled up integrated treatment and care model using peer-based treatment support • Established treatment quality review and Patient Info System • Implemented global budget treatment financing model with good outcomes • Supported training for 73 local doctors at two training centers • Improved CD4 test quality and supported initiation of VL testing in Urumqi Denotes Current CF Site Location

36. Clinical Capacity Building Laboratory Capacity Building • Builds upon existing health system to deliver HIV treatment • Long-term expert clinical support to train and mentor HIV doctors at each site for local clinical leadership • Training workshops for ART physicians and nurses, as well as MMT and Prison doctors • Two training centers for Xinjiang HIV clinician base • Core technical support to develop capacity and quality system of CD4 labs • Support Xinjiang CDC in training to develop VL testing capacity and facilitate initiation of VL treatment monitoring in Urumqi • Donation of VL test reagents Peer-Based Community Treatment Support Program Management / Treatment Financing Pilot • Partnership with local BoH/CDC and hospitals: • Peer health workers at clinic sites support patients in enrollment, adherence education and treatment support • Electronic patient information system being implemented for medical record and case management • CDC and peer health workers cooperate in community-based referrals and care coordination • Together they build linkages with networks for prevention, harm reduction and other services, supporting a patient-centered approach • Xinjiang BOH mentors local HIV program management to build capacity and assure program efficiency • Targeted patient support facilitates ART enrollment and retention, and reduces financial barriers to quality HIV treatment • Innovative pilot for local global budgets to finance treatment costs encourages early enrollment and cost-effective treatment, managing patients for long-term outcomes. • Participatory M&E with XJ BOH, CHAI and China Health Economics Institute Components of the Comprehensive Care and Treatment ModelCornerstones of cooperative support

37. Integrated Services

38. Health Workers, Peer Community Workers

39. Xinjiang Treatment Outcomes: Since the program start in 2007, loss-to-follow-up and mortality rates have improved. In 2009, patient info systems will facilitate better reporting of current-year and treatment response (CD4) outcomes. Impact of the program on loss-to-follow-up rates1 LTFU rates (cumulative, all sites) Impact of the program on mortality rates2 • Mortality rate of PLWHA enrolled on ART has declined • 5.1% cumulatively at YE2008 • 7.1% mortality before program began in March 2007 Cumulative LTFU rate These outcomes support a preliminary assessment of efficacy for the comprehensive continuum of care model and peer-based community treatment support 1 Source: Xinjiang Regional BoH and Local BoH 2 Source: Xinjiang Regional BoH and Local BoH

40. Snapshot of Xinjiang Program Highlights - Non-ARV Treatment Cost Financing Pilot County A County B • Treatment program costs are funded as global budget, managed by the local BOH: • Total payments to providers are based on agreed targets for : • new and old patients treated • per patient costs for outpatient and inpatient services • Standard cost per patient * enrollment = global budget for the district (local BOH) • Funds are intended to be used as “gap” funds after patient self-pay, other programs, and insurance. • Providers are incentivized to enroll patients early and to manage patients well • This is to avoid OI episodes (a longitudinal approach to HIV care delivery) • Strong program monitoring and evaluation to ensure providers do not skimp on care. Financial bonus for good outcomes Preliminary data on average treatment spend per patient indicate that this approach has allowed localities to manage non-ARV costs well within 850 RMB per patient per year, without sacrificing quality of enrollment objectives

41. CONTAINMENT CARE & TREATMENT Bringing Target Population into Treatment Identifying and providing access to C&T for HIV+ target populations such as: • Pediatric patients • IDU • HIV+ pregnant women • TB patients • Incarcerated PLHIV • Plasma donors • MSMs • CSWs Supporting Population in Treatment Development / implementation of models to ensure retention of HIV+ individuals in successful C&T and other interventions, including • Treatment education • IDU adherence pilots • Family Care Pilot • Engagement of PLWHAs National Policy, Planning & Program Coordination Provide platform / framework to enable a continuum of C&T nationwide through: • Laws, Protocols, Guidelines • Procurement • M&E • Research Treatment Infrastructure Development/establishment of sustainable health systems models for HIV/AIDS, including: • Clinical Capacity • Reliable Labs • Affordable / accessible drugs & lab supplies Partner Support Strategy Continuum of C&T Continuum of Care ModelCHAI’s approach for supporting comprehensive HIV treatment and care

42. CHAI China’s National Level Partnerships:National Pediatric Treatment ProgramLixin Rural HIV Clinical Training CenterHIV Lab Capacity BuildingEarly Infant Diagnosis and PMTCT PilotsIncreasing Drug Access in Neglected Diseases

43. Anhui Lixin Rural HIV Clinical Training Center Program Components Highlights • Clinical leadership for Lixin training center and its network of physicians: • - High quality clinical training approach with • practice-based training in community settings • - Clinical practice in outpt and inpt settings • - Clinical training, TOT and trainee-follow-up • Provide clinical support to local physicians and improve patient care • Consultation support for pediatric treatment • Completed intensive training for 72 rural clinician leaders since 2004 • - Train 18 per year from high prevalence areas • Work at village, township and county levels to improve local quality care and strengthen the referral network • Build local capacity for: • - Dx and treatment of TB / HIV and other OIs • - 2nd line treatment (national pilot site) • Innovated model for village doctor training to support PLWHA and implemented village doctor training across Anhui Province with CDC

44. Lixin Program - Practice-Based Clinical Training

45. Lixin Program - Practice-Based Clinical Training

46. Lixin Patient Stories

47. Lixin Patient Stories

48. Lixin Training Program • 2004-2009 • 72 Trainees • 4 Fellows

49. CHAI and China Pediatrics Partnership Children on Treatment Number of Provinces Year End 2005 150 4 Year End 2006 292 10 Year End 2007 996 21 Year End 2008 1,440 24 • The national pediatric ART program was established in January 2005 with CHAI-MoH to supply pediatric ARVs • CHAI donated drugs for 200 pediatric HIV/AIDS patients urgently needing treatment • Training, mentoring and program support • First treatment site opened in Shangcai, Henan – epicenter of epidemic in China - June 2005 • CHAI committed to expanding donations for up to 2000 children in June 2005 • Drug supply supported by global UNITAID program from November 2006 • Currently, > 1500 children are on treatment across all of China • Initiation of 2nd line ART with CHAI and UNITAID supported ARVs started early 2008 * Note: CHAI and China NCAIDS estimate that 2,115 children currently need treatment.

50. Kids