Chennai, India February 18, 2009

1. Controlling the HIV Epidemic among Injection Drug Users in China Global AIDS Program (GAP)China-US Cooperation中美合作 - 全球艾滋病项目 Chennai, India February 18, 2009

2. Vision Statement USG will assist the Government of China to reduce HIV transmission and mitigate the impact of AIDS and to achieve the goal of having less than 1.5 million HIV cases by 2015

3. Estimated HIV Cases – Known & Unknown预测艾滋病病例—已知晓的与未知晓的 cases 美国 中国

4. Distribution of Reported HIV Cases by Province

5. USAID and CDC Global AIDS Program Activity Areas in China Heilongjiang Ningxia Inner Mongolia Xinjiang Beijing Shandong Qinghai Henan Jiangsu GAP Focus Provinces GAP Moderate Support GAP Technical Assistance Only USAID and GAP Support Anhui Tibet Sichuan Guizhou Yunnan Guangxi Guangdong

6. 四两可拨千斤

7. GAP Operational Principles for Technical Support in China • Integration– Integrate to accelerate effective implementation of national and provincial programs (by Chinese technical officers) • Evidence based - Link to national planning process • Technical assistance - Support technical and management development at national and provincial levels • Seconding staff - to Global Fund office and China CDC • Technical exchange - visits to US and other countries to witness programs in action; bring in technical experts to help with key areas of need • Maintain flexibility in a rapidly changing environment

8. Number of Registered Drug Users1990-2005

9. HIV Prevalence among Drug Users（1995-2008）

10. Compulsory Detoxification - Major Measure for IDU Control in China

11. Risk reduction education

12. Methadone Maintenance Treatment (MMT) Program

13. Growth of MMT Program in China Number of clinics

14. Development of MMT in China

15. Development of MMT in China 2008 吉林 新疆 2 27 内蒙 北京 9 3 1 天津 山西 宁夏 3 青海 3 甘肃 2 河南 21 陕西 1 江苏 18 13 安徽 上海 湖北 四川 重庆 8 9 37 36 26 浙江 江西 27 湖南 12 48 贵州 福建 54 9 云南 广东 67 广西 56 50 600 clinics in 23 provinces 海南 23

16. Mobile MMT Clinic Model in Ruili (Yunnan Province) • In 2006, GAP supported the first mobile MMT clinic in China • The mobile MMT clinic in Ruili covers 50 rural villages near the border • Retention rate is 76% • Now the Ruili model has been replicated by GoC in 9 provinces with 21 mobile MMT clinics

18. Rapid Increase in Patients on MMT Accumulated patients

19. Participants Response to MMT Base(N0=10657) 1Year(N1=2199) 2Years(N2=811) Crime for injection drug in the past 3 months Do have a job Going well with family Being satisfied with MMT Have injected during the last month

20. Needle Exchange Program (NEP)

21. Needle Exchange in China • Pilot in late 90’s • Became national program in 2004 • In the 3rd quarter of 2008: • there were 901 NEP centers in 395 counties/districts in 17 Provinces • covering >38,000 clients • Monthly syringe distribution: 1.12 million • Monthly syringe retrieval: 1.03 million

22. Challenges • Attitudes towards drug users – marginalization and stigma • The public • The police • The health workers

23. Challenges • Some local officials do not attach importance to the control of HIV/AIDS among IDU, especially with NEP. • Multi-sector collaboration need further strengthening • Harassment from local police from time to time

24. Challenges • Coverage • Low enrollment and high drop-out in some MMT clinics

25. Challenges • Low capacity of some MMT clinic staff • Weak in comprehensive intervention • Low methadone dosage (45-55mg/day) • Lack of effective linkage between MMT and NEP

26. Strategies - 1 • Expose policy-makers to ‘harm reduction’ in other countries: • Australia, the Netherlands, the US, etc. (with support from GAP China) • “Seeing is believing” about harm reduction • Thinking about change in China

27. Strategies - 2 • Policy modification • Policies for MMT • 3 Ministries • Ministry of Public Security • Narcotics Control Law

28. “Provisional Protocol for MMT Pilot” Jointly issued by MOH and MOPS in 2003

29. The Law of the People’s Republic of China on Narcotics Control • The Law of the People’s Republic of China on Narcotics Control was enacted June 1, 2008. • Article 51 The administrative department of health under the people’s government of a province, autonomous region, or municipality directly under the Central Government shall, together with the public security organ and the drug supervision and administration department, and in light of the needs for cementing the drug rehab achievements and the prevalence of HIV/AIDS in this administrative region, organize maintenance treatment with drug-relief medicines.

30. Strategies - 3 • Publicity and community education • Communication strengthening between public health and public security • Training of MMT staff • PHE – increase methadone dosage plus enhanced intervention

31. Proportion of Patients on ART by Year, China National Free ART Program, 2003-07 Other Blood- product Sex -transmission IDU FPD

32. A Model Program: The Lixin Rural Clinical AIDS Training Program in Anhui Province • As of July 2008, 72 doctors have been trained (in close collaboration with Clinton Foundation and China CDC) • 90% of graduates now clinical experts in their home counties • Graduates care for 15,300 patients on ART in China

33. Key Obstacles Faced in Implementing Technical Assistance in China • Enormous size of the population with multiple HIV ‘hot spots’ and sub-epidemics • Human capacity development (lowest at the local levels, especially the poorest regions) • National and local resource allocation does not yet match the strategic HIV priorities • Limited civil society (NGO) involvement • Despite very rapid economic growth, there is severe poverty and inequitable financing of basic health care.