Delivering Antiretroviral Therapy: Challenges and Lessons Learnt in China

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Delivering Antiretroviral Therapy Challenges
and Lessons Learnt in China
Fujie Zhang, MD Division of Treatment and
Care National Center for AIDS/STD Prevention and
Control Chinese Center for Disease Control and
Prevention
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Outline

• Brief overview of HIV/AIDS in China
• National treatment and care policies
• The ART program for adult and pediatric patient
  populations
• Operational research
• Challenges and future work

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The HIV/AIDS epidemic in China

• It was estimated that 650,000PLWHA (including
  75,000 AIDS patients)1 by 2005.
• Total Reported HIV infected183,733 (including
  AIDS 40,667) by October 2006
• Exact figures are difficult to arrive at 2

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Distribution of HIV infectionsby age and
residential area
50 yrs 17.82
lt20 yrs 2.23
Urban 30
Rural 70
20-49 yrs 79.34
Age Distribution
Residency Distribution
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Four Frees and One Care

• Announced by the Ministry of Health in December
  20033
• Free ART for all rural AIDS patients and urban
  residents in financial difficulty
• FREE voluntary counseling and testing
• Free education to children orphaned by AIDS
• Free VCT and PMTCT services for pregnant women
• Care and economic assistance to the households of
  people living with HIV/AIDS

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Financial responsibility

• The central government is responsible for the
  cost of ART for qualified recipients
• Local governments are responsible for other
  costs, including drugs for treatment of
  opportunistic infections, training, outreach, and
  removing barriers to access

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The Free ART Program

• First piloted in 12/02 when 100 patients received
  
• AZT DDI EFV
• Rapidly expanded through the China Comprehensive
  AIDS Response (CARES) Program
• 57 counties in 8 provinces initially
• 7,000 patients on ART by the end of 2003
• 80 AZT DDI NVP
• 20 D4T DDI NVP

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The Free ART Program

• Cumulative cases on Treatment- 35,095 adults in
  31 provinces/regions , 298 cities, 905 counties
  (June 2007)
• Continuous 28,646 cases, 82.06
• Drop out 6,449 cases, 6.89
• Death 4,072 cases, 11.03
• First Line Recommended Regimen now
• AZT or D4T 3TC NVP or EFV

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Cumulative cases on Treatment
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The emergence of side effects after 6 months of
treatment
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Reasons For Drop Out
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Treatment model

• Three tiered system village, township, county
• Local CDC Community and/or home-based care with
  regular ART follow up at township/village level
• County Hospital Advanced supervision of ART
• Emphasis on community-level care
• Consultation and referral linkages for complex
  cases with prefectural, provincial, and national
  facilities
• Develop health team that includes adherence
  workers and community support

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ART in the National Program

• Current drugs on the free ARV list
• Domestically produced generics AZT, D4T, DDI,
  NVP, IDV
• Imported, branded drugs 3TC, EFV
• Second-line ART in seven provinces support by
  GF. (Keletra, TDF)
• Outside the national program, the cost of the
  generic drugs is 330 RMB/month (US 40/month)

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Pediatric treatment

• Cumulative reported HIV infected pediatric-1888
  by August 2006
• 1259 alive (March 2005)
• 698 on treatment (June, 2007)
• No pediatric ART formulations were available in
  China until 5/05 when the Clinton Foundation
  donated AZT, D4T, 3TC, NVP, EFV, and
  cotrimoxazole
• Treatment started 7/05 with an initial target of
  six sites
• Care is county-based initially with subsequent
  follow-up at the village and township level

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Pediatric treatment

• Treatment teams consist of national/ provincial
  and local physicians (both pediatricians and
  infectious disease specialists) along with
  community health workers
• The program has scaled-up to the whole country as
  more children are identified

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International Partners

• Global Found
• second line ARV
• capacity building
• some CD4 equipments and reagents
• DOT and etc
• WHO, UNICEF
• U.S. CDC GAP, U.S. NIH
• Clinton Foundation HIV/AIDS Initiative
• China U.K.
• UCSF/University of Maryland/University of North
  Carolina

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Operational research

• Designed to improve delivery of HIV/AIDS
  treatment and care
• On-going projects at NCAIDS
• ART adherence study in the IDU population
• Cotrimoxazole side effects and adherence
• Pediatric observational cohort
• HIV and other pathogens (HCV,HBV) coinfection
  study
• Family care project
• TB/HIV coinfection pilot
• Drug resistance studies
• Behavioral interventions

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Challenges

• Addressing poor adherence, insufficient community
  support, stigma and discrimination
• Laboratory capacity and quality
• Second-line ART
• Adequate clinical training and health care system
  development, especially in rural areas
• Establishing comprehensive care networks

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• Thank you for your attention!
• Fujie Zhang, MD
• treatment_at_chinaids.org.cn