Published online 20 May 2011 | Nature | doi:10.1038/news.2011.310

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AIDS mortality drops in China

Antiretroviral programme marks dramatic success, but report shows what still needs to be done.

hiv in ChinaChina's public health campaign against HIV/AIDS has been a success, but there are still challenges ahead.Frederic J. Brown/Reuters/Corbis

The first comprehensive look at the use of antiretroviral AIDS treatments in China has found striking success in lowering mortality rates.

According to the report, published online on 19 May in Lancet Infectious Diseases1, coverage of the populations most in need of therapies shot up from nearly none in 2002 to more than 63% in 2009. During that time, mortality from AIDS dropped by 64%.

"It is a robust finding," says Ka-Hing Wong, an HIV specialist at Hong Kong's Department of Health, who was not involved in the study. "China was one of the first to scale up a national programme. It's quite remarkable that they could increase coverage to this extent." The United Nations' HIV/AIDS programme, UNAIDS, puts the global treatment coverage at about 43%.

But with many people still not treated, or not treated effectively, the study points as much to future needs as to past success.

Reaching the needy

Discussing HIV was more or less taboo in China until 2002, when the government first recognized that the country had a possible 1 million cases of the condition (see 'Arrest of AIDS activist underlines China's impending HIV crisis'). The same year, the China National Free Antiretroviral Treatment Programme (NFATP) began distributing antiretroviral drugs.

The destructive path of HIV is tracked by monitoring the decrease in blood levels of immune cells expressing the CD4 protein. Only those whose CD4 counts drop below 350 cells per microlitre are eligible for treatment under China's programme. (In 2008, China raised the level from 200 — the threshold used as a diagnosis of AIDS — two years ahead of World Health Organization recommendations to do so.) Of the estimated 740,000 HIV carriers in China, 323,252 had been diagnosed by the end of 2009. Of those, the NFATP has so far treated 82,540.

The programme focused first on the hundreds of thousands of farmers in Henan and other Chinese provinces who had been infected through unhygienic blood-collection businesses (see 'Chinese clinical trials: Consenting adults? Not necessarily...'). By 2009, more than 80% of target populations in those regions were on antiretrovirals.

But the programme has achieved poorer results in other populations. Only 62% of sexually infected people and only 43% of those infected through drug use are being treated.

Fujie Zhang, an HIV specialist at the National Centre for AIDS/STD Control and Prevention of China's Center for Disease Control (CDC) in Beijing, a founder of the NFATP and the lead author of the latest report, says that he wants 40,000 more people to begin treatment this year, but he knows that the programme will need to reach these difficult groups.

"Colleagues are doing an analysis on why we're not getting more. So far what we can say is that intravenous-drug users and sex workers move more frequently so it is difficult to enrol them and follow up. There is also discrimination," says Zhang. To raise the numbers, "we'll have to work closely with the local CDCs".

The study did give one lead as to how more vulnerable people can be reached. Drug users who visited methadone clinics were much more likely to get on the regimen, adhere to it, and live longer than other users. "It's a small group, but it was an interesting finding," says Zhang.

Increased screening is also essential, the report finds. Chinese people are often diagnosed late in the course of their disease, and there is a roughly six-month lag before treatment starts. The result is that by the time that many patients start therapy, it is no longer very effective. "Low CD4 count is the most important risk factor for mortality of patients receiving antiretrovirals," says Zhang. "HIV testing and early diagnosis is essential."

But stigmatization, by making those infected afraid to come forward, derails those efforts. Specialized infectious-disease hospitals care for HIV patients, but surgical hospitals, for example, will sometimes refuse to treat them. Zhang says the International Labour Organization in Geneva, Switzerland, criticized these discriminatory practices in a report on 18 May.

Raising the standard

Economic and infrastructure limitations will make some improvements difficult. For example, in developed countries, patients have the amount of HIV in their body measured every three or four months to ensure that non-adherence, resistance or other problems are not compromising the ability of the drugs to suppress the HIV levels, but this is not happening in China, says Wong. "If doctors don't detect failure, they won't see an indication to change," he says.

China is also working with a limited drug supply. Only 11 of the 24 antiretroviral drugs currently approved in the United States are available in China, partly because of the expense. The median age of a person newly diagnosed with the condition in China is 37, and they will usually live some 30 or 40 more years. The drugs cost US$40,000 per person per year. "You can imagine how much it will cost," says Zhang. He is working with pharmaceutical companies to try to get better access to medications.

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The limited drug selection complicates another question: whether to start treatment at higher CD4 levels, such as the 500-CD4-count threshold used in the United States. Last week, the US National Institute of Allergy and Infectious Diseases (NIAID) in Bethesda, Maryland, released a study showing that putting those infected with HIV on antiretrovirals as soon as they were diagnosed greatly reduced the risk of passing it to a partner or spouse. The results were so marked — only one patient in the early-treatment group passed the condition on, compared with 27 in the non-treatment group — that the NIAID closed the study four years earlier than scheduled.

But this is a tough call for China, where the available drugs are less effective and have more side effects. "Many don't want to take them because they are afraid of the toxicity," says Zhang. "I really want to ask people in the United States, if they were using the Chinese first-line medicines, would they switch to 500? Or should we keep the criteria at 350?"

Zhang is continuing to fine-tune the NFATP, through new guidelines that should be ready by the end of the year. He says that they will stick with 350 as the recommended threshold for prescribing medicines, but will probably single out cases — such as couples with only one infected partner, pregnant women and patients co-infected with Hepatitis B — for immediate or early treatment.

China has had success with a large-scale public-health approach to HIV and AIDS, but the country still lacks the ability to look at the specific clinical needs of individual patients, such as severe reactions to drugs, says Wong. "The public-health approach lacks clinical acumen, clinical expertise. [Health-care workers] are trained for narrow scope," says Wong. "Over time, however, they might get enough experience." 

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