International cooperation projects support China’s HIV/AIDS prevention and control efforts in a number of ways. First, international projects have brought important funding to China, significantly increasing HIV/AIDS program resources. More importantly, along with the projects, there are concepts, strategies, best practices and innovative models concerning HIV/AIDS control and prevention. By influencing the HIV/AIDS policy environment, building institutional infrastructure, strengthening capacity and developing civil society, new concepts and strategies have been put into effect in several areas and have dramatically improved China’s response to HIV/AIDS. In addition, the effects of international cooperation have allowed China to reach a level where China is now taking on a more active role in supplying international aid to other countries for their own HIV/AIDS response.6,7
Making up for deficiencies in HIV/AIDS resources
Although the Chinese government has increased domestic annual funding for HIV/AIDS prevention and control to >100 million USD,1
the actual needs remain far greater.8
Funding from international cooperation makes up for this deficiency to a great extent and accounts for one-third of the total funding for HIV/AIDS programs since 1988.
Beginning in 2000, many international cooperation projects like the World Bank Health 9 Project, China–Germany Program have provided continuous support for the development of laboratory equipment, training, technical assistance, management capacity to the National AIDS Reference Laboratory and the national laboratory networks and quality control system. This has strengthened HIV/AIDS laboratories greatly. The GFATM of China AIDS Project and UNICEF provide vehicles for remote areas in an attempt to address the problems caused by traffic inconveniences on AIDS prevention work.
International support has not only been provided to governmental agencies, but also to Chinese domestic NGOs, civil society organization or grassroot organizations. From 2005 to 2008, 11.8 million USD was provided for their activities, including training and prevention interventions.
Based on the satisfactory performance in past rounds of the China GFATM, the Rolling Continuation Channel (RCC) was successfully established. This programme is a 6-year (2010–15) comprehensive programme, covering all 31 provinces and municipalities and fully integrated with the national HIV/AIDS program. The total RCC budget is 510 million USD, with 59.5 million USD approved in 2010. The RCC program is the largest and one of the most influential international cooperation HIV/AIDS projects in China.
Yunnan province has received at least 30 million USD to date through international cooperative efforts.5
During the implementation of these projects, the Yunnan HIV/AIDS Prevention and Control Program has adapted international experiences to local contexts, integrated their HIV/AIDS prevention and control resources and ensured all projects were compatible with their province framework. International projects have reduced the shortage of financial and technical support in Yunnan. They have achieved remarkable success in advocating for policy change, building capacity, establishing interventions, conducting surveillance, testing MARPs and providing anti-retroviral treatment to those in need. Studies found that the incidence of HIV dropped among the MARPs from 15.4% in 2004 to 9.8% in 2007, even though risk behaviours still remain in the local population. 9–11
Introducing advanced concepts, strategies, technologies and best practices
International cooperation projects not only bring funding to China, but also introduce advanced theories and strategies. These strategies have been employed in several areas, including using surveillance to promote testing and early diagnosis of HIV infection, increasing universal access to AIDS care and treatment and preventing second-generation HIV transmission, among others. These activities have significantly accelerated the improvement of China’s HIV/AIDS surveillance strategy from passive surveillance to active case finding combined with case management. In 2000, China initiated a voluntary counselling and testing (VCT) pilot programme with the support of the WHO, the UNFPA and the China–UK programme. Based on the experiences of the pilot programme, VCT became a national strategy in 2004 and was expanded to 7335 sites by December 2009. The surveillance strategy has also changed from sero-surveillance to behavioural surveillance, and later to comprehensive surveillance, which is the combination of the serology and the behavioural surveillance. The development of surveillance system impacts the determination of AIDS policy and the use of HIV/AIDS resource.12–14
UNAIDS and WHO have recommended a series of intervention measures for high-risk populations including VCT, health education, condom promotion and social marketing, methadone maintenance treatment and needle exchange. In 2001, with the cooperation of WHO, China launched a condom promotion project in Hubei, Jiangsu, Hunan and Hainan provinces. In Yunnan and Sichuan provinces, the China–UK program also began to explore intervention models among commercial sex workers and condom social marketing. These projects proved to be useful in the Chinese context. Several interventions, including condom promotion, STD clinic-based outreach and intervention among low-fee sex workers and clients, have all been developed and are still improving. These methods have been adopted as national guidelines for HIV/AIDS control and were scaled-up throughout the country. Experiences accumulated in these projects have been very helpful to explore appropriate intervention models for high-risk populations in China. These experiences have established a base for the generalization of best practices and have informed strategies at the national level. For example, condom promotion was adopted in the national HIV/AIDS Prevention and Treatment Regulation in 2006.
In 2002, the first government-initiated intervention programme for MSM was conducted in Yunnan and Sichuan provinces under the support of the China–UK AIDS program. Several innovative intervention activities were conducted with the cooperation of the MSM community, including hotlines, face-to-face counselling, theme parties, internet-based education and peer education. These intervention methods were widely scaled-up and continue to play a leading role in behavioural interventions among MSM in China. In 2008–09, China conducted a survey among MSM in 61 cities to determine the extent of HIV infection among this population with support from BMGF.15
International cooperation projects have played a vital role in exploring models for the prevention of mother-to-child transmission of HIV (PMTCT). Moreover, many international organizations, such as WHO, Global Fund China AIDS Program, CHAI, UNFPA and CDC–GAP, are involved in a number of activities including monitoring and evaluation, staff training, development of technical documents, strategy research and service model exploration in the field of PMTCT.
Some international cooperation projects fill gaps in China’s response to HIV and AIDS. For example, the Clinton Foundation provides free antiretrovial therapy (ART) medicine for children, whereas the GFATM China AIDS Program provides second-line ART medicine. These projects significantly improve China’s ART program for children and adults.
Improving the social environment surrounding HIV/AIDS
Through these collaborations, China has increased the number of government agencies collaborating on the response to AIDS. These agencies have in turn adopted policies emphasizing transparency and the open sharing of data. To some extent, the involvement of international cooperation makes the various levels of government more serious about HIV prevention and pushes to improve the social environment surrounding HIV/AIDS. Advocacy for policy change and the development of strategic plans are a major task in the early stage of most international cooperation projects. Through a series of activities, including training, investigations, study sessions and workshops involving government officials and policy-makers from multiple sectors, an enabling environment has been created promoting cooperation between multiple sectors. This provides strong support for national leadership development and policy advocacy. China’s HIV/AIDS comprehensive response mechanism, which is a government-led, multi-sector cooperation and involves participation of the whole society, was created one step at a time. Top national leaders have visited AIDS patients, supervised HIV prevention work and encouraged health workers during the annual World AIDS Day activities. This has set a good example for the whole society to follow. Supported by these programmes, the State Council AIDS Working Committee Office has issued several documents and guidelines such as Mid/Long-Term Plan for HIV/AIDS Prevention and Control in China (1998–2010), China’s Action Plan for the Containment and Control of HIV/AIDS (2001–05; 2006–10), ‘Four Frees and One Care’ AIDS policy, State Council Notice on Strengthening HIV/AIDS Prevention and Treatment Work and various technical guidance documents and practical suggestions on promoting condom use and community-based methadone maintenance treatment, among others. The issue of these documents has improved the social environment of AIDS control in China.16,17
Strengthening capacity and developing grassroots social organizations
With the aid of international cooperation projects, the capacity of staff at HIV prevention and control departments at the national, provincial and local levels has been improved. Improving the capacity of personnel is consistently one of the most important objectives for international projects. Technical documents, developed by different projects, have proven helpful to local health workers in mounting a rapid response to emergencies as well as in improving problem-solving capabilities and technical standardization. Some international cooperation projects have organized training sessions, workshops and study tours to improve abilities in project management, specialized knowledge and research methods. International cooperation projects create a team of HIV/AIDS fighters who are not only familiar with advanced international information and technology, but who also have ample field work experience. They have become the main force in fighting AIDS in China. In addition, programmes support applied research in HIV/AIDS prevention and control. The results of research provide valuable knowledge and scientific evidence for improving China’s HIV/AIDS prevention and control work.18,19
Training has also been conducted at village and township levels. With the cooperation with US CDC–GAP and the Clinton Foundation, the first Rural HIV/AIDS Clinical Training Centre was established in Lixin County, Anhui Province. The centre has trained more than 100 village doctors on HIV/AIDS treatment and care. In 2010, US CDC–GAP established the second training centre in Luzhai County, Guangxi Autonomous Region. Supported by the GFATM Round 3 China AIDS Project, second-line ART regimens were used in seven provinces in central China where AIDS patients have been on treatment the longest. The Clinton Foundation’s donation of paediatric ARV drugs and technical inputs greatly supported the implementation of the National Paediatric ART Program. GFATM Round 4 China AIDS Project supported the implementation of paediatric treatment evaluation and drug resistance screening among paediatric patients.
Over the past 20 years, China has made use of the flexibility of foreign resource to encourage and emphasize involvement of CBOs in HIV/AIDS prevention and control activities by actively supporting and facilitating CBO development through providing funds and technical support. The professional guidance relationship between China’s Ministry of Health and international NGOs, including CHAI and BMGF, was established creating a new aspect of civil cooperation in foreign affairs. With the support of international cooperation projects, domestic CBOs are continually developing, growing and contributing to domestic HIV/AIDS prevention and control work. The number of CBOs has increased dramatically from a dozen in 1990 to several hundred in 2009. There were 357 CBOs registered to participate in the GFATM China Country Coordinating Mechanism development in 2009.
Establishing a platform for communication and experience sharing with the international community
The implementation of international cooperation projects has established a platform of communication and cooperation between China and other countries. Through the support of international cooperation projects, China’s National AIDS Reference Laboratory (NARL) has been strengthened. The reference laboratory passed the international quality control and quality assurance certification tests relating to STI/HIV/AIDS in 2008. The China Integrated Program for Research on AIDS (CIPRA), a joint collaboration with the US National Institutes of Health (NIH)/National Institute of Allergy and Infectious Disease (NIAID) from 2002 to 2008, has pursued research in behavioural interventions, viral immunity, clinical management and vaccine research through research projects in China. The research project has generated 101 articles published in peer-reviewed journals.
China has embraced its international obligation to support other developing countries with HIV/AIDS prevention and control assistance by providing financial and technical support. Focuses of assistance have included training HIV/AIDS professionals in African countries; implementing cross-border activities with Myanmar, Laos and Vietnam; having donated 10 million USD to GFATM and just announced donating another 14 million USD in next 3 years; introducing China’s HIV/AIDS prevention and control experiences to visitors and study groups from developing countries and actively participating in international and regional HIV/AIDS prevention and control conferences to communicate and share information.