HIV Care and Treatment in China
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Transcript of HIV Care and Treatment in China
HIV Care and Treatment in China
2William J. Clinton Foundation HIV/AIDS Initiative
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
HIV/AIDS Situation in China
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China in Context: Regional and Domestic Influences on the Development of an HIV Epidemic
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1985
1989
1995
1998
Spread of HIV/AIDS epidemic 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.
HIV/AIDS Context in China
IVDU Regions
FPD 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.
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HIV/AIDS Epidemic in China
Drug Users
Sex Workers
Family
ChildrenSource Population
Bridge Population
General Population
China’s “Free ART” HIV Care and Treatment
Program
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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.
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HIV/AIDS Epidemic and National ART in China
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
Comparison Between Cum. Reported Cases of HIV and Patients on ART
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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.
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China’s National Free ART Program: Outcomes Analysis
Change over time by mortality and survival following treatment initiation for previously ART-naïve adult AIDS patients
Zhang FJ, et al: Four Year Outcomes of the China National Free Antiretroviral Treatment Program. XVII International AIDS Conference, Mexico City, 2008.
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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
Clinton Foundation in China
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Clinton HIV/AIDS Initiative (CHAI) China Cooperation Partners
Clinton Foundation
Ministry of Health
Bureau of Disease Control
Department of Comm., M&C Health
Department of Hospital Admin.
Department of Int’l Cooperation
Xinjiang BOH
Yunnan BOH
China CDC
CAMS
NCTB
NCAIDS
NCWCH
ARC
Anhui CDCCMU No.1 Hospital
Ministry of Civil Affairs
Bureau of NGO Management
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CHAI Global Structure & Services
Access Services
• Pharmaceuticals• Global Diagnostics
• UNITAID liaison• Malaria• Nutrition
Country Operations
• Africa • Asia
• Latin America & the Caribbean
• Eastern Europe
Programs
• 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
17William J. Clinton Foundation HIV/AIDS Initiative CHAI Regional Meeting 2007
Care & Treatment
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
Bringing target population 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 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
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
Containment
Continuum of C &T: CF China Partner Support Strategy CHAI Cooperative Support Strategy in China
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Regional Treatment & Care Partnerships
Target Populations and Regions:
PLWHA without access to HIV treatment and care services•Challenge: Develop new local systems for quality HIV treatment and care
Rural epidemics in rugged border regions of SW and NW China•Challenge: Getting services out in remote areas with dispersed populations
IVDU prevalent epidemic areas, poor and minority PLWHA •Challenge: Patients are hard to identify and reach; many barriers to retention in care
Rising HIV prevalence, at risk for becoming generalized epidemics
•Objective: Develop effective treatment and care services integrated with community outreach, prevention, and harm reduction in order to achieve containment of the epidemic
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Regional Treatment & Care Partnerships
Approach: Work with government and multisectoral partners to support developing capacity and integrated systems for high quality AIDS treatment
• YUNNAN Province Bureau of Health
• XINJIANG Uyghur Autonomous Region Bureau of Health
• Government is responsible for HIV/AIDS control; CF supports government’s HIV/AIDS treatment and care work
• Integrate with other resources, avoiding overlap with other programs
• Facilitate collaborative linkages with government agencies across sectors (hospitals, CDCs, MCH, DCs, MMT, etc)
• Support partners to pilot new HIV/AIDS treatment and management models in local settings (e.g., integration of ART with MMT, expansion of treatment and care in closed settings)
• Build capacity by working closely with local BOH partners and participatory M&E
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Background on Regional Treatment & Care Programs
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
XinjiangYunnan
Program Objectives:
•Increase number of patients in care and on ARV treatment
•Maximize number of patients who are successfully treated and retained in care
•Create sustainable replicable models for comprehensive HIV/AIDS treatment and care
Yunnan Province Bureau of Health - Clinton FoundationCooperative HIV / AIDS Treatment and Care Program
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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.
Si chuan
Yunnan
Xi nj i ang
Ti bet
Gansu
Qi nghai
Nei menggu
Guangxi Guangdong
Chongqi ng
Hunan
Gui zhou
Hubei
Henan
J i angxii
Fuj i an
Anhui
Zhej i ang
J i angsu
Shandong
Shaanxi
Shanxi
Hebei
Li aoni ng
J i l i n
Hei l ongj i ang
Bei j i ng
Ti anj i n
Shanghai
Tai wan
Hai nan
Ni ngxi a
40,001-60,000
20,001-30,000
30,001-40,000
101-500
1-100
501-1,000
1,001-5000
5,001-10,000
10,001-20,000
HIV/AIDS Cases
Geographic distribution of cumulative reported HIV cases in China (as of October 2007)
Source: People’s Republic of China Proposal Form, Rolling Continuation Channel (RCC) to the Global Fund, November 2008
IVDU Regions
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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
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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.
No
. of
pat
ien
ts e
nro
lled
on
AR
T
Number of patients enrolled on ARTFigures at YE, 2005 - 2008
487
1,397
2,762
4,657
458
1,254
2,393
3,926
0
1,000
2,000
3,000
4,000
5,000
2005 2006 2007 2008
Cumulative on ART at YE Active on ART at YE
Source: Analysis using SIMCLIN and Patient Information System dataNote: 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.
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Yunnan Program Outcome: Site Scale-upOne important focus of the program has been on accessing hard-to-reach patients in closed facilities.
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
Key achievements By March 31, 2009
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Components of the Comprehensive Care and Treatment ModelThe four key components of support:
Clinical 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
Laboratory Capacity Building
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
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
Program Management / Local HIV Care Coordination
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
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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.
Ann
ual L
TF
U r
ate
Impact of the program on lost-to-follow-up rates1
Annual LTFU rate2
4.6%
1.8% 1.6%
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
3.5%
4.0%
4.5%
5.0%
Before program 2007 2008
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%
1 ACC Analysis of the 9 sites that had ACC presence for more than one year as of YE 20082 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
These rates demonstrate the efficacy of the comprehensive continuum of care model, with especial emphasis on peer-based community treatment support
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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 undetectable = successful ART outcome
VL outcomes in Yunnan sites have consistently been ~90%, placing them among the best in nationwide surveys
Pat
ien
ts a
s o
f Y
E20
08
Viral load suppression as indicator for treatment success
202
1,651
0
200
400
600
800
1,000
1,200
1,400
1,600
1,800
2,000
Pts who have received VLtest in last 6 mo.
Percent of patients who have undetectable VL results in last 6 mo.= 89%
Undetectable
1 Analysis includes adults and children66% of all patients on who have been on treatment for more than 6 months have received a VL test in the last 6 months89% 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)
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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.
0.2 0.8
1.4
4.7
1.2
1.9
2.9
2.6
-
0.7
1.2
0.1
0.7
1.2
1.8
0.3
0.5
0.6
1.0
-
2.0
4.0
6.0
8.0
10.0
12.0
2005 2006 2007 2008
Program Management
Clinical Treatment and Care
Community Treatment Support
Lab Program
Capacity Building
M RMB
1.8M 3.5M 6.8M 11.3M
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.
Xinjiang Uyghur Autonomous Region Bureau of Health – Clinton Foundation Cooperative HIV / AIDS Treatment and Care Program
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More photos . . . The end.
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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
Si chuan
Yunnan
Xi nj i ang
Ti bet
Gansu
Qi nghai
Nei menggu
Guangxi Guangdong
Chongqi ng
Hunan
Gui zhou
Hubei
Henan
J i angxii
Fuj i an
Anhui
Zhej i ang
J i angsu
Shandong
Shaanxi
Shanxi
Hebei
Li aoni ng
J i l i n
Hei l ongj i ang
Bei j i ng
Ti anj i n
Shanghai
Tai wan
Hai nan
Ni ngxi a
40,001-60,000
20,001-30,000
30,001-40,000
101-500
1-100
501-1,000
1,001-5000
5,001-10,000
10,001-20,000
HIV/AIDS Cases
Geographic distribution of cumulative reported HIV cases in China (as of October 2007)
Source: People’s Republic of China Proposal Form, Rolling Continuation Channel (RCC) to the Global Fund, November 2008
IVDU Regions
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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
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Xinjiang Program Outcome: EnrollmentSince 2007, the program has supported enrollment ~1760 patients on treatment, and initiated pediatric ART now providing treatment for 62 children.
No
. of
pat
ien
ts e
nro
lled
on
AR
T
Number of active patients enrolled on ART
Source: Xinjiang Regional BoH and CHAI
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Xinjiang Program Outcome: Site Scale-upImplementing comprehensive HIV treatment/care services through local BoH management
County-level site locations
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
Key achievements by YE 2008
Denotes Current CF Site Location
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Components of the Comprehensive Care and Treatment ModelCornerstones of cooperative support
Clinical 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
Laboratory Capacity Building
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
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
Program Management / Treatment Financing Pilot
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
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Integrated Services
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Health Workers, Peer Community Workers
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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.
Cum
ulat
ive
LTF
U r
ate
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
1 Source: Xinjiang Regional BoH and Local BoH 2 Source: Xinjiang Regional BoH and Local BoH
These outcomes support a preliminary assessment of efficacy for the comprehensive continuum of care model and peer-based community treatment support
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Snapshot of Xinjiang Program Highlights- Non-ARV Treatment Cost Financing Pilot
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
Budgeted Actual (sample site, 600 patients enrolled)
850 RMBper pt per year
650 RMBper pt per year
County A County B
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Continuum of Care ModelCHAI’s approach for supporting comprehensive HIV treatment and care
CARE & TREATMENT
CONTAINMENT
National Policy, Planning & Program Coordination
Provide platform / framework to enable a continuum of C&T nationwide through:
Laws, Protocols, Guidelines Procurement
M&E Research
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
Treatment Infrastructure
Development/establishment of sustainable health systems models for HIV/AIDS, including: Clinical Capacity Reliable Labs Affordable / accessible drugs & lab supplies
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
CHAI China’s National Level Partnerships:
National Pediatric Treatment Program
Lixin Rural HIV Clinical Training Center
HIV Lab Capacity Building
Early Infant Diagnosis and PMTCT Pilots
Increasing Drug Access in Neglected Diseases
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Anhui Lixin Rural HIV Clinical Training Center
Scope National Clinical Training Center Patients Impacted by Graduates 15,000
Partners
NCAIDS, US CDC GAP, Anhui CDC Number of Trainees 72
Highlights
• 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
Program Components
• 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
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Lixin Program - Practice-Based Clinical Training
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Lixin Program - Practice-Based Clinical Training
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Lixin Patient Stories
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Lixin Patient Stories
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Lixin Training Program
2004-2009•72 Trainees• 4 Fellows
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CHAI and China Pediatrics Partnership
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
Children on Treatment
Year End 2006
Year End 2007
Year End 2005
292
150
996
Year End 2008 1,440
Number of Provinces
10
4
21
24
* Note: CHAI and China NCAIDS estimate that 2,115 children currently need treatment.
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Kids
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China Pediatrics Overview
Majority of ENROLLED patients are from Henan Province Need significantly more case finding in provinces such as Yunnan and Xinjiang Implementation of Early Infant Diagnosis will lead to higher patient numbers
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Main CF Pediatric Program Activities
Pediatrics
Case Finding Procurement/Lab Training & Monitoring
Technical support to draft and conduct training of treatment guidelines
Continuous trainings management support for clinicians at the national,provincial and local levels
Provide regular monitoring and mentoring to local
clinicians
Provide consultations and evaluations at non-CF sites
Patient management for OIs, diagnosis, transportation,
nutrition, etc.
1st line drugs
2nd line drugs
Prophylaxis
Nutrition
Lab support for CD4, drug resistance tests and EID
Community-based case finding activities in IVDU areas
Early infant diagnosis (EID)
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