China's substantial efforts to scale up access to highly active antiretroviral therapy (HAART) over the past several years has resulted in national treatment coverage increasing from almost zero to 63.4% and HIV-related deaths decreasing by more than 60%, just 7 years after the introduction of free HAART for HIV patients. However, there remains an urgent need for earlier diagnosis and increased treatment for injecting drug users, those infected sexually, and men. The findings, published Online First in The Lancet Infectious Diseases, are the first to report nationwide HIV treatment and mortality data for China.
"Given the size of the country, and the geographical spread of individuals with HIV...China's treatment coverage is remarkable...but it is far from the goal of complete coverage of people who meet the treatment criteria", explain Fujie Zhang from the National Centre for AIDS/STD Control and Prevention, Beijing, China and colleagues.
By the end of 2009, 323 252 people were reported as having HIV in China, of whom 82 540 have been treated by the China National Free Antiretroviral Treatment Programme (CNFATP). The government launched the national programme in 2002 and in 2003 it became one of the first to scale-up HIV treatment in a developing country, initially to diagnose and treat former plasma donors and then the rest of the country.
In this study, the authors quantify the impact of China's free HAART programme on national treatment coverage and mortality outcomes in adults.
The researchers used data from the national HIV epidemiology and treatment databases to identify adults with HIV who were eligible for HAART between 1985 and 2009. They calculated mortality in terms of person-years, meaning the number of years of life lost due to premature death from HIV, and treatment coverage as the proportion of time patients who were eligible for treatment received treatment.
Findings showed that 7 years after the programme was introduced treatment coverage had increased from almost zero to 63.4%, and overall mortality had fallen among eligible patients from 39.3 per 100 person-years in 2002 to 14.2 per 100 person-years by 2009.
The biggest success of China's national HIV programme was made in former plasma donors. Targeted large-scale HIV screening and successful treatment of those eligible resulted in 80.2% treatment coverage by 2009 and mortality decreasing to 6.7 deaths per 100 person-years.
However, this success was not replicated in those infected sexually (61.7% coverage; 17.5 deaths per 100 person-years) or through injecting drugs (15.9 deaths per 100 person-years; 42.7% coverage).
The two strongest risk factors related to death from HIV/AIDS were not receiving HAART and having a low CD4 cell count when first declared eligible for treatment.
The authors conclude: "Injecting drug users, those infected sexually, men, and those underserved by the public health system, such as migrants, the elderly, and minority groups, are at greater risk of not receiving treatment. Increased attention must be given to these populations to diagnose HIV infection earlier and increase treatment coverage."
In a Comment Ka-Hing Wong and Kenny Chi-Wai Chan from the Department of Health, Hong Kong, China say: "The study...[provides] evidence for the feasibility of a public health approach to generate continued positive outcomes in a large population of patients...The achievements of the underpinning treatment programme...[are] a clear example of the difference that can be made with high-level political commitment."
However, they remark that: "The CNFATP has to be supplemented by nationwide clinical management systems to cater for patients whose clinical needs are not met by the public health approach."
Professor Fujie Zhang from the National Centre for AIDS/STD Control and Prevention, Beijing, China. T) +86 10 6303 9086 E) firstname.lastname@example.org
Dr Ka-Hing Wong, Department of Health, Hong Kong, China.T) +852 3143 7288 E) email@example.com