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91–218 PDF 2004

CHINA’S MOUNTING HIV/AIDS CRISIS: HOW

SHOULD THE UNITED STATES RESPOND?

ROUNDTABLE

BEFORE THE

CONGRESSIONAL-EXECUTIVE

COMMISSION ON CHINA

ONE HUNDRED EIGHTH CONGRESS

FIRST SESSION

OCTOBER 20, 2003

Printed for the use of the Congressional-Executive Commission on China

(

Available via the World Wide Web: http://www.cecc.gov

CONGRESSIONAL-EXECUTIVE COMMISSION ON CHINA

LEGISLATIVE BRANCH COMMISSIONERS

House Senate

JIM LEACH, Iowa, Chairman

DOUG BEREUTER, Nebraska

DAVID DREIER, California

FRANK WOLF, Virginia

JOE PITTS, Pennsylvania

SANDER LEVIN, Michigan

MARCY KAPTUR, Ohio

SHERROD BROWN, Ohio

DAVID WU, Oregon

CHUCK HAGEL, Nebraska, Co-Chairman

CRAIG THOMAS, Wyoming

SAM BROWNBACK, Kansas

PAT ROBERTS, Kansas

GORDON SMITH, Oregon

MAX BAUCUS, Montana

CARL LEVIN, Michigan

DIANNE FEINSTEIN, California

BYRON DORGAN, North Dakota

EXECUTIVE BRANCH COMMISSIONERS

PAULA DOBRIANSKY, Department of State*

GRANT ALDONAS, Department of Commerce*

LORNE CRANER, Department of State*

JAMES KELLY, Department of State*

JOHN FOARDE, Staff Director

DAVID DORMAN, Deputy Staff Director

* Appointed in the 107th Congress; not yet formally appointed in the 108th

Congress.

(II)

(III)

C O N T E N T S

Page

STATEMENTS

Bhat, Amarmath, M.D., director, Office of Asia and the Pacific, Office of

Global Health Affairs, Department of Health and Human Services, Rockville, MD ............................................................................................................... 2

Wan, Yanhai, M.D., director, Beijing Aizhi Education Institute, and world

fellow, Yale University, New Haven, CT ........................................................... 5

Frost, Kevin Robert, vice president, Clinical Research and Prevention Programs, American Foundation for AIDS, New York, NY ................................... 7

Nieburg, Phillip, M.D., senior associate, HIV/AIDS Task Force, Center for

Strategic & International Studies [CSIS], Charlottesville, VA ........................ 10

APPENDIX

PREPARED STATEMENTS

Bhat, Amarnath ....................................................................................................... 30

Wan, Yanhai ............................................................................................................. 32

Frost, Kevin Robert ................................................................................................. 33

(1)

CHINA’S MOUNTING HIV/AIDS CRISIS: HOW

SHOULD THE UNITED STATES RESPOND?

MONDAY, OCTOBER 20, 2003

CONGRESSIONAL-EXECUTIVE

COMMISSION ON CHINA,

Washington, DC.

The roundtable was convened, pursuant to notice, at 2:30 p.m.,

in room 2255, Rayburn House Office Building, John Foarde (staff

director) presiding.

Also present: David Dorman, deputy staff director; Susan Weld,

general counsel; Carl Minzner, counsel; and Anne Tsai, specialist.

Mr. FOARDE. Let us get under way. On behalf of Chairman Jim

Leach and Co-chairman Senator Chuck Hagel of the CongressionalExecutive Commission on China, welcome to this issues roundtable

on ‘‘China’s Mounting HIV/AIDS Crisis: How Should the United

States Respond? ’’

We are delighted to have four extremely distinguished and

knowledgeable panelists with us this afternoon to continue our look

into questions of public health in China and how that affects the

human right to health, as articulated, among other places, in the

International Covenant on Economic, Social and Cultural Rights.

We have done an HIV roundtable in the past and some private

briefings, and wanted to get some experts together to carry on this

conversation about what is going on in China and what we might

do as a country to help persuade the Chinese Government to take

the action that is necessary to arrest the intensity of what seems

to be about to happen in China on HIV and AIDS.

Our panelists are Dr. Amar Bhat, director of the Office of Asia

and Pacific, Office of Global Health Affairs from the Department of

Health and Human Services [HHS]; Kevin Frost, vice president of

Clinical Research and Prevention Programs, the American Foundation for AIDS; Dr. Wan Yanhai, who needs no introduction, but is

the director of the Beijing AIZHI Education Institute, and this year

a World Fellow at Yale University; and an old friend, Dr. Phil

Nieburg, senior associate now with the HIV/AIDS Task Force at

the Center for Strategic & International Studies [CSIS].

We are going to follow our usual practice in going from wall to

window, and also our usual practice of having each panelist speak

for 10 minutes and make a presentation. After 8 minutes, I’ll let

you know you have 2 minutes remaining, and then that is your signal to wrap things up and we will go on to the next panelist.

Inevitably, there are points in your presentation that you will not

have time to cover, and we understand that, and we will try to pick

2

them up in the question and answer session after each panelist has

made a presentation.

We would ask each panelist to speak into the microphone, if you

would, so we can get a good record for the transcript, which will

eventually be available on our Web site. That is: www.cecc.gov. On

our Web site you can find both the transcripts and papers from our

previous hearings and roundtables, and also announcements about

upcoming events.

Before we start, we had some good news today. We were just

talking a minute ago about it, and it is hard to characterize things

like this, because this man should not have been arrested in the

first place.

But we received news over the weekend that Ma Funwan, the

deputy director for Disease Control in the Henan Provincial Health

Department, was released. Ma had been held by the government

for allegedly leaking documents about the HIV/AIDS epidemic in

that province.

We are a little bit unclear about when he was actually formally

arrested, but he seems to have been pretty much incommunicado

since the spring, and perhaps formally arrested in August. So, we

are really pleased that he is out and hope that this signifies some

real progress on transparency, but we are not holding our breath.

Anyway, I would like to begin then and call on Dr. Amar Bhat,

from the U.S. Department of Health and Human Services. You

have 10 minutes. Please go ahead.

STATEMENT OF AMARNATH BHAT, M.D., DIRECTOR, OFFICE

OF ASIA AND THE PACIFIC, OFFICE OF GLOBAL HEALTH AFFAIRS, DEPARTMENT OF HEALTH AND HUMAN SERVICES,

ROCKVILLE, MD

Dr. BHAT. Thank you very much. I appreciate the opportunity to

speak before the Commission. I also welcome the news about Dr.

Ma.

Again, my name is Amar Bhat. I am the Director of the Office

of Asia and the Pacific in the Office of Global Health Affairs, which

is in the Office of the Secretary, Tommy Thompson.

As such, I am the coordinator of all Asia Pacific activities in the

Department of Health and Human Services and a spokesperson for

Secretary Thompson in the Department in all matters pertaining

to this region.

This hearing today is quite timely, in that Secretary Thompson

is just now returning from his first visit to China as HHS Secretary. His visit was very brief, basically daylight hours of Sunday,

yesterday, coming on the heels of last week’s meeting of the Board

of Directors of Global Fund to Fight AIDS, Tuberculosis, and Malaria.

As you may have heard, at this meeting of the Global Fund

board, the Board of Directors did choose to accept and approve the

Chinese proposal to the Global Fund for work in HIV.

In the case of China, the third time was the charm. This was

China’s third attempt to garner funds for its HIV/AIDS work, the

previous two attempts having failed.

China’s third-round application had the same focus as the second-round application, rapidly commencing and scaling up VolVerDate 11-MAY-2000 09:43 Jan 15, 2004 Jkt 000000 PO 00000 Frm 00006 Fmt 6633 Sfmt 6633 91218.TXT China1 PsN: China1
3

untary Counseling and Testing [VCT], associated with critical care

and treatment options for large numbers of HIV-positive persons

living in seven Central China provinces most heavily affected by

the dangerous plasma selling practices of the mid-1990s, Yunnan

Province included.

The 2-year commitment for this grant is US$21 million. I believe

the entire request from the Chinese Government, or to Chinese

CCM, I should say, was US$98 million.

Rather than provide you with an exhaustive list of HHS activities in China, I would rather provide a description of three HHS

programs which have had significant investments in China. These

three programs are ones where we have felt that HHS is having

great impact, not only in China, but globally, utilizing HHS’s

unique blend of resources and skills.

Finally, I will end by touching on Severe Acute Respiratory Syndrome [SARS], for when it comes to China, at least, I feel it is impossible to talk about HIV, or for that matter any other major

health problem in China, without addressing SARS and the impact

that this disease has had, and will have, on China.

HHS has been involved in China since the opening of relations

in 1979. Since then, we have had a health protocol for cooperation,

covering cooperation in health and biomedical research. It is a

broad-based agreement covering all sorts of health topics.

We will be reviewing this protocol in the next few months before

the anticipated visit of Chinese Premier Wen Jiabao.

Recently, HHS has made a concerted effort to examine our relationship and to increase our investment in China. We believe that

part of the reason why is an acknowledgement of the substantial

scientific talent in China right now, many of whom were trained

in the United States, the greater participation of China in world

affairs, WTO being just one example, and the ever-increasing presence of disease, particularly infectious diseases such as tuberculosis

and HIV. With the onset of SARS earlier this year, the importance

of health has again leaped to the forefront more than ever before.

I will not take time to discuss why and how China has begun to

pay more attention to HIV/AIDS. I am sure some of the other panelists here can talk about that to a much better extent.

However, I can say that the greater openness of China and the

Chinese officials have made it easier for us to increase our investments there and take advantage of the considerable assets they

have to make a difference in the global war on AIDS.

Emblematic of this new relationship is the new Memorandum of

Understanding for AIDS Cooperation that Secretary Thompson and

then-Minister of Health Zhang signed last year here in Washington.

As I mentioned before, HHS has only begun to invest heavily in

China. Starting late last year, or actually earlier this year, I guess,

in February, the Centers for Disease Control’s [CDC] Global AIDS

Program [GAP] opened an office in China.

This two-person office officially opened its doors earlier today in

a brief ceremony involving the CDC Director, Dr. Julie Gerberding,

who was accompanying Secretary Thompson to China.

While a recent development, this office has been long in coming.

In fact, the beginnings of the GAP program in China can be traced

4

to a 2-week assessment visit in 2001 led by my pal here, Dr. Phil

Nieburg.

As part of that assessment, Dr. Nieburg and his team identified

several areas where China had significant deficits that CDC could

help to rectify. Still in its infancy, GAP in China currently focuses

on improving surveillance in VCT around the country. I should

note that the CDC does not provide direct health care services, nor

do any of the HHS components in China.

Also last year the National Institutes of Health’s [NIH] National

Institute of Allergy and Infectious Diseases, awarded a $14.8 million, 5-year grant to the China CDC, China’s Center for Disease

Control, and the Chinese Academy of Medical Sciences.

This multi-project grant, known as the Comprehensive International Program of Research on AIDS [CIPRA], is expanding China’s research activities in HIV/AIDS prevention, treatment, and

vaccine development in cooperation with experts from U.S. universities and medical schools.

CIPRA is unusual in that it is one of the few NIH-supported

research programs where, by design, the principal investigator is

located outside the United States. In this case, the principal investigator is Dr. Yiming Shao of the China CDC. The grant itself

consists of five interrelated projects, touching on a range of HIV/

AIDS-related questions.

In a third area where HHS has made considerable investments

in China is in training. While both the CIPRA and GAP have training components, there is another program I would like you to know

about.

Many of you know that untold numbers of Chinese professionals

have come to the United States for advanced training in a number

of scientific areas. Biomedical research is no exception.

At the intramural laboratories of NIH here in Bethesda, at any

one time we may have approximately 300 Chinese scientists visiting in our labs, conducting research side-by-side with other scientists at NIH.

Additionally, there must be thousands more in American universities around the nation, many of them here temporarily or others

planning to settle permanently in the United States. Dr. Yiming

Shao is actually one of those who was at NIH for a number of years

before going back to China.

Additionally, the NIH has made considerable investment in

training Chinese and other developing country scientists in highpriority areas of research, including HIV/AIDS and other infectious

diseases. The NIH’s Fogarty International Center administers the

AIDS International Training and Research Program [AITRP] which

supports HIV/AIDS and related TB international training and research for health scientists, clinicians, and allied heath workers

from China and dozens of other developing countries.

The primary goal of this program is to build biomedical and behavioral research capacity for the prevention of AIDS and related

TB infections, and for the identification of appropriate interventions to provide care to those adults and children affected with

HIV.

Under AITRP, scientists are trained to address the global HIV/

AIDS epidemic through skills development and fostering of longVerDate 11-MAY-2000 09:43 Jan 15, 2004 Jkt 000000 PO 00000 Frm 00008 Fmt 6633 Sfmt 6633 91218.TXT China1 PsN: China1
5

term relationships between individual scientists and institutions in

both countries.

The scope of training includes epidemiology, biostatistics, behavioral interventions, program evaluation, research in drug use, blood

safety, vaccine development and evaluation, virology, diagnosis,

and treatment.

To date, 12 doctoral degrees, 4 master’s degrees, and 24 postdoctoral fellowships have been awarded to Chinese scientists and

physicians through AITRP. Others have been trained through incountry workshops using faculty from U.S. universities supported

by AITRP.

One of the wonderful aspects of AITRP is that it leverages and

complements much of what NIH is already funding through U.S.

universities, medical schools, and also other major funders, such as

the World Bank, are also supporting.

While these are three major HIV-related programs HHS has undertaken in China, there are numerous other activities outside of

HHS you may be interested in hearing more about. USAID is starting

to involve Yunnan Province in its Greater Mekong HIV prevention

initiative. Another initiative is a workshop taking place later this

week—Friday, in fact—in Beijing, organized by the State Department and the Development Research Center of the State Council.

The primary purpose of this 1-day workshop will be to present

and discuss various methodologies that can be adopted to estimate

and forecast the macroeconomic impact of HIV/AIDS in a society at

both the local, provincial, regional level, and at the national level,

with a focus on the situation in China.

The State Department is also funding a proposal from the Shanghai Academy of Social Sciences to support the development of

model AIDS legislation.

Now, as I mentioned, I wanted to touch on the impact that SARS

has had, and will have, on HIV in China. In the short term, SARS

has slowed the momentum we saw building in 2001 and 2002.

During the worst of the epidemic, staff at the China CDC, and

even our own HHS staff in Beijing, were pulled from their normal

duties and asked to devote their full attention to addressing the

national emergency. This, in particular, impacted heavily the first

year of GAP.

Mr. FOARDE. Why do we not come back, because I would very

much like to hear you finish that particular part of the presentation, in the question and answer.

Dr. BHAT. All right.

Mr. FOARDE. Thank you, Dr. Bhat.

Dr. BHAT. Thank you.

[The prepared statement of Dr. Bhat appears in the appendix.]

Mr. FOARDE. I would like to go on please, to Dr. Wan. Please go

ahead.

STATEMENT OF WAN YANHAI, M.D., DIRECTOR, BEIJING AIZHI

EDUCATION INSTITUTE, AND WORLD FELLOW, YALE UNIVERSITY, NEW HAVEN, CT

Dr. WAN. First, I am very honored to speak at the roundtable.

Thanks for inviting me to talk about information transparency and

6

the public participation in AIDS work on both the Chinese and

American sides.

I am Wan Yanhai. I am the director of the Beijing Aizhi Institute

of Health Education. Our institute was officially registered last October. Our program has been active for about 10 years, but at the

end of last September, early October, we got official registration.

I want to talk about information transparency and the public

participation. I think this is very important in the fight against

AIDS in China.

So, first, on China’s side, I want to mention that recently the

Chinese State Environmental Protection Agency has adopted a policy of open government information and public participation in environment protection issues and monitoring of government work.

Second, article 23 of the Law on the Control and Prevention of

Infectious Diseases clearly demands that the government publish

information on infectious disease.

Third, the State Secrets Law contains no provisions relating to

health information. Moreover, in 1999, the Ministry of Health

issued a notice to all provincial health departments stating very

clearly that the AIDS-related information is not a state secret.

Fourth, I believe there is no fundamental legal barrier or policy

that prohibits publication of information related to AIDS and other

health information.

Fifth, unfortunately, in the past few years, and most recently

with SARS, the Chinese Government has covered up important

health-related information, including, of course, AIDS-related information.

Sixth, the essentially nationwide blood sales-related epidemic became known to the central government, among others, in the mid1990s, but it was only in December 2002 that the former Minister

of Health, Zhang Wenkang, reported it to the National People’s

Congress that the blood sales-related AIDS epidemic was present

in 23 provinces. The Chinese Government has not informed the

public which provinces and which counties are affected.

It has said, however, that in many of these affected areas, the

HIV infection rate among blood donors is 10 to 20 percent, and in

some areas it is as high as 60 percent.

I want to talk about how the United States can help in both information transparency and in public participation. First, in the

past few years the U.S. Government, foundations, institutions,

NGOs, and the U.N. and other international organizations have

fortunately started to turn their attention to the AIDS crisis in

China.

Second, I would like to encourage the U.S. Government, NGOs,

and any other organizations working in this area in China to share

information with the Chinese public, to seek their comments and

input on programs and strategies, and to involve the Chinese people

in their work. Specifically, these entities should involve the Chinese people in the planning, implementation, monitoring, and evaluation of AIDS-related programs.

These foreign entities should work with Chinese NGOs, academics, health institutes, and other emerging, informal groups who

focus on AIDS-related issues.

7

What I want to emphasize is the importance of informal groups,

because of the difficulties of getting official registration for labor

rights organizations, gay/lesbian rights organizations, women’s activities, organizations for immigrant workers and some religious

groups to get involved in the work.

In addition to working with and soliciting comments and feedback from these groups, U.S. and other foreign AIDS-related organizations should reach out more broadly to the Chinese public, for

example, in the following ways: collecting and publishing information on the Internet, establishing a hotline and communicating

with the Chinese public directly, and conducting research and public surveys.

Before ending my presentation, I want to thank the people in the

United States and the U.S. Government for helping Dr. Ma Shiwen

to be released, and also to ask for human rights protection in China’s AIDS crisis.

Thank you very much.

[The prepared statement of Dr. Wan appears in the appendix.]

Mr. FOARDE. Thank you. Dr. Wan. You have given us a lot to

think about, and we will be coming back to some of those topics

when we get to the question and answer session.

It is my great pleasure now to introduce Kevin Frost. Please go

ahead.

STATEMENT OF KEVIN ROBERT FROST, VICE PRESIDENT,

CLINICAL RESEARCH AND PREVENTION PROGRAMS, AMERICAN FOUNDATION FOR AIDS, NEW YORK, NY

Mr. FROST. Thank you. My name is Kevin Robert Frost and I am

the vice president for Clinical Research and Prevention Programs

at the American Foundation for AIDS Research [amfAR].

AmfAR was founded in 1985 and is the Nation’s leading nonprofit organization dedicated to the support of HIV/AIDS research,

AIDS prevention, treatment education, and the advocacy of sound

AIDS-related public policy.

I am also the director of amfAR’s international initiative, Therapeutics Research, Education, and AIDS Training in Asia [TREAT

Asia].

TREAT Asia is a cooperative venture designed to help Asia and

the Pacific, which is expected to become the next epicenter of the

pandemic, to prepare for the safe and effective delivery of HIV/

AIDS treatments as they become more widely available.

The program pairs the resources and experience of clinical centers in Asia with amfAR’s education, training, and clinical research

expertise. The goals of TREAT Asia are to develop the skills of the

health care workforce in the safe and effective delivery of drug

treatments for HIV/AIDS, to enhance existing health care infrastructure and formulate strategies for capacity building to prepare

for expanded access to HIV/AIDS drug treatments, to develop a

framework for regional collaboration on a therapeutics research

agenda that is responsive to the needs of patient populations in the

region, and to define and address national and regional policy

issues that impede expanded access to drug treatments for HIV/

AIDS, and by working with regional and in-country NGOs to

strengthen civil society’s preparedness for treatment programs.

8

China’s HIV/AIDS epidemic has been gaining momentum, and

the Chinese Government currently estimates that 840,000 persons

are infected with HIV/AIDS. Intravenous drug use and contaminated blood have been the two primary routes for infection in

China, representing two distinct and separate epidemics.

However, HIV infection is increasingly spread through sexual

transmission, with rising rates of infection among commercial sex

workers in several provinces. Among those who acquired infection

through tainted blood collection practices in Central China during

the 1990s, large numbers are now falling ill and have minimal access to care and treatment in China’s underfunded rural health

care system.

Relative to most developing countries with severe AIDS

epidemics in Africa and Southeast Asia, China has a functioning

health care infrastructure, and antiretroviral therapy is starting to

be offered through public hospitals and clinics at the county, township, and village levels in severely affected communities.

However, health care providers at these levels have little training or experience in counseling and treating AIDS patients,

compounding the problem of side effect management and drug compliance. The lack of health care provider capacity to administer

antiretrovirals is one of the biggest obstacles to treatment preparedness in China.

While by all accounts China has become more open in dealing

with HIV/AIDS, denial of the full extent of the epidemic persists.

Unfortunately, there are no reliable data that accurately assess the

scope of the epidemic.

Chinese doctors privately suggest that the epidemic is at least 5

times, and possibly even 10 times, greater than the official estimates. The HIV epidemic in China’s Central Province of Henan is

instructive. With an estimated population of 110 million, Henan is

China’s largest province. If only 1 percent of this population were

infected through the blood trade, more than a million people would

be HIV-positive in Henan alone. Yet a recent survey showed that

the prevalence rate among commercial blood donors in rural eastern China was 12.5 percent, and 2.1 percent among their non-donor

spouses.

In January 2002, the Henan Health Department reported that 80

percent of Houyang village residents were HIV-positive. Of its

4,000 residents between the ages of 16 and 55, some 90 percent

participated in blood donation programs. More than 400 villagers

have developed AIDS, and 150 died between November 2000 and

November 2001.

In December 2002, former Health Minister Zhang Wenkang acknowledged that 23 provinces, autonomous regions, and municipalities were affected by unhygienic blood collection.

This is to say nothing of the epidemic among injecting drug users

in the south and northwest provinces of Yunnan, Sichuan, and

Xinjiang, among others.

When asked by amfAR recently by the size and scope of China

and India’s epidemics in an article published in amfAR’s quarterly

newsletter for the TREAT Asia Report, Dr. Richard Feachem, executive director of the Global Fund for AIDS, TB, and Malaria, had

this to say:

9

There has been this strange collusion between Western experts, international organizations, and the Chinese and Indians to first say that the HIV epidemic is not

seriously going to affect China and India at all, and then to say, ‘‘Well, maybe

they’re going to have a small epidemic,’’ and then to say, ‘‘Well maybe they’re going

to have a rather larger epidemic.’’

But only very recently has there been anything approaching a

consensus that China and India are set for very large epidemics.

Because of this history of minimizing the epidemics in China, India

and in Asia more generally, I would go with the higher-end estimates now being produced.

Recently, there have been promising signs of an increasing willingness in China to confront its HIV/AIDS epidemic. China has just

been awarded a grant from the Global Fund to carry out voluntary

counseling and testing and treatment programs in seven provinces

where many infected through blood collections during the 1990s are

falling ill.

Prior to this, the Chinese Government had initiated a treatment

program in four of these provinces that offer antiretroviral therapy

to about 3,000 persons now, with a target of 5,000 by the end of

2003.

The Global Fund’s support will be used to scale up treatment, including antiretrovirals, to 40,000 AIDS patients in 56 counties in

seven provinces by 2008. Many experts believe that even the

40,000 target is a significant underestimate of the patients in these

communities who will require treatment in the next 5 years.

While the Chinese Government’s goal of extending free

antiretroviral treatment to rural AIDS patients is laudable, many

problems exist with China’s current treatment policy program beyond the issue of the number of sick persons who will have access

to free treatment.

One significant problem has to do with the affordability of stateof-the-art antiretroviral therapy that is both easier for patients to

tolerate and for health care providers to supervise. For example,

fewer doses, less complicated regimens, with fewer side effects.

As a new member of the World Trade Organization, China has

been careful to respect international trade agreements and only

manufacture drugs that are off patent. Two Chinese pharmaceutical companies have begun to produce generic versions of four

off-patent drugs that the government has acquired for its public

treatment program.

Patented drugs such as Combivir (AZT and 3TC) are imported,

but considered too expensive to use routinely and are only used in

a handful of patients when domestically manufactured drugs are

not tolerated.

The treatment protocols currently being used are not optimal and

have not been well-tolerated by patients, resulting in severe side

effects which local health care providers have no training or experience in managing.

Because of these side effects, the treatment options currently

available in China in many ways represent the worst possible

choices and offer the potential for disaster. Yet, China is taking the

approach that most developing countries are forced to take when

it comes to choosing treatment regimens.

Rather than developing public health strategies for delivering

treatments to the population of HIV-infected individuals, China is

10

left in the undesirable position of having to settle for what it can

get rather than what it needs.

Unless serious attention is paid to acquiring better combination

treatments, the failure rate of the current regimens is likely to be

enormously high and could have dire consequences in terms of diminished long-term efficacy of treatment programs in China and

the widespread development of HIV drug resistance, with implications for the rest of the world.

Similar lack of access to imported reagents for HIV and CD4

testing has constrained the ability of the health system to do the

necessary counseling and testing and to properly monitor patients.

The mix of insufficiently trained medical staff with poor counseling skills, poorly tolerated drug regimens, and lack of testing

and laboratory monitoring capacity is a worrisome combination of

factors.

In an editorial published in the South China Morning Post in August 2003, Drew Thompson of the Center for Strategic and International Studies in Washington, DC, wrote:

To safely treat HIV sufferers with powerful antiretroviral drugs, it is crucial to

have trained physicians with access to laboratories which can carry out advanced

blood testing . . . By jumping the gun and beginning treatment before doctors and

counselors are properly trained, a drug-resistant disaster is waiting to happen.

Now that China has been granted a big infusion of funds through

the Global Fund mechanism, it will quickly be scaling up its treatment program. It is imperative that education and training programs are rapidly expanded and accelerated in order to ensure that

the best available drugs are being provided by trained medical

professionals, with proper counseling and rigorous monitoring and

follow-up testing.

At amfAR, and within the TREAT Asia program, we believe it is

here that the United States has much to offer. China desperately

needs—and there is growing evidence of China’s willingness to

seek—international support for rapidly developing and scaling up

education and training programs for health care providers in the

delivery of HIV/AIDS drugs. It is my sincere hope that we will find

the necessary resources to provide precisely that support.

Thank you.

[The prepared statement of Mr. Frost appears in the appendix.]

Mr. FOARDE. Thank you very much, Kevin. Very interesting, and

again, very rich topics to take up during the question and answer

session.

We now welcome our old friend, Dr. Phil Nieburg. As I was saying before this session, he has been a participant sitting in the

back of the room as an auditor of some of these sessions, and we

have always wanted to get him here in front of the microphone. So,

we are delighted that we had the chance to do that today. It is your

10 minutes.

STATEMENT OF PHILLIP NIEBURG, M.D., SENIOR ASSOCIATE,

HIV/AIDS TASK FORCE, CENTER FOR STRATEGIC & INTERNATIONAL STUDIES [CSIS], CHARLOTTESVILLE, VA

Dr. NIEBURG. Thank you. I would like to thank the Commission

for this opportunity to talk about what is clearly a very important

11

issue. I would also like to specifically thank Susan Weld and Anne

Tsai for providing clear guidance on the goals of this session.

As a preamble, I would just like to clarify my current status. I

am a pediatrician trained in infectious disease. Until August of this

year, I was a career employee at the Centers for Disease Control

and Prevention.

As Dr. Bhat mentioned, I traveled to China as part of an HIV/

AIDS assessment in 2001 and have been back several times for the

purpose of helping arrange the CDC program that is now getting

under way in China.

However, I am no longer with CDC, and the views that I am

going to express today are purely my own.

It is still too early to know with any certainty whether China is

going to experience a self-sustaining heterosexual pandemic of HIV

of the magnitude that is now devastating a number of African

countries. However, it appears that the possibility of a large problem in China is very real and the potential consequences for China

and its citizens are great.

I thought that my most useful contribution today would be to discuss the broad categories of activities that the U.S. Government

and other non-Chinese agencies could undertake now and in the

future for the purpose of helping China both acknowledge, and appropriately respond, to the large and growing HIV problem.

My presentation today is going to be divided into three parts.

First, I will talk about the need for a clear vision and clear goals

for China’s HIV control efforts and for U.S. activities in support of

those efforts.

I will then discuss several categories of HIV control activities in

which the United States could participate and that would have

lasting benefits for the Chinese people that would extend well beyond any successes in HIV/AIDS control.

Finally, I will have a few closing remarks about things we should

be cautious about when dealing with China on HIV/AIDS issues.

First, to the issue of vision for HIV control. Do we really know

what the Chinese Government wants to accomplish in terms of

HIV control? Is their priority having the smallest number of HIVinfected people? Is the priority having the largest proportion of

AIDS patients receiving appropriate care and treatment? Is it minimizing the societal impact of HIV/AIDS? As I will point out in a

minute, because of resource constraints, it may not be possible to

do all three of those different activities.

Also, what do we in the United States want to accomplish in

China and for the Chinese people with regard to HIV? How compatible are U.S. goals with the Chinese goals?

In my view, global HIV control activities in a community, a country, or on a global scale tend to take one of three broad approaches,

each with its own set of goals. Because the goals of these three approaches are only partially overlapping, we and the Chinese need

to think about them carefully. There is a table on the handout that

outlines the three approaches.

The first approach, is that of HIV/AIDS care. Providing care is

a humanitarian activity that includes, but is not limited to, treatment of persons with AIDS. Care is the goal of helping individual

people infected with HIV in their household and family members.

12

The care approach focuses on HIV-infected persons and tends to operate on a ‘‘medical model.’’ Although in this country, national and

state governments finance an important proportion of clinical care,

that care is largely delivered by the private sector here.

The second approach is HIV prevention. That is a set of public

health or public policy activities that seeks to prevent or minimize

spread of HIV in populations by reducing the risk of person-to-person HIV transmission. To date, such prevention activities have

largely, although not exclusively, focused on HIV-uninfected individuals, a different population of focus.

In contrast to delivery of care, prevention of the spread of lifethreatening disease such as HIV within and across national borders has generally been seen to be the responsibility of national

governments. Although the private sector may be involved in such

efforts, that involvement has been secondary.

Finally, a third approach is mitigation, which means reducing

the impact of community or societal disruption arising as a result

of HIV/AIDS killing or disabling large numbers of individuals.

Some simple examples of this type of population-level problem

needing mitigation are: (1) large numbers of orphans needing shelter and care; and (2) reduced local food availability due to illness

among local subsistence farmers.

HIV care, prevention, and mitigation activities and goals have

some overlap. For example, prevention activities can help identify

HIV-infected persons needing care, and HIV care activities can provide entryways for prevention for, example, family members who

could benefit.

However, this overlap is not nearly as complete as is commonly

assumed. For example, the skills and resources needed to effect behavioral change among sexually active young people are different

from the skills and resources (including laboratory and pharmacy

resources) needed to educate health professionals about proper use

of antiretroviral drugs. The resource needs for comprehensively addressing a large orphan population are different yet again.

So, at this moment, China has to deal with all three of these

issues. It is facing rapid increases in numbers of persons known to

be infected with HIV who need care. In at least some parts of the

country, China has to deal with entire communities of people needing external support of various kinds to mitigate the impact of HIV

spread through plasma cells. People need not only direct AIDS

care, but food, shelter, income, et cetera.

Finally, at the same time, China must begin to slow the internal

spread of HIV. In fact, slowing the spread of HIV seems to me to

be the most important current public policy priority for the Chinese

Government, at least in part because those persons becoming infected today are the vanguard of a very large burden that China’s

health system will face by 2010 or 2015.

Even with a lot of external support, there are still not enough

resources, not enough trained people to address all three of these

approaches simultaneously and quickly, so China’s government is

now facing some very difficult allocation decisions.

My second set of comments is about HIV interventions that the

United States might give priority to in supporting China’s HIV control efforts. These are each activities that would have a spin-off

13

benefit in China, and perhaps for U.S. policy in China, by encouraging constructive political change in a way that could have implications well beyond the HIV/AIDS arena.

The first one is access to accurate information, which might be

viewed as transparency. By this I mean that information about

HIV/AIDS, including its risks and its consequences, should be

widely available and widely discussed in Chinese society. The goal

would be that decisionmaking by both government and by individual Chinese citizens would be based on accurate information at

all levels.

In this arena, the United States should support a strong emphasis on increasing AIDS awareness and awareness of other sexually

transmitted infections and tuberculosis as well, not only among the

public, but also among health workers and among political leaders.

Health workers, teachers, parents, and as many others as possible should be educated about HIV/AIDS in a ‘‘training of trainers’’ style. That is, they should be trained and equipped to also educate

others they come in contact with—their patients, their children,

their colleagues—about HIV/AIDS issues. In this regard, the sexual

nature of HIV spread needs a lot of attention.

Counseling and testing programs for HIV should be made widely

available so that any individual wanting to know his or her own

HIV status can find out in a truly confidential setting where good

post-test counseling is available.

Finally, I strongly support efforts to improve and expand the

process of public health surveillance to provide accurate information on HIV, AIDS, tuberculosis, high-risk behaviors to local, provincial, and national governments.

An effective surveillance system will also require that China

eliminate, or at least address in some way, current criminal sanctions on social behaviors associated with HIV spread. Surveillance

data should be made widely available.

A second point in terms of interventions is a set of issues: confidentiality and discrimination. By this, I mean that information

about HIV/AIDS status of specific individuals should not become

widely available. When it must be known by some people for clinical or public health purposes, that knowledge should be safeguarded, that is, not shared or used as a basis for adverse actions.

Where laws or regulations on these issues exist, they should be

examined to see if they are helpful. If helpful, they should be

enforced.

Finally, in this category, the work of non-governmental organizations in HIV/AIDS care and prevention should be encouraged and

supported whenever possible.

As in our country, organizations not directly affiliated with the

government are often more able to publicly address sensitive topics

such as substance abuse, homosexuality, prostitution, and sexuality

in general.

These are each topics on which China desperately needs public

discussion in order to empower individuals to remain uninfected by

HIV, or if already infected, to seek care.

So, the United States has much we can contribute to China’s efforts. I would just close with two brief caveats. First, since we are

such a large and influential player in the global arena, it is imporVerDate 11-MAY-2000 09:43 Jan 15, 2004 Jkt 000000 PO 00000 Frm 00017 Fmt 6633 Sfmt 6633 91218.TXT China1 PsN: China1
14

tant that our messages and our advice to Chinese leadership be

consistent over time, and also between U.S. agencies. Once committed, we should remain committed.

Second, we in the United States have limited experience with the

kind of extreme poverty that China faces, including the need to ration resources in a way that China must to reach its control goals.

We also have limited experience with health care systems in which

the government is a major provider. While we can provide a lot of

useful technical support in these latter two areas of rationing and

government provision of health care, I would urge a measure of humility in offer advice in these, or any other areas, where our own

experience is limited.

Thank you for your attention.

[The prepared statement of Dr. Nieburg appears in the appendix.]

Mr. FOARDE. Thanks very much, Phil. Very interesting stuff as

well. We will get into some of these issues in more detail in just

a moment.

I will give our panelists a chance to catch their breath and I will

make an administrative announcement or two.

First, I think everyone in the room, I hope, knows that the Commission’s annual report came out on October 2. It is available in

PDF format and HTML format on the CECC Web site.

But if you should want to have a hard copy for your collection,

please send us an e-mail, and in the subject line say, ‘‘Mail Copy

of Report’’ to infocecc@mail.house.gov, and we will mail you out a

hard copy until we no longer have any more. We still have quite

a few.

Next, I would like to remind you that our next issues roundtable

will be, instead of 2 weeks from today, just 1 week from today, on

October 22. Instead of at 2:30, it will be at 1:30 p.m. in the Gold

Room, which I think is room 2168, here in the Rayburn Building.

We are going to pick up the case of Sun Zhigang and try to look,

in the aftermath of his detention and death, what has happened,

if anything, to China’s prisons and detention systems. We have

very fine panelists lined up for next week. Again, it will be at 1:30

rather than 2:30. So, we look forward to seeing everyone there.

Now on to our question and answer session. As we usually do,

we will give each of the staff members on the panel up here 5 minutes to ask and hear answers to questions.

Normally we try to address the questions specifically to a panelist, but if any of the other panelists have remarks they would like

to make, we want to hear them. So, make yourself known if you

want to comment.

I will exercise the prerogative of the chair and start by asking

if Dr. Bhat would finish his presentation on the SARS angle and

how it ties in with AIDS, comparing and contrasting it, because I

think this is a really important issue and I would like to hear what

you have to say on that, if you would, please.

Dr. BHAT. I appreciate the opportunity to finish a little bit more

completely on my thoughts on that.

As I was saying, SARS did slow the momentum of progress made

in years 2001 and 2002 in kind of opening up or acknowledging the

AIDS epidemic. As I said, they pulled a lot of staff from both the

Ministry of Health, as well as our own staff, to focus on SARS. But

15

I am hopeful that SARS will have a positive impact in the long

term.

It has certainly brought health to the immediate attention of the

seniormost leaders, and also brought to their attention the need to

improve their own public health infrastructure, which had been deteriorating badly over the years.

They realized also that there are severe consequences for not

paying attention to issues such as disease surveillance and outbreak response. So, we are hopeful that they are going to be open

to improving and investing more in their health infrastructure.

And certainly they have asked us, the U.S. Government, for assistance in this matter.

So, we are in the process of developing a menu of items, working

with our colleagues at CDC, NIH, and the Food and Drug Administration [FDA], to provide a package of items that they can use to

help improve their own public health infrastructure. These range

from epidemiology and surveillance issues, some of the things that

Phil was referring to. Some of it is more focused on research elements, kind of borrowing from our activities already in HIV/AIDS

and applying them to SARS.

Finally, also, we are looking to see how we can speed up some

of the regulatory systems they have here in the United States and

in China so that we can respond more quickly to outbreaks with

new drugs, new vaccines, and new diagnostics. Right now, we do

not have an appropriate diagnostic for SARS and we certainly

could use one, especially with the compounding effects of influenza.

So, I am hopeful that they will make an effort to improve the

health system in cooperation with us. But at the same time, I

would note that addressing their own SARS epidemic in their own

country, they did employ some rather onerous, as I call it, economic

control techniques to kind of get a handle on the situation.

These are things that I do not think we would tolerate in this

country, and many other democracies. But at the same time, I am

sure that for some these type of techniques were validated in their

own eyes.

So in the process of helping them, I am hoping also that we can

transmit some basic values that are fundamental to our own system here, such as transparency and accuracy in reporting, and a

non-punitive system for reporting disease information so you do not

get penalized for giving unpleasant or unwelcome information.

Then, also, the value of sharing information, data and samples

around the world with the global network of scientists and public

health officials that we have. So, I am hopeful, but we can only tell

over the course of time.

Mr. FOARDE. Very useful. Thank you.

I am so short on time, that I think I am going to hold my next

set of questions until the next round.

So, I would recognize my friend and partner, Dave Dorman, who

works for Senator Chuck Hagel, our co-chairman, for a question.

David.

Mr. DORMAN. Thank you to each of you for coming today and

helping us illuminate this very important issue for each of our

Commissioners.

16

I just have a very brief question, but it has a very long introduction. I need to explain why it is I ask a question like this.

I spent part of this weekend reading the new Human Rights

Watch report on HIV/AIDS and found it just excellent. But a number of questions are raised in the introductory portion of that report, and I think some of these questions are very relevant to our

commissioners and to other Members of Congress in terms of the

U.S. response to the mounting HIV/AIDS crisis in China.

In particular, the Human Rights Watch report actually raises

this issue, and it has also come up in testimony today, after a very

fitful start, Beijing was able to mobilize its state resources to bring

the SARS epidemic under control, in many cases using some rather

harsh command-and-control techniques. Many in this country see

the larger and more dangerous challenge of HIV/AIDS in China,

but do not see a similar strong commitment by the Chinese Government to act.

Is this a question of will or is this a question of capacity? The

question I will leave each of you with is, ‘‘Does China have the capacity to combat HIV/AIDS without international support, without

U.S. support? ’’ Could each of you answer this question very briefly in any way

that you choose?

Dr. Bhat.

Dr. BHAT. All right. Since the microphone is on this side, I will

go first.

Well, I think the answer is obvious that they do not. But, then

again, I would say also that even the United States does not have

the capability to tackle the AIDS epidemic from a global perspective by itself.

I mean, we are in a very interdependent world and we need the

resources, skills, and expertise of just about everybody. I am speaking mostly from the research perspective.

One thing that I probably did not emphasize enough is that

while we have a wealth of scientific talent in this country, we do

not have everything that is needed in order to make a dent in the

research, really. We need to partner with other countries such as

China where the epidemics are rising and where you see increasing

incidence.

Similarly, they need us in order to have some of the scientific expertise, the biotechnology skills, etc., that are needed to put the

whole thing together. So, if only from the research perspective, yes,

we all need each other. I will leave it to the rest to talk about the

internal capacities in China.

Mr. DORMAN. An important point.

Dr. WAN. Yes. AIDS is a worldwide challenge to many countries,

including my country, China. I think in China we do have some resources to fight against AIDS, like public government information

and involving the Chinese people in campaigns.

But there are some political or legal problems, like some restriction on the development of NGOs. The Chinese Government still

does not provide funding for NGOs to work on nonprofit social

causes.

So, I think, working together with other countries to get experience, to get help, is very important. I do think that the experience

17

of U.S. NGOs is very important, and the United States has a lot

of capacity for research.

So, about education, I think it is still sometimes controversial,

even here in the United States. But I do think a working relationship between the United States and China is very important.

Mr. FROST. You asked specifically the question of capacity. I limited my remarks largely to the issue of treatment and care, which

is a reflection of our programmatic activities in China. So, if I may,

I will respond as it relates to capacity in that realm, the realm of

treatment and care.

I think it is clear that China does not have the capacity to respond in this arena, particularly. In the United States, we built up

20 years of experience in dealing with this epidemic over time

when the first treatments became available—AZT in 1987, and

then later we used dual-combination therapy, and then triple-combination therapy—and we had very large programs, communitybased research programs, as well as programs at the NIH based in

academia that led to that wealth of experience in treating for and

caring for patients.

Many treatments for HIV patients in this country were developed through community doctors. I am thinking of aerosolized

pentamidine for pneumocystic pneumonia. So, we built a wealth of

information over 20 years. But in this regard, the treatment of HIV

is really oftentimes more art than it is science.

It is one that I think requires a tremendous amount of experience and knowledge. I think we have that knowledge, and we are

gaining that knowledge more and more every day. Therefore, I

would say we have a lot to offer in that regard.

But it is clear to me that China, on its own today, dealing with

the massive epidemic that it faces, does not have the capacity to

at least address that aspect of the epidemic.

Dr. NIEBURG. Thank you. Let me start by saying that I agree

with what Mr. Frost has said about treatment. China, on its own,

does not have the capacity to deal with its current treatment

needs, to say nothing of what China is going to be facing in a few

years.

On the prevention side, I have mixed feelings. HIV transmission

is largely a behavioral issue and China essentially eradicated other

sexually transmitted diseases in the 1950s and 1960s. So, they

proved that even with a complex issue like sexuality, they could

mount a large-scale effort.

On the other hand, China currently has an economic boom which

is fueling HIV transmission, and I am not sure that can be adequately dealt with.

HIV is now, in my sense, a chronic disease, and I think it is an

endemic disease in China. I think, however successful a treatment

is going to be, that is going to mean there are lots of HIV-infected

people who will be around for a long time and potentially can

transmit to others. So I guess my sense is that they do not now

have the capacity by themselves to deal with the prevention issue

either.

Mr. FOARDE. I next recognize the general counsel of the Commission, Susan Roosevelt Weld, for some questions.

Susan.

18

Ms. WELD. Thanks, John.

I want to ask a question which seems somewhat adversarial, but

it has to do with the priorities that the Chinese Government relies

on in allocating funds. From some of the information we have been

receiving, one of the basic problems is there is insufficient funding

allocated out of the central budget to the question of AIDS at the

center, and particularly allocating money from the center down to

the provinces that are hardest hit.

Is there a way that U.S. assistance could encourage spending the

allocation of resources on HIV/AIDS? Let me start with Amar.

Dr. BHAT. All right. That is a good question. I am not certain of

the best way to answer it. Just in terms of our activities, I do not

think the research activities really have any influence on spending

at the provincial levels. They will tangentially impact the provision

of care, but it is certainly not a direct relationship.

More so with the technical assistance. Obviously, when you talk

about China you have to talk about providing assistance at the provincial levels. That is precisely what we are doing.

But, again, in terms of just resources, I have very little confidence that our programs, per se, will have a direct impact on the

allocation of just pure monetary resources.

It is more along the lines of what Phil was referring to earlier

with training the trainers, increasing the capacity, increasing their

knowledge base, but less so in terms of providing goods or direct

resources.

Dr. WAN. I want to talk about the Chinese people. When we are

talking about the AIDS crisis in China, we are still facing a silent

majority. A lot of Chinese people are still not completely informed

and not prepared with an anti-AIDS campaign.

So, if the U.S. Government could invest in supporting capacity

building of the communities, NGOs, academia, and to get people involved to increase the capacity of the people, if people could be educated and they could work with our government to help increase

the budget at the central level and the provincial levels, in research policy, and the human rights issues, and providing legal aid

for people, then I think that is fundamental in an anti-AIDS campaign in China. If people are not informed, are still silent, I would

suspect the future investment by our own government.

Mr. FROST. Not easily. But neither should that deter us in our

efforts. I think it is always difficult to influence the priorities of

another government. My own view is that, until China takes ownership and provides real leadership on this particular issue, the inroads will be long and difficult.

But I do not think that should deter us in any way from continuing to provide the kind of support assistance that we are capable of providing and making a difference in areas where we can

make a difference. I think we have a responsibility to do that, and

I would argue that we should.

Dr. NIEBURG. Thanks. I actually agree with all three of the previous speakers. At lunch time we were talking about how the U.S.

contribution to the Global Fund is essentially a matching contribution. Our maximum is 33 percent of the total. So, what we give to

the Global Fund depends on what other nations give. There have

19

been discussions about having the same kind of arrangement with

the Chinese Government.

I also mentioned at lunch time that Kevin and I were in China

on the trip in January, listening to the Chinese Government say

to us one day that they were short on resources. The next day,

there was a large announcement in the paper about the Chinese

space program. So, one has to think carefully about the fungibility

of funds, et cetera.

Mr. FROST. It was not our best day. [Laughter.]

Mr. FOARDE. The other member of our staff who looks at HIV/

AIDS issues is Anne Tsai. It is over to you for questions, please.

Ms. TSAI. Susan and I have been looking at this issue and have

had various meetings with Chinese and non-Chinese experts on

this topic about the best way of providing assistance through either

the central government, getting full cooperation with the Public

Health Ministry, or just going directly into the provincial and local

levels.

We have heard arguments on both sides. We are curious as to

what each of you thinks is the most effective model and how the

United States should pursue it. We can start with Phil.

Dr. NIEBURG. Yes. I have mixed feelings about this. I mean,

China, functionally, is a federal system in the sense that the provinces operate pretty independently of the center.

In our assessment, our teams went to four different provinces.

Our sense at the end was that these provinces, given resources,

could do a lot, given resources and guidance. So, I think there is

a strong argument for not tying money up in a Beijing bureaucracy.

On the other hand, we are dealing with another, sovereign national government and there are clearly arguments for trying to

improve cooperation between us as well.

Mr. FROST. My answer actually also sort of relates to Susan’s

question, which is that not all of the support that the United

States offers, or can offer to China, has to go to the Chinese Government.

In fact, I think one of the biggest challenges that the Global

Fund faces is that the money that it provides to address the epidemic in countries, for the most part, goes to governments and

works through government systems, whether that be the country

coordinating mechanism or some other government system.

I actually think that the strengthening of civil society and working through non-governmental organizations in countries, and

international organizations that are on the ground and have been

on the ground—and there are several in China that are on the

ground and working and have experience in dealing with the epidemic—are an avenue of support that we can provide that allows

for a measure of accountability, a measure of success of our programs that does not necessarily mire the program in the bureaucracies of either the national or provincial governments.

So, I think it is worth considering how we can provide support

on both the national and the local level, but thinking outside the

box and going beyond just sort of these bilateral government-togovernment arrangements and working with in-country groups

that have a vast amount of experience working on the ground.

20

Dr. WAN. Yes. I think both working with the central government

and the local government could help, but you have to have a very

strict monitoring and evaluation process. The central government

has a lot of technical and financial resources. Maybe not many, but

many compared to provincial governments. In the counties, I do

think it is very important to put more resources into training programs.

But because it is a decentralized situation in China, we have to

face the reality of corruption, local government corruption issues.

So, I would suggest that when you support a program for a government institution, you need some time to get the involvement of

local Chinese people, and also to support some kind of watchdog,

independent nongovernment organization, to do research about

their policy, about the program, to follow up on what is going on.

Dr. BHAT. I want to address your question from a couple of different angles. One, is the diplomatic perspective. Essentially, the

ministry of health for the United States is the Department of

Health and Human Services. We have a kind of relationship, not

just in AIDS but in all areas of health, with the Chinese Ministry

of Health and out of mutual respect, really, it is really appropriate

for us to work directly with the Ministry and only work at the provincial or other levels with their permission. That is the diplomatic

look at it.

But China also is a big country. We do not have a lot of resources, honestly, to put into China. In fact, we were concerned,

starting with the GAP program in China, that it would overwhelm

our own resources for this program.

That said, we have looked for ways to maximize our resources.

One of the ways is to focus our initial efforts, at least, in Beijing.

Then once we are on the inside, we can start to look where we can

most effectively make an impact at the local and provincial levels.

Perhaps over time we will be focusing more at the provincial levels,

because that is where the work needs to be done. But, in the beginning, it is in Beijing.

Mr. FOARDE. Let us go on and recognize our friend and colleague,

Carl Minzner, who is senior counsel working on the grassroots-level

rule of law issues.

Carl, questions?

Mr. MINZNER. Yes. Thank you very much. Thank you all again

for coming today.

I want to return to a question that Mr. Dorman had begun to

ask. He brought up the distinction between the will and the competence, and he proceeded to ask a question about the ability of the

Chinese Government to handle the AIDS situation.

I want to ask about the will. In fact, last week there was a professor, I believe from the Harvard Public Health School, who came

here and gave a lecture not associated with the Congress. She drew

a parallel between the SARS and the AIDS developments, and

noted that were the local will to be exercised, the government could

bring to bear quite a large number of resources very quickly on a

public health problem. The government could concentrate a lot of

the news media and the public information resources that would be

necessary to address the problem.

21

So she raised the possibility that there is a blockage somewhere

in the system, that something is not giving way. But, were that obstacle to give way, it could change the dynamics of the system very

quickly.

For you all, who have had a long series of interactions with the

Chinese Government, if each of you had to pick one place where

that blockage is, it could be as specific as naming names, or if you

just had particular areas where you felt that there is a lack of local

will, be it a particular ministry, be it a particular level of government, whatever, what would you identify as the main blockage

when it comes to the question of political will to handle this issue?

Dr. BHAT. Again, I will start since the mic is near me.

I actually do not think the blockage is at the Ministry of Health.

I think, you might say, they have ‘‘got religion’’ on this issue. I

think it is elsewhere.

Now, actually this workshop I mentioned that is taking place

this Friday in China is an experiment, in the sense that we are targeting the audience, not the Ministry of Health, the usual characters, but rather at the State Council through the Development

Research Center to see if we can enlighten them a little bit about

the future impact of HIV/AIDS on their society.

Basically, we are testing a hypothesis and we will see whether

we can get them to be motivated to spread the word within the

State Council, that this is a serious issue and that it needs to be

addressed. The hoped for outcome is the drafting of a white paper

that would be circulated among the top level of the government. So,

we will see.

Now, as for the will, I think they are capable of the will. As Phil

mentioned with the STD control earlier, the SARS control earlier

this year, they definitely have a will and capacity. It is just a matter of overcoming some of the other concerns. I think personally

that they do not want to be labeled as an AIDS country, therefore,

they are trying to deny it. But once the numbers get so large that

they will be known as it anyway, well, by then, probably, the cat

is out of the bag.

Dr. WAN. About the will. I think our government does have the

will to combat the AIDS crisis. But I also think that it is not

strong, and sometimes not clear.

I want to talk about different issues. From the leaders, the

former president, Jiang Zemin, talked about AIDS earlier this year.

On the Web site of China’s CDC, you can find that President Hu

Jintao talked about AIDS issues, and Premier Wen Jiabao also is

talking about AIDS.

The current Minister has worked very hard in handling SARS

issues and helped China to handle that issue, and it was a big success, I think. But she has kept silent on AIDS until recently. Dr.

David Ho, in Beijing, in early September, talked about AIDS. We

still do not know, for the Minister of Health, whether her will is

strong or not.

Deputy Minister Gao Qiang, after he became the Deputy Minister, talked about AIDS. But compared with the former Minister

of Health and the former Deputy Minister of Health, it just seems

that they are now willing to talk about SARS more than talking

about AIDS.

22

Also, in China, they talk about other health issues, tuberculosis

and other health issues. I agree that China faces different health

challenges, but there is no reason for no work on AIDS.

When we look at people with AIDS, we can find it related to sex

workers, drug users, blood donors in rural areas, farmers in rural

areas. And people in gay communities have a moral, social taboo.

So, people who are infected do not have much political, economic,

legal, or moral courage to speak out. Our leaders have some will,

but I believe it is not strong enough.

Mr. FROST. If you had asked me this question pre-SARS, I would

have said that I think one of the greatest challenges was the lack

of authority or the lack of power, if you will, of the Ministry of

Health within the Chinese system. China, like many developing

and developed countries, puts emphasis on ministries that generate

revenue, not ministries that lose revenue. Health loses revenue.

That is where you spend money, you do not make it. So, I would

have said the problem is the lack of real authority.

In the aftermath of SARS, that has clearly changed. The appointment of Wu Yi as Minister of Health makes her the highest-ranking

minister in the government, frankly. So, I think that her appointment has had an influence.

I think that, certainly, in the aftermath of SARS, our programmatic work has become a little easier. There is more openness

and there does seem to be more willingness to exchange information, share data, and develop cooperative programs in China.

Having said that, it is also still clear to me that there is a disconnect in the Chinese system. Most often, it seems to me that that

disconnect is between the provincial level and the central government. How that takes place mechanically is not always clear to me.

Without getting into the complexities of the relationship of the

Communist Party to government workers, I think that it is very

difficult to understand where that breaks down within the system,

whether it is outright denial of what does exist in terms of the epidemic, and therefore an unwillingness to either address it out of

denial, or whether or not there is an understanding of the extent

of the epidemic and a direct desire to suppress that information.

It is not clear to me what the answer is. It is clear to me that

it has gotten better. How long it will remain better is anybody’s

guess, or if we are on an upward trajectory that could in fact lead

to real strengthening of programs and collaboration.

But I think our hope is that, in fact, we are looking at the latter

and that there is more willingness to be open since there is common recognition in the aftermath of SARS of what can happen

when one tries to address an infectious disease by trying to clamp

down on information and not be open about it.

Dr. NIEBURG. Thank you. I think the technical people in the Ministry of Health clearly understand the risk that China faces. I

would tend to agree with what Dr. Bhat said about the obstacle,

if there is one that can be identified, being somewhere at the State

Council or beyond.

My sense is, actually, that people in other ministries may not understand. I do not think it is an issue of political will. I think there

is a genuine lack of understanding of the risks that China is facing.

23

The comment that I have heard several times on more than one

trip was that China is not Africa, as if that is the end of the problem and there is no need to go any further.

I just want to point out that the three global success stories that

I know the most about, which are Uganda, Thailand and Brazil,

are all examples where political leadership at the highest level

made the difference. Actually, I am not aware of any real success

stories without political leadership at the highest level. So far, that

seems to be missing in China.

Mr. FOARDE. Very useful. Hearing you talk about the higher-level

leadership, and thinking about the attitude that China is not Africa, reminds me the first time I had a conversation with a Chinese

Government official about HIV/AIDS back in 1990 when I was attached to the U.S. Embassy in Beijing. We were basically told the

same sorts of things that we had been told at just about that same

time period on the issue of narcotics trafficking. ‘‘Oh, that is a

problem we have solved in the past.’’ ‘‘Well, HIV/AIDS? ’’ we asked,

and they said, ‘‘That is a foreigners’ problem. There are only foreigners involved here. Once we get rid of that little problem, this

AIDS issue will be gone.’’ We kept trying to tell them that this was

not our experience in the United States. During that time period,

we were still very much grounded with what was going on here

and trying to get our arms around the enormity of the problem.

So, even in that period 14 or 15 years ago to get them to talk

seriously about it was a serious problem, and I see that things

have not changed, at least at the top level. It is good that they are

changing at some level, anyway.

I would like to continue, because we have a few minutes, by picking up a theme that both Dr. Wan and Phil Nieburg brought up.

That is, the information available to the ordinary Chinese person.

For this specific question, I am interested in the impact, if any,

of the Voice of America [VOA] and Radio Free Asia [RFA] on the

information available to the Chinese man and woman in the street

about HIV/AIDS.

Are VOA and RFA doing programming on HIV? How effective is

it in conveying the types of messages that you want? Is there more

that could be done by those outlets of international broadcasting

that the U.S. Government has?

Let me start with Dr. Wan, and then go around.

Dr. WAN. In the past few years, Radio Free Asia, Voice of America, and some other international radio programs have done a lot

of work on AIDS and AIDS-related sex education, blood safety,

rights of people with AIDS, policy issues, legal issues, a lot of news

coverage related to AIDS in China.

I think it has contributed a lot to the ordinary people in China.

For example, last year in late September and early October, I went

to my hometown in a county, a town, in Anhui Province. Many government officials and retired county officials, school teachers, and

regular people, know information about what happened in China.

A lot of information comes from Radio Free Asia and Voice of

America.

Mr. FOARDE. Anhui seems to be a very good place for reception

for VOA.

Dr. WAN. Maybe, yes.

24

Mr. FOARDE. I was on a VOA program last week, and quite a

number of calls were from there.

Dr. WAN. Yes. Also, at some time I visited a place where I lived

before. There was a group of senior, retired workers. They gathered

together every night to talk about political issues or social issues.

When I came, they were talking about AIDS issues. I was interviewed and actually I do not know how the radio program reported

on my points. I spoke to the radio quite well, even some things I

have forgotten. So, I think it is very important to have international radio, yes.

Mr. FOARDE. Is there more that could be done or is the level

about right?

Dr. WAN. I think they have done a lot. But I think you would

have to consult some scientists or some policy experts to talk about

issues, because it seems like the current information mostly focuses

on what is happening in China, human rights issues, and coming

from people like me. But I think it is very important to invite a

broad range of people, experts, to make comments about AIDS

issues.

Mr. FOARDE. So, more of a scientific focus would be useful?

Dr. WAN. A scientific focus, policy, human rights focus are all important.

Mr. FOARDE. Phil, do you agree?

Dr. NIEBURG. Yes. Yes, I do. I mean, I do not know a lot about

the VOA broadcasts, although I do know HIV is a constant topic

of theirs. But I think, both a technical focus and actually an internal focus is important.

So, for example, in this country every week, the CDC publishes

data on every disease of public health risk. Every state health department now has newsletters that publish data about not only disease counts, but epidemics and risk factors.

There are journalists who are interested in that topic, so a lot of

public education goes on based on the national surveillance system.

That could happen in China. You may be aware that Kaiser is

funding a program to educate Chinese journalists about HIV.

I do not know if it is just on HIV, but on disease reporting. I

think that having VOA focus on this is helpful, but I think it is

going to take internal discussion of these issues, internal reporting

for the Chinese to be able to believe the information.

Mr. FOARDE. So the principal source of information for China’s

media industry is not going to be VOA or RFA. One hopes for the

best.

Dr. NIEBURG. One hopes. I mean, if that turns out to be the primary source, then I think China is in bigger trouble than I realized.

Mr. FOARDE. Useful.

Dave Dorman, for more questions.

Mr. DORMAN. In our nearly 11⁄2 hour conversation, I think you

have all established very clearly, at least for me, that in terms of

HIV/AIDS in China, the danger is great, the need is great.

So just to help me understand, and this goes back to Dr. Bhat’s

comment that China’s third proposal to the Global Fund was the

first one accepted for funding.

25

Should we read anything into this? It seems to me, based on

what I just heard, China’s first proposal should have been accepted. Why did it take three tries?

Dr. BHAT. Well, I have not studied all three Chinese proposals

to see what the differences are, but part of it has to do with just

the sheer scope of the problem. That is, what do you choose to actually apply for?

In other words, what do you choose to actually put into the application that you would like to try to address? The whole scope of the

program. One doable aspect of it is, do you ask for hundreds of millions of dollars? Do you ask for a small bit of money?

I understand some of the issues had to do with a lack of understanding or a lack of putting into the application in the initial

round enough of a demonstration of the need. It may have been

just implicit that China is in need of these funds, so just go ahead

and get the money.

Then also translation issues as well, translating from Chinese to

English. I know that this time, this last round, they spent a lot of

effort into making sure that their proposal was in readable

English.

At the TRP, relatively few are going to be native Chinese speakers and can understand and appreciate the language. So, they said,

expend a lot more effort. In fact, I think we may have even had

some Chinese-Americans in the drafting stages.

I think also—and this is less substantiated in my mind, at

least—there was a concern that there was a lack of significant or

substantive NGO involvement. As you may know, at the Global

Fund there is a strong commitment to a public/private partnership

involving civil society, and China does not have a long tradition of

civil society. Most of their organizations that are involved are more

the mass organizations such as the All-China Women’s Federation,

and groups like that. So, there are some concerns at that level as

well.

Mr. DORMAN. So the fact of third tries says nothing about the severity of the problem in China compared to other countries.

Dr. BHAT. Nothing to do with the severity, but just more of how

you demonstrate the need and what do you actually ask for.

Mr. FROST. Can I add something? I do not want to over-analyze it, but China asked for $98 million, and in their third proposal they

are seeking to scale up treatment for 40,000 people in those seven

central provinces. If one divides $98 million by 40,000, the per capita expenditure

of that grant works out to be an enormous amount of money by

global standards for the treatment of HIV/AIDS.

I think China has an approach in mind that allows them to seek

support from the Global Fund for an epidemic without really revealing or stating how extensive the epidemic is.

If you will remember, a year before the Global Fund was announced, before Kofi Annan called for the formation of the Global

Fund, China said they did not have an HIV problem. It was only

1 month after the Global Fund was announced that China admitted it did have an HIV problem. The number of people officially

said to be infected in China went from 30,000 to 1 million in a single day.

26

Now, the cynical side of me would tell you that it is very difficult

to ask for money and international support for an epidemic that

you do not have. I think that that probably has a lot to do with

the approach that they have taken in seeking support.

They want to seek support for an epidemic without stating how

extensive the epidemic is. I think that is part of the denial that exists within the Chinese system about the full extent of the epidemic

and seeking support to address it comprehensively.

Mr. FOARDE. I will recognize for the last questions of today

Susan Roosevelt Weld.

Susan.

Ms. WELD. Thanks, John. I have a lot of questions. [Laughter.]

As you will remember, when we were just in China talking to the

Ministry of Health, I asked, what would be a model country who

has responded to its epidemic of HIV/AIDS in a way that you feel

would be useful for China?

And of course, through all of our minds, including the person

from the Ministry of Health, flashed Uganda, Brazil, Thailand. The

answer was, well, there is no other country which is going to be

like China. China is unique in its epidemic, and in the ways that

are appropriate for dealing with it.

I wonder if it would be useful if the United States—I know that,

Phil, you have done some of this in the past—were to sketch out

its own difficulties, its own response to HIV/AIDS, not in the sense

that it would be a correct model for China, but to bring the Chinese

to understand that this is a problem that every country has had,

a problem of the world, not a problem only for the small countries,

backward countries of the world.

Do you have a good technique for doing that?

Dr. NIEBURG. Yes. Actually, Susan is referring to a presentation

I did in Beijing last year. We were sketching out the evolution of

the U.S. HIV epidemic and the U.S. response. As I prepared for

that, I realized I was struck by the similarity between the two situations.

So, I think you are right. I understand that the Chinese often

think themselves unique in various ways. But I think you are

right, that they are wrong to think what is happening in China is

different, except in scale, with what has happened in many other

places.

Mr. FOARDE. Anybody else have a comment on that one?

[No response.]

Ms. WELD. It was such a short one, I will have to fill in.

Mr. FOARDE. You have got 31⁄2 minutes.

Ms. WELD. The other issue is the rule of law. We are also a rule

of law commission. Among the things that we try to promote are

rule of law programs in China having to deal with legal assistance

for certain groups and clinical legal programs so individuals who

have problems can be empowered to assert their rights in their

particular situations.

I see HIV/AIDS as a disease that breeds the kind of situation

where a person might wish to assert his or her rights. Do you think

it as possible that U.S. assistance could go into that kind of effort?

I do not mean in a way that is adversarial to the Chinese Government. But if a person is not getting the treatment the government

27

has ordained for that person to get, or is being discriminated

against, could we buildup those kinds of legal assistance programs?

Dr. WAN. I want to answer that question. There are some legal

aid programs for environmental issues, for migrant workers, for

labor rights issues, some by the United States, some by the European Union, Canada, and Australia, and maybe some sponsored domestically. There are some teaching programs, clinical teaching

programs in China. There are some research programs sponsored

by the Ford Foundation, UNDP on legal reform related to AIDS.

And there are some lawyers and law firms now that have some

willingness to help people with AIDS and to handle AIDS-related

policy and legal issues.

Our institute has done a lot of work to advocate for people with

AIDS. We have a plan to provide legal education, and human

rights education related to AIDS. Last month, just a week after the

Human Rights Watch report on AIDS and human rights, our institute published a report about AIDS law and human rights in

Henan Province. We focused on one province.

We found that it is very important because recently only those

in the area, only when they spoke up, only when they get to understand policy and they used the law and the policy to advocate for

their rights to get treatment, and for their children to get an education, only then were they successful. So I think legal aid, legal

education, and human rights are very important.

Mr. FOARDE. Anyone else want to address that?

Dr. NIEBURG. Yes.

Mr. FOARDE. Phil, please.

Dr. NIEBURG. I am not quite sure how to phrase this, but I would

like to make a brief editorial comment about this. I think that paying attention to the human rights of people who are infected with

HIV in China and elsewhere is very important.

One of the issues that is not often discussed is the right of people

who are not infected to remain uninfected. It is important that

there be some balance in how that is addressed, particularly in a

country like China where access to information about ways to remain uninfected is not so easy. The human rights issue, to the extent it is raised, should be raised for both uninfected and infected

people.

Mr. FOARDE. Well, I think we are going to have to leave it there

for today, having reached the magic hour.

Amar Bhat, Wan Yanhai, Kevin Frost, Phil Nieburg, thanks to

all of you for sharing your expertise with us this afternoon.

On behalf of Chairman Jim Leach and Co-chairman Chuck Hagel

and all the members of the Congressional-Executive Commission

on China, thanks to all who came this afternoon. I hope we will see

you next week at 1:30 for our next roundtable. We will send a reminder a little later in the week.

With that, this discussion will close. Thanks very much.

[Whereupon, at 4:05 p.m. the roundtable was concluded.]

(29)

A P P E N D I X

30

PREPARED STATEMENTS

PREPARED STATEMENT OF AMARNATH BHAT

OCTOBER 20, 2003

Hello. My name is Amar Bhat and I am the Director of the Office of Asia and

the Pacific, Office of Global Health Affairs in the Office of Secretary Tommy Thompson.

As such, I am the coordinator of all Asia-Pacific activities within the Department

of Health and Human Services (HHS) and a spokesman for Secretary Thompson and

the Department on all matters pertaining to this region.

This hearing today is timely in that Secretary Thompson is just returning from

his first visit to China as HHS Secretary. His visit was very brief, coming on the

heels of last week’s meeting of the Board of Directors of the Global Fund to Fight

AIDS, Tuberculosis and Malaria. As you may have heard, at this meeting of the

Global Fund Board, the Chinese proposal to the Global Fund for work in HIV was

approved. In the case of China, the third time was the charm, i.e. this was China’s

third attempt to garner funds for their HIV/AIDS work; the previous two attempts

having failed. China’s third-round application had the same focus as the secondround application: rapidly commencing and scaling up voluntary counseling and

testing (VCT), associated with credible care and treatment options, for large numbers of HIV-positive persons living in seven Central China provinces most heavily

affected by the dangerous plasma selling practices of the mid–1990’s. The 2-year

commitment for this grant is for $21 million.

Rather than provide you with an exhaustive list of activities in which HHS is engaged in China, I would rather try to provide a description of three HHS programs

which have had significant investments in China. These three programs are ones

where we have felt that HHS is having great impact, not only in China, but globally, utilizing our unique blend of resources and skills. And finally, I will end by

touching on Severe Acute Respiratory Syndrome [SARS], for when it comes to

China, I feel it is impossible to talk about HIV or for that matter any other major

health problem in China without talking a little about SARS and the impact that

this disease has had and will have on China.

HHS has been involved in China since the opening of relations in 1979. Since

then, we have had a Health Protocol to cover cooperation in health and biomedical

research. We will be renewing this protocol in the next few months, during the

anticipated visit of Premier Wen Jiabao.

But only recently have we made a concerted effort to examine our relationship

and indeed increase our investments in that country. Part of the reasons why has

been the acknowledgement of the substantial scientific talent within China (many

of whom were trained in the United States), the greater participation of China in

world affairs, and the ever-increasing presence of disease, particularly infectious diseases such as tuberculosis and especially HIV. With the onset of SARS earlier this

year, the importance of health has leapt to the forefront, more than ever before.

I won’t take the time to discuss why and how China has begun to pay more attention to HIV/AIDS. I am sure some of the other panelists can do a much better job.

However, I can say that the greater openness of China and Chinese officials has

made it much easier for us to increase our investments in the country and take advantage of the considerable assets in the country to make a difference in the global

war on AIDS. Emblematic of this renewed relationship is the Memorandum of Understanding for AIDS cooperation that Secretary Thompson and then-Minister of

Health Zhang Wenkang signed last year here in Washington.

As I mentioned before, HHS has begun to invest heavily in China. Starting late

last year, CDC’s Global AIDS Program (GAP) opened an office in China. This twoperson office officially opened its doors earlier today in a brief ceremony involving

the CDC Director, Dr. Julie Gerberding, who was accompanying Secretary Thompson to China. While a recent development, this office has been long in coming. In

fact, the beginnings of the GAP program in China can be traced to a 2-week assessment visit in 2001 led by Dr. Phil Nieburg, here with us today. As part of that

assessment, Dr. Nieburg and his team identified several areas where China had

significant deficits that CDC could help to rectify. Still in its infancy, GAP in China

currently focuses on improving surveillance and VCT around the country. I should

note that the CDC does not provide direct provision of health care services, nor do

any of HHS components working in China.

Also last year, NIH’s National Institute of Allergy and Infectious Diseases awarded

a $14.8 million 5-year grant to the China CDC and the Chinese Academy of Medical

31

Sciences. This multi-project grant, known as the Comprehensive International Program of Research on AIDS (CIPRA), is expanding China’s research activities in HIV/

AIDS prevention, treatment and vaccine development, in cooperation with experts

from U.S. universities and medical schools. CIPRA is unusual in that it is one of

the few NIH-supported research programs where by design the principal investigator is based outside of the United States. In this case, the principal investigator

is Dr. Yiming Shao of the China CDC. Five interrelated projects, touching on a

range of HIV-related questions.

A third area where HHS has made considerable investments in China is in training. While both the CIPRA and GAP have training components, there is another

program I would like you to know about. Many of you know that untold thousands

of Chinese professionals have come to the United States for advanced training in

a number of scientific areas. Biomedical research is no exception. At the intramural

laboratories of NIH, at any one time we may have approximately 300 Chinese scientists visiting our labs, conducting research side-by-side with other scientists at

NIH. Additionally, there must be thousands more in American universities across

the land, many of them here temporarily and others planning to settle permanently

in the United States.

Additionally, the NIH has made considerable investment in training Chinese and

other developing country scientists in high-priority areas of research, including HIV/

AIDS and other infectious diseases. The NIH’s Fogarty International Center administers the AIDS International Training and Research Program (AITRP) which

supports HIV/AIDS and related TB international training and research for health

scientists, clinicians, and allied health workers from China and dozens of other

developing countries. The primary goal of this program is to build biomedical and

behavioral research capacity for the prevention of HIV/AIDS and related TB infections and for the identification of appropriate interventions to provide care to those

adults and children infected with HIV. Under AITRP, scientists are trained to address the global HIV/AIDS epidemic through skills development and the fostering

of long-term relationships between individual scientists and institutions in both

countries.

The scope of training includes epidemiology, biostatistics, behavioral interventions, program evaluation, research in drug use, blood safety, vaccine development

and evaluation, virology, diagnosis and treatment. To date, 12 doctoral degrees, four

masters degrees and 24 postdoctoral fellowships have been awarded to Chinese scientists and physicians through AITRP. Others have been trained through in-country

workshops using faculty from U.S. universities supported by AITRP. One of the

wonderful aspects of AITRP is that it leverages and complements much of what NIH

is already funding through U.S. universities and medical schools, and also what

other major funders, such as the World Bank, are also supporting.

While these are three major HIV-related programs HHS has undertaken in China,

there are numerous other activities outside of HHS you may be interested in hearing about. USAID is starting to involve Yunnan province in their Greater Mekong

HIV prevention initiative. Another initiative is a workshop taking place later this

week in Beijing organized by the State Department and the Development Research

Center of the State Council. The primary purpose of this 1-day workshop will be

to present and discuss various methodologies that can be adopted to estimate and

forecast the macroeconomic impact of HIV/AIDS in a society, at both the local/provincial level and the national level, with a focus on the situation in China. State

Department is also funding a proposal by the Shanghai Academy of Social Sciences

to support the development of model AIDS legislation.

Now, as I mentioned, I wanted to touch on the impact that SARS has had and

will have on HIV/AIDS in China. In the short term, SARS has slowed the momentum we saw building in 2001 and 2002. During the worst of the epidemic, staff at

the China CDC, and even our own HHS staff in Beijing, had been pulled from their

normal HIV-related activities and asked to devote their full attention to addressing

the national emergency. This in particular impacted heavily the first year of

progress for our GAP team in China.

However, in the long-term, I am hopeful that SARS will indeed provide positive

impacts for HIV and health in general in China. The epidemic brought to the attention of the senior-most leaders in China the importance of health to their economy

and the need to pay attention to their public health infrastructure. China’s leaders

have realized that they have neglected basic public health and disease surveillance

and now know that there are consequences for doing so. I also believe that they

were stung by the global condemnation they received for allowing this to happen

and are eager to show the world that they won’t let this happen again.

However, I am not so naive to think that they will abandon their practices and

turn a new leaf overnight. In gaining control over the epidemic, they employed onerous

32

command and control techniques that would not be allowed in most democratic societies. For some, I am sure this only validated their system in their own eyes.

Nonetheless, we are hoping to take advantage of this window of opportunity to

provide substantive and long-term technical assistance in epidemiology and surveillance, information technology and communications, as well as make some additional

investments in basic research, treatment, vaccine and diagnostics development, and

eventually, we hope, vaccine trials. Work in these areas will only aid in addressing

other epidemics such as HIV/AIDS. This work will also add to the buildup of their

health care system and improve the ability of the Chinese government to detect and

control disease outbreaks, and to appreciate the role of health in their overall economic development. In the process, we also hope to transmit some basic values such

as transparency and accuracy in disease reporting, the value of communicating new

developments quickly with international organizations and scientific colleagues

around the world, and the need to share data and samples widely with the global

network of scientists in order to arrive at a solution as quickly as possible.

That ends my formal presentation. I would be glad to take any questions you may

have.

PREPARED STATEMENT OF WAN YANHAI

OCTOBER 20, 2003

CHINA—INFORMATION TRANSPARENCY AND PUBLIC PARTICIPATION

1. Recently, the Chinese State Environmental Protection Agency (SEPA) has

adopted a policy of open information and public participation in environmental protection issues and monitoring of government work.

2. Article 23 of the Law on the Control and Prevention of Infectious Diseases

clearly demands that the government publish information on infectious diseases.

3. The State Secrets Law contains no provisions relating to health information.

Moreover, in 1999, the Ministry of Health issued a notice to all provincial health

departments stating very clearly that AIDS-related information is not a State secret.

4. I believe there is no fundamental legal barrier or policy that prohibits publication of information related to HIV/AIDS and other health information.

5. Unfortunately, in the past few years, and most recently with SARS, the Chinese government has covered-up important health- related information, including,

of course, AIDS related information.

6. The essentially nationwide blood-sales related AIDS epidemic became known to

the central government (among others) in the mid-1990s, but it was only in December 2002 that the former Minister of Health, Zhang Wenkang, reported to the National People’s Congress that the blood sales related AIDS epidemic was present in

23 provinces. The Chinese government has not informed the public which provinces

and which counties are affected. It has said, however, that in many of these affected

areas, the HIV infection rate among blood donors is 10–20 percent, and in some it’s

as high as 60 percent.

UNITED STATES—PUBLIC PARTICIPATION

1. In the past few years, the U.S. Government, foundations, NGOs, the U.N. and

other international organizations have fortunately started to turn their attention to

the AIDS crisis in my country.

2. I would encourage the U.S. Government, NGOs and any other organizations

working in this field in my country to share information with the Chinese public,

to seek their comments and input on programs and strategies and to involve the

Chinese people in their work. Specifically, these entities should involve the Chinese

people in the planning, implementation, monitoring and evaluation of AIDS-related

programs.

3. These foreign entities should work with Chinese NGOs, academics, health institutes and other emerging, informal groups who focus on AIDS related issues.

4. In addition to working with and soliciting comments and feedback from these

groups, U.S. and other foreign AIDS-related organizations should reach out more

broadly to the Chinese public, for example in the following ways: collecting and publishing information on the Internet, establishing a hotline, conducting empirical

research and public surveys.

33

PREPARED STATEMENT OF KEVIN ROBERT FROST

OCTOBER 20, 2003

INTRODUCTION

My name is Kevin Robert Frost and I am Vice President for Clinical Research and

Prevention Programs at the American Foundation for AIDS Research (amfAR).

Founded in 1985, amfAR is the nation’s leading nonprofit organization dedicated

to the support of HIV/AIDS research, AIDS prevention, treatment education, and

the advocacy of sound AIDS-related public policy. I am also the director of amfAR’s

international initiative, Therapeutics Research, Education, and AIDS Training in

Asia, or TREAT Asia. TREAT Asia is a cooperative venture designed to help Asia

and the Pacific region—which is expected to become the next epicenter of the pandemic—prepare for the safe and effective delivery of HIV/AIDS treatments as they

become more widely available. The program pairs the resources and experience of

clinical centers in Asia with amfAR’s education, training, and clinical research expertise.

The goals of TREAT Asia are to:

Develop the skills of the health care workforce in the safe and effective delivery of drug treatments for HIV/AIDS;

Enhance existing health care infrastructure and formulate strategies for capacity building to prepare for expanded access to HIV/AIDS drug treatments;

Develop a framework for regional collaboration on a therapeutics research

agenda that is responsive to the needs of patient populations in the region;

Define and address the national and regional policy issues that impede expanded access to drug treatments for HIV/AIDS and, by working with regional

and in-country NGOs, strengthen civil society’s preparedness for treatment programs.

SIZE AND SCOPE OF THE EPIDEMIC IN CHINA

China’s HIV/AIDS epidemic has been gaining momentum and the Chinese government estimates that currently 840,000 persons are infected with HIV/AIDS. Intravenous drug use and contaminated blood have been the two primary routes for

infection in China, representing two distinct and separate epidemics. However, HIV

infection is increasingly spread through sexual transmission, with rising rates of

infection among commercial sex workers in several provinces. Among those who acquired infection through tainted blood collection practices in central China during

the 1990s, large numbers are now falling ill and have minimal access to care and

treatment in China’s under funded rural health care system. Relative to many developing countries with severe AIDS epidemics in Africa and Southeast Asia, China

has a functioning health care infrastructure, and antiretroviral therapy is starting

to be offered through public hospitals and clinics at the county, township, and village levels in severely affected communities. However, healthcare providers at these

levels have little training or experience in counseling and treating AIDS patients,

compounding the problem of side effect management and drug compliance. The lack

of healthcare provider capacity to administer antiretrovirals is one of the biggest obstacles to treatment preparedness in China.

Though by all accounts China has become more open in dealing with HIV/AIDS,

denial of the full extent of the epidemic persists. Unfortunately, there are no reliable data that accurately assess the scope of the epidemic. Chinese doctors privately

suggest that the epidemic is at least 5 times—and possibly even 10 times—the official estimates.

The HIV epidemic in China’s central province of Henan is instructive. With an

estimated population of 110 million, Henan is China’s largest province. If only 1 percent of this population was infected through the ‘‘blood trade,’’ more than a million

people would be HIV-positive in Henan alone. Yet a recent survey showed that the

prevalence rate among commercial blood donors in rural eastern China was 12.5

percent and 2.1 percent among their non-donor spouses. In January 2002, the

Henan Health Department reported that 80 percent of Houyang village residents

were HIV-positive. Of its 4,000 residents between the ages of 16 and 55, some 90

percent participated in blood donation programs. More than 400 villagers have

developed AIDS, and 150 died between November 2000 and November 2001. In

December 2002, former Health Minister Zhang Wenkang acknowledged that 23

provinces, autonomous regions, and municipalities were affected by unhygienic blood

collection. And this is to say nothing of the epidemic among injecting drug users in

the south and northwest provinces of Yunnan, Sichuan, and Xinjiang among others.

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When asked by amfAR recently about the size and scope of China and India’s epidemics in an article published in amfAR’s quarterly newsletter for the TREAT

Asia Report, Dr. Richard Feachem, Executive Director of the Global Fund for AIDS,

TB, and Malaria, had this to say:

‘‘There has been this strange collusion between Western experts, international organizations, and the Chinese and Indians to first say that the

HIV epidemic is not seriously going to affect China and India at all, then

to say, well, maybe they’re going to have a small epidemic, and then to say,

well, maybe they’re going to have a rather larger epidemic. ‘‘But only very recently has there been anything approaching a consensus

that China and India are set for very large epidemics. Because of this

history of minimizing the epidemics in China, India, and in Asia more generally, I would go with the higher-end estimates now being produced.’’

CHINA’S RESPONSE

Recently there have been promising signs of an increasing willingness in China

to confront its HIV/AIDS epidemic. China has just been awarded a grant from the

Global Fund to carry out voluntary counseling and testing (VCT) and treatment programs in seven provinces where many infected through blood donation during the

1990s are falling ill. Prior to this, the Chinese government had initiated a treatment

program in four of these provinces that offers antiretroviral therapy to about 3,000

persons now, with a target of 5,000 by the end of 2003. The Global Fund support

will be used to scale up treatment, including antiretrovirals, to 40,000 AIDS patients in 56 counties in these seven provinces by 2008. Many experts believe even

the 40,000 target is a significant underestimate of the number of patients in these

communities who will require treatment in the next 5 years.

While the Chinese government’s goal of extending free antiretroviral treatment to

rural AIDS patients is laudable, many problems exist with China’s current treatment policy program beyond the issue of the numbers of sick persons who will have

access to free treatment. One significant problem has to do with the affordability

of state-of-the-art antiretroviral therapy that is both easier for patients to tolerate

and for health care providers to supervise (i.e., fewer doses, less complicated regimens with fewer side effects). As a new member of the World Trade Organization,

China has been careful to respect international trade agreements and only manufacture drugs that are off patent. Two Chinese pharmaceutical companies have begun

to produce generic versions of 4 off-patent drugs that the government has acquired

for their public treatment program. Patented drugs, such as combivir (AZT + 3TC),

are imported but considered too expensive to use routinely and are only used in a

handful of patients when domestically manufactured drugs are not tolerated. The

treatment protocols currently being used are not optimal and have not been well tolerated by patients, resulting in severe side effects which local health care providers

have no training or experience in managing.

Because of these side effects, the treatment options currently available in China

in many ways represent the worst possible choices and offer the potential for disaster. Yet China is taking the approach that most developing countries are forced

to take when it comes to choosing treatment regimens. Rather than developing public health strategies for delivering treatments to the population of HIV-infected individuals, China is left in the undesirable position of having to settle for what it can

get, rather than what it needs. Unless serious attention is paid to acquiring better

combination treatments, the failure rate of the current regimens is likely to be enormously high and could have dire consequences in terms of diminished long-term efficacy of treatment programs in China and widespread development of HIV drug

resistance, with implications for the rest of the world. Similar lack of access to imported reagents for HIV and CD4 testing has constrained the ability of the health

system to do the necessary voluntary counseling and testing, and to properly monitor those patients on treatment.

The mix of insufficiently trained medical staff with poor counseling skills, poorly

tolerated drug regimens, and lack of testing and laboratory monitoring capacity is

a worrisome combination of factors. In an editorial published in The South China

Morning Post in August 2003, Drew Thompson of the Washington DC-based Center

for Strategic and International Studies wrote: ‘‘To safely treat HIV sufferers with

powerful antiretroviral drugs, it is crucial to have trained physicians with access to

laboratories which can carry out advanced blood testing. . . . By jumping the gun

and beginning treatment before doctors and counselors are properly trained, a drugresistant disaster is waiting to happen.’’

Now that China has been granted a big infusion of funds through the Global Fund

mechanism, it will quickly be scaling up its treatment program. It is imperative that

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education and training programs are rapidly expanded and accelerated in order to

ensure that the best available drugs are being provided by trained medical professionals, with proper counseling and rigorous monitoring and follow-up testing.

At amfAR, and within the TREAT Asia program, we believe that it is here the

United States has much to offer. China desperately needs (and there is growing evidence of China’s willingness to seek), international support for rapidly developing

and scaling up education and training programs for healthcare providers in the

delivery of HIV/AIDS drugs. It is my sincere hope that we will find the necessary

resources to provide precisely that support.

Thank you.

Æ