The goal of this implementing mechanism is to build the capacity of the Chinese Center for Disease Control and Prevention (China CDC) to improve the coverage, efficiency, and quality of HIV/AIDS services in China. U.S. CDC will collaborate with China CDC at the national level to develop technical guidelines and manuals and to strengthen laboratory and surveillance systems. U.S. CDC will also support 15 provincial CDCs to explore innovative models and conduct operational research. This implementing mechanism has a strong history of producing successful models, which are scaled up using host country resources. Moreover, beginning in FY12, provinces supported by this implementing mechanism will match funds 1:1. Since China has a concentrated HIV epidemic, target populations include PWID, MSM, and FSW. U.S. CDC will provide technical assistance to improve data collection, analysis, and utilization for monitoring and evaluation at all levels.

This implementing mechanism supports clinicians and health care workers in five counties in Henan to provide follow-up services, including adherence counseling, CD4 testing, and CTX prophylaxis, in county CDCs, county and township hospitals, and village clinics. The Henan Community Care program also includes support groups for PLHA. In addition, this implementing mechanism supports outreach and home visits for PLHA in Anhui and Guangxi by clinicians from the Lixin and Luzhai Rural AIDS Clinical Training Centers, who provide adherence counseling, clinical monitoring, and OI management. The Luzhai Rural AIDS Clinical Training Center also strengthens linkages between MMT, PMTCT, and care and treatment services.

HIV-positive pregnant women, their partners and infants also receive care services, such as clinical monitoring, partner testing, and EID, through the enhanced PMTCT program at 112 ANC clinics and hospitals in Guangxi. This program increases referrals between PMTCT, care, and treatment services and between village, township, and county levels of the three-tiered health system.

Through this implementing mechanism, U.S. CDC provides technical assistance to China CDC and 15 provincial CDCs. This implementing mechanism focuses on the development of models for scale-up by GOC. In FY12, U.S. CDC will assist GOC to scale up community and home-based care through the Essential Care Package model.

Joint site visits are conducted for program monitoring and evaluation.

Through this implementing mechanism, U.S CDC facilitates collaboration between the National Center for AIDS/STD Control and Prevention (NCAIDS) and the National Center for TB Control and Prevention (NCTB) within China CDC to ensure alignment of national policies and technical guidelines.This implementing mechanism supports TB/HIV services, including TB screening for PLHA, HTC for TB patients, and TB and ARV treatment for TB/HIV co-infected patients, in five counties in Henan and one county in Guangxi. In FY11, 96% of PLHA were screened for TB and 99% of TB patients were tested for HIV at supported sites. Other accomplishments include the development of a manual for health care providers on TB/HIV co-infection management and an M&E plan for an IPT pilot.

Building on these accomplishments, in FY12, U.S. CDC will provide technical assistance to NCTB to monitor and evaluate the IPT pilot, to draft a manual on IPT, and to scale up TB/HIV services. NCTB will integrate TB/HIV M&E plans into local assessments of TB and HIV/AIDS programs in two counties. This will be done through building capacity at both the clinic and laboratory level for TB/HIV diagnosis, improving the quality of data collection, strengthening the reporting system, and facilitating collaboration between TB and HIV/AIDS programs.

This implementing mechanism also supports training for county-level clinicians on TB/HIV services through the Rural AIDS Clinical Training Centers in Lixin, Anhui and Luzhai, Guangxi.

This implementing mechanism does not include direct provision of pediatric HIV care, since GOC covers pediatric care under the Four Frees and One Care policy. Instead, it focuses on technical assistance: to define an improved package of services, including cotrimoxazole prophylaxis for infants; to implement EID by dried blood spot at 6-8 weeks of age in 7 provinces through a network of specialized laboratories; and to investigate possible transmission routes for HIV-positive children with HIV-negative mothers. This implementing mechanism also supports in-service training for county-level clinicians to provide quality pediatric HIV care through the Rural AIDS Clinical Training Centers in Lixin, Anhui and Luzhai, Guangxi.

China has a well-established multi-tier HIV laboratory network that spans CDC, hospital, and MCH systems. The top two tiers of the network consist of the National AIDS Reference Laboratory (NARL) at NCAIDS and 35 provincial confirmatory laboratories. In 2010, GOC opened an additional 283 confirmatory laboratories in prefectural CDCs and large hospitals and more than 8,870 screening laboratories in county CDCs, blood stations, and MCH facilities. About 32% of laboratories are in CDCs and 57% are in hospitals. Serologic testing services have been extended to 97% of prefecture level health systems. Laboratory technical guidelines for HIV testing were developed in close consultation with USG, WHO, and the Clinton Health Access Initiative. All HIV laboratories have been ISO-17025 accredited.

This implementing mechanism focuses on technical assistance. Activities for FY12 include: Develop a national five-year laboratory strategic plan

; Evaluate the utility of Alere point-of-care (POC) CD4 technology

; Formulate an evaluation protocol to test Alere POC viral load (VL) technology; Deveop a comprehensive HIV-1 drug resistance (DR) monitoring system to ensure timeliness, accuracy, and usefulness to clinicians by standardizing the report on DR results based on clinically useful DR mutations; Assist NARL to upgrade laboratory quality management to attain College of American Pathologists (CAP) accreditation; Continue to support the evaluation and commercialization of affinity-based incidence assay and convene a training workshop with domestic and international participants from neighboring countries; Facilitate regional exchange of laboratory knowledge.

This implementing mechanism provides technical assistance to develop, implement, and document innovative SI methods and models to build capacity for data collection, analysis, and use at national and sub-national levels.

Activities for FY12 include:

Harmonize indicators and streamline reporting for MARPs in line with national guidelines

; Conduct cost-effectiveness analyses of national HIV/AIDS programs

; Improve the quality and sustainability of the national HIV surveillance system and strengthen the capacity of data analysis and use at national and sub-national levels by training provincial, city, and county CDC staff

; Apply recommendations from national HIV sentinel surveillance system evaluation

; Support development and dissemination of provincial surveillance reports

; Support national population size estimation of MARPs, HIV incidence estimation using multiple methods particularly BED-CEIA testing, and data triangulation using national HIV and STI sentinel surveillance data.

This implementing mechanism addresses the lack of capacity at sub-national levels to manage operational and fiduciary functions through the Provincial Program Management Training Program. This program provides provincial HIV/AIDS program managers with one month of classroom instruction and five months of hands-on learning through rotations in NCAIDS divisions and in the field.

Although China currently produces an adequate number of health care providers, their training and capacity in HIV prevention, care, and treatment remain low, particularly at the county level and below. This implementing mechanism supports two Rural AIDS Clinical Training Centers for county-level clinicians to improve the quality of HIV/AIDS services.

This implementing mechanism also strengthens linkages between vertical health systems by facilitating collaboration between NCWCH, NCAIDS, and NCTB at the national level and supporting referral mechanisms between MCH, CDC, and hospitals at the local level.

According to the 2009 National Sentinel Surveillance, HIV prevalence among MARPs is 9.3% for PWID, 5.0% for MSM, and 0.6% for FSW. HTC coverage is 37.3% for PWID, 44.9% for MSM, and 36.9% for FSW. HIV prevalence among pregnant women ages 15-24 is 0.2%.

Through this implementing mechanism, U.S. CDC provides technical assistance to NCAIDS, provincial CDCs, and CBOs to increase HTC coverage, particularly among MARPs, and to link HTC to prevention, care, and treatment services. In FY12, China CDC will continue to pursue multiple approaches, including VCT, CHCT, and PITC. This implementing mechanism will support MSM CBOs to provide on-site and mobile VCT using oral rapid tests. Having contributed to the recently released technical guidelines on HIV rapid tests, U.S. CDC will continue to support implementation by providing technical assistance on QA and QC. Implementing mechanism activities include CHCT pilots in high prevalence provinces, including two pilots for MSM couples. U.S. CDC will continue to assist with the development and implementation of technical guidelines on PITC. U.S. CDC will also provide technical assistance to scale up PITC pilots in both low and high HIV prevalence provinces. This implementing mechanism will continue to support PITC in pre-marriage health screenings and ANC clinics for PMTCT and in TB clinics for TB/HIV co-infection management. Because approximately one-third of heterosexual transmission occurs between discordant couples, these activities also promote partner testing through PMTCT and care services.

Targets and results by approach:

VCT

- FY12 target: 3,300 (1,500 MSM through Tianjin bathhouse pilot + 1,800 from Henan Community Care program); FY11 result: 3,666.

CHCT

- FY12 target: 600 partners tested through CHCT pilots in Sichuan and Xinjiang

; FY11 result: 0.

PITC

- FY12 target: 45,238 (43,700 pregnant women, 126 partners and 112 infants of HIV-positive pregnant women through PMTCT and 1,300 TB patients through Henan Community Care program)

; FY11 result: 69,518.

In addition, this implementing mechanism will continue to support 38 provincial-level sentinel surveillance sites, which will provide HTC for 17,000 individuals (PWID, STI patients, and college students). This implementing mechanism will also support HTC for 5,164 MARPs through operational research studies.

U.S. CDC provided technical assistance to NCAIDS to develop national indicators to monitor follow-up from HTC to care and treatment, including CD4 testing. U.S. CDC will continue to provide technical assistance to NCAIDS to improve VCT data quality and utilization. In particular, U.S. CDC will assist with protocol development for VCT data quality evaluation.

Target population: MSM;

Approximate Dollar Amount: $70,218;

Coverage: 4,100

; Activities:

Train local CDC staff and MSM peer educators on outreach

; Pilot intervention for MSM in bathhouse, including condom promotion and distribution, on-site VCT using oral rapid tests, and linkages to STI management and HIV care and treatment services (1,500 MSM)

; Support comprehensive HIV prevention intervention, including risk reduction counseling, condom promotion and distribution, and STI referrals, for MSM in 3 provinces (Guangzhou, Guizhou, and Xinjiang); promote quality assurance through supportive supervision and regular client satisfaction surveys (1,500 MSM)

; Support provincial CDCs to conduct operational research on interventions targeting MSM (1,100 MSM)

; Promote direct provision of VCT by MSM CBOs using rapid tests.

Target population: FSW;

Approximate Dollar Amount: $46,812

; Coverage: 1,764;

Activities:

Conduct cross-sectional survey on risk perceptions and behaviors among low-fee FSW to inform behavioral interventions; provide risk reduction counseling, condom promotion and distribution, HIV, syphilis, and herpes testing, and referrals for free syphilis treatment, discounted herpes treatment, and partner testing to participants (1,564 FSW)

; Support provincial CDC to conduct operational research in Inner Mongolia (200 FSW)

; Provide technical assistance to provincial CDCs to field test interventions for low-fee FSW and older clients who are often not reached by current venue-based 100% CUP

; Provide technical assistance to improve the quality of 100% CUP by revising national guidelines and strengthening linkages to VCT, STI management, and HIV care and treatment services; Train local CDC staff and FSW peer educators on outreach.

There is no agreed upon population size estimate for MSM in China. In 2007, the NCAIDS estimate was 3.1 to 6.3 million MSM. However, this may be an underestimate, as many other sources report much higher figures, the most common being 5-10 million MSM, and with some national estimates as high as 18-20 million.

In 2007, NCAIDS in collaboration with UNAIDS and WHO, estimated the population size of sex workers to be 1.8 to 3.8 million. Population size estimates were based on sentinel surveillance data, behavioral surveillance data, Public Security Bureau (PSB) registration data, and published literature.

In 2007, NCAIDS estimated the population size of PWID to be 1.5 to 3.0 million. The prevalence of injecting drug use among people aged 15-64 years is 0.25% or an estimated 2,350,000 persons, according to the United Nations Office on Drugs and Crime. The China National Narcotics Control Commission reported that the registered number of drug users in 2009 was 1,335,920 of whom 978,226 (73.2%) were heroin users. By 2009, approximately 238,280 PWID were estimated to be infected with HIV, primarily in the provinces of Xinjiang, Yunnan, Guizhou, Guangxi, and Guangdong, each of which had more than 10,000 PWID infected with HIV.

MMT is the core intervention for PWID in China. Since 2004, GOC has expanded the national MMT program to 715 clinics in 28 provinces. In 2010, GOC launched NSP. There are now 937 NSP sites in 26 provinces.

In FY12, U.S. CDC will continue to provide technical assistance to increase the coverage and improve the quality of MMT services. This implementing mechanism will support NCAIDS and provincial CDCs to train MMT clinic staff and PWID peer educators on outreach to increase MMT enrollment and retention. Other activities include piloting gender-specific programming for female PWID and female sexual partners of male PWID, including condom promotion and distribution, HTC, and PMTCT, in combination with MMT and NSP. U.S. CDC will promote messages and interventions for FSW who inject drugs that address the dual risk of sex work and injecting drug use. U.S. CDC will also provide technical assistance to strengthen linkages between MMT and ART.

This implementing mechanism supports an enhanced PMTCT pilot program at 112 ANC clinics and hospitals in high HIV prevalence areas of Guangxi. By promoting PITC and strengthening linkages between the village, township, and county levels of the three-tiered health system, this model successfully increased HIV testing to 97% of pregnant women, provided ARV prophylaxis to 87% of HIV-positive pregnant women, and reduced MTCT to 3% of HIV-exposed infants at USG-supported sites.

As part of the Four Frees and One Care policy, GOC provides PMTCT at a unit cost of $2,000 per patient. In FY10, GOC announced the expansion of the national PMTCT program from 333 to 1,156 high HIV prevalence counties and the integration of PMTCT for HIV, HBV, and syphilis with routine MCH services. The National Action Plan (2011-2015) includes PMTCT targets for testing 80% of pregnant women for HIV, providing ARV prophylaxis to 90% of HIV-positive pregnant women, and reducing MTCT to 5% of HIV-exposed infants. GOC has developed a national M&E plan for PMTCT and is in the process of implementing a tiered M&E system at the provincial, city, and county levels to guide implementation and support improvement. Through this implementing mechanism, U.S. CDC provides technical assistance (TA) on guidelines, manuals, and M&E.

Activities for FY12 include:

Continue to support clinicians to conduct active case finding at 112 sites in Guangxi

; Continue to support referral mechanisms between MCH, CDC, and hospital systems to ensure retention

; Promote PITC at pre-marriage health screenings to increase HIV diagnosis and CD4 testing prior to delivery

; Support Guangxi BOH to scale-up PMTCT to all 109 counties

; Support NCWCH to supervise PMTCT scale-up at provincial and local levels

; Provide TA to improve national PMTCT database as well as data collection, analysis, and utilization at all levels

; Provide TA to evaluate feasibility and acceptability of repeat HIV testing in late pregnancy and/or at delivery

; Strengthen linkages between MMT, PMTCT, and ART in Guizhou.

This implementing mechanism supports in-service training for county-level clinicians at two Rural AIDS Clinical Training Centers in Lixin, Anhui and Luzhai, Guangxi. In FY11, the Lixin Rural AIDS Clinical Training Center was transitioned to local ownership, but U.S. CDC will continue to provide technical assistance on second line ART. In FY12, U.S. CDC will continue to support the Luzhai Rural AIDS Clinical Training Center, including accomodation and stipends for trainees. In order to gain hands-on experience, trainees provide treatment services such as adherence counseling and clinical monitoring under the supervision of clinicians at county and township hospitals.

This implementing mechanism also supports clinicians in five counties in Henan to provide clinical monitoring, CD4 and viral load testing, and adherence counseling as part of a comprehensive care and treatment model. This model also includes PLHA support groups to improve adherence and retention.

The partner, NCAIDS, tracks and evaluates clinical outcomes of the National Free ART Program, including sites supported by this implementing mechanism, through the national treatment database. U.S. CDC provides technical assistance on data analysis and utilization.

Local CDCs provide free CD4 and viral load testing for treatment monitoring. In 2010, the Ministry of Finance approved reimbursement to PLHA for the cost of transportation and meals to access facility-based CD4 testing in order to improve retention.

This implementing mechanism includes technical assistance to scale up the Essential Care Package (ECP), which includes adherence counseling, clinical monitoring, and CTX prophylaxis. It also supports referral mechanisms to strengthen linkages between HIV prevention, care, and treatment services.

This implementing mechanism does not include direct provision of pediatric HIV treatment. GOC covers pediatric treatment under the National Free ART Program.

This implementing mechanism supports in-service training for county-level clinicians to provide pediatric HIV treatment at two Rural AIDS Clinical Training Centers in Lixin, Anhui and Luzhai, Guangxi. It also includes technical assistance to implement EID by dried blood spot at 6-8 weeks of age in 7 provinces through a network of specialized laboratories and to improve pediatric HIV data collection, analysis, and utilization.