The goal of this cooperative agreement award to China CDC is to facilitate China's prevention, treatment and care programs for HIV/AIDS by improving the effectiveness of national and provincial programs. This award spans all technical areas in which CDC GAP-China works: PMTCT, sexual prevention, drug use, counseling and testing, adult and pediatric care and treatment, TB, lab, SI and health systems strengthening.

China CDC's programs cover the entire country and population. Most of the HIV/AIDS programs focus on targeting specific MARPs including IDU, MSM, FSW and other vulnerable populations.

China CDC is the leadership body for HIV/AIDS programs in China. They propose national policies, develop the national action plan, influence provincial and local level activities and reporting mechanisms, carry out GFATM programs and facilitate donor coordination. China CDC supports national, regional and district level systems that deal with financing HIV/AIDS programs.

Since China CDC works in all areas of HIV/AIDS programming several cross-cutting and key issues are addressed, including HRH, TB, gender and mobile populations.

HRH

China CDC runs 13 HIV/AIDS clinical training centers to ensure physicians from across China are familiar with HIV/AIDS care and treatment issues. China CDC contributes to the Lixin and proposed Luzhai Rural HIV/AIDS Clinical Training Centers for physicians and the PPMTP training program for HIV/AIDS program managers.

Gender

Many of the China CDC HIV/AIDS programs touch on gender issues including PMTCT, testing and counseling and care and treatment for FSW, female IDU and wives of MSM. These programs deal both with providing services to women and providing gender equity for all HIV-infection persons.

Mobile Populations

Mobile populations are one of the other vulnerable populations targeted in China. Many people move from the countryside to urban areas for work. In addition to internal mobile populations, there are also immigrants who enter China from areas of higher HIV/AIDS prevalence. These people include women who enter China to become brides and mobile populations at the border areas. Recently many Chinese workers have been traveling to sub-Saharan Africa to work. These men may be sailors or workers who live and work in Africa. Many of them return to China when their work is over. These mobile populations are targeted by testing and counseling efforts. Since many may move again after they have been diagnosed, additional efforts are made to continue their treatment.

One of USGs main strategies is to help China CDC become more cost efficient. This is done through increased coordination and de-duplication of efforts with GFATM, other international partners, and other China CDC divisions, including the NCWCH and TB divisions.

China CDC is in the process of evaluating their HIV/AIDS program and developing a new M&E framework to go along with the next 5-year National Plan for HIV/AIDS implementation. The current efforts will include evaluating both outputs and impacts to see if the HIV/AIDS program has been effective in its efforts.

Base (GAP account): $93,300

GHCS (State): $155,800

The population covered by China CDC's efforts is the entire population of China. Since China has a targeted HIV epidemic, MARP groups including MSM, IDU and FSW are targeted more aggressively than others. China CDC provides care and support services to HIV/AIDS patients through the Four Frees and One Care program which covers rural and poor populations in China. Most service delivery sites are facility-based, although there is a movement to become more community- and home-based.

Activities supported in adult care and support in COP FY10 by GAP funds will include:

Providing TA to China CARES and RCC to better implement comprehensive care and support services to PLHA, including serodiscordant couples.

Assist in the enrollment of PLHA into MMT clinics and the provision of peer psychological support and follow-up services to these IDU

Assist in the use of IDU peers to improve ART adherence among PLHA

Assist RCC to scale up MMT clinics as a platform for care and support to HIV- positive IDU as well as promote the integration of care and support with ART services in seven IDU driven HIV epidemic provinces. Activities will include establishing PLHA self-help groups for improving enrollment rates, follow-up rates and adherence, setting up DOT in MMT clinics, conducting quarterly CD4 testing, providing cotrimoxazole for OI prevention, and setting up referral services to ANC, ARV, and TB clinics.

Work toward strengthening links between VCT, prevention, care, and treatment to increase follow-up and referral rates and develop comprehensive care packages

Base (GAP account): $87,000

GHCS (State): $98,800

The population covered by China CDC's efforts is the entire population of China. Since China has a targeted HIV epidemic, MARP groups including MSM, IDU and FSW are targeted more aggressively than others. China CDC provides treatment to HIV/AIDS patients through the Four Frees and One Care program which covers rural and poor populations in China. However, information about all patients on AIDS treatment, including test results and clinical outcomes, are tracked using the national web-based disease database. Clinical outcomes are evaluated using CD4 count and viral load levels, which are maintained the database. GoC has begun using WHO Early Warning Indicators for drug resistance and have pilot studies directly assessing drug resistance in specific areas. The GoC recently published a paper in the Annals of Internal Medicine titled Five-Year Outcomes of the China National Free Antiretroviral Treatment Program, quantifying clinical treatment outcomes from the past five years. China CDC estimates 85,000 people currently in need of ART and expects to provide ART to 80,000 people by 2010. Cotrimoxazole prophylaxis is not recorded in the web-based database system, so less information is known on coverage of its use. TB screening is carried out by the Division of TB and is not yet fully integrated with the HIV program.

Training activities for physicians are provided through 13 HIV/AIDS national clinical training centers, the Lixin Rural HIV/AIDS Clinical Training Center and proposed Luzhai Rural HIV/AIDS Clinical Training Center. These centers will provide residency programs to practicing physicians. In-service training is provided to laboratory staff to conduct CD4 count, viral load, and drug resistance testing.

Activities supported in adult treatment through FY10 GAP funds will include:

Providing TA to China CARES and RCC to better implement the National Free ART program which provides 1st and 2nd line ART, OI management and prophylaxis, CD4 and viral load testing, clinical monitoring and follow-up

Assisting the RCC scale-up a community- and home-based treatment model in 76 counties. This will include strengthening the three-tier village, township and county health network system to provide quality ART services to patients.

Providing TA to NCAIDS to scale up the 2nd line ARV program to additional provinces and will assist 15 provinces improve CD4 and VL testing rates based on the national guidelines.

Provide TA on integrating the new M&E plan into the National Free ART Program.

Assist in the pilot of HIV/HBV and HCV co-infection programs in Guangdong and Guangxi provinces.

In cooperation with Guangxi Health Bureau, open the 2nd Rural AIDS Clinic Training Center in Luzhai, Guangxi. The placement will help the scale-up ART services to rural and suburban IDU populations and will strengthen referral services between MMT clinics, PMTCT and ART programs, particularly in that high-prevalence area

Base (GAP account): $141,400

GHCS (State): $236,300

CDC China will be supported for testing and counseling activities both at the national and provincial CDC level. Testing and counseling activities will focus on MARPs and discordant couples.

GAP-supported testing and counseling activities will include several projects. Assisting with the development ofa VCT data quality evaluation protocol. Assisting with the implementation of a VCT data quality evaluation. Improving VCT utilization and quality. Assisting in the development of the Chinese PITC technical guidance and guidelines for PITC implementation. Facilitating PITC advocacy and policy support at the central level. Technical support for pilot tests of saliva rapid test acceptance.

Testing and counseling activities at the provincial level will include: Assisting with scale-up, summary and promotion of PITC models. Supporting testing and counseling activities among MARPs. Assisting with pilots of multiple testing and counseling models such as couples testing and counseling and community-based testing and counseling. Assisting with improvement of VCT services.

Base (GAP account): $27,600

GHCS (State): $46,200

The population targeted by China CDC is the population of China. Testing, care, support and treatment for HIV positive children is provided by the GoC through the Four Frees and One Care policy and the National Free HIV/AIDS Pediatric Treatment Program.

GAP funds support China CDC's pediatric care and support by providing technical assistance and training. Activities to be conducted with FY10 funds include:

Assisting Global Fund strengthen the three-tiered health system to involve families in pediatric care and support, including OI screening and management

Train physicians in screening and treatment of pediatric OIs, including TB, and revise the national HIV/AIDS training curriculum to include best practices

Increasing links between NCWCH and NCAIDS to ensure that children placed on ART receive proper care services

Encourage the use of cotrimoxazole when indicated for children and champion for collection of this information in the web-based reporting system

Collaborate with UNICEF, WHO and Clinton Foundation to assist NCWCH and NARL in establishing a sound China-specific EID testing algorithm, guidelines and laboratory capacity

Clarify and publicizing new EID guidance. Provide technical assistance on pilot projects for EID.

Base (GAP account): $32,300

GHCS (State): $38,000

The population targeted by China CDC is the population of China. Testing, care, support and treatment for HIV positive children is provided by the GoC through the Four Frees and One Care policy and the National Free HIV/AIDS Pediatric Treatment Program. China CDC supplies free drugs to pediatric AIDS patients.

GAP funds support China CDC's pediatric treatment program by providing technical assistance and training. Activities to be conducted with FY10 funding include:

Assisting Global Fund strengthen the three-tiered health system to involve families in pediatric treatment and improve adherence

Train physicians in pediatric screening and treatment, including 2nd line treatment, and revise the national HIV/AIDS training curriculum to include best practices

Increasing links between NCWCH and NCAIDS to ensure that children placed on ART receive proper clinical monitoring

Base (GAP account): $147,300

GHCS (State): $210,000

CDC GAP China funds will provide technical assistance for SI activities in HMIS, M&E and surveillance. GAP-supported SI activities through China CDC will include:

Assisting with development of China's Five-Year Action Plan for HIV/AIDS (2011-2016), particularly for M&E.

Facilitating national M&E of provincial HIV/AIDS control activities.

Providing assistance with size estimations and projections of HIV among MARPs.

Supporting training in the Asian Epidemic Model (AEM).

Assisting with trainings on the national surveillance system.

Providing technical assistance for contact tracing among newly-reported HIV cases in 3 provinces.

Assisting with development of provincial Five-Year Action Plans for HIV/AIDS, particularly for M&E.

Facilitating program-level M&E of provincial AIDS control activities.

Supporting provincial training in data analysis and use.

Base (GAP account): $58,300

GHCS (State): $97,400

China CDC in collaboration with USG will address the need for a health workforce capable of managing and implementing HIV/AIDS programs at the provincial and local levels of government as well as capable of providing HIV/AIDS specific medical services in rural areas of China. Additionally, China CDC will address strengthening laboratory quality, surveillance methods, PITC, roll-out of 2nd line ART, and challenges of controlling HIV/AIDS in a vertical system.

China CDC will address system barriers in a multitude of ways including requesting support for technical assistance from CDC. The three training programs (Lixin Rural AIDS Clinical Training Center, Luzhai Rural AIDS Clinical Training Center, and Provincial Program Management Training Program) will continue to be co-managed by China CDC and USG and are designed to support in-service training of health care workers who will be able to conduct HIV/AIDS activities at a higher quality.

Laboratory quality will be a major area of emphasis in FY10 and FY11 for China CDC. This includes adoption of accreditation systems for laboratories in China, strengthening the capacity of existing laboratories to operate at high standards of quality, and piloting of newer techniques and international best practices.

China CDC has and will continue to support intentional spill-overs of systems in China as related to HIV since strengthening across these systems will directly and indirectly impact HIV control. This includes continued work with the TB system to address TB/HIV co-infections, MCH to strengthen PMTCT, and MMT clinics and detoxification centers to address the high rates of HIV among IDU.

Base (GAP account): $49,100

GHCS (State): $82,000

In recent years, sexual transmission of HIV has outpaced injecting drug use as the primary route for new HIV infections. FSW (especially low-fee ones), men who have multiple concurrent partners, HIV discordant couples, and MSM are all contributing to the increase of sexual transmission of HIV. Compared to that of other groups, the epidemic among MSM in China is rapidly increasing.

Under COP FY10, China CDC will continue to strengthen HIV sexual prevention interventions in 15 provinces.

To prevent HIV transmission through commercial sex, GoC has set up "high-risk intervention teams" throughout the country to insure implementation of the 100% CUP. Shortcomings of the current 100% CUP, including poor implementation due to low staff capacity, low coverage, and reliance on the stand-alone intervention of condom distribution without concurrent efforts placed on VCT, behavior change, and STI service provision, will all be addressed.

China CDC will also conduct field test of interventions for street-based FSW and older clients. This subgroup of FSW and older male clients who visit them have higher prevalence of HIV and STIs, and they are usually not reached by current entertainment venue-based 100% CUP programs.

For MSM interventions, political opinion leader (POL) has become a standard intervention model focusing on change of group norms. In the FY10 COP, prevention counseling and other individual level intervention will be incorporated into the comprehension intervention package to enhance its effectiveness. CDC technical staff will ensure service quality through regular monitoring and regular client satisfaction surveys. CDC has also designed a program database system to routinely track outputs and achievements.

With FY10 funds, USG will continue to provide technical support to GoC to improve the quality of sexual prevention interventions by revising the national guidelines, strengthening the capacity of implementing staff, and linking sexual prevention with STI treatment, HIV testing, counseling, care, and treatment.

Base (GAP account): $102,300

GHCS (State): $170,900

Drug use is an important driver of the HIV/AIDS epidemic in China and the major transmission mode in China's southwestern provinces and Xinjiang in the northwest. The cumulative number of reported HIV cases in China as of October 2008 was 276,335, 32.8% of whom were infected via IDU. Of the 1.1 million registered drug users in China by the end of 2008, approximately 15% are women. The estimated number of actual drug users is 2-3 times higher than the registered number. It is estimated that 77.5% drug users use heroin and 55.7% inject.

MMT is the core intervention for IDUs in China. By May 2009, 625 MMT clinics have been set up in 23 provinces. GoC has a target of 1,000 MMT clinics to be operational by the end of 2009. As of May 2009, there were 204,165 clients enrolled in the national MMT program with 104,239 clients currently on treatment. As a complement to MMT, GoC has also launched a nation-wide needle and syringe program (NSP) to reduce HIV transmission risk among IDU. By the end of 2008, 897 NSP sites were set up in 26 of 31 provinces, covering 526 counties. The average monthly coverage of the program is 36,000 IDU.

Funds to China CDC in the FY10 COP will support improvements in MMT services including scale up of peer educators and outreach workers to increase MMT enrollment countrywide and improve retention. An assessment of the national MMT program will provide information for program improvements and generate data for decision making. Building strong linkages with care and support services will promote referrals between detoxification centers and MMT as well as with MMT and HIV/AIDS treatment and care programs. China CDC will support an evaluation of the NSP program to determine its efficacy. In addition, China CDC will develop a technical assistance program aimed at sharing China's MMT experiences with other countries that have an IDU-driven epidemic, such as Vietnam, Ukraine, Kazakhstan and other Central Asian countries. The program will consist of workshops, sending Chinese experts abroad as consultants, and receiving study tours from other countries.

Via provincial CDCs, China CDC will support provincial MMT clinics and associated community groups to train outreach workers and female IDU peer educators on condom promotion and behavior change targeting female IDU.

Via China CDC, USG and its partners will continue strong integration and collaboration with national and local government partners, GFATM, and the Australian government-funded highly active antiretroviral therapy (HAARP) project to promote success in reducing the HIV epidemic.

Base (GAP account): $24,800

GHCS (State): $41,400

CDC-GAP China funds will support the GoC in carrying out comprehensive PMTCT activities at the community, district and provincial levels and coordinate the program areas of testing, treatment, care, lab, and SI. These activities will help the GoC reach their national goal of reaching over 3.2 million women in 533 counties (nearly 20% coverage nationally) by September 2010.

Specific GAP-supported PMTCT activities with FY10 funding will include:

Piloting routine syphilis and HIV rapid screening in ANC clinics in two provinces

Evaluating the feasibility and applicability of repeat HIV testing in late pregnancy and/or at delivery targeting high-risk populations of women

Supporting a model PMTCT pilot program in Guangxi and adding 25 counties

Supporting a new PMTCT model pilot program in Yangjiang city, Guangdong

Providing technical assistance implementing early infant virologic diagnosis in 7 provinces

Assisting with additional development of the national web-based PMTCT data management and reporting system

Strengthening linkages between MMT and PMTCT services

Conducting supervisory visits by senior staff to improve implementation in the provinces

Updating PMTCT regimen guidelines

Assisting with the harmonization of PMTCT guidelines

Supporting the application of the new WHO PMTCT guidelines (expected in November 2009).

Clearing key policy barriers

Expanding PITC in premarital health screenings

Base (GAP account): $142,000

GHCS (State): $237,200

CDC GAP China funds will support China CDC laboratory activities for capacity building in the National AIDS Reference Laboratory (NARL) in NCAIDS and provincial CDC laboratories.

GAP-supported laboratory activities at NCAIDS will include:

Strengthening the national laboratory test quality by assisting NARL's CAP accreditation process and extending domestic PT program network

Assisting with the establishment of an early infant diagnosis laboratory network using testing algorithms, guidelines, and supplementary nucleic acid assay(s) for the timely return of high quality lab data. Linking infected infants to care to treatment following the upcoming Chinese PMTCT/EID expansion efforts

Piloting new incidence assays developed by US CDC and evaluating their use as independent assays or in combination with BED to enhance the accuracy of incidence measurement

Evaluating the potential and utility of novel point-of-care and specimen collection/transport technologies in partnership with international manufacturers to overcome low CD4 and viral load coverage obstacles

Evaluating the utility of fourth generation assays for the identification of persons with acute HIV infection and the utility and effectiveness of using oral exudates-based assays for most-at-risk populations including IDU, MSM and FCW

Assisting NARL and provincial CDCs with quality assurance of domestic rapid tests and their appropriate use at VCT sites

Base (GAP account): $9,600

GHCS (State): $16,000

The TB division of China CDC creates host county national policies and strategic plans and is the main actor on TB issues in China. Training of health care providers on TB/HIV co-infection will be conducted at the Lixin and proposed Luzhai Rural HIV/AIDS Clinical Training Centers. These centers will provide residency programs to practicing physicians. Training includes TB and other OI screening, prevention and treatment among HIV positive patients. National TB data is reported through the web-based China Information System for Diseases Control and Prevention database. TB data is reported separately from HIV data. The TB and HIV programs also have separate M&E programs.

FY10 COP funding to CDC China will assist the national TB and HIV programs by promoting screening, treatment and care models for TB/HIV co-infected patients.

GAP-supported TB/HIV activities will include: providing daily technical assistance and support to National TB Center and NCAIDS on TB/HIV related issues, including technical guideline, data collecting and reporting, and M&E; assisting with operation manual development on TB/HIV co-infected IDU, and piloting the manual at one IDU-driven site; promoting PITC in TB clinics in 7 high HIV prevalence provinces; promoting TB screening in ARV clinics, and HIV PITC in TB clinics in 5 counties in Henan; and supporting training of physicians to treat HIV and TB co-infections at the Lixin and Luzhai training centers.