The perils of the mainland's free Aids-drug policy
In April, China began providing free anti-retroviral drugs to some HIV-positive residents in Henan, Hubei, Hunan, Anhui and Sichuan provinces. However, successful treatment is unlikely, due to an insufficient number of doctors and trained social workers to oversee procedures, and inadequate laboratory equipment to monitor patients.
The advent of poorly monitored anti-retroviral drug treatment virtually guarantees the emergence of a drug-resistant HIV 'superinfection' likely to spread to other parts of China, Asia and the rest of the world.
Anti-retroviral regimens are complex, have serious life-threatening side effects, and many patients find it difficult to adhere to treatment guidelines. Giving drugs to patients without adequate supervision and counselling creates potentially serious consequences.
Studies in the United States have shown that unless 90-95 per cent of all doses are taken by the patient, the risk of developing drug-resistant strains increases dramatically. According to surveys, up to one-third of US patients missed doses - highlighting the challenge for China.
China's Ministry of Health estimates that between 100 and 150 doctors have been trained to diagnose and treat HIV/Aids. With more than one million cases reported, the UN predicts that China could have between 10 and 15 million HIV infections by 2010, further underscoring the need to begin treatment and prevention campaigns as soon as possible.
To safely treat HIV sufferers with powerful anti-retroviral drugs, it is crucial to have trained physicians with access to laboratories which can carry out advanced blood testing. The most important tests are to measure the HIV 'viral load' and 'CD4', which measures the degree of immunodeficiency. These tests must be carried out on each patient to determine whether the prescribed drug cocktail is effective, or whether potentially drug-resistant strains are surviving.
Treating HIV/Aids is not just about access to medication, but also about counselling and regular testing to ensure treatment regimens are effective. It has been reported that patients have already stopped taking their medication because of serious side effects.
Beginning treatment before doctors and counsellors have been trained, and laboratories with the necessary equipment and technicians are in place, virtually guarantees that patients will begin regimens that they are unable to keep up, resulting in the emergence of drug-resistant strains.
As we have seen from both Sars and HIV/Aids, diseases will migrate from one place to another without respect for international borders. The poor application of anti-retroviral drugs could, potentially, create drug-resistant strains that will emerge from central China, affecting Hong Kong and the rest of the world.
In its third application to the Global Fund to Fight Aids, Tuberculosis and Malaria, China has requested US$98 million (HK$764.5 million). It wants to use the money for infrastructure, doctor training, anti-retroviral drugs and counselling in 56 counties where HIV is prevalent among former blood donors. The international fund was inspired by UN Secretary-General Kofi Annan and is supported by donations from Microsoft chief Bill Gates, and several nations. A decision on China will be made in October.
The infrastructure and training mechanisms for which China hopes to get funding are not yet in place. The equipment to test CD4 and viral loads has not been purchased, doctors and counsellors have not been trained, and no referral chain exists that enables patients at the village level to be treated at the township or county level if their drug regimens are not successful.
With the financial support of the Global Fund, trained doctors can put in place the mechanisms to train hundreds more village doctors and health-care workers to properly administer the drugs and educate rural people about preventing the spread of HIV.
Assuming China's application is approved, it will be many months before laboratory equipment is purchased and shipped to the counties, technicians are trained and video-training seminars are produced and distributed. However, China's previous two HIV/Aids applications were turned down, so funding is by no means assured. By jumping the gun and beginning treatment before doctors and counsellors are trained, a drug-resistant disaster is waiting to happen.
The decision reflects the hard choices facing China's government in dealing with HIV/Aids. The farmers who contracted the Aids virus at government-run blood donation centres have become increasingly restive.
When World Health Organisation doctors visited one hard-hit county in Henan in May in connection with the Sars outbreak, HIV-positive villagers were forcibly detained and prevented from meeting doctors. In June, security forces reportedly stormed another 'Aids village'. Several people were hurt and others were arrested.
Sars challenged the new generation of Chinese leaders, who were forced to confront the realisation that under-investment in health care causes social instability and reduced economic growth. The leadership now expects that the dual policies of suppressing unrest and providing access to medication will help relieve social strain. China's leaders are obviously concerned about the plight of people in rural areas, and they have made a political decision to provide free medication, without sufficient regard for the implications.
China has a plan for building infrastructure so treatment can be administered responsibly, but by distributing free drugs without proper medical supervision, the government is acting prematurely and irresponsibly, thereby placing the rest of China - and the world - at increased risk.
Drew Thompson is a research associate for the Freeman Chair in China Studies at the Centre for Strategic and International Studies in Washington
