Dr. Bernhard Schwartlander, UNAIDS China Country Coordinator spoke to Ms. Sabita Gyawali and Ms. Shristi Joshi about the issues and challenges around HIV&AIDS in China.

1. How do you see the current HIV & AIDS situation in China?
   
   Overall HIV prevalence in China remains low—estimated at less than 0.1 percent of the total population—but the epidemic continues to grow in all parts of China. HIV transmission associated with the sale of blood and blood plasma in central China in the 1990s appears largely contained and the majority of new HIV infections are related to injecting drug use and sexual transmission.
   
   Since 1985, approximately 223,000 cases of HIV including 63,000 cases of AIDS have been reported. The 2007 estimate of the number of people living with HIV was 700,000 and the estimated number of people living with AIDS was 85,000. The number of people who have a high risk of exposure to HIV could be 30-50 million: mainly injecting drug users and their sexual partners, sex workers and their clients.
   
   What are the major gaps in the response to the HIV & AIDS epidemic in China?
   
   The Chinese government has shown its strong political commitment to the AIDS response. Senior leaders have met with people living with HIV almost every year since 2003, and issued the Decree and Action Plan on AIDS in early 2006. However, commitment at all levels of the government needs to be strengthened in order to assure the translation of good policy into good implementation. All sectors, especially non-health sectors, including private Chinese owned companies, mass media and academic institutions need to be more involved into the AIDS response. It is especially important that the judicial system and the public security departments find ways to collaborate with and provide support to public health efforts to prevent HIV among IDU, MSM and sex workers.
   
   A significant gap in the response is the low coverage of most-at-risk populations with preventive services and PLHIV with quality first line and second line ARV drugs. The current coverage figures for prevention and treatment were well behind the National Five year plan targets for 2007 and it seems difficult to meet the 2010 targets.
   
   AIDS is not given a human face - AIDS is still thought of as a very deadly disease, and people living with HIV are thought to be very sick and likely to die soon. In a recent survey, 65% of adults surveyed in a survey of 6000 people living in 6 Chinese cities said that they would be unwilling to live in the same household as a person living with HIV. 47.8% would be unwilling to eat with a person living with HIV, and 41.3% would be unwilling to work with a person living with HIV. These attitudes mean that very few Chinese people living with HIV are willing to come out publicly, which worsens misconceptions and stigma regarding AIDS.
   
   
2. What is the care, support and treatment situation for PLHIV?
   
   Treatment, care and support has improved significantly over the last 5 years since 2003, when the government adopted the “Four Frees One Care” policy nationally, including free voluntary HIV screening tests, free 1st line ARVs, free prevention of mother to children transmission services (PMTCT), free education for children orphaned by AIDS and care and economic assistance to the households of people living with HIV & AIDS. Currently about 48,000 people are on the free ARV programme. 2nd line ARVs are being piloted in some provinces and will be scaled up soon.
   
   Late diagnosis puts people living with HIV at risk of developing serious opportunistic infections (OIs). The expensive cost of OI treatment is unaffordable for most of people and their families, especially as the social welfare system is still weak and medical insurance does not cover AIDS-related diseases.
   
   In addition, stigma and discrimination among health care personnel still exist.
   
   
3. How does UNAIDS categorize the Government’s response?
   
   The government at the highest political levels has shown commitment since 2003. This has been backed up by substantial financial commitments by the Central Government and some provincial governments. A lot of work remains to achieve the Five Year plan (2006-2010) targets in prevention and treatment by the end of 2010.
   
   
4. How is the budget allocation pattern - from the government’s side and from external support?
   
   The overall funding situation is that central and provincial budgeting accounts for approximately two-thirds of the total with international sources contributing the remainder. The central government over the past few years have been allocating funds in the range of 120-140 million USD annually with the provincial governments allocating additional 50-60 million USD. External funding including that from Global Fund have ranged between 80-95 million USD annually.
   
   
5. What are the major challenges and gaps in ensuring Universal Access in China?
   
   Universal Access targets for China are the same as the National Five year Plan (2006-2010) targets. A significant challenge in achieving these targets is the lack of national and provincial costed strategic plans. Programme management structures at Central and provincial levels need strengthening and enhanced civil society involvement through capacity building and financial empowerment is crucial.
   
   Stigma and discrimination towards people living with HIV undermines the AIDS response. For example, where there are high levels of stigma and discrimination, people, including young people and high risk behaviour populations remain reluctant to seek knowledge and look for help. Few people are actively willing to be tested for HIV, so a large proportion of the people estimated to be living with HIV are unaware of their status, and are less likely to take any preventive measures.
   
   Drug resistance resulting from low adherence levels is one of the most worrying problems related to treatment. Some patients do not have good adherence because of a lack of sufficient information relating to drugs, adherence, side effects and risks of resistance to first line drugs. Community-based counseling through peer education can be strengthened to address these issues, especially in the hardest hit areas, most of which are rural areas, where there is usually a shortage of medical staff.
   
   
6. It is said that Chinese civil society has limited space within China. How do you see the role of civil society in responding to the epidemic?
   
   The Chinese government have understood and articulated the need for a stronger involvement of civil society in the response to AIDS and in the past few years some space has opened up for AIDS related NGOs and CBOs in China. In parallel with this change in the attitude of the government, the number of community based organizations (CBOs) in China has grown significantly in number over the past 5 years. There are estimated to be around 400-500 CBOs. Chinese civil society is increasingly playing an important role in the AIDS response in China, especially in advocacy and provision of prevention services amongst high-risk behaviour populations and with treatment adherence education and counseling. The GIPA principle has also been implemented through the participation of CBOs in project design, implementation, monitoring and decision making. A good example is the China Global Fund CCM, where two member seats are reserved for CBOs and people living with HIV. These two sectors have seized the opportunity and initiated a transparent and open process for electing their own representatives to the CCM as the CCM provides civil society an equal footing with other stakeholders in the Global Fund’s governance structure.
   
   However, significant legal and policy issues as well as formal and informal obstacles constituted by non-health government agencies are hampering the effective functioning of civil society organizations, for instance, most CBOs find it very difficult to legally register as civil society entities making it difficult for them to receive funds directly. Several basic issues need to be addressed to facilitate an improved realization of the potentially resourceful contribution of civil society and a positive change in the human rights situation of HIV positive people and most at risk populations (MARPs).
   
   Additionally,, Chinese civil society is still at an early stage of development and capacity and coordination remains weak. CBOs tend to work in isolation and so far have limited coordination and representation at the national level. There are inadequate communication channels, partnership opportunities and constructive dialogue between individual civil society organizations, as well as between civil society, government and other bodies. This limits many aspects of China’s AIDS control efforts, including anti-stigma campaigns, reaching marginalized populations (IDU, CSW, MSM) with prevention and treatment services, and improving policy and legal environments.
   
   There is a need to build capacity of civil society to function at the national level as credible and constructive partners in the national AIDS response through a systematic approach in policy formulation and advocacy, especially for effective comprehensive prevention, treatment and care services. The establishment of national networks of NGOs/CBOs and organisations of people living with HIV will strengthen coordination and improve accountability within the networks and is therefore important for the development of civil society in China.
   
   
7. How do you see the role of people's networks like APACHA in connecting with Chinese civil society?
   
   It is important that Chinese civil society is linked into and involved with regional and global civil society movements. China can learn and adapt lessons from other countries, and also contribute to the formulation of best practice at a regional and international level.
   
   As I mentioned earlier, Chinese civil society is still at an early stage of development. I believe a network like APACHA can play an active role in providing technical support and experience sharing. People-led movements can also provide inspiration for Chinese civil society and people living with HIV to get involved in the response to AIDS.
   
   
8. Given the current economic crisis, how do you foresee the major challenges in responding to the epidemic in China?
   
   Many people predict that China will receive less and less international funding considering the rapid economic growth in China and the global economic crisis. The biggest challenge in my mind is not a result of less funding, but more related to how different funding sources can be coordinated, and how external resources can be integrated into a sustainable national healthcare system. In April this year, an international conference was held in Beijing where participants called for joint action against AIDS and TB. It is becoming increasingly clear that there is an overlap between these two epidemics. Better collaboration and integration will make services more user-friendly, but will also allow the AIDS response to function better in the context of the financial crisis.
   
   
9. Your message to civil society.
   
   I have been touched by AIDS personally and I have lost friends to AIDS. But I have also been touched by the enthusiasm and energy of people from civil society, who are working on the ground every day in the fight against AIDS. I can say without hesitation that I have learned more from my friends in civil society and my friends living with HIV than I have learned from anybody else! I believe civil society will play an ever more active role in the global AIDS response.