CHAPTER 3 CHALLENGES AND RECOMMENDATIONS

The past two years have seen achievements in the response to the AIDS epidemic in China, particularly in terms of commitment by national leadership, multi-sector cooperation, establishing a supportive national policy framework and legislations, improved understanding of the key elements of the epidemic, extending comprehensive prevention interventions to the most at risk groups and providing treatment, care and support. Nevertheless, a number challenges remain, especially realizing the Five-Year Action Plan objectives; capacity building, particularly at the 'grass roots' level, and strengthening monitoring and evaluation at all levels.

3.1 Programme Management and Accountability

Challenges   

Accountability: There are no clear responsibilities, power and resource allocation of some key sectors and lack of accountability for implementation of AIDS programmes. The limited commitment by some local level governments to the AIDS responses, results in not incorporating AIDS program into the government agencies' routine work and social development plans.

Cross-sector responses: Currently the proactive involvement of some sectors remains weak particularly at local levels. The limited communication between agencies results in poor implementation of AIDS programmes.

Resource management: Resources are not effectively integrated into the priority areas of the AIDS response, nor are resources being utilized effectively at the local level. Some high prevalence areas lack comprehensive action plans. Delays in the transfer of central earmarked funds to local levels and insufficient local investment also restrict programme implantation.

Recommendations

Further strengthen advocacy and training of leaders, especially those dations    who have recently been appointed and the leaders of key agencies.
• To strengthen the accountability of agencies and work units to efficiently and effectively use their resources and strengthen assessment management so that upper level government officials can monitor achievement of policy implementation against targets and take responsibility for effective resource use. Assessment of government offices' performance need to be carried out effectively and action taken to cor-rect any shortcomings, including publicising the results.
•    Work units at all levels need to strengthen their resource needs estimation procedures and capacity, better prioritize their required resources against the most effective outcomes and ensure that available resources are used efficiently.
•    Promote strengthening of cross-sector communication and coordination to strengthen their proactive involvement. Relevant sectors need to prepare joint strategic plans that tackle priority responses with clear lines of responsibility.

3.2 Awareness Campaigns and Anti-discrimination

Challenges   

Information, education and communication (IEC) interventions: The scale and depth of the current IEC activities are unsatisfactory, especially in its reach to youth not in school, minorities, migrant workers, remote and rural areas with migrating populations. The challenge is to design and implement more effective IEC interventions that relate to the target audience, reach focal populations and bring about desired attitude changes among the target group. Evaluation the effective outcomes of IEC intervention need to be strengthened.

Tackling discrimination: Stigma and discrimination against PLHIV remain widespread in some communities and work places, including among health-care workers. The involvement of people affected by AIDS in the design and implementation of IEC messages remains weak and needs to be strengthened for more effective outcomes.

Recommendations

• Evaluate the effectiveness of various IEC models among different target groups and document those with outstanding results as 'best practice' that can applied with similar groups elsewhere. On the basis of this research, the national AIDS Publicity and Education Guidelines should be revised and updated.
•    Better utilise existing sector networks, particularly those in ethnic affairs and youth education, to strengthen the technical and financial support to remote rural areas on IEC intervention.
•    Strengthen training and advocacy for discrimination reduction among health care workers and encourage the involvement of beneficiaries, especially PLHIV in the design and implementation of IEC messages in HIV awareness and publicity initiatives to give greater authority to anti-discrimination messages.

3.3 Comprehensive Interventions2

Challenges   

Limited knowledge of most-at-risk populations: Effective follow-up is constrained by the lack of reliable information on key target populations, particularly MSM, such as size of the population, behaviour patterns and HIV epidemic among MSM.

Comprehensive prevention packages to address high risk behaviour: Coverage of most-at-risk populations is limited, only some elements of the comprehensive package are available and due to the low frequency and intensity of contact. The capacity of comprehensive interventions remains an area of weakness.

PMTCT and STI services: 'The coverage of PMTCT is limited and the quality of service delivery has room for improvement. STI clinics can play a key role in HIV prevention and referral, but their weak management and poor integration with HIV interventions reduces their effectiveness.

Linkage and referral services: The linkage between the identification of HIV status and referral to different parts of the treatment and care response is weak and is not standardized. As a result, insufficient information is available to provide follow-up treatment, care and support.

Recommendations

 • Additional epidemiological surveys of MSM populations are required to better understand their size, demographic characteristics and the epidemic situation, thereby assisting the design of effective comprehensive
intervention models for MSM.

•    Better targeted, in-depth and sustained comprehensive packages are required to address high risk behaviour in terms of HIV transmission, particularly, condom use promotion. Priority should be given to middle-and low-level sex workers and floating sex workers.

•    Expand the range of comprehensive packages for behavioural change among IDUs, including clean needle exchange programmes as another tool for harm reduction and the use MMT clinics as a platform for cost-effective service delivery.

•    To further strengthen the quality and increase the coverage of PMTCT programmes through the training of staff in service delivery.

•    To strengthen STI screening and service delivery among the most-at-risk populations to promote appropriate health seeking behaviour, with integration of STI measures with reproductive health and HIV prevention.
• To increase the coverage and quality of comprehensive services. Explore integrated comprehensive management models for PLHIV, including testing, counselling and informing PLHIV of results, and follow-up management.

3.4 Treatment, Care and Support

Challenges   

Improving access to and quality of treatment: Implementation of 'Four Free, One Care' initiatives has been uneven, with poor linkages between different services. Some locations lack clear policies on treatment-related testing and 01 treatment, while the management of ART requires further strengthening. The side-effects of available drugs remains a challenge, with some AIDS patients dropping out of treatment because of this, while others have developed drug-resistance, often due to non-standard drug-taking. 'There are also difficulties in obtaining supplies of second line ART drugs. Also, some AIDS patients would like to receive the traditional Chinese medicine but currently cannot readily gain access to them.

Effective support for HIV positive people and their families: While some promising pilot projects have been implemented to preserve or recover livelihoods for families affected by AIDS, other care and support activities have been carried out at the local level without the full range of standard protocols to ensure they are carried out to professional standards.

Identifying the social and economic impacts of AIDS: A significant challenge is the limited amount of evidence-based data available on the social and economic impacts of AIDS. Expanding evaluative investigations in this will provide valuable insights into the nature of the epidemic and the interventions required to ameliorate the impact of AIDS on households and communities.

Adherence to standard protocols: Some units undertaking testing do not reach professional standards and some ART departments do not follow national protocols or follow up on patients.

Recommendations

• Increase support to local governments to strengthen treatment policies and increase investment to implement the 'Four Free One Care' policy. To explore long-term, stable and sustainable ART delivery mechanisms that are integrated with the development of the urban residents' basic health care insurance reforms and the new countryside cooperative medical system.
•    Review the procedures for AIDS treatment in order to increase the adherence of treatment. Continue to facilitate second-line drug research and development and their registration; and take measures to improve access for AIDS patients to traditional Chinese medicine treatment where this is required as a supplement to ART.
•    Expand the scale and strengthen the quality of data collection and its analysis to assess the impact of AIDS on communities, households and individuals. Initiate further social research to provide guidance on the effectiveness of HIV prevention and AIDS treatment programmes.
•    To further strengthen the procedures for HIV testing and AIDS treatment protocols, including guidance on confidentiality, in order to deliver comprehensive counselling, care and support services.

3.5 All Society Involvement

Challenges   

Capacity development and engagement: All society involvement is insufficient. Mass organizations involvement is limited, while the capacity and experience of civil society organizations is not satisfactory. Difficulties in obtaining formal registration and legal status have limited the number of community-based organizations working in the AIDS field and constrain the further development and professionalism of these organizations.

Communication channels: There are inadequate communication channels and dialogue between individual civil society organizations, and between civil society, government and other bodies.

Private sector involvement: Involvement in AIDS work by business enterprises and individuals remains limited and the principles and opportunities to incorporate HIV awareness and prevention into the workplace are not widely understood.

Recommendetions

•    Further adjust and complete regulations and laws to establish an dations    enabling policy environment for the development of civil society organizations dealing with AIDS.
•    Through different methods, strengthen communication within civil society organizations and between these organizations and related government agencies.
•    Given the role of civil society organizations in fund-raising, the government also needs to provide support with supplementary financial and technical assistance in accordance with the actual needs. Technical support and guidance should assist civil society organizations to link with target groups that government agencies have difficulty accessing, thereby becoming key partners in the AIDS response, covering both implementation and evaluation of outcomes and impact.
•    Corporate social responsibility contribution and individual commitment should be fostered, backed by more intensive workplace HIV awareness and anti-discrimination campaigns.
•    Strengthen the capacity of volunteer groups for more effective involvement in the AIDS response and establish an enabling environment for all society participation.

3.6 Capacity-building of Response Teams

Challenges  

Prevention and control team building: Some related response teams and related efforts do not play their full roles. Compared with the needs of the AIDS response, the number and capability of response teams at local level is not adequate and stable.

Strengthening staff' s knowledge and attitudes: Staff in many organisations at all levels still lack adequate knowledge and capacity of HIV transmission and prevention principles, especially in rural areas with poor health facilities.

Recornmendations

• Integration of response efforts from different services, such as rural and urban community, family planning and women and child care workers needs to be addressed in order to achieve more effective prevention,
treatment and care outcomes.

•    Strengthen establishment and capacity-building of the professional teams. Professional teams dealing with AIDS should be built up at the provincial, prefecture and county level in key areas. In addition, speed up the establishment of healthcare service networks at the local level and strengthen the knowledge and competence of first-line health workers in dealing with AIDS.

•    Set up motivation mechanism for grass roots response team and encourage graduates and township doctors to work at the grass roots level.

3.7 Monitoring and Evaluation (M&E) Systems

Challenges   

Monitoring and evaluation: The monitoring and evaluation systems remain underdeveloped and are constrained by poor capacity to undertake quality M&E work. There is a lack of M&E professionals with good experience and the integration of M&E results with planning is inadequate, resulting in the limited utilization of the lessons from M&E into improved project and programme design. There is a lack of scientific evaluation of the effectiveness and impact of AIDS interventions.

Strengthening the quality of surveillance system data: While the coverage of surveillance data collection has been strengthened, the quality of data and its interpretation remains an area of weakness.

Recommendation

•    The M&E Framework issued by SCAWCO needs to be fully dations    implemented. Priority needs to be given to strengthening the M&E system and facilitate the CRMIS to be fully functional.
•    Promote surveillance information collection system and strengthen the quality and analysis of data to provide basic information for effective monitoring and evaluation. A larger M&E staff establishment is required and their capacity need to be strengthened through supervision and training.
•    M(SLE system should be integrated with planning and implementation to ensure that the results are fully utilized. Experience of success and failure from evaluation should be summarized and shared with policy and decision-makers and implementers in terms of what can be applied more widely as 'best practice'.

2 A comprehensive approach brings together proven preventive and treatment interventions and adapts them as the epidemic evolves in terms of changes in infection patterns and social norms. Comprehensive prevention packages, for example, use a combination of actions that promote safe sexual behaviour, reduce social and biological vulnerability to transmission, encourage the use of prevention technologies (such as condoms, clean needle exchange and MMT) and promote social norms that favour risk reduction.