China Confronts AIDS

Peter Brazutis INTERNATIONAL EFFORT: Yunzhen Cao left the Aaron Diamond AIDS Research Center in New York last summer to set up an AIDS research lab in China. Her researchers will be trained at Aaron Diamond, whose David Ho is pictured on the wall. Epidemiogical Deficiencies Epidemiological studies in Yunnan Province1 indicate that in some areas there is a high rate of HIV-seroprevalence among IV drug abusers--in some places as high as 85.7 percent. Furthermore, the infected drug users are transmitting the virus to their spouses: by 1997, 12.3 percent of spouses were seropositive. Only 3.1 percent were seropositive in 1990. These figures should indicate that infected mothers are giving birth to HIV-infected babies; however, according to virologist and clinician Yunzhen Cao, head of the clinical virology division of NCAIDS, only eight cases of maternal-fetal transmission have been reported in China. But such data are unreliable, as there have not yet been studies of maternal-fetal transmission. Furthermore, many of these mothers, according to Zheng, are unaware that they are infected. Shao and colleagues have been studying the molecular epidemiology of the different subtypes of HIV-1 present in China (A, B, B', C, D, E, and F). They know that subtype E, which entered China from Thailand and Laos and is present on China's southeastern coast, is transmitted sexually. Subtype B' is the Thai subtype, which traveled from Thailand to Myanmar (formerly Burma) in the late 1980s and mid-1990s and infects IV drug users. This subtype is present through much of southwestern, central, and northeastern China. Subtype B (the North American subtype) is mainly found among homosexuals in the large cities. Subtype C, which originated in India, entered China through migrant populations. It is confined to a band of provinces and areas leading from Yunnan in the southwest to Mongolia. Subtype D has been found in technical workers returned to China from Africa. Subtype F is closely linked to the South American subtype. China also has a unique recombinant C/B' strain. Subtype A is present in five provinces: Jilin, adjacent to North Korea; Shandong and Jiangsu, on the coast; Hubei; and Gansu. Despite the amount of information available, Chinese researchers agree that they need more detailed epidemiological studies so they can determine precisely the numbers of infected individuals and the future trends of the epidemic. Lack of Money, Resources Researchers, however, cite many problems that make it more difficult to get a handle on the epidemic's extent. One is a lack of financial resources for education of local health workers dealing with AIDS patients and their symptoms. Another is a dearth of supplies and reagents. Cao, an American who was born in China and has worked with David Ho at the Aaron Diamond AIDS Research Center in New York for the last 12 years, has to hand-carry blood vacuum collection vials into China from Ho's lab. The major pieces of equipment for her laboratory are donations from drug and biotechnology companies. Shao admits that his molecular epidemiology work is funded by a "huge" grant of the equivalent of about $200,000 from the Chinese government. But AIDS vaccine research he is carrying out with German scientists needs more than Chinese government funds. The European Union has given grants to him and his partners, and the Joint United Nations Programme on HIV/AIDS (UNAIDS; www.unaids.org) has funded some of the molecular epidemiology. Peter Brazutis SHOW OF SUPPORT: Chinese government officials, along with a representative of UNAIDS (center, in white), officially open an HIV/AIDS educational exhibit at the Museum of the Chinese Revolution on Tiananmen Square in Beijing, Dec. 1, 1998. Human resources, too, are limited. Although there is a large network of health care workers beginning at the provincial level and extending to the local level, Zeng points out that there are about 30 to 35 medical and pharmacological academicians with expertise in the field of HIV/AIDS. (Many, including Shao and Zheng, were Zeng's students.) Despite the small number of people with such expertise, Arthur Ammann, former president of the American Foundation for AIDS Research (AmFAR; www.amfar.org) and the Pediatric AIDS Foundation, states that China's "scientific resources in terms of their training are excellent." Ammann currently heads Global Strategies for HIV Prevention (San Rafael, Calif.), a not-for-profit agency focusing on AIDS prevention, particularly in China and India. But perhaps even more serious in preventing knowledge of the full scope of China's AIDS problem are the attitude toward AIDS and the need for public education. Even well-educated, urban residents seem to believe that HIV can be transmitted by shaking hands. People may not want to know if they're HIV-positive because of the social opprobrium that results if anyone finds out. This is true for all sexually transmitted diseases. Zeng recalls that an HIV-positive worker who returned from Africa was thrown out by his family. He moved to south China, where he worked until he developed AIDS and became so ill he returned home; he was left to die alone. Cao, who is establishing a clinical trial network to test herbal medicines, and, when they become available in China, antiviral drugs, says her patients at the Beijing Infectious Diseases Hospital do not give her their real names or telephone numbers. Thus, she cannot even contact them. Most serious of all, however, is that the only treatments available for AIDS patients are painkillers, antidiarrheal drugs, and other symptomatic treatments. Chinese herbal medicines are also used, and although there is some evidence that they may boost the immune system, there have been no scientifically controlled studies to determine their efficacy against AIDS. Cao is now organizing clinical trials with both herbal medicines and antiretrovirals. Because of China's drug-approval system, antiretrovirals cannot yet be sold in China. Shao explains that China requires single-drug evaluation for approval. Unfortunately, he adds, single drugs are not likely to be effective in treating AIDS. The government, however, is making a special case for AIDS drugs, and the researchers are confident that some antiretroviral therapies will soon be available, at least for patients in clinical trials and for pregnant HIV-positive women. But even if available, such drugs will be beyond the financial reach of all but a small group of wealthy people. And, as Shao points out, the farmer with AIDS has no health insurance at all. (The communal health insurance systems disappeared with communal farms.) Even those with insurance, says Cao, are not insured if they have AIDS. Thus, at present, anyone in China who becomes infected with HIV is destined to "die in the worst possible way," says Yichen Lu of Avant Immunotherapeutics Inc. of Needham, Mass. Lu is an AIDS vaccine researcher who is helping the Chinese research effort. High Government Concern Fortunately, the Chinese government recognizes the importance of stopping the spread of HIV and is willing to commit resources to the task. NCAIDS was established in July 1998 under the CAPM and the Ministry of Health (MOH). The center, according to Ke-an Wang, CAPM president, was set up at a time when the ministries have been downsized almost in half: the MOH went from more than 400 employees to slightly more than 200. "But the center was approved to be set up, so it's a very rare situation and it's a symbol of the central government paying attention to HIV and AIDS prevention in China," says Wang. The center has nearly 50 staff members, and is expected to expand to 80, or perhaps even 120. Dedicated entirely to the study of HIV/AIDS in China, the center is composed of four divisions: epidemiology and field surveys, headed by Zheng; a reference laboratory, headed by Shao; a behavior and health education information division; and a division for clinical work and pharmaceuticals, headed by Cao. The government's supportive role in establishing this center convinced Cao to return to China from Aaron Diamond this past summer to set up a clinical laboratory that will result in international exchange of scientists. A visible show of central government concern was the opening of a public exhibition on HIV/AIDS in honor of World AIDS Day, Dec. 1, 1998, at the Museum of the Chinese Revolution on Tiananmen Square in Beijing. The exhibition--with graphic photographs of lesions on the bodies (including the reproductive organs) of AIDS patients, instructions on how to use male and female condoms, and maps and data describing the current status of HIV and AIDS infections throughout the world--is sponsored by the Chinese Foundation for Prevention of STD and AIDS. At the opening ceremony for the exhibit, Vice Minister of Public Health Dakui Yin spoke. Avant's Lu is impressed with the locale, pointing out that Tiananmen Square and the buildings surrounding it are steeped in China's Communist history. "Just imagine the magnitude of change there!" he exclaims. To him this means that the government has really put its hat into the ring to support public education on HIV/AIDS. Not Going It Alone But the researchers and government officials know that China cannot pursue the goals of HIV research--epidemiological, pharmacological, and vaccine--alone. That the educational exhibit begins with photographs of Aaron Diamond's David Ho, Peter Piot of UNAIDS, and Luc Montagnier, one of the discoverers of HIV, now at Queens College in New York, indicates that they are looking outside for assistance. The CAPM's Wang points out that they are cooperating with the European Union in research and hope they can cooperate with international organizations, including UNAIDS, WHO, the U.S. Centers for Disease Control and Prevention (CDC), and organizations in Japan. He points out that Seth Berkley, president of the International AIDS Vaccine Initiative (IAVI; www.iavi.org) in New York, has visited them several times. Berkley explains that there is a state-of-the-art vaccine production facility in Kunming that could be used for HIV vaccine research and production. Shao says his group is looking, with IAVI, into cooperation between the developed and developing worlds on HIV vaccine research. Shao and Zeng have both been working with Hans Wolf of the University of Regensburg, Germany, on an HIV vaccine. Meanwhile, the Ministry of Health and NCAIDS are planning to sponsor an international HIV vaccine seminar in China in March or April of this year to increase international input and cooperation. Avant's Lu is organizing an international consortium that will include Zeng and Shao in China, a group in Thailand, and researchers in the United States for developing, testing, and producing an HIV vaccine. Lu, Zeng, and Shao have received visiting faculty appointments at Nankai University in Tianjin so they can begin to train graduate students for work on the project. Lu explains that the Chinese government can provide the basic infrastructure for the project, but the group needs help, specifically from the U.S. National Institutes of Health (NIH). International Effort Cao has set her laboratory up to be international. She is sending her staff and technicians to Aaron Diamond for training, and invites foreign scientists to become involved in her clinical research. She points out that some of the research that cannot be done here can be done in China. For example, in studies of maternal-fetal transmission of HIV, it is important to have the placenta to determine exactly when in the pregnancy transmission occurs. Although there are many places, such as the United States, where the placenta is not available for study, it is available in China. Global Strategies for HIV Prevention's Ammann is planning to ask a delegation from China to visit the United States and speak with members of Congress, the NIH, the CDC, the World Bank, and other groups "to talk about what they need to get things moving." He's working with the Fogarty International Center at NIH to set up a "workshop" on AIDS in China. Ammann points out that the Chinese don't need to send people to the U.S. for training. What they need instead is for people to go there, to teach them, and to work with them. "Here's a nation, the most populous nation in the world right now, where we have an opportunity to step in and prevent it from becoming an Africa," in terms of AIDS statistics, says Ammann. Berkley explains that other Asian countries are looking to China and India for leadership in dealing with the epidemic. At the recent meeting in Tokyo, organized by UNAIDS and WHO, focusing on "AIDS Vaccines in Asia, Needs and Opportunities," Berkley says, "A number of countries turned to China and India and told them they had a special role" in the region. Xi-wen Zheng et al., "A cohort study of HIV infection among intravenous drug users in Ruili and other two counties in Yunnan Province, China, 1992-1995," Chinese Journal of Epidemiology, 18:259-262, 1997. Myrna E. Watanabe is a freelance writer based in Patterson, N.Y.

China Confronts AIDS

Epidemiogical Deficiencies

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