Increasing rates of HIV testing or
expanding the use of antiretroviral therapy will not be enough to eliminate new
HIV transmissions in China, according to a mathematical model published in the
online edition of AIDS.
However, a “combination prevention”
approach including an expansion of testing, targeted harm reduction programmes
and wider use of HIV therapy was shown to have a potentially significant impact on the
course of the epidemic in China.
“This is the first study to consider the
cost-effectiveness of treatment, testing, harm reduction and combinations of
these strategies at a national level in China,” write the authors. “Research to
date has only considered the strategies in isolation and only in certain
provinces and cities.”
At the end of 2009 there were an estimated
48,000 new HIV infections in China and the total number of infections in the
country is thought to be in the region of 740,000.
The epidemic is concentrated in specific
provinces (Yunnan, Guangxi, Guandong, Xinjiang and Henan) and focused on certain
high-risk groups (injecting drug users, female sex workers and men who have sex
A national government-led strategy
advocates a comprehensive package of prevention, treatment and support as a way
of controlling the epidemic. Nevertheless, the rate of testing among high-risk
groups is generally low; there is limited access to harm reduction services such as
needle exchange; and only a quarter of eligible patients are receiving
Given this situation, investigators wanted
to gain a better understanding of the potential course of the HIV epidemic in
China. They also wished to determine which of four prevention strategies would avert
the greatest number of new infections and be most cost effective. The
- Expanded voluntary couselling and testing (VCT).
- Expanded antiretroviral
therapy: coverage of HIV treatment is increased to 50% of those eligible (CD4
cell count below 350 cells/mm3).
- Expanded harm reduction
programmes: expanded to reach entire populations of injecting drug users.
- Combination strategies: a
combination of any two or more of the above.
Cost-effectiveness was measured by
calculating incremental quality-adjusted life years (QALYS) per life year
The model predicted the course of the
epidemic over 30 years.
The investigators’ calculations showed that
without any new interventions, by 2040 the cumulative number of HIV infections
in China would be 3.41 million. Three-quarters of these infections would be in
high-risk groups. An estimated 25% of all injecting drug users would be
HIV positive, whereas prevalence in men who have sex with men would reach 14%.
A VCT-only strategy, which involved annual
HIV tests for high-risk individuals and one-off screening in lower-risk groups
would avert an estimated 7% of all new infections at a cost of $5810 per QALY.
Expanding treatment would prevent an
estimated 340,000 infections at a cost of
$4840 per QALY. A targeted harm-reduction programme would
prevent 710,000 infections, costing $5010 per QALY.
“Biomedical interventions, such as VCT and
treatment, can have a significant impact on HIV and are cost effective under
certain implementation strategies,” comment the authors. However, they caution
that, on their own, these interventions will not be able to eliminate HIV
Combination prevention approaches were
shown to have a bigger potential impact on the epidemic.
A combination of any two interventions
would avert between 17 and 29% of new infections at a cost of between $5030
and $5310 per QALY. A combination of all three interventions – testing,
treatment and harm reduction – was shown to avert 1.2 million new infections at
an estimated cost of $5550 per QALY.
The investigators repeated their
calculations to take account of the marginalisation of drug users and men who
have sex with men in China. They believed that this would potentially make
these high-risk groups harder to reach.
However, they showed that the combined use
of all three methods of prevention could avert between 21 and 43% of projected
infections over the next 30 years.
“This study shows that it may be possible
to significantly control HIV growth amongst high-risk populations in China
through a combination of VCT, treatment and harm reduction programmes,”
conclude the authors. “These raise the possibility that China will face a
future largely free of this disease if it acts now to implement a widespread
expansion of both biomedical and harm reduction strategies.”