[Joint House and Senate Hearing, 108 Congress]
[From the U.S. Government Publishing Office]



 
 CHINA'S MOUNTING HIV/AIDS CRISIS: HOW SHOULD THE UNITED STATES RESPOND?

=======================================================================

                               ROUNDTABLE

                               before the

              CONGRESSIONAL-EXECUTIVE COMMISSION ON CHINA

                      ONE HUNDRED EIGHTH CONGRESS

                             FIRST SESSION

                               __________

                            OCTOBER 20, 2003

                               __________

 Printed for the use of the Congressional-Executive Commission on China


         Available via the World Wide Web: http://www.cecc.gov

                                 ______

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                            WASHINGTON : 2004
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              CONGRESSIONAL-EXECUTIVE COMMISSION ON CHINA

                    LEGISLATIVE BRANCH COMMISSIONERS

           House                        Senate

          JIM LEACH, Iowa, Chairman     CHUCK HAGEL, Nebraska, Co-Chairman
          DOUG BEREUTER, Nebraska       CRAIG THOMAS, Wyoming
          DAVID DREIER, California      SAM BROWNBACK, Kansas
          FRANK WOLF, Virginia          PAT ROBERTS, Kansas
          JOE PITTS, Pennsylvania       GORDON SMITH, Oregon
          SANDER LEVIN, Michigan        MAX BAUCUS, Montana
          MARCY KAPTUR, Ohio            CARL LEVIN, Michigan
          SHERROD BROWN, Ohio           DIANNE FEINSTEIN, California
          DAVID WU, Oregon              BYRON DORGAN, North Dakota 

                     EXECUTIVE BRANCH COMMISSIONERS

                 PAULA DOBRIANSKY, Department of State*
                 GRANT ALDONAS, Department of Commerce*
                   LORNE CRANER, Department of State*
                   JAMES KELLY, Department of State*

                      John Foarde, Staff Director
                  David Dorman, Deputy Staff Director

* Appointed in the 107th Congress; not yet formally appointed in 
  the 108th Congress.

                                  (ii)




                            C O N T E N T S

                              ----------                              
                                                                   Page

                               STATEMENTS

Bhat, Amarmath, M.D., director, Office of Asia and the Pacific, 
  Office of Global Health Affairs, Department of Health and Human 
  Services, Rockville, MD........................................     2
Wan, Yanhai, M.D., director, Beijing Aizhi Education Institute, 
  and world fellow, Yale University, New Haven, CT...............     5
Frost, Kevin Robert, vice president, Clinical Research and 
  Prevention Programs, American Foundation for AIDS, New York, NY     7
Nieburg, Phillip, M.D., senior associate, HIV/AIDS Task Force, 
  Center for Strategic & International Studies [CSIS], 
  Charlottesville, VA............................................    10

                                APPENDIX

                          Prepared Statements

Bhat, Amarnath...................................................    30
Wan, Yanhai......................................................    32
Frost, Kevin Robert..............................................    33


CHINA'S MOUNTING HIV/AIDS CRISIS: HOW SHOULD THE UNITED STATES RESPOND?

                              ----------                              


                        MONDAY, OCTOBER 20, 2003

                            Congressional-Executive
                                       Commission on China,
                                                    Washington, DC.
    The roundtable was convened, pursuant to notice, at 2:30 
p.m., in room 2255, Rayburn House Office Building, John Foarde 
(staff director) presiding.
    Also present: David Dorman, deputy staff director; Susan 
Weld, general counsel; Carl Minzner, counsel; and Anne Tsai, 
specialist.
    Mr. Foarde. Let us get under way. On behalf of Chairman Jim 
Leach and Co-chairman Senator Chuck Hagel of the Congressional-
Executive Commission on China, welcome to this issues 
roundtable on ``China's Mounting HIV/AIDS Crisis: How Should 
the United States Respond? ''
    We are delighted to have four extremely distinguished and 
knowledgeable panelists with us this afternoon to continue our 
look into questions of public health in China and how that 
affects the human right to health, as articulated, among other 
places, in the International Covenant on Economic, Social and 
Cultural Rights.
    We have done an HIV roundtable in the past and some private 
briefings, and wanted to get some experts together to carry on 
this conversation about what is going on in China and what we 
might do as a country to help persuade the Chinese Government 
to take the action that is necessary to arrest the intensity of 
what seems to be about to happen in China on HIV and AIDS.
    Our panelists are Dr. Amar Bhat, director of the Office of 
Asia and Pacific, Office of Global Health Affairs from the 
Department of Health and Human Services [HHS]; Kevin Frost, 
vice president of Clinical Research and Prevention Programs, 
the American Foundation for AIDS; Dr. Wan Yanhai, who needs no 
introduction, but is the director of the Beijing AIZHI 
Education Institute, and this year a World Fellow at Yale 
University; and an old friend, Dr. Phil Nieburg, senior 
associate now with the HIV/AIDS Task Force at the Center for 
Strategic & International Studies [CSIS].
    We are going to follow our usual practice in going from 
wall to window, and also our usual practice of having each 
panelist speak for 10 minutes and make a presentation. After 8 
minutes, I'll let you know you have 2 minutes remaining, and 
then that is your signal to wrap things up and we will go on to 
the next panelist.
    Inevitably, there are points in your presentation that you 
will not have time to cover, and we understand that, and we 
will try to pick them up in the question and answer session 
after each panelist has made a presentation.
    We would ask each panelist to speak into the microphone, if 
you would, so we can get a good record for the transcript, 
which will eventually be available on our Web site. That is: 
www.cecc.gov. On our Web site you can find both the transcripts 
and papers from our previous hearings and roundtables, and also 
announcements about upcoming events.
    Before we start, we had some good news today. We were just 
talking a minute ago about it, and it is hard to characterize 
things like this, because this man should not have been 
arrested in the first place.
    But we received news over the weekend that Ma Funwan, the 
deputy director for Disease Control in the Henan Provincial 
Health Department, was released. Ma had been held by the 
government for allegedly leaking documents about the HIV/AIDS 
epidemic in that province.
    We are a little bit unclear about when he was actually 
formally arrested, but he seems to have been pretty much 
incommunicado since the spring, and perhaps formally arrested 
in August. So, we are really pleased that he is out and hope 
that this signifies some real progress on transparency, but we 
are not holding our breath.
    Anyway, I would like to begin then and call on Dr. Amar 
Bhat, from the U.S. Department of Health and Human Services. 
You have 10 minutes. Please go ahead.

STATEMENT OF AMARNATH BHAT, M.D., DIRECTOR, OFFICE OF ASIA AND 
  THE PACIFIC, OFFICE OF GLOBAL HEALTH AFFAIRS, DEPARTMENT OF 
            HEALTH AND HUMAN SERVICES, ROCKVILLE, MD

    Dr. Bhat. Thank you very much. I appreciate the opportunity 
to speak before the Commission. I also welcome the news about 
Dr. Ma.
    Again, my name is Amar Bhat. I am the Director of the 
Office of Asia and the Pacific in the Office of Global Health 
Affairs, which is in the Office of the Secretary, Tommy 
Thompson.
    As such, I am the coordinator of all Asia Pacific 
activities in the Department of Health and Human Services and a 
spokesperson for Secretary Thompson in the Department in all 
matters pertaining to this region.
    This hearing today is quite timely, in that Secretary 
Thompson is just now returning from his first visit to China as 
HHS Secretary. His visit was very brief, basically daylight 
hours of Sunday, yesterday, coming on the heels of last week's 
meeting of the Board of Directors of Global Fund to Fight AIDS, 
Tuberculosis, and Malaria.
    As you may have heard, at this meeting of the Global Fund 
board, the Board of Directors did choose to accept and approve 
the Chinese proposal to the Global Fund for work in HIV.
    In the case of China, the third time was the charm. This 
was China's third attempt to garner funds for its HIV/AIDS 
work, the previous two attempts having failed.
    China's third-round application had the same focus as the 
second-round application, rapidly commencing and scaling up 
Voluntary Counseling and Testing [VCT], associated with 
critical care and treatment options for large numbers of HIV-
positive persons living in seven Central China provinces most 
heavily affected by the dangerous plasma selling practices of 
the mid-1990s, Yunnan Province included.
    The 2-year commitment for this grant is US$21 million. I 
believe the entire request from the Chinese Government, or to 
Chinese CCM, I should say, was US$98 million.
    Rather than provide you with an exhaustive list of HHS 
activities in China, I would rather provide a description of 
three HHS programs which have had significant investments in 
China. These three programs are ones where we have felt that 
HHS is having great impact, not only in China, but globally, 
utilizing HHS's unique blend of resources and skills.
    Finally, I will end by touching on Severe Acute Respiratory 
Syndrome [SARS], for when it comes to China, at least, I feel 
it is impossible to talk about HIV, or for that matter any 
other major health problem in China, without addressing SARS 
and the impact that this disease has had, and will have, on 
China.
    HHS has been involved in China since the opening of 
relations in 1979. Since then, we have had a health protocol 
for cooperation, covering cooperation in health and biomedical 
research. It is a broad-based agreement covering all sorts of 
health topics.
    We will be reviewing this protocol in the next few months 
before the anticipated visit of Chinese Premier Wen Jiabao.
    Recently, HHS has made a concerted effort to examine our 
relationship and to increase our investment in China. We 
believe that part of the reason why is an acknowledgement of 
the substantial scientific talent in China right now, many of 
whom were trained in the United States, the greater 
participation of China in world affairs, WTO being just one 
example, and the ever-increasing presence of disease, 
particularly infectious diseases such as tuberculosis and HIV. 
With the onset of SARS earlier this year, the importance of 
health has again leaped to the forefront more than ever before.
    I will not take time to discuss why and how China has begun 
to pay more attention to HIV/AIDS. I am sure some of the other 
panelists here can talk about that to a much better extent.
    However, I can say that the greater openness of China and 
the Chinese officials have made it easier for us to increase 
our investments there and take advantage of the considerable 
assets they have to make a difference in the global war on 
AIDS.
    Emblematic of this new relationship is the new Memorandum 
of Understanding for AIDS Cooperation that Secretary Thompson 
and then-Minister of Health Zhang signed last year here in 
Washington.
    As I mentioned before, HHS has only begun to invest heavily 
in China. Starting late last year, or actually earlier this 
year, I guess, in February, the Centers for Disease Control's 
[CDC] Global AIDS Program [GAP] opened an office in China.
    This two-person office officially opened its doors earlier 
today in a brief ceremony involving the CDC Director, Dr. Julie 
Gerberding, who was accompanying Secretary Thompson to China.
    While a recent development, this office has been long in 
coming. In fact, the beginnings of the GAP program in China can 
be traced to a 2-week assessment visit in 2001 led by my pal 
here, Dr. Phil Nieburg.
    As part of that assessment, Dr. Nieburg and his team 
identified several areas where China had significant deficits 
that CDC could help to rectify. Still in its infancy, GAP in 
China currently focuses on improving surveillance in VCT around 
the country. I should note that the CDC does not provide direct 
health care services, nor do any of the HHS components in 
China.
    Also last year the National Institutes of Health's [NIH] 
National Institute of Allergy and Infectious Diseases, awarded 
a $14.8 million, 5-year grant to the China CDC, China's Center 
for Disease Control, and the Chinese Academy of Medical 
Sciences.
    This multi-project grant, known as the Comprehensive 
International Program of Research on AIDS [CIPRA], is expanding 
China's research activities in HIV/AIDS prevention, treatment, 
and vaccine development in cooperation with experts from U.S. 
universities and medical schools.
    CIPRA is unusual in that it is one of the few NIH-supported 

research programs where, by design, the principal investigator 
is located outside the United States. In this case, the 
principal investigator is Dr. Yiming Shao of the China CDC. The 
grant itself 
consists of five interrelated projects, touching on a range of 
HIV/AIDS-related questions.
    In a third area where HHS has made considerable investments 
in China is in training. While both the CIPRA and GAP have 
training components, there is another program I would like you 
to know about.
    Many of you know that untold numbers of Chinese 
professionals have come to the United States for advanced 
training in a number of scientific areas. Biomedical research 
is no exception.
    At the intramural laboratories of NIH here in Bethesda, at 
any one time we may have approximately 300 Chinese scientists 
visiting in our labs, conducting research side-by-side with 
other scientists at NIH.
    Additionally, there must be thousands more in American 
universities around the nation, many of them here temporarily 
or others planning to settle permanently in the United States. 
Dr. Yiming Shao is actually one of those who was at NIH for a 
number of years before going back to China.
    Additionally, the NIH has made considerable investment in 
training Chinese and other developing country scientists in 
high-priority areas of research, including HIV/AIDS and other 
infectious diseases. The NIH's Fogarty International Center 
administers the AIDS International Training and Research 
Program [AITRP] which supports HIV/AIDS and related TB 
international training and research for health scientists, 
clinicians, and allied heath workers from China and dozens of 
other developing countries.
    The primary goal of this program is to build biomedical and 
behavioral research capacity for the prevention of AIDS and 
related TB infections, and for the identification of 
appropriate interventions to provide care to those adults and 
children affected with HIV.
    Under AITRP, scientists are trained to address the global 
HIV/AIDS epidemic through skills development and fostering of 
long-term relationships between individual scientists and 
institutions in both countries.
    The scope of training includes epidemiology, biostatistics, 
behavioral interventions, program evaluation, research in drug 
use, blood safety, vaccine development and evaluation, 
virology, diagnosis, and treatment.
    To date, 12 doctoral degrees, 4 master's degrees, and 24 
post-
doctoral fellowships have been awarded to Chinese scientists 
and physicians through AITRP. Others have been trained through 
in-country workshops using faculty from U.S. universities 
supported by AITRP.
    One of the wonderful aspects of AITRP is that it leverages 
and complements much of what NIH is already funding through 
U.S. universities, medical schools, and also other major 
funders, such as the World Bank, are also supporting.
    While these are three major HIV-related programs HHS has 
undertaken in China, there are numerous other activities 
outside of HHS you may be interested in hearing more about. 
USAID is starting to involve Yunnan Province in its Greater 
Mekong HIV prevention initiative. Another initiative is a 
workshop taking place later this week--Friday, in fact--in 
Beijing, organized by the State Department and the Development 
Research Center of the State Council.
    The primary purpose of this 1-day workshop will be to 
present and discuss various methodologies that can be adopted 
to estimate and forecast the macroeconomic impact of HIV/AIDS 
in a society at both the local, provincial, regional level, and 
at the national level, with a focus on the situation in China.
    The State Department is also funding a proposal from the 
Shanghai Academy of Social Sciences to support the development 
of model AIDS legislation.
    Now, as I mentioned, I wanted to touch on the impact that 
SARS has had, and will have, on HIV in China. In the short 
term, SARS has slowed the momentum we saw building in 2001 and 
2002.
    During the worst of the epidemic, staff at the China CDC, 
and even our own HHS staff in Beijing, were pulled from their 
normal duties and asked to devote their full attention to 
addressing the national emergency. This, in particular, 
impacted heavily the first year of GAP.
    Mr. Foarde. Why do we not come back, because I would very 
much like to hear you finish that particular part of the 
presentation, in the question and answer.
    Dr. Bhat. All right.
    Mr. Foarde. Thank you, Dr. Bhat.
    Dr. Bhat. Thank you.
    [The prepared statement of Dr. Bhat appears in the 
appendix.]
    Mr. Foarde. I would like to go on please, to Dr. Wan. 
Please go ahead.

    STATEMENT OF WAN YANHAI, M.D., DIRECTOR, BEIJING AIZHI 
  EDUCATION INSTITUTE, AND WORLD FELLOW, YALE UNIVERSITY, NEW 
                           HAVEN, CT

    Dr. Wan. First, I am very honored to speak at the 
roundtable. Thanks for inviting me to talk about information 
transparency and the public participation in AIDS work on both 
the Chinese and American sides.
    I am Wan Yanhai. I am the director of the Beijing Aizhi 
Institute of Health Education. Our institute was officially 
registered last October. Our program has been active for about 
10 years, but at the end of last September, early October, we 
got official registration.
    I want to talk about information transparency and the 
public participation. I think this is very important in the 
fight against AIDS in China.
    So, first, on China's side, I want to mention that recently 
the Chinese State Environmental Protection Agency has adopted a 
policy of open government information and public participation 
in environment protection issues and monitoring of government 
work.
    Second, article 23 of the Law on the Control and Prevention 
of Infectious Diseases clearly demands that the government 
publish information on infectious disease.
    Third, the State Secrets Law contains no provisions 
relating to health information. Moreover, in 1999, the Ministry 
of Health issued a notice to all provincial health departments 
stating very clearly that the AIDS-related information is not a 
state secret.
    Fourth, I believe there is no fundamental legal barrier or 
policy that prohibits publication of information related to 
AIDS and other health information.
    Fifth, unfortunately, in the past few years, and most 
recently with SARS, the Chinese Government has covered up 
important health-related information, including, of course, 
AIDS-related information.
    Sixth, the essentially nationwide blood sales-related 
epidemic became known to the central government, among others, 
in the mid-1990s, but it was only in December 2002 that the 
former Minister of Health, Zhang Wenkang, reported it to the 
National People's Congress that the blood sales-related AIDS 
epidemic was present in 23 provinces. The Chinese Government 
has not informed the public which provinces and which counties 
are affected.
    It has said, however, that in many of these affected areas, 
the HIV infection rate among blood donors is 10 to 20 percent, 
and in some areas it is as high as 60 percent.
    I want to talk about how the United States can help in both 
information transparency and in public participation. First, in 
the past few years the U.S. Government, foundations, 
institutions, NGOs, and the U.N. and other international 
organizations have fortunately started to turn their attention 
to the AIDS crisis in China.
    Second, I would like to encourage the U.S. Government, 
NGOs, and any other organizations working in this area in China 
to share information with the Chinese public, to seek their 
comments and input on programs and strategies, and to involve 
the Chinese people in their work. Specifically, these entities 
should involve the Chinese people in the planning, 
implementation, monitoring, and evaluation of AIDS-related 
programs.
    These foreign entities should work with Chinese NGOs, 
academics, health institutes, and other emerging, informal 
groups who focus on AIDS-related issues.
    What I want to emphasize is the importance of informal 
groups, because of the difficulties of getting official 
registration for labor rights organizations, gay/lesbian rights 
organizations, women's activities, organizations for immigrant 
workers and some religious groups to get involved in the work.
    In addition to working with and soliciting comments and 
feedback from these groups, U.S. and other foreign AIDS-related 
organizations should reach out more broadly to the Chinese 
public, for example, in the following ways: collecting and 
publishing information on the Internet, establishing a hotline 
and communicating with the Chinese public directly, and 
conducting research and public surveys.
    Before ending my presentation, I want to thank the people 
in the United States and the U.S. Government for helping Dr. Ma 
Shiwen to be released, and also to ask for human rights 
protection in China's AIDS crisis.
    Thank you very much.
    [The prepared statement of Dr. Wan appears in the 
appendix.]
    Mr. Foarde. Thank you. Dr. Wan. You have given us a lot to 
think about, and we will be coming back to some of those topics 
when we get to the question and answer session.
    It is my great pleasure now to introduce Kevin Frost. 
Please go ahead.

   STATEMENT OF KEVIN ROBERT FROST, VICE PRESIDENT, CLINICAL 
RESEARCH AND PREVENTION PROGRAMS, AMERICAN FOUNDATION FOR AIDS, 
                          NEW YORK, NY

    Mr. Frost. Thank you. My name is Kevin Robert Frost and I 
am the vice president for Clinical Research and Prevention 
Programs at the American Foundation for AIDS Research [amfAR].
    AmfAR was founded in 1985 and is the Nation's leading 
nonprofit organization dedicated to the support of HIV/AIDS 
research, AIDS prevention, treatment education, and the 
advocacy of sound AIDS-related public policy.
    I am also the director of amfAR's international initiative, 
Therapeutics Research, Education, and AIDS Training in Asia 
[TREAT Asia].
    TREAT Asia is a cooperative venture designed to help Asia 
and the Pacific, which is expected to become the next epicenter 
of the pandemic, to prepare for the safe and effective delivery 
of HIV/AIDS treatments as they become more widely available.
    The program pairs the resources and experience of clinical 
centers in Asia with amfAR's education, training, and clinical 
research expertise. The goals of TREAT Asia are to develop the 
skills of the health care workforce in the safe and effective 
delivery of drug treatments for HIV/AIDS, to enhance existing 
health care infrastructure and formulate strategies for 
capacity building to prepare for expanded access to HIV/AIDS 
drug treatments, to develop a framework for regional 
collaboration on a therapeutics research agenda that is 
responsive to the needs of patient populations in the region, 
and to define and address national and regional policy issues 
that impede expanded access to drug treatments for HIV/AIDS, 
and by working with regional and in-country NGOs to strengthen 
civil society's preparedness for treatment programs.
    China's HIV/AIDS epidemic has been gaining momentum, and 
the Chinese Government currently estimates that 840,000 persons 
are infected with HIV/AIDS. Intravenous drug use and 
contaminated blood have been the two primary routes for 
infection in China, representing two distinct and separate 
epidemics.
    However, HIV infection is increasingly spread through 
sexual transmission, with rising rates of infection among 
commercial sex workers in several provinces. Among those who 
acquired infection through tainted blood collection practices 
in Central China during the 1990s, large numbers are now 
falling ill and have minimal access to care and treatment in 
China's underfunded rural health care system.
    Relative to most developing countries with severe AIDS 
epidemics in Africa and Southeast Asia, China has a functioning 
health care infrastructure, and antiretroviral therapy is 
starting to be offered through public hospitals and clinics at 
the county, township, and village levels in severely affected 
communities.
    However, health care providers at these levels have little 
training or experience in counseling and treating AIDS 
patients, compounding the problem of side effect management and 
drug compliance. The lack of health care provider capacity to 
administer antiretrovirals is one of the biggest obstacles to 
treatment preparedness in China.
    While by all accounts China has become more open in dealing 
with HIV/AIDS, denial of the full extent of the epidemic 
persists. Unfortunately, there are no reliable data that 
accurately assess the scope of the epidemic.
    Chinese doctors privately suggest that the epidemic is at 
least 5 times, and possibly even 10 times, greater than the 
official estimates. The HIV epidemic in China's Central 
Province of Henan is instructive. With an estimated population 
of 110 million, Henan is China's largest province. If only 1 
percent of this population were infected through the blood 
trade, more than a million people would be HIV-positive in 
Henan alone. Yet a recent survey showed that the prevalence 
rate among commercial blood donors in rural eastern China was 
12.5 percent, and 2.1 percent among their non-donor spouses.
    In January 2002, the Henan Health Department reported that 
80 percent of Houyang village residents were HIV-positive. Of 
its 4,000 residents between the ages of 16 and 55, some 90 
percent participated in blood donation programs. More than 400 
villagers have developed AIDS, and 150 died between November 
2000 and November 2001.
    In December 2002, former Health Minister Zhang Wenkang 
acknowledged that 23 provinces, autonomous regions, and 
municipalities were affected by unhygienic blood collection.
    This is to say nothing of the epidemic among injecting drug 
users in the south and northwest provinces of Yunnan, Sichuan, 
and Xinjiang, among others.
    When asked by amfAR recently by the size and scope of China 
and India's epidemics in an article published in amfAR's 
quarterly newsletter for the TREAT Asia Report, Dr. Richard 
Feachem, executive director of the Global Fund for AIDS, TB, 
and Malaria, had this to say:

    There has been this strange collusion between Western 
experts, international organizations, and the Chinese and 
Indians to first say that the HIV epidemic is not seriously 
going to affect China and India at all, and then to say, 
``Well, maybe they're going to have a small epidemic,'' and 
then to say, ``Well maybe they're going to have a rather larger 
epidemic.''

    But only very recently has there been anything approaching 
a consensus that China and India are set for very large 
epidemics. Because of this history of minimizing the epidemics 
in China, India and in Asia more generally, I would go with the 
higher-end estimates now being produced.
    Recently, there have been promising signs of an increasing 
willingness in China to confront its HIV/AIDS epidemic. China 
has just been awarded a grant from the Global Fund to carry out 
voluntary counseling and testing and treatment programs in 
seven provinces where many infected through blood collections 
during the 1990s are falling ill.
    Prior to this, the Chinese Government had initiated a 
treatment program in four of these provinces that offer 
antiretroviral therapy to about 3,000 persons now, with a 
target of 5,000 by the end of 2003.
    The Global Fund's support will be used to scale up 
treatment, including antiretrovirals, to 40,000 AIDS patients 
in 56 counties in seven provinces by 2008. Many experts believe 
that even the 40,000 target is a significant underestimate of 
the patients in these communities who will require treatment in 
the next 5 years.
    While the Chinese Government's goal of extending free 
antiretroviral treatment to rural AIDS patients is laudable, 
many problems exist with China's current treatment policy 
program beyond the issue of the number of sick persons who will 
have access to free treatment.
    One significant problem has to do with the affordability of 
state-of-the-art antiretroviral therapy that is both easier for 
patients to tolerate and for health care providers to 
supervise. For example, fewer doses, less complicated regimens, 
with fewer side effects.
    As a new member of the World Trade Organization, China has 
been careful to respect international trade agreements and only 
manufacture drugs that are off patent. Two Chinese 
pharmaceutical companies have begun to produce generic versions 
of four off-patent drugs that the government has acquired for 
its public treatment program.
    Patented drugs such as Combivir (AZT and 3TC) are imported, 
but considered too expensive to use routinely and are only used 
in a handful of patients when domestically manufactured drugs 
are not tolerated.
    The treatment protocols currently being used are not 
optimal and have not been well-tolerated by patients, resulting 
in severe side effects which local health care providers have 
no training or experience in managing.
    Because of these side effects, the treatment options 
currently available in China in many ways represent the worst 
possible choices and offer the potential for disaster. Yet, 
China is taking the approach that most developing countries are 
forced to take when it comes to choosing treatment regimens.
    Rather than developing public health strategies for 
delivering treatments to the population of HIV-infected 
individuals, China is left in the undesirable position of 
having to settle for what it can get rather than what it needs.
    Unless serious attention is paid to acquiring better 
combination treatments, the failure rate of the current 
regimens is likely to be enormously high and could have dire 
consequences in terms of diminished long-term efficacy of 
treatment programs in China and the widespread development of 
HIV drug resistance, with implications for the rest of the 
world.
    Similar lack of access to imported reagents for HIV and CD4 
testing has constrained the ability of the health system to do 
the necessary counseling and testing and to properly monitor 
patients.
    The mix of insufficiently trained medical staff with poor 
counseling skills, poorly tolerated drug regimens, and lack of 
testing and laboratory monitoring capacity is a worrisome 
combination of factors.
    In an editorial published in the South China Morning Post 
in August 2003, Drew Thompson of the Center for Strategic and 
International Studies in Washington, DC, wrote:

    To safely treat HIV sufferers with powerful antiretroviral 
drugs, it is crucial to have trained physicians with access to 
laboratories which can carry out advanced blood testing . . . 
By jumping the gun and beginning treatment before doctors and 
counselors are properly trained, a drug-resistant disaster is 
waiting to happen.

    Now that China has been granted a big infusion of funds 
through the Global Fund mechanism, it will quickly be scaling 
up its treatment program. It is imperative that education and 
training programs are rapidly expanded and accelerated in order 
to ensure that the best available drugs are being provided by 
trained medical 
professionals, with proper counseling and rigorous monitoring 
and follow-up testing.
    At amfAR, and within the TREAT Asia program, we believe it 
is here that the United States has much to offer. China 
desperately needs--and there is growing evidence of China's 
willingness to seek--international support for rapidly 
developing and scaling up education and training programs for 
health care providers in the delivery of HIV/AIDS drugs. It is 
my sincere hope that we will find the necessary resources to 
provide precisely that support.
    Thank you.
    [The prepared statement of Mr. Frost appears in the 
appendix.]
    Mr. Foarde. Thank you very much, Kevin. Very interesting, 
and again, very rich topics to take up during the question and 
answer session.
    We now welcome our old friend, Dr. Phil Nieburg. As I was 
saying before this session, he has been a participant sitting 
in the back of the room as an auditor of some of these 
sessions, and we have always wanted to get him here in front of 
the microphone. So, we are delighted that we had the chance to 
do that today. It is your 10 minutes.

STATEMENT OF PHILLIP NIEBURG, M.D., SENIOR ASSOCIATE, HIV/AIDS 
   TASK FORCE, CENTER FOR STRATEGIC & INTERNATIONAL STUDIES 
                  [CSIS], CHARLOTTESVILLE, VA

    Dr. Nieburg. Thank you. I would like to thank the 
Commission for this opportunity to talk about what is clearly a 
very important issue. I would also like to specifically thank 
Susan Weld and Anne Tsai for providing clear guidance on the 
goals of this session.
    As a preamble, I would just like to clarify my current 
status. I am a pediatrician trained in infectious disease. 
Until August of this year, I was a career employee at the 
Centers for Disease Control and Prevention.
    As Dr. Bhat mentioned, I traveled to China as part of an 
HIV/AIDS assessment in 2001 and have been back several times 
for the purpose of helping arrange the CDC program that is now 
getting under way in China.
    However, I am no longer with CDC, and the views that I am 
going to express today are purely my own.
    It is still too early to know with any certainty whether 
China is going to experience a self-sustaining heterosexual 
pandemic of HIV of the magnitude that is now devastating a 
number of African countries. However, it appears that the 
possibility of a large problem in China is very real and the 
potential consequences for China and its citizens are great.
    I thought that my most useful contribution today would be 
to discuss the broad categories of activities that the U.S. 
Government and other non-Chinese agencies could undertake now 
and in the 
future for the purpose of helping China both acknowledge, and 
appropriately respond, to the large and growing HIV problem.
    My presentation today is going to be divided into three 
parts. First, I will talk about the need for a clear vision and 
clear goals for China's HIV control efforts and for U.S. 
activities in support of those efforts.
    I will then discuss several categories of HIV control 
activities in which the United States could participate and 
that would have lasting benefits for the Chinese people that 
would extend well beyond any successes in HIV/AIDS control.
    Finally, I will have a few closing remarks about things we 
should be cautious about when dealing with China on HIV/AIDS 
issues.
    First, to the issue of vision for HIV control. Do we really 
know what the Chinese Government wants to accomplish in terms 
of HIV control? Is their priority having the smallest number of 
HIV-infected people? Is the priority having the largest 
proportion of AIDS patients receiving appropriate care and 
treatment? Is it minimizing the societal impact of HIV/AIDS? As 
I will point out in a minute, because of resource constraints, 
it may not be possible to do all three of those different 
activities.
    Also, what do we in the United States want to accomplish in 
China and for the Chinese people with regard to HIV? How 
compatible are U.S. goals with the Chinese goals?
    In my view, global HIV control activities in a community, a 
country, or on a global scale tend to take one of three broad 
approaches, each with its own set of goals. Because the goals 
of these three approaches are only partially overlapping, we 
and the Chinese need to think about them carefully. There is a 
table on the handout that outlines the three approaches.
    The first approach, is that of HIV/AIDS care. Providing 
care is a humanitarian activity that includes, but is not 
limited to, treatment of persons with AIDS. Care is the goal of 
helping individual people infected with HIV in their household 
and family members. The care approach focuses on HIV-infected 
persons and tends to operate on a ``medical model.'' Although 
in this country, national and state governments finance an 
important proportion of clinical care, that care is largely 
delivered by the private sector here.
    The second approach is HIV prevention. That is a set of 
public health or public policy activities that seeks to prevent 
or minimize spread of HIV in populations by reducing the risk 
of person-to-person HIV transmission. To date, such prevention 
activities have largely, although not exclusively, focused on 
HIV-uninfected individuals, a different population of focus.
    In contrast to delivery of care, prevention of the spread 
of life-threatening disease such as HIV within and across 
national borders has generally been seen to be the 
responsibility of national governments. Although the private 
sector may be involved in such efforts, that involvement has 
been secondary.
    Finally, a third approach is mitigation, which means 
reducing the impact of community or societal disruption arising 
as a result of HIV/AIDS killing or disabling large numbers of 
individuals. Some simple examples of this type of population-
level problem needing mitigation are: (1) large numbers of 
orphans needing shelter and care; and (2) reduced local food 
availability due to illness among local subsistence farmers.
    HIV care, prevention, and mitigation activities and goals 
have some overlap. For example, prevention activities can help 
identify HIV-infected persons needing care, and HIV care 
activities can provide entryways for prevention for, example, 
family members who could benefit.
    However, this overlap is not nearly as complete as is 
commonly assumed. For example, the skills and resources needed 
to effect behavioral change among sexually active young people 
are different from the skills and resources (including 
laboratory and pharmacy resources) needed to educate health 
professionals about proper use of antiretroviral drugs. The 
resource needs for comprehensively addressing a large orphan 
population are different yet again.
    So, at this moment, China has to deal with all three of 
these issues. It is facing rapid increases in numbers of 
persons known to be infected with HIV who need care. In at 
least some parts of the country, China has to deal with entire 
communities of people needing external support of various kinds 
to mitigate the impact of HIV spread through plasma cells. 
People need not only direct AIDS care, but food, shelter, 
income, et cetera.
    Finally, at the same time, China must begin to slow the 
internal spread of HIV. In fact, slowing the spread of HIV 
seems to me to be the most important current public policy 
priority for the Chinese Government, at least in part because 
those persons becoming infected today are the vanguard of a 
very large burden that China's health system will face by 2010 
or 2015.
    Even with a lot of external support, there are still not 
enough 
resources, not enough trained people to address all three of 
these approaches simultaneously and quickly, so China's 
government is now facing some very difficult allocation 
decisions.
    My second set of comments is about HIV interventions that 
the United States might give priority to in supporting China's 
HIV control efforts. These are each activities that would have 
a spin-off benefit in China, and perhaps for U.S. policy in 
China, by encouraging constructive political change in a way 
that could have implications well beyond the HIV/AIDS arena.
    The first one is access to accurate information, which 
might be viewed as transparency. By this I mean that 
information about HIV/AIDS, including its risks and its 
consequences, should be widely available and widely discussed 
in Chinese society. The goal would be that decisionmaking by 
both government and by individual Chinese citizens would be 
based on accurate information at all levels.
    In this arena, the United States should support a strong 
emphasis on increasing AIDS awareness and awareness of other 
sexually transmitted infections and tuberculosis as well, not 
only among the public, but also among health workers and among 
political leaders.
    Health workers, teachers, parents, and as many others as 
possible should be educated about HIV/AIDS in a ``training of 
trainers'' style. That is, they should be trained and equipped 
to also educate others they come in contact with--their 
patients, their children, their colleagues--about HIV/AIDS 
issues. In this regard, the sexual nature of HIV spread needs a 
lot of attention.
    Counseling and testing programs for HIV should be made 
widely available so that any individual wanting to know his or 
her own HIV status can find out in a truly confidential setting 
where good post-test counseling is available.
    Finally, I strongly support efforts to improve and expand 
the process of public health surveillance to provide accurate 
information on HIV, AIDS, tuberculosis, high-risk behaviors to 
local, provincial, and national governments.
    An effective surveillance system will also require that 
China eliminate, or at least address in some way, current 
criminal sanctions on social behaviors associated with HIV 
spread. Surveillance data should be made widely available.
    A second point in terms of interventions is a set of 
issues: confidentiality and discrimination. By this, I mean 
that information about HIV/AIDS status of specific individuals 
should not become widely available. When it must be known by 
some people for clinical or public health purposes, that 
knowledge should be safeguarded, that is, not shared or used as 
a basis for adverse actions.
    Where laws or regulations on these issues exist, they 
should be examined to see if they are helpful. If helpful, they 
should be 
enforced.
    Finally, in this category, the work of non-governmental 
organizations in HIV/AIDS care and prevention should be 
encouraged and supported whenever possible.
    As in our country, organizations not directly affiliated 
with the government are often more able to publicly address 
sensitive topics such as substance abuse, homosexuality, 
prostitution, and sexuality in general.
    These are each topics on which China desperately needs 
public discussion in order to empower individuals to remain 
uninfected by HIV, or if already infected, to seek care.
    So, the United States has much we can contribute to China's 
efforts. I would just close with two brief caveats. First, 
since we are such a large and influential player in the global 
arena, it is important that our messages and our advice to 
Chinese leadership be consistent over time, and also between 
U.S. agencies. Once committed, we should remain committed.
    Second, we in the United States have limited experience 
with the kind of extreme poverty that China faces, including 
the need to ration resources in a way that China must to reach 
its control goals. We also have limited experience with health 
care systems in which the government is a major provider. While 
we can provide a lot of useful technical support in these 
latter two areas of rationing and government provision of 
health care, I would urge a measure of humility in offer advice 
in these, or any other areas, where our own experience is 
limited.
    Thank you for your attention.
    [The prepared statement of Dr. Nieburg appears in the 
appendix.]
    Mr. Foarde. Thanks very much, Phil. Very interesting stuff 
as well. We will get into some of these issues in more detail 
in just a moment.
    I will give our panelists a chance to catch their breath 
and I will make an administrative announcement or two.
    First, I think everyone in the room, I hope, knows that the 
Commission's annual report came out on October 2. It is 
available in PDF format and HTML format on the CECC Web site.
    But if you should want to have a hard copy for your 
collection, please send us an e-mail, and in the subject line 
say, ``Mail Copy of Report'' to [email protected], and we 
will mail you out a hard copy until we no longer have any more. 
We still have quite a few.
    Next, I would like to remind you that our next issues 
roundtable will be, instead of 2 weeks from today, just 1 week 
from today, on October 22. Instead of at 2:30, it will be at 
1:30 p.m. in the Gold Room, which I think is room 2168, here in 
the Rayburn Building.
    We are going to pick up the case of Sun Zhigang and try to 
look, in the aftermath of his detention and death, what has 
happened, if anything, to China's prisons and detention 
systems. We have very fine panelists lined up for next week. 
Again, it will be at 1:30 rather than 2:30. So, we look forward 
to seeing everyone there.
    Now on to our question and answer session. As we usually 
do, we will give each of the staff members on the panel up here 
5 minutes to ask and hear answers to questions.
    Normally we try to address the questions specifically to a 
panelist, but if any of the other panelists have remarks they 
would like to make, we want to hear them. So, make yourself 
known if you want to comment.
    I will exercise the prerogative of the chair and start by 
asking if Dr. Bhat would finish his presentation on the SARS 
angle and how it ties in with AIDS, comparing and contrasting 
it, because I think this is a really important issue and I 
would like to hear what you have to say on that, if you would, 
please.
    Dr. Bhat. I appreciate the opportunity to finish a little 
bit more completely on my thoughts on that.
    As I was saying, SARS did slow the momentum of progress 
made in years 2001 and 2002 in kind of opening up or 
acknowledging the AIDS epidemic. As I said, they pulled a lot 
of staff from both the Ministry of Health, as well as our own 
staff, to focus on SARS. But I am hopeful that SARS will have a 
positive impact in the long term.
    It has certainly brought health to the immediate attention 
of the seniormost leaders, and also brought to their attention 
the need to improve their own public health infrastructure, 
which had been deteriorating badly over the years.
    They realized also that there are severe consequences for 
not paying attention to issues such as disease surveillance and 
outbreak response. So, we are hopeful that they are going to be 
open to improving and investing more in their health 
infrastructure. And certainly they have asked us, the U.S. 
Government, for assistance in this matter.
    So, we are in the process of developing a menu of items, 
working with our colleagues at CDC, NIH, and the Food and Drug 
Administration [FDA], to provide a package of items that they 
can use to help improve their own public health infrastructure. 
These range from epidemiology and surveillance issues, some of 
the things that Phil was referring to. Some of it is more 
focused on research elements, kind of borrowing from our 
activities already in HIV/AIDS and applying them to SARS.
    Finally, also, we are looking to see how we can speed up 
some of the regulatory systems they have here in the United 
States and in China so that we can respond more quickly to 
outbreaks with new drugs, new vaccines, and new diagnostics. 
Right now, we do not have an appropriate diagnostic for SARS 
and we certainly could use one, especially with the compounding 
effects of influenza.
    So, I am hopeful that they will make an effort to improve 
the health system in cooperation with us. But at the same time, 
I would note that addressing their own SARS epidemic in their 
own country, they did employ some rather onerous, as I call it, 
economic control techniques to kind of get a handle on the 
situation.
    These are things that I do not think we would tolerate in 
this country, and many other democracies. But at the same time, 
I am sure that for some these type of techniques were validated 
in their own eyes.
    So in the process of helping them, I am hoping also that we 
can transmit some basic values that are fundamental to our own 
system here, such as transparency and accuracy in reporting, 
and a non-punitive system for reporting disease information so 
you do not get penalized for giving unpleasant or unwelcome 
information. Then, also, the value of sharing information, data 
and samples around the world with the global network of 
scientists and public health officials that we have. So, I am 
hopeful, but we can only tell over the course of time.
    Mr. Foarde. Very useful. Thank you.
    I am so short on time, that I think I am going to hold my 
next set of questions until the next round.
    So, I would recognize my friend and partner, Dave Dorman, 
who works for Senator Chuck Hagel, our co-chairman, for a 
question.
    David.
    Mr. Dorman. Thank you to each of you for coming today and 
helping us illuminate this very important issue for each of our 
Commissioners.
    I just have a very brief question, but it has a very long 
introduction. I need to explain why it is I ask a question like 
this.
    I spent part of this weekend reading the new Human Rights 
Watch report on HIV/AIDS and found it just excellent. But a 
number of questions are raised in the introductory portion of 
that report, and I think some of these questions are very 
relevant to our commissioners and to other Members of Congress 
in terms of the U.S. response to the mounting HIV/AIDS crisis 
in China.
    In particular, the Human Rights Watch report actually 
raises this issue, and it has also come up in testimony today, 
after a very fitful start, Beijing was able to mobilize its 
state resources to bring the SARS epidemic under control, in 
many cases using some rather harsh command-and-control 
techniques. Many in this country see the larger and more 
dangerous challenge of HIV/AIDS in China, but do not see a 
similar strong commitment by the Chinese Government to act.
    Is this a question of will or is this a question of 
capacity? The question I will leave each of you with is, ``Does 
China have the capacity to combat HIV/AIDS without 
international support, without U.S. support? ''
    Could each of you answer this question very briefly in any 
way that you choose?
    Dr. Bhat.
    Dr. Bhat. All right. Since the microphone is on this side, 
I will go first.
    Well, I think the answer is obvious that they do not. But, 
then again, I would say also that even the United States does 
not have the capability to tackle the AIDS epidemic from a 
global perspective by itself.
    I mean, we are in a very interdependent world and we need 
the resources, skills, and expertise of just about everybody. I 
am speaking mostly from the research perspective.
    One thing that I probably did not emphasize enough is that 
while we have a wealth of scientific talent in this country, we 
do not have everything that is needed in order to make a dent 
in the research, really. We need to partner with other 
countries such as China where the epidemics are rising and 
where you see increasing incidence.
    Similarly, they need us in order to have some of the 
scientific expertise, the biotechnology skills, etc., that are 
needed to put the whole thing together. So, if only from the 
research perspective, yes, we all need each other. I will leave 
it to the rest to talk about the internal capacities in China.
    Mr. Dorman. An important point.
    Dr. Wan. Yes. AIDS is a worldwide challenge to many 
countries, including my country, China. I think in China we do 
have some resources to fight against AIDS, like public 
government information and involving the Chinese people in 
campaigns.
    But there are some political or legal problems, like some 
restriction on the development of NGOs. The Chinese Government 
still does not provide funding for NGOs to work on nonprofit 
social causes.
    So, I think, working together with other countries to get 
experience, to get help, is very important. I do think that the 
experience of U.S. NGOs is very important, and the United 
States has a lot of capacity for research.
    So, about education, I think it is still sometimes 
controversial, even here in the United States. But I do think a 
working relationship between the United States and China is 
very important.
    Mr. Frost. You asked specifically the question of capacity. 
I limited my remarks largely to the issue of treatment and 
care, which is a reflection of our programmatic activities in 
China. So, if I may, I will respond as it relates to capacity 
in that realm, the realm of treatment and care.
    I think it is clear that China does not have the capacity 
to respond in this arena, particularly. In the United States, 
we built up 20 years of experience in dealing with this 
epidemic over time when the first treatments became available--
AZT in 1987, and then later we used dual-combination therapy, 
and then triple-combination therapy--and we had very large 
programs, community-based research programs, as well as 
programs at the NIH based in academia that led to that wealth 
of experience in treating for and caring for patients.
    Many treatments for HIV patients in this country were 
developed through community doctors. I am thinking of 
aerosolized pentamidine for pneumocystic pneumonia. So, we 
built a wealth of information over 20 years. But in this 
regard, the treatment of HIV is really oftentimes more art than 
it is science.
    It is one that I think requires a tremendous amount of 
experience and knowledge. I think we have that knowledge, and 
we are gaining that knowledge more and more every day. 
Therefore, I would say we have a lot to offer in that regard.
    But it is clear to me that China, on its own today, dealing 
with the massive epidemic that it faces, does not have the 
capacity to at least address that aspect of the epidemic.
    Dr. Nieburg. Thank you. Let me start by saying that I agree 
with what Mr. Frost has said about treatment. China, on its 
own, does not have the capacity to deal with its current 
treatment needs, to say nothing of what China is going to be 
facing in a few years.
    On the prevention side, I have mixed feelings. HIV 
transmission is largely a behavioral issue and China 
essentially eradicated other sexually transmitted diseases in 
the 1950s and 1960s. So, they proved that even with a complex 
issue like sexuality, they could mount a large-scale effort.
    On the other hand, China currently has an economic boom 
which is fueling HIV transmission, and I am not sure that can 
be adequately dealt with.
    HIV is now, in my sense, a chronic disease, and I think it 
is an endemic disease in China. I think, however successful a 
treatment is going to be, that is going to mean there are lots 
of HIV-infected people who will be around for a long time and 
potentially can transmit to others. So I guess my sense is that 
they do not now have the capacity by themselves to deal with 
the prevention issue either.
    Mr. Foarde. I next recognize the general counsel of the 
Commission, Susan Roosevelt Weld, for some questions.
    Susan.
    Ms. Weld. Thanks, John.
    I want to ask a question which seems somewhat adversarial, 
but it has to do with the priorities that the Chinese 
Government relies on in allocating funds. From some of the 
information we have been receiving, one of the basic problems 
is there is insufficient funding allocated out of the central 
budget to the question of AIDS at the center, and particularly 
allocating money from the center down to the provinces that are 
hardest hit.
    Is there a way that U.S. assistance could encourage 
spending the allocation of resources on HIV/AIDS? Let me start 
with Amar.
    Dr. Bhat. All right. That is a good question. I am not 
certain of the best way to answer it. Just in terms of our 
activities, I do not think the research activities really have 
any influence on spending at the provincial levels. They will 
tangentially impact the provision of care, but it is certainly 
not a direct relationship.
    More so with the technical assistance. Obviously, when you 
talk about China you have to talk about providing assistance at 
the provincial levels. That is precisely what we are doing.
    But, again, in terms of just resources, I have very little 
confidence that our programs, per se, will have a direct impact 
on the allocation of just pure monetary resources.
    It is more along the lines of what Phil was referring to 
earlier with training the trainers, increasing the capacity, 
increasing their knowledge base, but less so in terms of 
providing goods or direct resources.
    Dr. Wan. I want to talk about the Chinese people. When we 
are talking about the AIDS crisis in China, we are still facing 
a silent majority. A lot of Chinese people are still not 
completely informed and not prepared with an anti-AIDS 
campaign.
    So, if the U.S. Government could invest in supporting 
capacity building of the communities, NGOs, academia, and to 
get people involved to increase the capacity of the people, if 
people could be educated and they could work with our 
government to help increase the budget at the central level and 
the provincial levels, in research policy, and the human rights 
issues, and providing legal aid for people, then I think that 
is fundamental in an anti-AIDS campaign in China. If people are 
not informed, are still silent, I would suspect the future 
investment by our own government.
    Mr. Frost. Not easily. But neither should that deter us in 
our efforts. I think it is always difficult to influence the 
priorities of 
another government. My own view is that, until China takes 
ownership and provides real leadership on this particular 
issue, the inroads will be long and difficult.
    But I do not think that should deter us in any way from 
continuing to provide the kind of support assistance that we 
are capable of providing and making a difference in areas where 
we can make a difference. I think we have a responsibility to 
do that, and I would argue that we should.
    Dr. Nieburg. Thanks. I actually agree with all three of the 
previous speakers. At lunch time we were talking about how the 
U.S. contribution to the Global Fund is essentially a matching 
contribution. Our maximum is 33 percent of the total. So, what 
we give to the Global Fund depends on what other nations give. 
There have been discussions about having the same kind of 
arrangement with the Chinese Government.
    I also mentioned at lunch time that Kevin and I were in 
China on the trip in January, listening to the Chinese 
Government say to us one day that they were short on resources. 
The next day, there was a large announcement in the paper about 
the Chinese space program. So, one has to think carefully about 
the fungibility of funds, et cetera.
    Mr. Frost. It was not our best day. [Laughter.]
    Mr. Foarde. The other member of our staff who looks at HIV/
AIDS issues is Anne Tsai. It is over to you for questions, 
please.
    Ms. Tsai. Susan and I have been looking at this issue and 
have had various meetings with Chinese and non-Chinese experts 
on this topic about the best way of providing assistance 
through either the central government, getting full cooperation 
with the Public Health Ministry, or just going directly into 
the provincial and local levels.
    We have heard arguments on both sides. We are curious as to 
what each of you thinks is the most effective model and how the 
United States should pursue it. We can start with Phil.
    Dr. Nieburg. Yes. I have mixed feelings about this. I mean, 
China, functionally, is a federal system in the sense that the 
provinces operate pretty independently of the center.
    In our assessment, our teams went to four different 
provinces. Our sense at the end was that these provinces, given 
resources, could do a lot, given resources and guidance. So, I 
think there is a strong argument for not tying money up in a 
Beijing bureaucracy.
    On the other hand, we are dealing with another, sovereign 
national government and there are clearly arguments for trying 
to improve cooperation between us as well.
    Mr. Frost. My answer actually also sort of relates to 
Susan's question, which is that not all of the support that the 
United States offers, or can offer to China, has to go to the 
Chinese Government.
    In fact, I think one of the biggest challenges that the 
Global Fund faces is that the money that it provides to address 
the epidemic in countries, for the most part, goes to 
governments and works through government systems, whether that 
be the country coordinating mechanism or some other government 
system.
    I actually think that the strengthening of civil society 
and working through non-governmental organizations in 
countries, and international organizations that are on the 
ground and have been on the ground--and there are several in 
China that are on the ground and working and have experience in 
dealing with the epidemic--are an avenue of support that we can 
provide that allows for a measure of accountability, a measure 
of success of our programs that does not necessarily mire the 
program in the bureaucracies of either the national or 
provincial governments.
    So, I think it is worth considering how we can provide 
support on both the national and the local level, but thinking 
outside the box and going beyond just sort of these bilateral 
government-to-government arrangements and working with in-
country groups that have a vast amount of experience working on 
the ground.
    Dr. Wan. Yes. I think both working with the central 
government and the local government could help, but you have to 
have a very strict monitoring and evaluation process. The 
central government has a lot of technical and financial 
resources. Maybe not many, but many compared to provincial 
governments. In the counties, I do think it is very important 
to put more resources into training programs.
    But because it is a decentralized situation in China, we 
have to face the reality of corruption, local government 
corruption issues. So, I would suggest that when you support a 
program for a government institution, you need some time to get 
the involvement of local Chinese people, and also to support 
some kind of watchdog, independent nongovernment organization, 
to do research about their policy, about the program, to follow 
up on what is going on.
    Dr. Bhat. I want to address your question from a couple of 
different angles. One, is the diplomatic perspective. 
Essentially, the ministry of health for the United States is 
the Department of Health and Human Services. We have a kind of 
relationship, not just in AIDS but in all areas of health, with 
the Chinese Ministry of Health and out of mutual respect, 
really, it is really appropriate for us to work directly with 
the Ministry and only work at the provincial or other levels 
with their permission. That is the diplomatic look at it.
    But China also is a big country. We do not have a lot of 
resources, honestly, to put into China. In fact, we were 
concerned, starting with the GAP program in China, that it 
would overwhelm our own resources for this program.
    That said, we have looked for ways to maximize our 
resources. One of the ways is to focus our initial efforts, at 
least, in Beijing. Then once we are on the inside, we can start 
to look where we can most effectively make an impact at the 
local and provincial levels. Perhaps over time we will be 
focusing more at the provincial levels, because that is where 
the work needs to be done. But, in the beginning, it is in 
Beijing.
    Mr. Foarde. Let us go on and recognize our friend and 
colleague, Carl Minzner, who is senior counsel working on the 
grassroots-level rule of law issues.
    Carl, questions?
    Mr. Minzner. Yes. Thank you very much. Thank you all again 
for coming today.
    I want to return to a question that Mr. Dorman had begun to 
ask. He brought up the distinction between the will and the 
competence, and he proceeded to ask a question about the 
ability of the Chinese Government to handle the AIDS situation.
    I want to ask about the will. In fact, last week there was 
a professor, I believe from the Harvard Public Health School, 
who came here and gave a lecture not associated with the 
Congress. She drew a parallel between the SARS and the AIDS 
developments, and noted that were the local will to be 
exercised, the government could bring to bear quite a large 
number of resources very quickly on a public health problem. 
The government could concentrate a lot of the news media and 
the public information resources that would be necessary to 
address the problem.
    So she raised the possibility that there is a blockage 
somewhere in the system, that something is not giving way. But, 
were that obstacle to give way, it could change the dynamics of 
the system very quickly.
    For you all, who have had a long series of interactions 
with the Chinese Government, if each of you had to pick one 
place where that blockage is, it could be as specific as naming 
names, or if you just had particular areas where you felt that 
there is a lack of local will, be it a particular ministry, be 
it a particular level of government, whatever, what would you 
identify as the main blockage when it comes to the question of 
political will to handle this issue?
    Dr. Bhat. Again, I will start since the mic is near me.
    I actually do not think the blockage is at the Ministry of 
Health. I think, you might say, they have ``got religion'' on 
this issue. I think it is elsewhere.
    Now, actually this workshop I mentioned that is taking 
place this Friday in China is an experiment, in the sense that 
we are targeting the audience, not the Ministry of Health, the 
usual characters, but rather at the State Council through the 
Development Research Center to see if we can enlighten them a 
little bit about the future impact of HIV/AIDS on their 
society.
    Basically, we are testing a hypothesis and we will see 
whether we can get them to be motivated to spread the word 
within the State Council, that this is a serious issue and that 
it needs to be addressed. The hoped for outcome is the drafting 
of a white paper that would be circulated among the top level 
of the government. So, we will see.
    Now, as for the will, I think they are capable of the will. 
As Phil mentioned with the STD control earlier, the SARS 
control earlier this year, they definitely have a will and 
capacity. It is just a matter of overcoming some of the other 
concerns. I think personally that they do not want to be 
labeled as an AIDS country, therefore, they are trying to deny 
it. But once the numbers get so large that they will be known 
as it anyway, well, by then, probably, the cat is out of the 
bag.
    Dr. Wan. About the will. I think our government does have 
the will to combat the AIDS crisis. But I also think that it is 
not strong, and sometimes not clear.
    I want to talk about different issues. From the leaders, 
the former president, Jiang Zemin, talked about AIDS earlier 
this year. On the Web site of China's CDC, you can find that 
President Hu Jintao talked about AIDS issues, and Premier Wen 
Jiabao also is talking about AIDS.
    The current Minister has worked very hard in handling SARS 
issues and helped China to handle that issue, and it was a big 
success, I think. But she has kept silent on AIDS until 
recently. Dr. David Ho, in Beijing, in early September, talked 
about AIDS. We still do not know, for the Minister of Health, 
whether her will is strong or not.
    Deputy Minister Gao Qiang, after he became the Deputy 
Minister, talked about AIDS. But compared with the former 
Minister of Health and the former Deputy Minister of Health, it 
just seems that they are now willing to talk about SARS more 
than talking about AIDS.
    Also, in China, they talk about other health issues, 
tuberculosis and other health issues. I agree that China faces 
different health challenges, but there is no reason for no work 
on AIDS.
    When we look at people with AIDS, we can find it related to 
sex workers, drug users, blood donors in rural areas, farmers 
in rural areas. And people in gay communities have a moral, 
social taboo. So, people who are infected do not have much 
political, economic, legal, or moral courage to speak out. Our 
leaders have some will, but I believe it is not strong enough.
    Mr. Frost. If you had asked me this question pre-SARS, I 
would have said that I think one of the greatest challenges was 
the lack of authority or the lack of power, if you will, of the 
Ministry of Health within the Chinese system. China, like many 
developing and developed countries, puts emphasis on ministries 
that generate revenue, not ministries that lose revenue. Health 
loses revenue. That is where you spend money, you do not make 
it. So, I would have said the problem is the lack of real 
authority.
    In the aftermath of SARS, that has clearly changed. The 
appointment of Wu Yi as Minister of Health makes her the 
highest-ranking minister in the government, frankly. So, I 
think that her appointment has had an influence.
    I think that, certainly, in the aftermath of SARS, our 
programmatic work has become a little easier. There is more 
openness and there does seem to be more willingness to exchange 
information, share data, and develop cooperative programs in 
China.
    Having said that, it is also still clear to me that there 
is a disconnect in the Chinese system. Most often, it seems to 
me that that disconnect is between the provincial level and the 
central government. How that takes place mechanically is not 
always clear to me.
    Without getting into the complexities of the relationship 
of the Communist Party to government workers, I think that it 
is very difficult to understand where that breaks down within 
the system, whether it is outright denial of what does exist in 
terms of the epidemic, and therefore an unwillingness to either 
address it out of denial, or whether or not there is an 
understanding of the extent of the epidemic and a direct desire 
to suppress that information.
    It is not clear to me what the answer is. It is clear to me 
that it has gotten better. How long it will remain better is 
anybody's guess, or if we are on an upward trajectory that 
could in fact lead to real strengthening of programs and 
collaboration.
    But I think our hope is that, in fact, we are looking at 
the latter and that there is more willingness to be open since 
there is common recognition in the aftermath of SARS of what 
can happen when one tries to address an infectious disease by 
trying to clamp down on information and not be open about it.
    Dr. Nieburg. Thank you. I think the technical people in the 
Ministry of Health clearly understand the risk that China 
faces. I would tend to agree with what Dr. Bhat said about the 
obstacle, if there is one that can be identified, being 
somewhere at the State Council or beyond.
    My sense is, actually, that people in other ministries may 
not understand. I do not think it is an issue of political 
will. I think there is a genuine lack of understanding of the 
risks that China is facing.
    The comment that I have heard several times on more than 
one trip was that China is not Africa, as if that is the end of 
the problem and there is no need to go any further.
    I just want to point out that the three global success 
stories that I know the most about, which are Uganda, Thailand 
and Brazil, are all examples where political leadership at the 
highest level made the difference. Actually, I am not aware of 
any real success stories without political leadership at the 
highest level. So far, that seems to be missing in China.
    Mr. Foarde. Very useful. Hearing you talk about the higher-
level leadership, and thinking about the attitude that China is 
not Africa, reminds me the first time I had a conversation with 
a Chinese Government official about HIV/AIDS back in 1990 when 
I was attached to the U.S. Embassy in Beijing. We were 
basically told the same sorts of things that we had been told 
at just about that same time period on the issue of narcotics 
trafficking. ``Oh, that is a problem we have solved in the 
past.'' ``Well, HIV/AIDS? '' we asked, and they said, ``That is 
a foreigners' problem. There are only foreigners involved here. 
Once we get rid of that little problem, this AIDS issue will be 
gone.'' We kept trying to tell them that this was not our 
experience in the United States. During that time period, we 
were still very much grounded with what was going on here and 
trying to get our arms around the enormity of the problem.
    So, even in that period 14 or 15 years ago to get them to 
talk seriously about it was a serious problem, and I see that 
things have not changed, at least at the top level. It is good 
that they are changing at some level, anyway.
    I would like to continue, because we have a few minutes, by 
picking up a theme that both Dr. Wan and Phil Nieburg brought 
up. That is, the information available to the ordinary Chinese 
person.
    For this specific question, I am interested in the impact, 
if any, of the Voice of America [VOA] and Radio Free Asia [RFA] 
on the information available to the Chinese man and woman in 
the street about HIV/AIDS.
    Are VOA and RFA doing programming on HIV? How effective is 
it in conveying the types of messages that you want? Is there 
more that could be done by those outlets of international 
broadcasting that the U.S. Government has?
    Let me start with Dr. Wan, and then go around.
    Dr. Wan. In the past few years, Radio Free Asia, Voice of 
America, and some other international radio programs have done 
a lot of work on AIDS and AIDS-related sex education, blood 
safety, rights of people with AIDS, policy issues, legal 
issues, a lot of news coverage related to AIDS in China.
    I think it has contributed a lot to the ordinary people in 
China. For example, last year in late September and early 
October, I went to my hometown in a county, a town, in Anhui 
Province. Many government officials and retired county 
officials, school teachers, and regular people, know 
information about what happened in China. A lot of information 
comes from Radio Free Asia and Voice of America.
    Mr. Foarde. Anhui seems to be a very good place for 
reception for VOA.
    Dr. Wan. Maybe, yes.
    Mr. Foarde. I was on a VOA program last week, and quite a 
number of calls were from there.
    Dr. Wan. Yes. Also, at some time I visited a place where I 
lived before. There was a group of senior, retired workers. 
They gathered together every night to talk about political 
issues or social issues.
    When I came, they were talking about AIDS issues. I was 
interviewed and actually I do not know how the radio program 
reported on my points. I spoke to the radio quite well, even 
some things I have forgotten. So, I think it is very important 
to have international radio, yes.
    Mr. Foarde. Is there more that could be done or is the 
level about right?
    Dr. Wan. I think they have done a lot. But I think you 
would have to consult some scientists or some policy experts to 
talk about issues, because it seems like the current 
information mostly focuses on what is happening in China, human 
rights issues, and coming from people like me. But I think it 
is very important to invite a broad range of people, experts, 
to make comments about AIDS issues.
    Mr. Foarde. So, more of a scientific focus would be useful?
    Dr. Wan. A scientific focus, policy, human rights focus are 
all important.
    Mr. Foarde. Phil, do you agree?
    Dr. Nieburg. Yes. Yes, I do. I mean, I do not know a lot 
about the VOA broadcasts, although I do know HIV is a constant 
topic of theirs. But I think, both a technical focus and 
actually an internal focus is important.
    So, for example, in this country every week, the CDC 
publishes data on every disease of public health risk. Every 
state health department now has newsletters that publish data 
about not only disease counts, but epidemics and risk factors.
    There are journalists who are interested in that topic, so 
a lot of public education goes on based on the national 
surveillance system. That could happen in China. You may be 
aware that Kaiser is funding a program to educate Chinese 
journalists about HIV.
    I do not know if it is just on HIV, but on disease 
reporting. I think that having VOA focus on this is helpful, 
but I think it is going to take internal discussion of these 
issues, internal reporting for the Chinese to be able to 
believe the information.
    Mr. Foarde. So the principal source of information for 
China's media industry is not going to be VOA or RFA. One hopes 
for the best.
    Dr. Nieburg. One hopes. I mean, if that turns out to be the 
primary source, then I think China is in bigger trouble than I 
realized.
    Mr. Foarde. Useful.
    Dave Dorman, for more questions.
    Mr. Dorman. In our nearly 1\1/2\ hour conversation, I think 
you have all established very clearly, at least for me, that in 
terms of HIV/AIDS in China, the danger is great, the need is 
great.
    So just to help me understand, and this goes back to Dr. 
Bhat's comment that China's third proposal to the Global Fund 
was the first one accepted for funding.
    Should we read anything into this? It seems to me, based on 
what I just heard, China's first proposal should have been 
accepted. Why did it take three tries?
    Dr. Bhat. Well, I have not studied all three Chinese 
proposals to see what the differences are, but part of it has 
to do with just the sheer scope of the problem. That is, what 
do you choose to actually apply for?
    In other words, what do you choose to actually put into the 
application that you would like to try to address? The whole 
scope of the program. One doable aspect of it is, do you ask 
for hundreds of millions of dollars? Do you ask for a small bit 
of money?
    I understand some of the issues had to do with a lack of 
understanding or a lack of putting into the application in the 
initial round enough of a demonstration of the need. It may 
have been just implicit that China is in need of these funds, 
so just go ahead and get the money.
    Then also translation issues as well, translating from 
Chinese to English. I know that this time, this last round, 
they spent a lot of effort into making sure that their proposal 
was in readable English.
    At the TRP, relatively few are going to be native Chinese 
speakers and can understand and appreciate the language. So, 
they said, expend a lot more effort. In fact, I think we may 
have even had some Chinese-Americans in the drafting stages.
    I think also--and this is less substantiated in my mind, at 
least--there was a concern that there was a lack of significant 
or substantive NGO involvement. As you may know, at the Global 
Fund there is a strong commitment to a public/private 
partnership involving civil society, and China does not have a 
long tradition of civil society. Most of their organizations 
that are involved are more the mass organizations such as the 
All-China Women's Federation, and groups like that. So, there 
are some concerns at that level as well.
    Mr. Dorman. So the fact of third tries says nothing about 
the severity of the problem in China compared to other 
countries.
    Dr. Bhat. Nothing to do with the severity, but just more of 
how you demonstrate the need and what do you actually ask for.
    Mr. Frost. Can I add something? I do not want to over-
analyze it, but China asked for $98 million, and in their third 
proposal they are seeking to scale up treatment for 40,000 
people in those seven central provinces.
    If one divides $98 million by 40,000, the per capita 
expenditure of that grant works out to be an enormous amount of 
money by global standards for the treatment of HIV/AIDS.
    I think China has an approach in mind that allows them to 
seek support from the Global Fund for an epidemic without 
really revealing or stating how extensive the epidemic is.
    If you will remember, a year before the Global Fund was 
announced, before Kofi Annan called for the formation of the 
Global Fund, China said they did not have an HIV problem. It 
was only 1 month after the Global Fund was announced that China 
admitted it did have an HIV problem. The number of people 
officially said to be infected in China went from 30,000 to 1 
million in a single day.
    Now, the cynical side of me would tell you that it is very 
difficult to ask for money and international support for an 
epidemic that you do not have. I think that that probably has a 
lot to do with the approach that they have taken in seeking 
support.
    They want to seek support for an epidemic without stating 
how extensive the epidemic is. I think that is part of the 
denial that exists within the Chinese system about the full 
extent of the epidemic and seeking support to address it 
comprehensively.
    Mr. Foarde. I will recognize for the last questions of 
today Susan Roosevelt Weld.
    Susan.
    Ms. Weld. Thanks, John. I have a lot of questions. 
[Laughter.] As you will remember, when we were just in China 
talking to the Ministry of Health, I asked, what would be a 
model country who has responded to its epidemic of HIV/AIDS in 
a way that you feel would be useful for China?
    And of course, through all of our minds, including the 
person from the Ministry of Health, flashed Uganda, Brazil, 
Thailand. The answer was, well, there is no other country which 
is going to be like China. China is unique in its epidemic, and 
in the ways that are appropriate for dealing with it.
    I wonder if it would be useful if the United States--I know 
that, Phil, you have done some of this in the past--were to 
sketch out its own difficulties, its own response to HIV/AIDS, 
not in the sense that it would be a correct model for China, 
but to bring the Chinese to understand that this is a problem 
that every country has had, a problem of the world, not a 
problem only for the small countries, backward countries of the 
world.
    Do you have a good technique for doing that?
    Dr. Nieburg. Yes. Actually, Susan is referring to a 
presentation I did in Beijing last year. We were sketching out 
the evolution of the U.S. HIV epidemic and the U.S. response. 
As I prepared for that, I realized I was struck by the 
similarity between the two situations.
    So, I think you are right. I understand that the Chinese 
often think themselves unique in various ways. But I think you 
are right, that they are wrong to think what is happening in 
China is different, except in scale, with what has happened in 
many other places.
    Mr. Foarde. Anybody else have a comment on that one?
    [No response.]
    Ms. Weld. It was such a short one, I will have to fill in.
    Mr. Foarde. You have got 3\1/2\ minutes.
    Ms. Weld. The other issue is the rule of law. We are also a 
rule of law commission. Among the things that we try to promote 
are rule of law programs in China having to deal with legal 
assistance for certain groups and clinical legal programs so 
individuals who have problems can be empowered to assert their 
rights in their particular situations.
    I see HIV/AIDS as a disease that breeds the kind of 
situation where a person might wish to assert his or her 
rights. Do you think it as possible that U.S. assistance could 
go into that kind of effort? I do not mean in a way that is 
adversarial to the Chinese Government. But if a person is not 
getting the treatment the government has ordained for that 
person to get, or is being discriminated against, could we 
buildup those kinds of legal assistance programs?
    Dr. Wan. I want to answer that question. There are some 
legal aid programs for environmental issues, for migrant 
workers, for labor rights issues, some by the United States, 
some by the European Union, Canada, and Australia, and maybe 
some sponsored domestically. There are some teaching programs, 
clinical teaching programs in China. There are some research 
programs sponsored by the Ford Foundation, UNDP on legal reform 
related to AIDS. And there are some lawyers and law firms now 
that have some willingness to help people with AIDS and to 
handle AIDS-related policy and legal issues.
    Our institute has done a lot of work to advocate for people 
with AIDS. We have a plan to provide legal education, and human 
rights education related to AIDS. Last month, just a week after 
the Human Rights Watch report on AIDS and human rights, our 
institute published a report about AIDS law and human rights in 
Henan Province. We focused on one province.
    We found that it is very important because recently only 
those in the area, only when they spoke up, only when they get 
to understand policy and they used the law and the policy to 
advocate for their rights to get treatment, and for their 
children to get an education, only then were they successful. 
So I think legal aid, legal education, and human rights are 
very important.
    Mr. Foarde. Anyone else want to address that?
    Dr. Nieburg. Yes.
    Mr. Foarde. Phil, please.
    Dr. Nieburg. I am not quite sure how to phrase this, but I 
would like to make a brief editorial comment about this. I 
think that paying attention to the human rights of people who 
are infected with HIV in China and elsewhere is very important.
    One of the issues that is not often discussed is the right 
of people who are not infected to remain uninfected. It is 
important that there be some balance in how that is addressed, 
particularly in a country like China where access to 
information about ways to remain uninfected is not so easy. The 
human rights issue, to the extent it is raised, should be 
raised for both uninfected and infected people.
    Mr. Foarde. Well, I think we are going to have to leave it 
there for today, having reached the magic hour.
    Amar Bhat, Wan Yanhai, Kevin Frost, Phil Nieburg, thanks to 
all of you for sharing your expertise with us this afternoon.
    On behalf of Chairman Jim Leach and Co-chairman Chuck Hagel 
and all the members of the Congressional-Executive Commission 
on China, thanks to all who came this afternoon. I hope we will 
see you next week at 1:30 for our next roundtable. We will send 
a reminder a little later in the week.
    With that, this discussion will close. Thanks very much.
    [Whereupon, at 4:05 p.m. the roundtable was concluded.]
                            A P P E N D I X

=======================================================================


                          Prepared Statements

                              ----------                              


                  Prepared Statement of Amarnath Bhat

                            october 20, 2003
    Hello. My name is Amar Bhat and I am the Director of the Office of 
Asia and the Pacific, Office of Global Health Affairs in the Office of 
Secretary Tommy Thompson. As such, I am the coordinator of all Asia-
Pacific activities within the Department of Health and Human Services 
(HHS) and a spokesman for Secretary Thompson and the Department on all 
matters pertaining to this region.
    This hearing today is timely in that Secretary Thompson is just 
returning from his first visit to China as HHS Secretary. His visit was 
very brief, coming on the heels of last week's meeting of the Board of 
Directors of the Global Fund to Fight AIDS, Tuberculosis and Malaria. 
As you may have heard, at this meeting of the Global Fund Board, the 
Chinese proposal to the Global Fund for work in HIV was approved. In 
the case of China, the third time was the charm, i.e. this was China's 
third attempt to garner funds for their HIV/AIDS work; the previous two 
attempts having failed. China's third-round application had the same 
focus as the second-round application: rapidly commencing and scaling 
up voluntary counseling and testing (VCT), associated with credible 
care and treatment options, for large numbers of HIV-positive persons 
living in seven Central China provinces most heavily affected by the 
dangerous plasma selling practices of the mid-1990's. The 2-year 
commitment for this grant is for $21 million.
    Rather than provide you with an exhaustive list of activities in 
which HHS is engaged in China, I would rather try to provide a 
description of three HHS programs which have had significant 
investments in China. These three programs are ones where we have felt 
that HHS is having great impact, not only in China, but globally, 
utilizing our unique blend of resources and skills. And finally, I will 
end by touching on Severe Acute Respiratory Syndrome [SARS], for when 
it comes to China, I feel it is impossible to talk about HIV or for 
that matter any other major health problem in China without talking a 
little about SARS and the impact that this disease has had and will 
have on China.
    HHS has been involved in China since the opening of relations in 
1979. Since then, we have had a Health Protocol to cover cooperation in 
health and biomedical research. We will be renewing this protocol in 
the next few months, during the 
anticipated visit of Premier Wen Jiabao.
    But only recently have we made a concerted effort to examine our 
relationship and indeed increase our investments in that country. Part 
of the reasons why has been the acknowledgement of the substantial 
scientific talent within China (many of whom were trained in the United 
States), the greater participation of China in world affairs, and the 
ever-increasing presence of disease, particularly infectious diseases 
such as tuberculosis and especially HIV. With the onset of SARS earlier 
this year, the importance of health has leapt to the forefront, more 
than ever before.
    I won't take the time to discuss why and how China has begun to pay 
more attention to HIV/AIDS. I am sure some of the other panelists can 
do a much better job. However, I can say that the greater openness of 
China and Chinese officials has made it much easier for us to increase 
our investments in the country and take advantage of the considerable 
assets in the country to make a difference in the global war on AIDS. 
Emblematic of this renewed relationship is the Memorandum of 
Understanding for AIDS cooperation that Secretary Thompson and then-
Minister of Health Zhang Wenkang signed last year here in Washington.
    As I mentioned before, HHS has begun to invest heavily in China. 
Starting late last year, CDC's Global AIDS Program (GAP) opened an 
office in China. This two-person office officially opened its doors 
earlier today in a brief ceremony involving the CDC Director, Dr. Julie 
Gerberding, who was accompanying Secretary Thompson to China. While a 
recent development, this office has been long in coming. In fact, the 
beginnings of the GAP program in China can be traced to a 2-week 
assessment visit in 2001 led by Dr. Phil Nieburg, here with us today. 
As part of that 
assessment, Dr. Nieburg and his team identified several areas where 
China had 
significant deficits that CDC could help to rectify. Still in its 
infancy, GAP in China currently focuses on improving surveillance and 
VCT around the country. I should note that the CDC does not provide 
direct provision of health care services, nor do any of HHS components 
working in China.
    Also last year, NIH's National Institute of Allergy and Infectious 
Diseases awarded a $14.8 million 5-year grant to the China CDC and the 
Chinese Academy of Medical Sciences. This multi-project grant, known as 
the Comprehensive International Program of Research on AIDS (CIPRA), is 
expanding China's research activities in HIV/AIDS prevention, treatment 
and vaccine development, in cooperation with experts from U.S. 
universities and medical schools. CIPRA is unusual in that it is one of 
the few NIH-supported research programs where by design the principal 
investigator is based outside of the United States. In this case, the 
principal investigator is Dr. Yiming Shao of the China CDC. Five 
interrelated projects, touching on a range of HIV-related questions.
    A third area where HHS has made considerable investments in China 
is in training. While both the CIPRA and GAP have training components, 
there is another program I would like you to know about. Many of you 
know that untold thousands of Chinese professionals have come to the 
United States for advanced training in a number of scientific areas. 
Biomedical research is no exception. At the intramural laboratories of 
NIH, at any one time we may have approximately 300 Chinese scientists 
visiting our labs, conducting research side-by-side with other 
scientists at NIH. Additionally, there must be thousands more in 
American universities across the land, many of them here temporarily 
and others planning to settle permanently in the United States.
    Additionally, the NIH has made considerable investment in training 
Chinese and other developing country scientists in high-priority areas 
of research, including HIV/AIDS and other infectious diseases. The 
NIH's Fogarty International Center administers the AIDS International 
Training and Research Program (AITRP) which 
supports HIV/AIDS and related TB international training and research 
for health scientists, clinicians, and allied health workers from China 
and dozens of other 
developing countries. The primary goal of this program is to build 
biomedical and behavioral research capacity for the prevention of HIV/
AIDS and related TB infections and for the identification of 
appropriate interventions to provide care to those adults and children 
infected with HIV. Under AITRP, scientists are trained to address the 
global HIV/AIDS epidemic through skills development and the fostering 
of long-term relationships between individual scientists and 
institutions in both countries.
    The scope of training includes epidemiology, biostatistics, 
behavioral interventions, program evaluation, research in drug use, 
blood safety, vaccine development and evaluation, virology, diagnosis 
and treatment. To date, 12 doctoral degrees, four masters degrees and 
24 postdoctoral fellowships have been awarded to Chinese scientists and 
physicians through AITRP. Others have been trained through in-country 
workshops using faculty from U.S. universities supported by AITRP. One 
of the wonderful aspects of AITRP is that it leverages and complements 
much of what NIH is already funding through U.S. universities and 
medical schools, and also what other major funders, such as the World 
Bank, are also supporting.
    While these are three major HIV-related programs HHS has undertaken 
in China, there are numerous other activities outside of HHS you may be 
interested in hearing about. USAID is starting to involve Yunnan 
province in their Greater Mekong HIV prevention initiative. Another 
initiative is a workshop taking place later this week in Beijing 
organized by the State Department and the Development Research Center 
of the State Council. The primary purpose of this 1-day workshop will 
be to present and discuss various methodologies that can be adopted to 
estimate and forecast the macroeconomic impact of HIV/AIDS in a 
society, at both the local/provincial level and the national level, 
with a focus on the situation in China. State Department is also 
funding a proposal by the Shanghai Academy of Social Sciences to 
support the development of model AIDS legislation.
    Now, as I mentioned, I wanted to touch on the impact that SARS has 
had and will have on HIV/AIDS in China. In the short term, SARS has 
slowed the momentum we saw building in 2001 and 2002. During the worst 
of the epidemic, staff at the China CDC, and even our own HHS staff in 
Beijing, had been pulled from their normal HIV-related activities and 
asked to devote their full attention to addressing the national 
emergency. This in particular impacted heavily the first year of 
progress for our GAP team in China.
    However, in the long-term, I am hopeful that SARS will indeed 
provide positive impacts for HIV and health in general in China. The 
epidemic brought to the attention of the senior-most leaders in China 
the importance of health to their economy and the need to pay attention 
to their public health infrastructure. China's leaders have realized 
that they have neglected basic public health and disease surveillance 
and now know that there are consequences for doing so. I also believe 
that they were stung by the global condemnation they received for 
allowing this to happen and are eager to show the world that they won't 
let this happen again.
    However, I am not so naive to think that they will abandon their 
practices and turn a new leaf overnight. In gaining control over the 
epidemic, they employed onerous command and control techniques that 
would not be allowed in most democratic societies. For some, I am sure 
this only validated their system in their own eyes.
    Nonetheless, we are hoping to take advantage of this window of 
opportunity to provide substantive and long-term technical assistance 
in epidemiology and surveillance, information technology and 
communications, as well as make some additional investments in basic 
research, treatment, vaccine and diagnostics development, and 
eventually, we hope, vaccine trials. Work in these areas will only aid 
in addressing other epidemics such as HIV/AIDS. This work will also add 
to the buildup of their health care system and improve the ability of 
the Chinese government to detect and control disease outbreaks, and to 
appreciate the role of health in their overall economic development. In 
the process, we also hope to transmit some basic values such as 
transparency and accuracy in disease reporting, the value of 
communicating new developments quickly with international organizations 
and scientific colleagues around the world, and the need to share data 
and samples widely with the global network of scientists in order to 
arrive at a solution as quickly as possible.
    That ends my formal presentation. I would be glad to take any 
questions you may have.
                                 ______
                                 

                    Prepared Statement of Wan Yanhai

                            october 20, 2003
        china--information transparency and public participation
    1. Recently, the Chinese State Environmental Protection Agency 
(SEPA) has adopted a policy of open information and public 
participation in environmental protection issues and monitoring of 
government work.
    2. Article 23 of the Law on the Control and Prevention of 
Infectious Diseases clearly demands that the government publish 
information on infectious diseases.
    3. The State Secrets Law contains no provisions relating to health 
information. Moreover, in 1999, the Ministry of Health issued a notice 
to all provincial health departments stating very clearly that AIDS-
related information is not a State secret.
    4. I believe there is no fundamental legal barrier or policy that 
prohibits publication of information related to HIV/AIDS and other 
health information.
    5. Unfortunately, in the past few years, and most recently with 
SARS, the Chinese government has covered-up important health- related 
information, including, of course, AIDS related information.
    6. The essentially nationwide blood-sales related AIDS epidemic 
became known to the central government (among others) in the mid-1990s, 
but it was only in December 2002 that the former Minister of Health, 
Zhang Wenkang, reported to the National People's Congress that the 
blood sales related AIDS epidemic was present in 23 provinces. The 
Chinese government has not informed the public which provinces and 
which counties are affected. It has said, however, that in many of 
these affected areas, the HIV infection rate among blood donors is 10-
20 percent, and in some it's as high as 60 percent.
                  united states--public participation
    1. In the past few years, the U.S. Government, foundations, NGOs, 
the U.N. and other international organizations have fortunately started 
to turn their attention to the AIDS crisis in my country.
    2. I would encourage the U.S. Government, NGOs and any other 
organizations working in this field in my country to share information 
with the Chinese public, to seek their comments and input on programs 
and strategies and to involve the Chinese people in their work. 
Specifically, these entities should involve the Chinese people in the 
planning, implementation, monitoring and evaluation of AIDS-related 
programs.
    3. These foreign entities should work with Chinese NGOs, academics, 
health institutes and other emerging, informal groups who focus on AIDS 
related issues.
    4. In addition to working with and soliciting comments and feedback 
from these groups, U.S. and other foreign AIDS-related organizations 
should reach out more broadly to the Chinese public, for example in the 
following ways: collecting and publishing information on the Internet, 
establishing a hotline, conducting empirical 
research and public surveys.
                                 ______
                                 

                Prepared Statement of Kevin Robert Frost

                            october 20, 2003
                              introduction
    My name is Kevin Robert Frost and I am Vice President for Clinical 
Research and Prevention Programs at the American Foundation for AIDS 
Research (amfAR).
    Founded in 1985, amfAR is the nation's leading nonprofit 
organization dedicated to the support of HIV/AIDS research, AIDS 
prevention, treatment education, and the advocacy of sound AIDS-related 
public policy. I am also the director of amfAR's international 
initiative, Therapeutics Research, Education, and AIDS Training in 
Asia, or TREAT Asia. TREAT Asia is a cooperative venture designed to 
help Asia and the Pacific region--which is expected to become the next 
epicenter of the pandemic--prepare for the safe and effective delivery 
of HIV/AIDS treatments as they become more widely available. The 
program pairs the resources and experience of clinical centers in Asia 
with amfAR's education, training, and clinical research expertise.
    The goals of TREAT Asia are to:

          Develop the skills of the health care workforce in the safe 
        and effective delivery of drug treatments for HIV/AIDS;
          Enhance existing health care infrastructure and formulate 
        strategies for capacity building to prepare for expanded access 
        to HIV/AIDS drug treatments;
          Develop a framework for regional collaboration on a 
        therapeutics research agenda that is responsive to the needs of 
        patient populations in the region;
          Define and address the national and regional policy issues 
        that impede expanded access to drug treatments for HIV/AIDS 
        and, by working with regional and in-country NGOs, strengthen 
        civil society's preparedness for treatment programs.
                size and scope of the epidemic in china
    China's HIV/AIDS epidemic has been gaining momentum and the Chinese 
government estimates that currently 840,000 persons are infected with 
HIV/AIDS. Intravenous drug use and contaminated blood have been the two 
primary routes for 
infection in China, representing two distinct and separate epidemics. 
However, HIV infection is increasingly spread through sexual 
transmission, with rising rates of 
infection among commercial sex workers in several provinces. Among 
those who acquired infection through tainted blood collection practices 
in central China during the 1990s, large numbers are now falling ill 
and have minimal access to care and treatment in China's under funded 
rural health care system. Relative to many developing countries with 
severe AIDS epidemics in Africa and Southeast Asia, China has a 
functioning health care infrastructure, and antiretroviral therapy is 
starting to be offered through public hospitals and clinics at the 
county, township, and village levels in severely affected communities. 
However, healthcare providers at these levels have little training or 
experience in counseling and treating AIDS patients, compounding the 
problem of side effect management and drug compliance. The lack of 
healthcare provider capacity to administer antiretrovirals is one of 
the biggest obstacles to treatment preparedness in China.
    Though by all accounts China has become more open in dealing with 
HIV/AIDS, denial of the full extent of the epidemic persists. 
Unfortunately, there are no reliable data that accurately assess the 
scope of the epidemic. Chinese doctors privately suggest that the 
epidemic is at least 5 times--and possibly even 10 times--the official 
estimates.
    The HIV epidemic in China's central province of Henan is 
instructive. With an estimated population of 110 million, Henan is 
China's largest province. If only 1 percent of this population was 
infected through the ``blood trade,'' more than a million people would 
be HIV-positive in Henan alone. Yet a recent survey showed that the 
prevalence rate among commercial blood donors in rural eastern China 
was 12.5 percent and 2.1 percent among their non-donor spouses. In 
January 2002, the Henan Health Department reported that 80 percent of 
Houyang village residents were HIV-positive. Of its 4,000 residents 
between the ages of 16 and 55, some 90 percent participated in blood 
donation programs. More than 400 villagers have 
developed AIDS, and 150 died between November 2000 and November 2001. 
In 
December 2002, former Health Minister Zhang Wenkang acknowledged that 
23 provinces, autonomous regions, and municipalities were affected by 
unhygienic blood collection. And this is to say nothing of the epidemic 
among injecting drug users in the south and northwest provinces of 
Yunnan, Sichuan, and Xinjiang among others.
    When asked by amfAR recently about the size and scope of China and 
India's epidemics in an article published in amfAR's quarterly 
newsletter for the TREAT Asia Report, Dr. Richard Feachem, Executive 
Director of the Global Fund for AIDS, TB, and Malaria, had this to say:

          ``There has been this strange collusion between Western 
        experts, international organizations, and the Chinese and 
        Indians to first say that the HIV epidemic is not seriously 
        going to affect China and India at all, then to say, well, 
        maybe they're going to have a small epidemic, and then to say, 
        well, maybe they're going to have a rather larger epidemic.
          ``But only very recently has there been anything approaching 
        a consensus that China and India are set for very large 
        epidemics. Because of this 
        history of minimizing the epidemics in China, India, and in 
        Asia more generally, I would go with the higher-end estimates 
        now being produced.''

                            china's response
    Recently there have been promising signs of an increasing 
willingness in China to confront its HIV/AIDS epidemic. China has just 
been awarded a grant from the Global Fund to carry out voluntary 
counseling and testing (VCT) and treatment programs in seven provinces 
where many infected through blood donation during the 1990s are falling 
ill. Prior to this, the Chinese government had initiated a treatment 
program in four of these provinces that offers antiretroviral therapy 
to about 3,000 persons now, with a target of 5,000 by the end of 2003. 
The Global Fund support will be used to scale up treatment, including 
antiretrovirals, to 40,000 AIDS patients in 56 counties in these seven 
provinces by 2008. Many experts believe even the 40,000 target is a 
significant underestimate of the number of patients in these 
communities who will require treatment in the next 5 years.
    While the Chinese government's goal of extending free 
antiretroviral treatment to rural AIDS patients is laudable, many 
problems exist with China's current treatment policy program beyond the 
issue of the numbers of sick persons who will have access to free 
treatment. One significant problem has to do with the affordability of 
state-of-the-art antiretroviral therapy that is both easier for 
patients to tolerate and for health care providers to supervise (i.e., 
fewer doses, less complicated regimens with fewer side effects). As a 
new member of the World Trade Organization, China has been careful to 
respect international trade agreements and only manufacture drugs that 
are off patent. Two Chinese pharmaceutical companies have begun to 
produce generic versions of 4 off-patent drugs that the government has 
acquired for their public treatment program. Patented drugs, such as 
combivir (AZT + 3TC), are imported but considered too expensive to use 
routinely and are only used in a handful of patients when domestically 
manufactured drugs are not tolerated. The treatment protocols currently 
being used are not optimal and have not been well tolerated by 
patients, resulting in severe side effects which local health care 
providers have no training or experience in managing.
    Because of these side effects, the treatment options currently 
available in China in many ways represent the worst possible choices 
and offer the potential for disaster. Yet China is taking the approach 
that most developing countries are forced to take when it comes to 
choosing treatment regimens. Rather than developing public health 
strategies for delivering treatments to the population of HIV-infected 
individuals, China is left in the undesirable position of having to 
settle for what it can get, rather than what it needs. Unless serious 
attention is paid to acquiring better combination treatments, the 
failure rate of the current regimens is likely to be enormously high 
and could have dire consequences in terms of diminished long-term 
efficacy of treatment programs in China and widespread development of 
HIV drug 
resistance, with implications for the rest of the world. Similar lack 
of access to imported reagents for HIV and CD4 testing has constrained 
the ability of the health system to do the necessary voluntary 
counseling and testing, and to properly monitor those patients on 
treatment.
    The mix of insufficiently trained medical staff with poor 
counseling skills, poorly tolerated drug regimens, and lack of testing 
and laboratory monitoring capacity is a worrisome combination of 
factors. In an editorial published in The South China Morning Post in 
August 2003, Drew Thompson of the Washington DC-based Center for 
Strategic and International Studies wrote: ``To safely treat HIV 
sufferers with powerful antiretroviral drugs, it is crucial to have 
trained physicians with access to laboratories which can carry out 
advanced blood testing. . . . By jumping the gun and beginning 
treatment before doctors and counselors are properly trained, a drug-
resistant disaster is waiting to happen.''
    Now that China has been granted a big infusion of funds through the 
Global Fund mechanism, it will quickly be scaling up its treatment 
program. It is imperative that education and training programs are 
rapidly expanded and accelerated in order to ensure that the best 
available drugs are being provided by trained medical professionals, 
with proper counseling and rigorous monitoring and follow-up testing.
    At amfAR, and within the TREAT Asia program, we believe that it is 
here the United States has much to offer. China desperately needs (and 
there is growing evidence of China's willingness to seek), 
international support for rapidly developing and scaling up education 
and training programs for healthcare providers in the 
delivery of HIV/AIDS drugs. It is my sincere hope that we will find the 
necessary resources to provide precisely that support.
    Thank you.

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