Extract of final draft on "Recommended HIV/AIDS
Strategies for Hong Kong 2002-2011"
Hong Kong Advisory Council on AIDS
When HIV first hit Hong Kong in 1984, prevention and control activities were coordinated by the then Medical and Health Department under the guidance of an Expert Committee on AIDS. Policy development focused on the formulation of technical guidelines on infection control, counselling, HIV antibody testing and the supervision of surveillance activities. It was not until 1990 that a comprehensive approach was adopted in addressing AIDS by the newly appointed Advisory Council on AIDS (ACA). Since 1994, the ACA has been producing recommended HIV/AIDS strategies for Hong Kong. Thus far 3 sets of documents were developed (Box 1). Appendix II shows the progress of achieving the targets laid down in the 2002-2006 strategies.
Box 1. Formulation of HIV/AIDS strategies by the
Advisory Council on AIDS in the past:
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There were several key processes which contributed to the formulation of the five-year Strategies from 2007 to 2011:
A) Community Assessment and Evaluation
The Community Forum on AIDS (CFA), established in 2005 by ACA in its sixth
term, embarked on an exercise of community assessment and evaluation. In response
to inputs from CFA members, seven groups were formed, namely men who have
sex with men (MSM), injecting drug users (IDU), sex workers and clients, cross-border
travellers, people living with HIV/AIDS, women and children, and youth. Convened
by a community expert, each Working Group invited members from relevant agencies
and stakeholders to provide their expert views. Technical and secretariat
support was provided by the Department of Health (DH)'s Special Preventive
Programme (SPP). A common assessment framework was adopted, including a review
of epidemiological data, an evaluation of current response, a review of overseas
guidelines and the drafting of recommendations for the next 5 years. The exercise
spanned from January to July 2006 and the reports generated from the Working
Groups were released in September 2006.
B) Estimation and projection exercise on HIV/AIDS in Hong Kong
The previous comprehensive exercise on the estimation and projection of HIV/AIDS
in Hong Kong was carried out in 1993. To better understand the current epidemiologic
situation and its future trend, an external consultant was engaged for the
study. Commissioned by the Centre for Health Protection (CHP), DH, Dr. Tim
Brown of East West Center, Hawaii, visited Hong Kong in April and July 2006.
Besides reviewing data pertaining to the local situation, Dr. Brown met with
the Secretary for Health, Welfare and Food, Director of Health, Controller
of CHP, Chairman and members of ACA, Council for the AIDS Trust Fund (ATF),
Scientific Committee on AIDS and STI (SCAS), NGO workers and community stakeholders.
He also visited community programmes and conducted training. His consultancy
report titled "HIV/AIDS in Hong Kong 2006 - Living on the Edge"
contained a detailed analysis of the latest local epidemiological HIV situation
and his recommendations on the way forward.
C) Opinion survey on AIDS programme and AIDS strategies
ACA issued a questionnaire survey from January to March 2006, both on-line
and by post, to collect opinions and feedback from stakeholders and members
of the public on the current AIDS programme and the implementation of the
2002-2006 AIDS Strategies. A total of 40 responses were received.
D) Work and deliberations of ACA and its committees
ACA itself systematically reviewed the 2002-2006 AIDS Strategies. Starting
from the previous term of ACA in 2002-2005, its 3 committees (Scientific Committee
on AIDS, Committee on Promoting Acceptance of People Living with HIV/AIDS
and AIDS Prevention and Care Committee) discussed various subjects of local
and international relevance within their respective spheres of expertise.
They put forward strategy recommendations, guidelines, consensus statements
and reports. The Community Forum on AIDS serves to draw input from the community
on the needs, gaps and response to support strategy development. While the
new SCAS was streamlined under the scientific advisory structure of CHP, effective
communication is maintained between ACA and SCAS.
E) Analysis by the Secretariat on non-local development
The ACA Secretariat operated by the SPP kept track of international developments
on HIV prevention and control. Relevant papers and documents were obtained
and made available whenever possible to Council members to facilitate their
efforts in strategy development in the Hong Kong context.
The broad-based approach of involving stakeholders (government and non-governmental organizations and the affected community) in the formulation process allows all key parties to participate and take ownership of the strategy recommendations. This approach facilitates the mapping of strategies pertinent to the local context but with an international perspective. The first draft of this strategy document was deliberated by the ACA in October 2006. The revised document was released for consultation through various channels including forums, internet and direct invitation to the stakeholders and community at large. ACA gratefully acknowledges all the organizations and individuals who have contributed their views and suggestions to the final document.
Since the recognition of AIDS as a new disease entity in 1981, HIV epidemic has developed into one of the most devastating pandemics in history. The estimated number of people living with HIV worldwide went up from 10 million in 1993 to about 40 million in 2005, with over 8 million in Asia1. In 2005 alone, 5 million new infections have occurred and 3 million lives were lost due to the infection. Cumulatively, some 25 million people have died from the disease.
The global pandemic consists of many diverse epidemics occurring at different pace and locations, affecting heterogeneous and often marginalised populations (Box 2).
Box 2. HIV epidemics around the world
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Hong Kong has remained a low HIV prevalence area but is constantly challenged by the concentrated epidemics in the nearby regions. The most plausible reasons for the past success are believed to be the generally low level of risk behaviours coupled with the maintenance of a low HIV prevalence beneath escalation threshold. Under the voluntary and anonymous HIV/AIDS reporting system, the Department of Health has recorded a total of 3004 reports of HIV infection at the end of June 2006. Apart from 38 perinatally transmitted or transfusion related cases, others were adults. Since 1996, the number of AIDS reports was stable at around 60 cases each year. At present, Pneumocystis pneumonia and tuberculosis are the commonest primary AIDS defining illnesses in Hong Kong. Identification of HIV-1 subtypes at molecular level is useful for understanding the epidemiologic pattern and important in finding clusters. Locally, the commonest subtypes identified from 2002 to 2005 are CRF_01AE (49%) and B (35%). Subtype C, CRF07_BC and CRF08_BC each occurred in 5%, 3% and 2% of the total cases respectively.
The evolution of HIV epidemic in Hong Kong can be roughly divided into three phases. The first phase lasting till the early 1990s was characterized by haemophiliac and then MSM infections. It was followed by the second phase when heterosexual transmission became prominent. Male infections predominated but as more females became infected, the 5-year averaged male to female ratio gradually dropped from 7:1 in 1990, 3.6:1 in 1995, and 2.4:1 in 2000 to 2.0:1 in 2005. About 80% of infected men were ethnic Chinese. However, a significant proportion of female infections came from non-Chinese Asians. Paediatric infection from mother-to-child transmission has been uncommon.
In the past few years, the HIV situation has quietly left its slow steady state and entered into a new third phase. There is a striking increase in infections among local MSM, against a stable heterosexual transmission. The surging MSM epidemic is supported by several observations (Box 3).
Box 3. Evidence pointing to a rising MSM epidemic
in Hong Kong
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The HIV situation in IDU population, although is still relatively low, has also become more apparent in last 1-2 years. This is largely because of the improved access to HIV testing, mainly through the universal screening programme in methadone clinics where a HIV prevalence of 0.2-0.3% is found among drug user attendees. Of the reported cases, it was observed that there was an increasing trend of non-Chinese cases and new diagnoses made from treatment/rehabilitation services.
According to Dr. Brown's HIV/AIDS estimation and projection report, 3240 people were living with HIV in Hong Kong as of 2005, with about 3700 infected cumulatively. In 2005, there were 340 new infections. Of the people living with HIV/AIDS (PLHA), MSM and clients of female sex workers each accounted for almost 40% of the infections.
Over the years, Hong Kong has established a comprehensive range of programmes and activities by various sectors of the community to address HIV/AIDS. The term programme denotes this unique set of collaborative efforts. This section serves to provide an outline as well as the highlights of the latest development.
Hong Kong's HIV/AIDS Programme are executed by a variety of agencies. Within the Government, the Department of Health's SPP is the designated unit working on AIDS. With the formation of CHP under Department of Health in 2004, SPP was put under its Public Health Services Branch. The Government-appointed Advisory Council on AIDS provides policy advice on all aspects of the infection. In 2004, the ACA released its report on the study of HIV-infected haemophiliacs "The Forgotten tragedy, the Unforgettable trauma", the recommendations of which were adopted by the Government. The new Community Forum on AIDS was set up by the Council in its sixth term of 2005-2008. A number of AIDS non-governmental organizations (NGO)s3 provide prevention and care services in community-based settings. Formed in February 1998, the Hong Kong Coalition of AIDS Service Organizations (HKCASO) aims to facilitate communication between its member agencies and to advocate on policy issues relating to HIV/AIDS in Hong Kong. The efforts of designated organizations/units are supplemented by other government services, public bodies, mainstream NGOs and the academia.
HIV/AIDS surveillance is a regular programme under the purview of the Department of Health. It is comprised of 4 inter-relating components: (i) voluntary reporting, (ii) seroprevalence studies, (iii) behavioural surveillance, and (iv) sexually transmitted infection (STI) surveillance. Quarterly statistics and annual surveillance reports are published on a regular basis. Updated statistics are released and disseminated to stakeholders through the website (www.aids.gov.hk) and quarterly press meetings. The DH2293 report form on HIV/AIDS was revised in late 2005 to collect more useful information. Based on several years of gainful experience from the pilot molecular epidemiology project, HIV-1 subtyping has been recently incorporated as a surveillance tool in Hong Kong.
The Government's HIV prevention and health promotion activities are implemented by both designated AIDS services and other departments/units. The Red Ribbon Centre is the resource centre that houses the Department of Health's HIV Prevention and Health Promotion Team. The Centre organizes three major categories of activities - communication and information projects on awareness and acceptance, targeted prevention, and capacity building. Its designation as the Joint United Nations Programme on HIV/AIDS (UNAIDS) Collaborating Centre for Technical Support was granted in 1998 and recently extended to mid-2008. A new wing of the Centre was opened in June 2006 to enhance its role in capacity building and training. The Department's Social Hygiene Service and Methadone Treatment Programme are outlets for STI treatment and harm reduction respectively. Territory-wide social marketing campaigns on harm reduction and safer sex were carried out in 2002 and 2005 respectively. In 2004, a universal yearly urine HIV testing programme was rolled out in all methadone clinics, to improve care, surveillance and control of HIV among drug users. In mid-2006, in partnership with the community, a HIV awareness campaign targeting MSM was launched. The Hong Kong Red Cross Blood Transfusion Service is on the forefront in safeguarding blood supply in Hong Kong. Nucleic acid amplification test for HIV and HCV was introduced in July 2002 to further shorten the window period of missing acute infections in blood donors.
On the community level, the AIDS NGOs have continued to consolidate their expertise in HIV prevention and care. AIDS Concern is a pioneer in the development of prevention activities targeting MSM, travellers and sex workers. The CHOICE, Action for Reach Out and Ziteng worked on female sex workers and clients. The Society for AIDS Care provides centre-based and home care services to people living with HIV/AIDS. The St John's Cathedral HIV Education Centre works on prevention among youth, women, Asian migrant workers and church congregations. TeenAIDS focused on HIV awareness and young people. The Hong Kong AIDS Foundation targets a range of populations and is notable for its collaboration with Mainland. Over the past few years, there was an increasing number of main stream organizations commencing work in the field of HIV/AIDS. The Society for the Aid and Rehabilitation of Drug Abusers works on drug users in outreach and treatment settings, the Society of Rehabilitation and Crime Prevention targets sex workers and ex-offenders, the Caritas - Hong Kong and the Boys and Girls' Club Association of Hong Kong focus on youth. The Hong Kong Federation of Women's Centres serves women.
HIV testing, diagnosis and care constitute another broad category of programme on AIDS. The Government's Public Health Laboratory Centre is the largest diagnostic laboratory on HIV in Hong Kong, supporting a variety of testing and patient monitoring services/programmes organized by the Department of Health, Hospital Authority, NGOs as well as private sectors (on confirmation testing). The advent of highly active antiretroviral therapy (HAART) has significantly changed HIV treatment and care around the world. At the end of year 2005, it was estimated that there were some 3200 PLHA in Hong Kong, with an estimated 1200 people on HAART. Longitudinal care of the vast majority of PLHA is provided by the public sector - Integrated Treatment Centre (ITC) of the Department of Health and the Special Medical Service of the Hospital Authority's Queen Elizabeth Hospital. Princess Margaret Hospital is providing in-patient care on HIV/AIDS and collaborates with ITC through the Infectious Disease Programme on AIDS. Queen Mary Hospital is the largest centre for HIV-infected paediatric patients. The Scientific Committee on AIDS and STI under the CHP formulates technical guidance and recommendations on public health and clinical practice. It issued two local recommendations on antiretroviral therapy and HIV care delivery framework in 2005.
Programme funding source comes mainly from the Government, both through regular established mechanisms and the ATF, to Government departments, public bodies and community organizations. The ATF introduced a technical review system and a 3-year programme funding mechanism in 2003. In 2005, the ATF established an additional ex-gratia payment scheme to provide financial assistance to HIV infected haemophiliac patients and their families.
In response to the rising MSM epidemic, the ATF in December 2006 launched a Special Project Fund for HIV prevention in MSM to support community projects for reducing risk behaviours and preventing HIV infections in MSM for the coming two financial years (2007 to 2009). The SPF funds prevention and research projects and, for the first time, predefined objectives and preferred project areas are listed for application. From 2002 to 2006, a total of 79 projects were funded by ATF, amounting to a total of HK$107 million. These covered patient support and care, HIV prevention and research. Besides, the NGOs have been active in raising funds for their operation and services to support community-based projects over the years.
Basic overview
As indicated in the previous chapters, the formulation of this strategy document
is based on assessment of the current situation, an evaluation of programmes,
a projection of changing trends, and the identification of gaps in the current
response. The proposed recommendations aim to guide the overall community-wide
AIDS response in the next five years. It is a product of objective, integrated
and consultative processes with a public health oriented approach.
Strategy objectives
The objective of this strategy document is to provide a common direction for
a coordinated AIDS response in Hong Kong, with the goals of:
(a) maintaining low HIV prevalence
(b) reducing HIV spread
(c) achieving early HIV diagnosis, treatment and care
(d) optimising health of HIV/AIDS patients
Guiding principles
The widely adopted international principles on HIV prevention, care and control
applies to Hong Kong. Solidarity with partners of Mainland China and international
community is indispensable. Several cross-cutting issues underpin all aspects
of HIV prevention, care and control in the local context. The guiding principles
for addressing these issues, after the processes of strategies development
and deliberation of ACA, are listed below:
Adopting evidence-based approach. The prevention and care needs should be evidence-based, taking reference of the latest situations on epidemiology, strategic research findings and programme response.
Encouraging community partnership and support. Community and NGOs are key partners in prevention, surveillance and care programmes for hard-to-reach and vulnerable populations. Greater collaboration among organizations as well as affected communities will enhance the overall collective response.
Building supportive and enabling environment. A non-discriminatory environment receptive to human rights is conducive to effective programme intervention.
Prioritizing funding. In order to maximize the impact from limited resources, a relatively greater proportion of funds should be channelled to areas where most infections occur.
Integrating monitoring and evaluation. Monitoring and evaluation (M&E) should be an integral component of local AIDS programme and conducted at various levels during the different phases of planning and implementation.
Cultivating expertise. The small mass of public health, community and clinical expertise is to be expanded and sustained, while strengthening the general capacity of supporting staff and volunteers.
Addressing vulnerability and risk behaviours with intensive coverage. Intervention for behaviour change communication (BCC) should be relevant and acceptable to the target population, so as to encourage active participation, dialogue and empowerment and to achieve a higher coverage. The increasing human mobility associated with risk behaviours within the region should also be tackled with targeted measures.
Enhancing communication and education. The wider public should also be engaged through sustained awareness-raising and public education efforts of AIDS organizations as well as mainstream NGOs.
This chapter sets out the priority areas for action under the following sections:
A. Scaling up targeted HIV prevention in risk populations with MSM being the
most pressing priority
B. Mobilising an effective community-based response with prioritization of
resources to the areas of need and the provision of adequate technical support
C. Enhancing HIV surveillance and testing
D. Sustaining access to quality treatment and care for people living with
HIV/AIDS
E. Interfacing with Mainland China and nearby regions for an effective response
The HIV situation in Hong Kong has taken on an urgency never seen before, with implications for both prevention and care. Epidemiologic evidence points to MSM as the highest priority risk community to target for at least the next few years. Dr. Tim Brown's study showed that Hong Kong has entered an accelerating phase of epidemic because of MSM infections. The currently far from satisfactory <60% consistent condom use during anal sex in MSM is of urgent concern. Hong Kong can easily move from a low level to a concentrated HIV epidemic should the current situation continues. According to Dr. Brown's estimation, the consequence of failure to prevent this epidemic would mean 3000 more MSM needing HAART by 2020. This would be translated into, human morbidities and social costs aside, a cumulative additional edtreatment cost exceeding one billion Hong Kong dollars by 2020.
All along MSM is among one of the hardest-to-reach populations for preventive interventions. Nevertheless, in face of the impending public health crisis, HIV prevention efforts for MSM must be rapidly scaled up and sustained. Increasing condom usage is the single most effective public health measure to reduce a sexually-driven HIV epidemic. The minimum HIV prevention target for increasing condom use at anal sex among MSM should be set at 80%. (Target one, see P.22) It is necessary to achieve a high coverage of practising safer sex among MSM. Increasing condom use apart, they should also be advised to avoid risky sexual practices, e.g., having multiple sex partners or having sex with unfamiliar people. To this end, community-based prevention programmes are advantageously positioned to reach MSM. The key to success for HIV prevention is to scale up pilot projects, which have been proven effective. This will ensure that the overall AIDS response will achieve a greater impact on the course of the epidemic. New preventive interventions targeting MSM can also be piloted to increase the overall effect.
The MSM community per se plays a crucial role and they should be informed, mobilized and provided with sufficient technical assistance and capacity building training to play an active part in the coming response.
Contrary to the drug user and heterosexual population, HIV infection among MSM is mostly locally-acquired and perpetuated. Yet, the upsurge observed in Hong Kong is also part of a rising regional trend. Human mobility and connectivity contributes to the spread of HIV beyond borders. Unsafe sex with MSM from other Asian countries with serious MSM epidemic predisposes to further risk. Greater awareness of the local and regional HIV situation and the high risk behaviours involved helps to reinforce the messages of safer sex in MSM.
More importantly, these preventive interventions must be conducted in a way that does not foster further stigmatisation and discrimination of the MSM community. Innovative strategies such as providing sexual health service for MSM should also be explored.
Prevention of HIV among drug users has been a success for Hong Kong, attributable to its wide coverage methadone treatment programme, unrestricted access to clean needles and syringes, high HIV awareness among drug users, relatively low sharing rates and most importantly, maintenance of an exceedingly low HIV prevalence. There are, however, emerging challenges to whether and how this low prevalence can be sustained, primarily in the face of ever-increasing human mobility in the Pearl River Delta and the rest of the region. Trends in HIV epidemiology and its related factors have to be tracked and monitored through various sources.
Social mixing with drug injection when injecting drug users travel across the border in either direction significantly increases the risk of upsurge in local epidemic. This is further complicated by increasing human mobility, migration and foreign travel in the region, where Mainland and some Asian countries have a differentially higher HIV epidemic in IDU than Hong Kong. Of the positive clients diagnosed at methadone clinics in 2005, 44% came from different parts of Mainland China. Surveys showed that 10-20% of Hong Kong IDUs reporting purchasing or consuming drugs in Mainland in the past 3 months to 1 year. Non-Chinese cases accounted for about 30%, 75% and over 90% of the reported HIV-infected IDU cases in 2004, 2005 and the first half of 2006 respectively. Furthermore, although the data is limited at present, the phenomenon of recreational psychotropic drug abuse among MSM must not be neglected, as it can potentially fuel a more severe HIV spread in the MSM community through unprotected sex.4,5
HIV transmission among IDU through needle-sharing is well documented for its exponential spread in a short duration. HIV taking root in IDU is often the impetus bridging to an extensive transmission in the heterosexual populations. HIV prevalence in IDU must be kept low. Effective harm reduction progammes are already in place and should be continued, notably the existing methadone programme combining with unrestricted access to clean needles/syringes/condoms and outreach programmes. Drug workers taking care of the drug users are in the best position to deliver HIV intervention activities. A supportive policy and societal environment has served as the pillar stones of success and shall continue to be so.
Augmented prevention should specifically target on the higher risk IDU segments, including those from Mainland China and ethnic minorities from Asian countries. Harm reduction programmes for IDU should be integrated and expanded, including active recruitment of IDU into methadone treatment network, outreach programme to promote HIV awareness, and risk reduction and HIV testing programme. Barriers such as culture and language must not be overlooked. These programmes should be provided with adequate and sustainable resource and technical support. HIV-positive IDU should be engaged and maintained in drug and HIV treatment programmes to reduce onward spread of HIV.
The increasing prevalence of midazolam/triazolam use in heroin abusers (about 10% of heroin injectors in 2001 to over 25% in 2005) locally needs to be addressed, as this can be associated with increased risk-taking behaviours.6,7, IDU visiting Mainland China and other places in the region should be warned about the high HIV prevalence over there. The prison setting in Hong Kong provides a good access point for HIV prevention as about one-third of inmates are drug users.
Unprotected sex in commercial sex settings risks HIV infection for both sex workers and their clients. Cross-border factor comes into play in these risk populations. It was found that Hong Kong men are less inclined to use condom when visiting female sex workers (FSW) in Mainland, and so are sex workers who have come from Mainland China, as compared to their practice with local sex workers. The apparently lower condom usage across the border is to be elevated. (Target one, see P.22) However, there is scarcity of information on the characteristics and behaviours relevant to HIV infection and prevention among sex workers from Mainland China and local men. More rigorous research and surveillance initiatives in this area will be required.
Prevention programmes targeting risk behaviours in different settings leading to heterosexual HIV transmission need to be implemented and expanded. Sex workers and their clients should be offered good access to HIV prevention services including condom distribution and sexually transmitted infections screening and treatment services. The same harm reduction public-health oriented approaches for drug users should be used for sexual transmission prevention, covering sex workers and their clients. In the long term interests of the community, it will be preferable to operate a non-discriminatory and high-coverage health care system for this vulnerable population.
Effective prevention for clients of sex workers would have benefits extended to low risk women population, who are mostly infected from their HIV-infected spouse (often sex worker clients) and constitute a large proportion of female living with the infection in Hong Kong. The chain-effect of infections arising from inter-linkages of commercial sex and non-commercial sex has to be acknowledged, and safer sex be promoted as deemed necessary for prevention. Family planning and reproductive health settings are potential sites for enhancing HIV education and prevention for the relatively low risk but big women population.
Universal antenatal HIV testing (UAT) was introduced in Hong Kong in September 2001 with satisfactory results. The current gap in preventing mother-to-child transmission (MTCT) lies in late presenting mothers who missed their HIV tests during pregnancy resulting in unknown HIV status at labour. Discerning the HIV status of these mothers in time for prompt prophylaxis to reduce MTCT is critical to narrowing the existing prevention gap. Drawing reference from overseas experiences and recommendations, rapid testing should be introduced to supplement the existing UAT programme as a point-of-care tool in these settings to allow timely diagnosis of infected mother and ensuing antiretroviral and obstetrical interventions to reduce MTCT. (Target two, see P.22)
Media programmes, publicity campaigns and education activities to increase public awareness have helped cultivating a conducive environment to HIV prevention in Hong Kong. The target audience of these efforts are the public, including youth, women and potentially at-risk people who may otherwise be missed by targeted prevention efforts. HIV prevention is strategically effected through AIDS education and sex education which is integrated into school moral and civic education for youth. Students are provided with ample opportunities to gain knowledge, develop concepts and values in relation to sex education and AIDS education in school curricula in different stages of learning. Promotion of HIV awareness, safer sex practice and avoidance of drug abuse deemed appropriate will help AIDS response, as preventive education should begin early in youth. Discrimination and stigmatization impede effective HIV prevention and care. Promoting acceptance of people living with HIV/AIDS also encourages those people who are at-risk or the infected to access prevention services, HIV testing and early care.
A majority of resources on HIV prevention, treatment and care in Hong Kong comes from public funding. In the face of a changing epidemic, particularly among high-risk populations, the distribution of such resources should be reviewed, re-prioritized and rationalized. (Target three, see P.22) To be cost-effective, efforts must be directed towards vulnerable groups rather than thinly spread among the low-risk populations. Resources should be allocated to address both local and non-local factors/settings fueling the local epidemic.
The Council for the AIDS Trust Fund is the major funder of community-based HIV prevention projects and activities. Its establishment in 1993 was a clear demonstration of the Government's commitment to tackle the AIDS problem. ATF's role remains pivotal to the thriving community-based work of numerous organizations. When the AIDS situation in Hong Kong was "low and slow" as in past years until the present, ATF have provided funds for prevention, treatment and care, and research activities for both high-risk groups and the population at large. With the rapid growth of the HIV epidemic, the ATF and ACA should work together for a coordinated effort. ATF should consider adjusting its funding priorities to ensure that resources are promptly channeled to the most at-risk and often hard-to-reach populations. The launch of a Special Project Fund by ATF to enhance HIV prevention among MSM is a move in this direction. In the medium term, a review of ATF funding mechanisms may be considered, with the aim of improving funding in the face of changing epidemic, needs and demands. (Target four, see P.22)
Besides ATF, other funding sources in the fields of social welfare, education, research and healthcare should also be opened to application from AIDS projects. These can take the form of on-going core prevention programmes or of innovative pilot projects that can be transformed into continued intervention programmes if shown to be successful. NGOs with proven track record could be commissioned to work on specific at-risk populations. Unnecessary duplication of effort would be avoided, while expertise would be retained and built up. On the other hand, collaboration between different organizations (AIDS, mainstream, community, academia, government) can foster mutual support, enhance cross-fertilization and facilitate widened breadth and depth of HIV projects. In the longer term, more sustainable and predictable operational support would facilitate the work of both NGOs and funders. Overall, umbrella agency like the Hong Kong Council of Social Service can play a pivotal role.
Technical assistance and capacity building are indispensable components besides resource support. Attention should be given to enhance long-term development and retention of expertise in both governmental and community sectors, for a sustained response with continuity. The pool of human expertise has to be expanded through recruitment and training with career development. Institutional and programme management capacity also need to be strengthened in general. For the purposes of accountability and to guide further development, mechanisms for monitoring and evaluation of programmes should be integrated into the funding system with earmarked resources.
In order to target efforts and resources more efficiently and effectively, a science-based, epidemiologically-targeted and regularly evaluated response to HIV/AIDS is needed. Data must be systematically collected, collated, analysed and interpreted to cover epidemiologic trends, new infections, risk behaviours and factors driving them, as well as programmatic coverage and gaps. The present surveillance effort within the Department of Health will have to be strengthened with the appropriate epidemiological, behavioural and programmatic expertise. Community surveillance programme would need to be initiated and regularized. (Target five, see P.22)
While surveillance at methadone clinics, data from the Central Registry of Drug Abuse and prison settings provide useful information on the HIV and drug use situation, there are gaps in the understanding and assessment of risks for rapid spread of HIV among drug users. Attributes of the non-local factors and the emerging drug-taking behaviours related to HIV are some areas to be explored.
Assessment and monitoring of HIV prevalence, risk behaviours and prevention needs of ethnic minorities, new immigrants, and cross-border travellers are key areas for new or expanded surveillance activities. The scenario among sex workers coming from Mainland China and Hong Kong clients patronizing commercial sex establishments across the border is far from clear. Their population size, demographic profile, risk behaviours and pattern, access to prevention service and HIV risk should be studied and tracked over time. For MSM, the size, characteristics, risk behaviour, cross border and travel patterns of many subpopulations are also largely unknown and should be examined.
Knowing their HIV status allows infected persons to seek early care and uninfected persons to take precaution and stay uninfected. HIV testing should be promoted among vulnerable communities and at-risk populations. (Target six, see P.22) The public health programme of universal testing for drug users implemented at methadone clinics has proved useful for enhancing surveillance, diagnosis and early care of infected persons. Regular screening should be encouraged for people with on-going risk behaviours or exposure. The means of improving access to HIV testing, including integration into non-HIV related health care services or expansion of voluntary HIV counseling and testing services in different settings, have to be explored. Understanding the profile of HIV positive people, especially the recently infected, can shed light into prevention and care needs.
Since HAART became the standard of care in Hong Kong in 1997, the mortality and morbidity of people living with HIV/AIDS has declined dramatically. This translates into not just health benefits for individuals but also public health impacts at the population level. Globally, scaling up the provision of HAART for the developing countries has been one of the main focus of the work of the World Health Organization in the past few years. Although the WHO's 3 by 5 initiative (i.e. treating 3 million HIV infections by 2005) was not reached, it still contributed to greatly increasing the number of patients being put on treatment. In line with the international trend, Mainland China has pledged to provide free antiretroviral treatment under its "Four Frees and One Care" policy, which was introduced in 2003.8
From clinical experience in both overseas and local studies, drug treatment appears to benefit the majority of treated patients for a prolonged period of time. The much extended life span coupled with fewer HIV-related complications emerging over time present new challenges for patients and health care providers. Against this background, the Scientific Committee on AIDS formulated a recommended framework on local HIV care delivery in 20059, with the goal of minimizing HIV morbidity and restoring optimal health (Box 4).
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Box 4. Principles of HIV clinical care delivery, SCA 2005
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The past success of HIV care in Hong Kong is probably multi-factorial, including the accessibility of state-of-the-art antiretroviral therapy, systemized health care delivery with expertise and support, attention to patient needs and concerns, commitment of the government and low HIV prevalence. The challenge ahead is to sustain the delivery of quality care in the face of growing numbers of PLHA. (Target seven, see P.22) Even if HIV prevalence remains low in Hong Kong for the years to come, the increasing number of cumulative patients from prolonged survival of existing patients and diagnosis of new patients cannot be ignored.
Virtually all infected patients are under the care of the public health services in Hong Kong, both in the past and for the foreseeable future. The medical and social complexities associated with HIV/AIDS management make it a specialized service in the local context. The Government's commitment for continual provision of quality care integrated with prevention programmes to PLHA is the way forward. Similarly, community involvement in support and care services has to be sustained.
The full benefits of HAART are realized only if there is good drug adherence. Evidence suggested that local patients generally adhere well to their antiretroviral therapy, but it is a life-long commitment to treatment. Drug adherence programme should be instituted within the clinical service to facilitate and support adherence to this life-saving therapy. On the other hand, salvage therapy is needed in a selected number of patients who failed standard treatment regimens. Newer drugs in the pipeline can provide hope for these patients. Participation in clinical trials provides access to novel drugs/regimens. The importance of managing opportunistic complications, e.g. TB/HIV coinfection, and provision of palliative care for patients in-need shall not be neglected. Provision of up-to-date laboratory diagnosis and monitoring is also important, as it supports and monitors clinical care and therapy and enhances overall patient management and cost-effectiveness.
Even if effective prevention measures are scaled up promptly, more and more already infected patients will surface in the coming future. Despite the growing number of PLHA, the critical mass of medical, nursing and other health care workers conversant with HIV management is relatively small. Professional training and career development on HIV medicine should be strengthened. With the changing health needs of long-living patients extending to non-HIV morbidities and mortalities, the need for a greater involvement of medical professionals other than HIV physicians also becomes more apparent. Promotion of acceptance and capacity building among the medical community and other health professionals are needed. Besides ensuring adequate professional human resources development, expansion of treatment, care and support facilities has to be in line with the growing demand. Regular monitoring and evaluation to gauge the standard of care up to international level and locally relevant applied research to improve service would be desirable.
PLHA themselves are crucial partners for both HIV care and prevention. Social services support is an integral part of PLHA management and care. Targeting positives for HIV prevention has been recognized and advocated as a key AIDS strategy overseas.10 Recruitment and engagement of PLHA into the HIV care network provides a channel for implementing targeted public health interventions, including partner counseling and referral and risk reduction counseling. Hence health and community services organizations for PLHA should incorporate preventive interventions in their care provision. It may also be timely for Hong Kong to develop HIV/AIDS self-help groups, so that local PLHAs can take an active part in the prevention and care of their fellow members.
Social rehabilitation recognizes the multiple complex patient and environmental factors that hinder reintegration of PLHA into the society, e.g. difficulties in finding employment. At present, various employment assistance programmes are offered by the government and NGOs. To help this unique group of clients, locally feasible augmentation of rehabilitation services shall be explored, given the changed and changing outlook of PLHA. Promoting acceptance of PLHA and making mainstream services more accessible to them are to be encouraged.
The voluminous and ever-increasing movement of visitors, workers and migrants between Hong Kong and Mainland China (particularly the neighbouring Pearl River Delta region of Guangdong), (Box 5) coupled with the differential and changing HIV prevalence among various risk populations make China connection the major external determinant of the future epidemic in Hong Kong.
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Box 5. Statistics and events in human mobility across the border
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The Mainland has shown greater political commitment and support and made positive moves on HIV prevention and control in recent years. Examples are seen in the enhanced surveillance and information systems, substantially uplifted funding at national and local levels, launch of the landmark "Four Frees and One Care" policy, and the rolling out of methadone clinics across the country after a pilot programme.
Exchange and joint efforts at government and community levels between Hong Kong and Mainland China on HIV and related fields has increased in the past few years. Various forms of regional networking, information exchange and collaboration can be further stepped up, (Target eight, see P.22) including experience sharing, visits and attachments, structured capacity building initiatives, setting up and facilitating exchange platforms and joint health promotion/prevention projects. Support from government policy bureaux shall be rendered as necessary and appropriate. There have been many HIV study tours from Mainland China and South East Asia to Hong Kong, notably on the internationally-recognized best practice of methadone programme and HIV prevention. In the last two years, Hong Kong has started providing structured fellowship training programme on clinical HIV medicine and nursing care for Mainland China health professionals. Regularization of information exchange on the latest HIV situation and response, as well as joint cross-border publicity and targeted prevention activities, will benefit both sides. Maintaining dialogue on care will be useful as PLHA move across the border for short or long-term stay. Interfacing with Mainland China and nearby regions would need additional resources support, which should be seen as an investment rather than purely expenditure when HIV observes no border and Hong Kong is heavily affected by the epidemic in neighbouring places.
ACA considers it important to monitor the progress of the collective local AIDS programme. As part of the global community, Hong Kong's AIDS response contributes to the international picture on AIDS. Firstly, ACA recommends that Hong Kong adopt the UNAIDS core indicators framework, which will allow for international comparison with other countries/places. Secondly, eight specific targets are set in this strategy document for moving responses towards common direction and goals. Thirdly, individual programmme/project should have its own monitoring and evaluation incorporated.
In August 2002, the UNAIDS published a set of guidelines to help national authorities construct indicators for monitoring the United Nations Declaration of Commitment.11 Using the UNAIDS framework, the ACA constructed the first set of core indicators for Hong Kong in 2004 with modification to be compatible with local conditions.12 The UNAIDS revised its core indicators guidelines in 2005 to better reflect the need on monitoring for different epidemic levels.13 The ACA deliberated the new recommendations, modified per local situations and came up with the recommended list of 9 indicators for Hong Kong as a low/concentrated HIV prevalence epidemic:
Local data on HIV knowledge, attitude, behaviour and prevalence for four most-at-risk populations, viz. MSM, female sex workers, their clients, and IDU were constructed basing on the currently best available information from regular statistics, community surveys and ad-hoc statistics (Appendix III). The enumeration frequency ranges from annual to 4-5 years per UN recommendation.
Eight targets in the form of deliverable/desired outcome are proposed:
| One | Increase condom use of MSM, sex workers and clients to 80% |
| Two | Incorporate rapid HIV testing for late presenting mothers to close gap of MTCT |
| Three | Develop one or more resource allocation plan to guide programme funding |
| Four | Review ATF funding mechanism to improve effective funding of community-based response |
| Five | Regularize community surveillance of risk populations at 1-2 year intervals |
| Six | Improve HIV testing coverage among risk populations |
| Seven | Sustain quality HIV care of international standards to people living with HIV/AIDS |
| Eight | Enhance collaboration with Mainland China through regular or ad-hoc programmes/projects |
A mid-term and a period-end review of achievement of the targets shall be made.
Hong Kong's AIDS programme is a collective effort of the government, non-governmental organizations and the academia. They partner with each other, perform different roles, supplement and complement, and serve the same cause. The following are the key players who would be working towards the new goals and objectives, with their anticipated roles:
Government policy bureaux - the Health, Welfare and Food Bureau (HWFB) is the lead agency in the development of the government's policy on HIV/AIDS. HWFB will be asked to examine and endorse the recommended strategies. In consolidating an integrative approach, other bureaux and advisory bodies are also involved, e.g. Education and Manpower Bureau and Security Bureau.
AIDS Trust Fund - The Council for the AIDS Trust Fund plays a crucial role in supporting community-based HIV activities, which is especially critical in responding to today's epidemic. It is proposed that ATF will continue its role as a key player of AIDS response, adequately fund community-based programme/projects, incorporate monitoring and evaluation, and review funding mechanism in face of changed and changing situation and needs.
Advisory Council on AIDS - The ACA advises the Government on policy relating to AIDS. ACA advises on the co-ordination and monitoring of programmes and services on prevention and care of HIV in the territory. The ACA shall propose a resource allocation plan and keep under review the progress of AIDS response in Hong Kong.
Government operations - The Centre for Health Protection of Department of Health, through its Special Preventive Programme, will be regularly monitoring the epidemic and providing support in building capacity relevant to prevention and care efforts. Together with the Hospital Authority and universities, there will be the delivery of quality patient services, development of clinical expertise on HIV care and treatment and the further prevention of mother-to-child transmission by strengthening the existing programme.
AIDS NGOs - the AIDS NGOs are the key players in delivering targeted preventions and surveillance to hard-to-reach populations and in the building of technical capacity in enhancing effectiveness of HIV prevention and care activities. They will also be partnering mainstream NGOs in expanding Hong Kong's response to AIDS.
Mainstream NGOs, the community and community organizations - Vulnerable community itself and its organizations are to be mobilized, in particular for MSM. They have to be supported by all other AIDS workers. The leadership and support of Hong Kong Council of Social Service and Social Welfare Department are influential in making and facilitating more mainstream NGOs to participate in AIDS work as well as enhancing the work of AIDS NGOs.
Academia - the academia would be important in undertaking appropriate studies to improve understanding of the situation and specific risk factors/patterns.
The wider society - several partners can also play key roles in moving the AIDS programme forward, including but not limited to media, government consultative bodies, district boards, schools, private sectors, professional bodies and philanthropic sectors.
