Free HIV treatment had been a pipe dream for Wu Wei (not his real name), a 27-year-old man from Liuzhou, a city in south China's Guangxi Zhuang Autonomous Region.

But he got lucky.

"I was running a high fever at a Liuzhou hospital when Dr Lu from Medecins Sans Frontieres (MSF) was sent there to see a patient whose health was getting worse. He took me here to the MSF clinic in Nanning and put me on free treatment," says the man, a heroin addict for a decade.

Now, four months into the treatment, Wu has put on more than 10 kilograms. His CD4 count, a vital indication of the immune system, has grown back to normal.

"I wouldn't have stopped taking drugs if I hadn't caught HIV. The doctor tells me I can stop taking medicine for tuberculosis after this month. Then I'm going to look for a job," he said.

His optimism comes from the care he gets from the MSF clinic. "I haven't seen such good doctors in my entire life," he said.

"You feel no discrimination here. Every time I'm given the medicine, I'm told how and when to take it as if I might have forgotten. I used to think that if I got AIDS, I would take revenge. But now, I wouldn't fool around with girls. I now feel that I just want to help others," he said.

In fact a staff member at the clinic said Wu had referred four other addicts who had shared needles with him to have an HIV test in Nanning.

Since its launch about a year ago as a joint program with the Guangxi Health Department and the Centre for Disease Prevention and Control (CDC), the MSF clinic has been aiming to give quality treatment and care to HIV patients without access to treatment.

"As a rule, with MSF across the world, the drugs we use here for anti-retroviral (ARV) treatment are all first-line drugs approved by the World Health Organization," says Yves Marchandy, head of the French section of the humanitarian medical aid agency.

As most of the first-line ARV drugs manufactured by large international pharmaceutical companies still have patent rights in China, MSF has to import them at very high prices.

"This (the China program) is in fact the most expensive MSF treatment as we cannot import generic drugs or fixed dose combinations (FDCs), which allows a patient to take only two pills a day," said the French doctor, who has been working in China for three years.

For ARV treatment, the MSF has to spend an average of 2,109 yuan (US$254) per month for each Chinese patient, which is five times the expense in Kenya. A 21.68 percent tariff is imposed on all imported drugs. This alone cost 750,000 yuan (US$90,000) last year.

"We know the Chinese Ministry of Finance issued regulations on the exemption of the value-added tax on ARV drugs starting in 2002. But when we inquired about this, we were told it's applicable only to government purchases," says Marchandy, who is still appealing for tax exemption whenever he can.

Now, nearly a year since it opened, the clinic has been following 205 patients, 150 of whom are receiving ARV treatment.

All patients are referred to the clinic after they have tested positive at the Guangxi CDC clinic, the only place to date authorized for HIV confirmation testing (the Western Blot test) in the autonomous region.

Adherence counselling

A specific feature of the MSF treatment has been adherence counselling, which starts well before a patient is put on ARV treatment and goes on throughout the process.

"ARV drugs need to be taken for life. We need at least 95 per cent adherence for the treatment to be effective. If not, resistance to medication will develop. And at this stage, there aren't many new ARV drugs for a patient to transfer to another regimen," says Charles Lancaster, counselling nurse and pharmacist at the clinic.

When people first come to the clinic, they are given an intensive counselling session, usually 2-3 times over 3-4 weeks, on HIV/AIDS. Those whose CD4 counts are below 200 are eligible for ARV, which is also known as the "cocktail" therapy. They will have ARV counselling to understand the therapy, how it affects the virus and the body as well as possible risks, before making the decision to receive the treatment.

Unlike patients in other areas who know nearly nothing about the drugs they are taking except their price, people coming here on a regular basis have a full understanding of the medication - the shapes, colours and names. "They're prepared for the side effects and won't panic when they actually happen," explains Li Lin, who is now on the MSF counselling team.

On a regular clinic day that falls on Tuesday, Wednesday and Thursday, the clinic, in an obscure corner of the CDC clinic, is very much alive. A patient scarcely walks through the door before he or she is greeted warmly by the staff. A casual pat on the shoulder, or a banter exchange, puts him at ease. A hushed and nervous silence that often reigns in a typical Chinese hospital or clinic is absent here.

In the waiting room, with bright-coloured chairs and posters on the wall, patients can pick up leaflets or bulletins on HIV/AIDS to read or take home. A TV set is always on. Patients can help themselves to water and condom packs from a small basket on the table.

"This is not at all like a hospital. I feel very relaxed," says a 27-year-old woman who, after attending the clinic for two months, still feels "incredible that everything here is free."

Helle Poulsen-Dobbyns, field coordinator of the Nanning project, is equally moved by reactions from the patients. "Little things like that (physical contact) make huge a difference. It takes just a little effort from the clinic, but it makes a huge difference to a patient's perception of the clinic. The patient will comply with treatment and the management programme at the clinic," she says.

The Australian nurse, who had joined MSF in a previous mission in Africa, has a unique perspective of such treatment, emphasizing: "We're all in it. It's not us (doctors and nurses) managing people. The patient is managing his treatment as well."

Those who have to pay frequent clinic visits and live far away are referred to a temporary "refuge" in town that is maintained by AIDS Care China, a program offering counselling services for positive people in neighboring Guangzhou, for free lodging and meals. If a patient has another disease like a lung or eye problem, MSF staff will escort him to a local hospital for treatment and pocket the bill.

What's more important, patients here don't have to feel heavy-hearted about the way they got infected because no one judges them on that.

"We don't tell injecting drug users 'It's illegal to have drugs.' We don't moralize with people. We would rather get through the message 'Please don't share your needles and please use condoms.'" "The only thing we insist on is that the patients are committed to treatment, that they comprehend the treatment and that they live within three or four hours' traveling distance of the clinic," she adds.

The founder of AIDS Care China, who wants to be known as Thomas, is full of praise for the MSF clinic. "I might sound a bit extreme, speaking from a patient's perspective. But the clinic is a good module in patient adherence and care," he said.

AIDS treatment is not solely a treatment issue, Thomas said, himself also being a HIV positive.

The survival of patients depends to a large extent on care and support. "Many people in China believe that drugs mean everything. I'm not that optimistic. Given the current patient-doctor relationship where trust and friendliness is often missing, once resistance to drugs appears as a result of poor adherence, treatment will become more complicated, not to mention a waste of medical resources," he says.

Peer education

Peer education is another major element in the treatment chain. Counselling by positive people offers great psychological support and emotional consolation. To Thomas' regret, "Hospitals in China still take it for granted that positive people have no role to play in treatment.

"It would be ideal for the MSF experience to be replicated in China," he says.

Chen Jie, deputy director of the Guangxi CDC who is regarded by Marchandy as the "key" person to the successful running of the clinic, considers collaboration with MSF as an effort to explore a module for community-based treatment with minimum operational cost.

"About 70 percent of HIV carriers in Guangxi are infected through drug injection. For this group, adherence is the hardest part of the treatment. The clinic serves as a training base for Chinese doctors. We can also monitor resistance to drugs, and get our own data on drug evaluation and side effects before scaling up treatment in Guangxi. But above all, patients are the immediate beneficiaries," he says.

As China is starting to provide its own ARV drugs for free, the MSF clinic believes it is necessary to redirect its role in the second year of the contract. "It's not decided yet. But we see a role in training and in HIV pediatrics," says Poulsen-Dobbins.

(China Daily December 15, 2004)