Response to HKCASO’s Comment and WUestions on the Mid-term Review of  the Recommended HIV AIDS Strategies

Response to HKCASO’s Comment and WUestions on the Mid-term Review of the Recommended HIV AIDS Strategies

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(CFA Paper 12/2008-2011) Community Forum on AIDS Response to HKCASO’s Comments and Questions on the Mid-term Review of the Recommended HIV/AIDS Strategies for Hong Kong 2007 – 2011 Purpose This paper summarizes the responses with input from relevant parties to the comments and questions raised by the HKCASO in relation to the mid-term review of the recommended HIV / AIDS strategies for Hong Kong 2007 – 2011 that was thpresented in the 15 Meeting of the Community Forum on AIDS. The responses are put under corresponding comments and questions (in italic) for ease of reference. Overall Comments  The NGOs and the communities concerned, including HKCASO, have not been involved and their views were therefore not included in the review.  The focus of the paper was very government oriented and the roles of the NGOs or community-based groups were not highlighted sufficiently.  The perspective of the paper was not comprehensive to reflect what efforts/responses actually took place in the past two years. 2. The mid-term review serves a start to gather information relevant to the eight targets, for discussion and inviting feedback, comments and inputs. It is by no means a comprehensive account of what has been done towards the targets. The paper resented and discussed at the CFA meeting aims to invite views and inputs from NGOs and community workers, work of which is of paramount importance to the local AIDS response. This paper serves as a ...

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(CFA Paper 12/2008-2011)
Community Forum on AIDS
Response to HKCASO’s Comments and Questions on the Mid-term Review of
the Recommended HIV/AIDS Strategies for Hong Kong 2007 – 2011

Purpose
This paper summarizes the responses with input from relevant parties to the
comments and questions raised by the HKCASO in relation to the mid-term review of
the recommended HIV / AIDS strategies for Hong Kong 2007 – 2011 that was
thpresented in the 15 Meeting of the Community Forum on AIDS. The responses are
put under corresponding comments and questions (in italic) for ease of reference.

Overall Comments
 The NGOs and the communities concerned, including HKCASO, have not been
involved and their views were therefore not included in the review.
 The focus of the paper was very government oriented and the roles of the NGOs
or community-based groups were not highlighted sufficiently.
 The perspective of the paper was not comprehensive to reflect what
efforts/responses actually took place in the past two years.

2. The mid-term review serves a start to gather information relevant to the
eight targets, for discussion and inviting feedback, comments and inputs. It is by no
means a comprehensive account of what has been done towards the targets. The
paper resented and discussed at the CFA meeting aims to invite views and inputs from
NGOs and community workers, work of which is of paramount importance to the
local AIDS response. This paper serves as a framework to facilitate members’
discussion on the eight targets. Before the end-period of the current Strategies, ACA
would actively seek input from community and other stakeholders on progress of the
eight targets.

Comments/Questions on the Eight Targets of the Recommended Strategies
Target 1 – Increase condom use of MSM, sex workers and their clients to > 80%
 The possession of condoms and lubricants has been continuously used as
supporting evidence for arresting and prosecuting sex workers. It is an act that
undermines the effectiveness of the safer sex campaign and could very probably
bring severe damages to public health. Have any efforts been made to initiate a
cross-bureau investigation aiming to review the law enforcers’ practices and its
impact on the violation of human rights and public health?
(CFA Paper 12/2008-2011)
3. The issue of confiscating condoms had been discussed at the Hong Kong
Advisory Council on AIDS (ACA) meetings on 10 July 2009 and 15 January 2010 at
which the FHB's representative was present. We have enlisted the assistance from an
ACA member, Mr Charles Wong, to look into the matter and liaise with the Police.
As reported by Charles Wong at the ACA meeting on 15.1.10, he suggested the
NGOs to record down the incidents of confiscation of condoms. In case there is
prima-facie evidence of abuse by Police on confiscating fronts, they could make a
formal complaint to the Police for independent investigation.

4. In addition, ACA Chairman wrote a letter to the Commissioner of Police on
the same issue. An extract of the reply from the Commissioner of Police has been sent
to Mid-night Blue, the coordinator of the four NGOs which wrote the joint letter to
ACA. It is noted that a mechanism has already been in place for regular dialogue with
NGOs and sex workers. The Police stepped up liaison with the NGOs and the no. of
meetings increased from two in 2008 to six in 2009. The ACA Secretariat has also
explored the possibility of delivering talk on HIV prevention to the Judiciary but no
suitable opportunities were identified yet.

 What was the population size for evaluating condom use specifically among
young people who are MSM, sex workers or clients of sex workers and what
were the findings?

5. Population size was not estimated in evaluating condom use among
different target groups. Instead, the evaluation was done by carrying out specially
conducted projects, which are given in the table below –

Survey Survey sample size response Age range Condom use rate
rate (median age)
MSM: PRISM (08/09) 843 44.8% 15-83 Use condom with
(94.4% have ever had anal (31) non-regular sex partner:
sex with another man) More than half in the past 6
months: 96%
Every time: 75%
ACTS (2008) 1349 Attendances - 18-64 Adult MSM:
(including 334 adult MSM) (30) Use condom with casual sex
partner*:
More than half in last year:
82%
#At last sex : 16%
At last anal sex: 71%
AIDS Concern 985 MSM cases - Median age group: Use condom more than
for anal sex in last 3 (2008) 26-30 half
months: 82%
At last anal sex: 72% (CFA Paper 12/2008-2011)
Sex workers CRISP (2009) 986 71.8% 17-60 Use condom more than half in
(female) (34) the past 1 week: 95.1%
Every time 91.1%
CSD (2008) 476 Females - CSW: CSW: use condom more than
(including 195 commercial 18-55 half in the past 1 week: 42%
sex workers) (33) Every time: 22%
SHS (2008) 400 Females - CSW: CSW: use condom more than
(including 22 commercial 17-46 half in the past 3 months: 95%
sex workers) (33) Every time: 73%
Clients of sex CSD (2008) 500 Males - Clients of sex worker: Clients of sex worker:
workers (male) (including 220 ever visited a 15-65 Use condom more than half in
commercial sex worker in (34) the past 1 year: 81%
the past one year) Every time: 63%
SKC (2008) 1489 Males - Client of sex worker Client of sex worker
(including 577 ever visited a 22-65 Use condom during the last
commercial sex worker in (39) sex contact: 82%
the past half year)
ACTS (2008) 1349 Attendances - Adult heterosexual Adult heterosexual male:
(including 792 adult males: Condom use more than half
Heterosexual males) 18-80 in last year: 90%
(32) Condom use at last sex: 50%
SHC (2008) 1141 new cases - Adult heterosexual Adult heterosexual males:
(including 552 adult males: Condom use more than half in
heterosexual males those 18-89 the past 3 months: 63%
ever had casual sex including (36) Condom use at last sex:
commercial sex) 61%
* casual sex partner: including commercial sex partner and non-regular non-commercial sex partner.
#
last sex including vaginal sex, anal sex and oral sex.

 As various local researches showed that there was a big gap between knowledge
and actual practice of safer sex among the MSM community, ATF should scale
up the funding support (both programme expenses and manpower) for
programmes which are labor-intensive but could have a more sustainable impact
on behavioral changes.

6. Funding applications of programme or project under ATF would be
considered on a case-by-case basis according to a structured technical review and
vetting process. Approval for extension of project or programme is given on their
own merit based on supporting evidence. The existing mechanism allows
accountability on one hand, and flexibility to adapt the evolving epidemic on the
other.

Target 3 – Develop one or more resource allocation plans to guide programme
funding
 Apart from the resource allocation plan for the years 2005 – 2008 (para 11), is
there any projection of resource allocation for different target groups from
2009/10 onwards? Also, what are the targets of the projects under Category B (CFA Paper 12/2008-2011)
(predefined areas) and do they include young people?

7. The resource allocation of ATF is echoing to "Recommended HIV/AIDS
Strategies for Hong Kong 2007 to 2011" by ACA. AIDS Trust Fund will accord
higher funding priorities to programmes targeted at the high risk groups, until further
recommendations from ACA. Targets, other than high risk groups, which fit in
predefined areas, will be regarded as Category B.

 In response to para 11, does it mean that the resource allocation of ATF will be
based on annual reported statistics and will there be any adjustment?

8. According to ATF Guidelines, in order to target efforts and resources more
efficiently and effectively, programme funded by the ATF should be targeting high
risk groups. A relatively greater proportion of funds should be channelled to areas
where most of the infection occurs.

Target 4 – Review ATF funding mechanism to improve effective funding of
community based response
 Whether the ATF has any stock taking on the effectiveness of : (a) individual
programme/project, (b) overall response as a result of the ATF funds, and (c)
service gaps for the GO and NGOs to take proper actions to fill such gaps?

Individual project / programme
9. According to the ATF application guidelines, an applicant must set out in
the application form the monitoring and evaluation plan for achieving the specific
targets of the programme/ project. The applicant should specify the quantifiable
method to evaluate the effectiveness (outcome indicator) of the programme / project.
The applicant needs to indicate their achievement in the interim and final report.
Failure to submit a satisfactory evaluation report may result in deferral or termination
of the programme / project funding. Furthermore, the effectiveness of the current
study not only affect the funding support of current programme / project but also
affect the funding support of new application and continuation of the programme /
project. In brief, funding support will be provided to the applicants who achieved
80% or above of the most outcome indicators.

Overall Response
10. A total of 1093 applications were handled by the Council since it was
established in year 1993, of which ATF approved 808 applications. As at 30 July (CFA Paper 12/2008-2011)
2009, ATF approved HK$405.3 million.

Service Gaps identified
11. As a rising trend of HIV infection has been detected among MSM in recent
years, the Hong Kong Advisory Council on AIDS highlighted five priority areas
targeted for HIV prevention in Recommended HIV/AIDS Strategies for Hong Kong
2007 to 2011. The ATF funding allocation is in line with the priority areas. Apart
from resources on persons living with HIV/AIDS, ATF allocated its resources to the
following priority order: MSM, sex workers and clients, injecting drug users, cross
border travellers, and others. Comprehensive information on coverage of the
programmes or projects under ATF funding is not available yet.

 Apart from what have been mentioned in para 13, HKCASO has organized an
AIDS Seminar in collaboration with ATF titled “Collaboration, capacity
building and the way forward” to promote experience sharing among AIDS
workers for effective HIV prevention and facilitate exchange between AIDS Trust
Fund and community organizations on AIDS work.

12. More such specific input on achievement or non-achievement of the targets
are welcomed.

Target 6 – Improve HIV testing coverage among risk populations
 In response to para 18, what is the current coverage of MSM testing services
after the SPF was abolished?

13. The last round of SPF application was over. Applicant could apply
MSS/PPE programmes/projects for continuation of their activities in SPF.
Evaluation of coverage of current HIV testing services could be assessed in the next
round of PRISM, or upon establishment of a common set of indicators for assessment
of coverage for similar services provided by the government and non-government
organizations.

 What is the annual usage of the Social Hygiene Clinics after the introduction of
fee charging for female NEPs?

14. The current charging policy on non-eligible persons (NEPs) is in line with
the recommendation of the Government's "Report of the Task Force on Population
Policy", published in 2003, that the principle of seven-year residence requirement (CFA Paper 12/2008-2011)
should be adopted for providing public healthcare services heavily subsidized by
public funds. The annual attendance of the Social Hygiene Clinics has been
declining since 2001, though the drop was more marked between 2002 and 2003. The
proportion of NEPs seen in Social Hygiene Clinics remained stable over the years and
contributed to <= 1% of all attendees. The decline of annual attendance is accounted
by various factors such as introduction of new treatment protocols for genital warts
which significantly reduce the number of revisits.

Target 7 –Sustain quality of HIV care of international standards to people living
with HIV/AIDS
 What are the stands of the Government with regard to WHO’s new treatment
guidelines, especially regarding the recommendation to start treatment at CD4
350 instead of 200? Is the government going to review the current guidelines
and if yes, what is the timeline for such a review?

15. In 2005, the Scientific Committee on AIDS published its recommended
principles of antiretroviral therapy. The document stated that, as a matter of principle,
the initiation of antiretroviral therapy should be a carefully meditated decision
following a thorough medical evaluation and informed discussion with the patient.
The absolute level of CD4 count is one of the many factors that are considered before
starting treatment. This document was recently review by the Committee in March
2010 and reaffirmed the above principles of prescription.

 Are there any discrepancies of standard of care (e.g. waiting time for medical
follow up, access to treatment, frequency of CD4 counts/viral load tests) among
the AIDS clinics run by DH and HA? If yes, is there any plan to standardize care
and treatment to sustain the quality of HIV care?

16. The local standard of HIV care is benchmarked by peer-reviewed guidelines
and clinical effectiveness. Both clinics have participated in the promulgation of
relevant guidelines and importantly have achieved a high level of effectiveness in
HIV disease management.

 In para 21, it was mentioned that 68% of the reported HIV cases received care at
the public specialist services in 2008 and the proportion of HIV cases under
specialist care showed a decreasing trend in recent two years. For those 32%
that did not receive specialist care, what was the proportion of non-eligible
persons? Is there any regional or international data indicating whether this level (CFA Paper 12/2008-2011)
of non-treated cases (seemingly quite high) is acceptable? Will DH identify the
causes and take any actions to turn back this trend?

17. Updated as 2009 Q3, 73% (316 out of 435) of the reported HIV cases
received care at the public specialist services, which is compatible with past years
figures. Patients may not attend HIV clinics for a variety of factors, e.g. transient stay
in Hong Kong, not ready, personal reasons and others. The public services strive their
best to provide quality HIV care.

th During the 15 meeting of the CFA held in September 2009, Dr KH Wong
mentioned that there was a 4-5% default rate each year amongst the cases being
treated at ITC and the reasons were unknown. What were the default rates at
QEH Special Medical Services and the new clinic at Princess Margaret Hospital
and did they have any study on the reasons why the patients did not continue to
have their follow up? Is a 4-5% default rate regarded as acceptable in clinical
terms? Did the three clinics have any plans for tracing the default cases and
reducing the default rates?

18. Ideally, the default rate should be zero. In Integrated Treatment Centre, the
default rate has been quite consistently at a low level of below 5%. This was within
the expected range. After each clinic session, all cases who default appointment are
reviewed by the attending doctor for need of active tracing. Cross-institution
comparison of default rate may not be meaningful because of the different
characteristics of the patient populations.

 Regarding para 22, it was mentioned that as a consequence of the limited service
capacity, care quality was at stake and hopefully the new clinic at PMH could
help relieve the continually growing service need. What proportion of the new
cases is PMH planning to take up in the coming years and are there any plans
for the three clinics to scale up their capacity in order to meet the needs of the
estimated 1,000 or more new cases in the next three years? What is the
proportion of the ATF funding allocation which will be given to care and support
for PLHIV in the coming years?

19. The Government is committed to providing treatment for HIV infected
patients. In recent years, extra funding has been allocated to both the Department of
Health and Hospital Authority to procure antiretroviral drugs. To uphold the standard
of care, it is indeed important to maintain and strengthen clinical capacity when (CFA Paper 12/2008-2011)
needed. The recent establishment of an HIV clinic at Princess Margaret Hospital is
exemplary of this effort. The situation is being reviewed on a continual basis. There
has been no pre-set ceiling for programme fund of the Council for the ATF as it will
continue to support worthy programmes. Currently, funding on supported
programmes has been in line with the resource allocation plan.

Recommendations
 It is recommended that NGOs and community-based groups should be actively
involved in the review process as their views would certainly help evaluate the
current situations as well as help formulate the next Recommended Strategies for
the years from 2011 onwards.
 It is also very important to ensure sufficient funding support to achieve the
objectives set in the Recommended Strategies.

20. Active efforts would be made to solicit views from the community and
other stakeholders to assess progress of the eight targets laid down in the current
strategies, as well as defining the objectives and necessary funding for the formulation
of next strategies in due course.

Compiled by ACA Secretariat
March 2010