A row of “massage parlors” in a Shanghai neighborhood. Although illegal, prostitution in China led to many cases of HIV among laborers who came to the cities from the country. PHOTO BY BERKSHIRE PUBLISHING.
Although the overall incidence of HIV/AIDS is low in China, it has reached epidemic proportions in several high-risk groups, including drug users and sex workers; migrant workers are especially vulnerable. The Chinese government has developed several programs that address prevention, treatment, and family services for HIV-affected populations. Discrimination against people living with HIV hampers effective identification and testing.
China’s first AIDS cases were discovered in 1989, but it took the outbreak of severe acute respiratory syndrome (SARS) in 2002 and 2003 to spur the government into launching aggressive measures against AIDS. The effectiveness of government and other organizational responses is hampered by the stigma and discrimination against those with HIV by the population at large, by the reluctance of public security authorities to support education and specialized treatment for those engaged in illegal activities (e.g., illicit drug use and commercial sex), and by the logistics of providing standard, consistent, and equal care in such a large, diverse country.
AIDS Situation in China
In 2007, studies showed that HIV was spreading both in numbers and geographically in China, but the percentage rate of new infection was decreasing from previous years. The incidence of HIV in China at the end of 2007 was very low overall at 0.05 percent, which translates to about 700,000 people. The estimated number of active AIDS cases was 85,000. Estimates have been much higher than the number of cases actually identified; nearly 80 percent of those living with HIV in China do not know they are HIV-positive. By comparison, only about 25 percent of Americans with HIV are unaware of their infection. HIV has been reported in all thirty-one Chinese provinces, municipalities, and autonomous regions, but it is most prevalent in Guangdong, Henan, Sichuan, and Yunnan provinces and in Guangxi and Xinjiang ARs. Henan was the site of a 1990s HIV outbreak among rural residents who became infected by unhygienic practices and contaminated equipment at commercial plasma-donation centers. Most other affected areas are in rural border provinces or along heroin-trafficking routes where HIV transmission is fueled by injection-drug use. HIV infection is highest in the twenty-nine- to thirty-nine-year age group; AIDS cases are concentrated in the twenty- to forty-nine-year age group. Routes of transmission include needles and/or drug use, heterosexual sex, and homosexual sex among men. Transmission by the sharing of infected needles among illicit drug users was the main mode of transmission until 2007, when sexual transmission became the more prevalent mode. Certain at-risk groups have a high incidence of infection, and HIV is spreading to the general population through sexual transmission. Migrants are considered especially vulnerable.
High-Risk, Vulnerable Groups
High-risk behavior by certain subpopulations is driving the epidemic, and the government has undertaken education and prevention programs that target these groups.
Injecting Drug Users
The use of contaminated needles when injecting illicit drugs is the second most common HIV transmission route in China. In 2007, approximately 8.3 percent of drug users had HIV. High-risk behavior includes needle sharing. Some support their habit by turning to commercial sex work, thus increasing transmission to the non-drug-using population.
Understanding that reducing drug use is linked to control of HIV/AIDS, the Chinese government authorized the rapid establishment of methadone-maintenance therapy sites, both fixed and mobile, along with needle exchange programs throughout the country.
Sex Workers
The commercial sex trade is increasing in China, especially in eastern areas. Some surveys suggest that one in ten sexually active men has bought sex from a prostitute. The real number may be higher. Knowledge of HIV and transmission routes is low among sex workers, and even if sex workers know about HIV/AIDS, it can be difficult for them to insist that clients use condoms. Official attitudes toward commercial sex workers make it difficult to target them in government-run education and health programs. The incidence of other sexually transmitted diseases (STDs) is also increasing in China; people, especially women, with untreated STDs are much more likely to catch HIV from infected partners than are people without STDs.
HIV-prevention efforts directed toward this high-risk group focus on the nighttime entertainment industry that is burgeoning in China. Condoms are distributed in hotel lobbies and guest rooms as well as popular karaoke clubs and other entertainment venues where transactional sex occurs.
Migrants
Chinese migrant workers, who are often young and single, flock from rural to urban areas to find work. The challenges of adjusting to urban life while being separated from their families and social networks increase the possibilities for high-risk behaviors among sexually active migrant workers: Male migrants might turn to prostitutes and have relations involving multiple sexual partners, while female migrants might engage in commercial sex. Many of the estimated 150 million migrant workers lack prevention knowledge and have limited access to community support, health services, condom supplies, and information about HIV, and so are especially vulnerable. Figures from the Hunan Province Center for Disease Control show that the mobile population, mainly migrant workers, accounted for 77.1 percent of HIV/AIDS patients in the province in 2008.
A 2008 joint program of China’s Ministry of Health, the All-China Federation of Trade Unions, and the International Labor Organization is designed to prevent the spread of HIV/AIDS among the mobile population in China. The three-year program, covering key industries in areas with a high concentration of migrant workers, will focus on prevention education, promote the use of voluntary testing, and will monitor discrimination in the workplace. Numerous other programs targeting migrants have been implemented across the country since 2004.
Former Blood Plasma Donors
At the end of 2007, over 19 percent of those with HIV/AIDS had been infected through blood and plasma collection. Donor blood, untested for HIV, was pooled and injected back into donors to prevent anemia. Because they were paid for their blood, many of these people donated multiple times. These individuals have been identified through aggressive testing campaigns, while treatment and prevention programs have effectively stopped HIV from spreading beyond this group. Blood-pooling practices have been outlawed, and China’s blood supply, now nearly 100 percent from volunteer donors, is regularly tested for HIV.
Homosexual Sex Among Men
HIV has been identified in some urban areas among male homosexuals, but this population is stigmatized and is difficult to survey. There are strong taboos against homosexual behavior in China, where men are expected to marry and produce male heirs. Estimates of the population of men who have sex with men range from 5 million to 10 million, and the number may well increase as social mores continue to change. Chinese health officials estimate that nationwide about 1 percent of male homosexuals are HIV positive, though some surveys have found
higher rates of infection. The government has increased budgets and established an advisory group that includes activists and behavioral specialists to formulate policies designed to reach this marginalized population.
Government Activities
A framework known as the “Three Ones” has helped to streamline and strengthen the national response to HIV/AIDS: one national plan (China’s Action Plan for Reducing and Preventing the Spread of HIV/AIDS 2006–2010); one national authority coordinating the response (State Council AIDS Working Committee); and one monitoring and evaluation system (AIDS Monitoring and Evaluation Protocol of June 2007). The Regulation on AIDS Prevention and Treatment was issued by the State Council in early 2006. Premier Wen Jiabao and Vice Premier Wu Yi showed their support of people living with HIV and children affected by AIDS through personal visits to “AIDS Villages” and AIDS wards in Beijing hospitals. Children orphaned by AIDS, along with doctors and teachers, were their guests at a gala concert in 2006.
In addition to targeted prevention programs, the Chinese government has developed programs and policies to care for those who have contracted HIV/AIDS. First implemented for former plasma blood donors who contracted HIV/AIDS, the China CARES program (China Comprehensive AIDS RESponse) has been instrumental in halting the epidemic in that group. Now operating in 127 rural counties and available to other HIV/AIDS patients, the program offers free antiretroviral treatment to HIV patients, provides family planning and free condoms, coordinates getting free education for children, subsidizes affected children, and operates orphanages for children whose parents are dead or incapacitated because of AIDS.
The “Four Frees and One Care” policy, operating as of 2007 in 1,190 counties in all provinces and autonomous regions, commits the government to providing many of the same services to rural residents and low-income urban residents: free antiretroviral drugs to those with HIV; free voluntary counseling and testing; free treatment to prevent the spread of HIV from pregnant women to newborns; free schooling for children orphaned by AIDS; and care and economic assistance to households affected by HIV.
International Cooperation
The United Nations—through its Theme Group on HIV/AIDS, which helps coordinate the international response against AIDS in China, and its China Country Team, which provides support for reducing vulnerability and risk behavior and improving treatment, care, and support for people living with HIV/AIDS and their families—is a major source of international support. The Global Fund to Fight AIDS, Tuberculosis, and Malaria is the largest monetary donor for China’s efforts to address the HIV/AIDS epidemic; the United Kingdom’s Department for International Development and the United Nations system also contributed.
China has provided assistance to other countries in their fight against HIV/AIDS. The Chinese government provides training in HIV/AIDS prevention for African countries, where the incidence of HIV/AIDS is the highest in the world. In return, China profits from African expertise in AIDS awareness programs.
Challenges
In their 2008 joint report on the status of AIDS in China, the State Council and UN China Theme Group on HIV/AIDS identified several challenges facing the HIV/AIDS response in China, with recommendations to increase the effectiveness of China’s HIV/AIDS programs.
Awareness campaigns to address widespread discrimination in communities and work places, including health care facilities, need to be undertaken. The involvement of people affected by AIDS in the design and implementation of informational and educational messages remains weak and should be strengthened for more effective outcomes. Antinarcotics policies and practices, such as surveillance and arrest of those seeking clean needles or methadone treatment, often conflict with HIV prevention efforts; more coordination with security authorities is needed. Current information, education, and communication activities need to be broadened, especially those for youth not in school, for minorities, and for remote and rural areas with migrating populations. Government-funded treatment programs are facing growing incidence of drug-resistant strains of HIV, requiring the provision of expensive, imported “second line” drugs and enhanced training for medical workers.
China has made great progress in its HIV/AIDS programs, moving from an emergency response to a standard treatment approach. But much remains to be done, especially in China’s rural areas, where the epidemic is most widespread and where poor residents have little access to health care. Thus, the work of controlling the epidemic will largely fall to county-level jurisdictions. As the Joint Assessment report notes, with more than three thousand counties in China, the task of ensuring an effective and relatively standard response will be an enormous one.
Further Reading
Burki, T. (2009). Conflicting policies in China’s fight against HIV/AIDS. The Lancet Infectious Diseases, 9, 84.
Cohen, J. E., & Amon, J. J. (2008). Health and human rights concerns of drug users in detention in Guangxi Province, China. PLoS Medicine, 5, Article e234. Retrieved February 13, 2009, from http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0050234
Gill, B., & Okie, S. (2007). China and HIV—A window of opportunity. New England Journal of Medicine, 356, 1801–1805.
ILO, China jointly work on AIDS education among Chinese migrant workers. (2008). Retrieved February 8, 2009, from http://news.xinhuanet.com/english/2008-07/28/content_8826953.htm
Migrant workers to get help in AIDS fight. (2008). Retrieved February 11, 2009, from http://www.china.org.cn/china/national/2008-07/29/content_16087508.htm
State Council AIDS Working Committee Office & UN Theme Group on AIDS in China. (2007). Joint Assessment of HIV/AIDS prevention, treatment & care in China. Retrieved February 8, 2009, from http://www.unaids.org.cn/uploadfiles/20080725151739.pdf
Thompson, D. (2005). China confronts HIV/AIDS. Washington, DC: Population Reference Bureau.
Wu Xunyou, Sullivan, S. G., Wang Yu, Rotheram-Borus, M. J., & Detels, R. (2007). Evolution of China’s response to HIV/AIDS. The Lancet, 369, 679–690.
Source: Thompson, Drew. (2009). HIV/AIDS. In Linsun Cheng, et al. (Eds.), Berkshire Encyclopedia of China, pp. 1036–1039. Great Barrington, MA: Berkshire Publishing.
HIV/AIDS (Rénlèi Mi?nyì Qu?xiàn Bìngdú/Aìz?bìng ????????/???)|Rénlèi Mi?nyì Qu?xiàn Bìngdú/Aìz?bìng ????????/??? (HIV/AIDS)
