There are currently an estimated 700,000 people living with HIV in China, including about 75,000 AIDS patients¹. During 2007 around 39,000 people died from AIDS². These large numbers must be considered in the context of China's extremely large population which is estimated at around 1,300 million³. Although UNAIDS reports that China’s HIV epidemic remains one of low prevalence overall (0.1%), there are pockets of high infection among specific sub-populations and there is danger of the epidemic spreading further into the general population⁴.

With one in five individuals in the world living in China, it is critical that the country continues with its efforts to prevent a generalised epidemic, as well as raising awareness and reducing infections in the higher prevalence groups of injecting drug users, former plasma donors, men who have sex with men and sex workers.

Initially characterised by denial and inaction, the Chinese government has recently realised the danger of ignoring HIV and AIDS and has initiated a broad programme to tackle the epidemic.

The history of AIDS in China

China’s first AIDS case was reported in a traveller from abroad who subsequently died in Beijing in 1985⁵. In the following five years a small number of further cases were reported among foreigners and Chinese, who were infected overseas or by imported blood products⁶.

During the early stages of the AIDS epidemic the Health Ministry concentrated its prevention efforts on the risk of infection from abroad. In 1987 it threatened to bar all foreign students from classes if they failed to comply with the mandatory AIDS screening programme.⁷ Although a National Programme for AIDS Prevention and Control was set up in 1987, the Public Health Authorities reported that AIDS would not become established as homosexuality and "abnormal" sexuality - thought to be the main causes of the spread of HIV - were a "limited" problem⁸.

In 1989, 146 injecting drug users (IDUs) in Southwest Yunnan were identified as HIV positive. By the end of the year the total number of infected people was reported as 153 Chinese and 41 foreigners⁹. At that time AIDS and drug addiction were seen as consequences of contact with the West, and AIDS was known as aizibing, the "loving capitalism disease"¹⁰.

By late 1994 it was clear that the reported AIDS cases amongst IDUs in Yunnan had signalled the beginning of an epidemic amongst drug users. National figures for HIV infection were growing quickly – in 1996 the Minister of Health, Chen Min-Zhang, put the number of infections at between 50,000 and 100,000¹¹ - and new cases were being reported in more regions. By 1998, HIV infections had been reported in all 31 provinces, autonomous regions and municipalities, with drug users accounting for 60-70% of reported infections¹².

The sharp increase in AIDS cases in China in the 1990s was also attributed to a large number of people infected through blood donation, which was widely reported by the western press, as well as transmission through heterosexual sex, which increased steadily to represent 7% of all HIV infections¹³.

There was a notable shift in government response to the epidemic in the new millennium. On World AIDS Day 2001, stories and testimonials of those infected with HIV alongside a television drama about AIDS reflected a far greater willingness to discuss the emerging epidemic¹⁴.

In 2003, the Health Minister’s change in attitude was evident. It is widely felt that the 2003 SARS epidemic prompted the change as it demonstrated to the government the impact public health could have on social and economic stability. He described the fight against AIDS as a "long-term war" and, as well as showing a new willingness to accept overseas assistance, requested that China’s AIDS budget of US$12.5 million be doubled.¹⁵.

On World AIDS Day 2003, Wen Jiabao became the first Chinese premier to shake hands with an HIV-positive person¹⁶.

Peter Piot, the Executive Director of UNAIDS commented:

“I really feel that there is a change going on... I know that for top state leaders in China today, AIDS is on the agenda.”¹⁷

Current estimates

UNAIDS estimate that 700,000 people were living with HIV in China in 2007¹⁸. This figure is lower than the previously published estimate of 840,000 in 2003. This is not because prevalence is falling, but is due to better data and improved methods of estimation. However, massive under reporting, especially in the rural areas, means that even the revised figures may be inaccurate.

“Exact figures are difficult to arrive at because government at local levels are very reticent to report on actual cases, a situation compounded by individuals who are reluctant to come forward because of discrimination.” Qi Xiaoqiu, director of China's Department of Disease Control¹⁹

UNAIDS and other organisations had previously estimated that by 2010 there could be a generalised epidemic with between ten and twenty million HIV positive Chinese²⁰. Although this is no longer anticipated there is still potential for a severe epidemic in China.

HIV sub-epidemics in China

The AIDS epidemic in China consists of several different sub-epidemics that often overlap and intersect with each other. High prevalence groups in China include injecting drugs users, men who have sex with men, former plasma donors, commercial sex workers and migrant workers.

Although it is customary to associate HIV/AIDS in China with these high-risk groups, boundaries are becoming increasingly blurred as the virus finds its way into the general population, and sex becomes the dominant transmission route²¹.

Injecting drugs users

In 1989 HIV was detected amongst injecting drug users (IDUs) in Yunnan province²². Needle sharing drove the epidemic and HIV spread rapidly to IDUs in neighbouring cities and along drug trafficking routes. By 2002 HIV was present amongst IDUs in all mainland Chinese provinces. It is believed that IDUs may have been the core source for all later sub-epidemics in China²³.

In 2007 there were a reported 937,000 registered injecting drug users in China²⁴, although unofficial estimates put the number closer to three or four million.

A zero tolerance attitude to drug use meant that the government was slow to implement HIV prevention and control measures for IDUs. Prevention activities tended to focus on posters outlining the harmful effects of drug use, or concentrated on reducing supply and demand.

In the late 1990s the Chinese government began to show a change in attitude towards preventing HIV transmission among injecting drug users²⁵.

A pilot needle exchange began in Guangdong in 2000. After initial positive results showed that participants were almost three times less likely to have shared needles in the past month, the programme was scaled up to approximately 92 sites in high prevalence regions²⁶. China now has more drug replacement clinics and needle social marketing programmes than any other country in Asia²⁷.

Further interventions for IDUs were also explored and in 2004 a methadone maintenance treatment programme was piloted. The programme found that the rates of heroin use, intravenous injection and crime related to drug use decreased in the pilot areas²⁸. By September 2006 there were 307 methadone clinics in China, covering two thirds of the country's provinces.

“I'm seeing a sea change in the policies and the leadership at the central level in the fight against AIDS... Frankly, two years ago I could not have dreamt that there would be close to 300 methadone-providing clinics for injecting drug-users across the country.” Peter Piot, executive director of UNAIDS, speaking in September 2006²⁹

Blood donors and recipients

At the end of 1994, a limited outbreak of HIV was reported among paid blood donors in central China³⁰.

It transpired that following a ban on imported blood products in the 1980s, thousands of blood and plasma collection stations were established around the country, particularly concentrated in poor rural areas³¹. These collection points typically offered 50 Yuan ($7) for plasma and 200 Yuan ($28) for blood³².

“We all sold our blood to make money. We sold blood to pay the local taxes, to support our kids through school, and to make a living. Woman from Henan Province³³

It is thought that the blood supply was initially contaminated with HIV by infected drug users. It then spread rapidly amongst paid blood donors due to methods used for plasma collection. Blood to be used for plasma collection was typically pooled and mixed together in a container from which the plasma was removed. The remaining blood was then injected back into the donors to speed recovery time. The exact number of individuals infected with HIV in this way is contentious, but is thought to number hundreds of thousands of people including both the paid donors and those who received blood transfusions³⁴.

By September 2003, cases of HIV related to blood or plasma donation had been reported in all provinces, autonomous regions and municipalities, except Tibet. The Chinese Ministry of Health reported that in 2005 infection among plasma donors and recipients of blood or blood products accounted for 10.7% of HIV infections³⁵. In the same year UNAIDS estimated that of the 75,000 people living with AIDS, approximately 22,000 had been infected in this way³⁶.

Since the mid 1990s, authorities have acted to improve the safety of China's blood supply by banning the most dangerous practices and closing illegal blood collection agencies. As a result the blood donation system is now much safer, and accounts for far fewer new infections than in the 1990s.

A report published in 2007 however claimed that China's blood supply is still not being properly monitored for HIV/AIDS. The report states "[t]he demand for blood and blood products is growing in China, and supply is short” which “creates an economic incentive for hospitals to rely on illegal, untested blood donations." ³⁷

Sex workers

The commercial sex industry in China has grown dramatically over the past two decades. In 2004 Chinese Public Security sources estimated that there were in the region of four to ten million sex workers in the country³⁸.

Commercial sex is driving the heterosexual sub-epidemic in China, especially as it provides a bridge for transmitting HIV from drug users to the general population (a high number of female drug users are involved in sex work and male IDUs are more likely to frequent sex workers than non drug users). UNAIDS estimated that in 2005 there were 127,000 sex workers and their clients living with HIV in China³⁹.

In the 1990s the government was reluctant to set up prevention schemes to educate sex workers about the risks of HIV infection and transmission as it felt that this would encourage prostitution and deteriorate China’s ‘spiritual civilization’⁴⁰.

However, due to the alarming increase in heterosexually acquired HIV, the Chinese government has altered its attitude to HIV prevention among sex workers.

Active condom promotion and prevention schemes vary between provinces depending on the local authorities and the severity of the HIV epidemic in the region⁴¹. Some regions have introduced a policy of 100% condom use, inspired by Thailand's success in reducing its number of new HIV infections.

Sex between men

An estimated 2.5 - 6.5% of men who have sex with men (MSM) in China are living with HIV⁴². High rates of unprotected anal sex between men are leading to concerns that HIV prevalence among this high risk group is rising⁴³.

The epidemic among men who have sex with men in China is complex and still understudied. It is thought to play an important role in transmission to other segments of society⁴⁴ as most gay men in China are under social pressure to hide their sexual orientation and the majority are married⁴⁵.

High levels of stigma surrounding MSM in Chinese society make intervention efforts difficult; homosexuality was not removed from the official list of mental disorders until 2001. Stigmatisation of homosexual behaviour fuels an epidemic, as it prohibits an atmosphere in which risk can be openly discussed and protective actions such as safer-sex practices can be adopted⁴⁶.

China is now beginning to take small steps towards addressing the needs of this high-risk group. In 2008 the Ministry of Health announced that gay men would be one of several groups to be targeted in specially formulated HIV/AIDS prevention programmes as part of its national health initiatives⁴⁷.

Migrant workers

There are approximately 130 million migrant workers in China, largely comprising of people from rural areas working in cities as labourers, restaurant workers or sex workers.

HIV prevention efforts for migrants are essential, as various studies have found that relative to non-migrants, migrants are at greater risk of contracting and transmitting HIV⁴⁸. Migrants’ perceived risk, knowledge of HIV, and rates of condom use are low and they face barriers to accessing education and healthcare⁴⁹.

“Being mobile in and of itself is not a risk factor for HIV infection. It is the situations encountered and the behaviours possibly engaged in during mobility or migration that increase vulnerability and risk regarding HIV/AIDS.”⁵⁰

Young rural-to-urban male migrants have been identified as the ‘tipping point’ for the AIDS epidemic in China as they play a crucial role in broadening social and sexual networks⁵¹. For example, male migrants infected with HIV in urban areas may infect their wives or regular partners when they return home to rural areas⁵².

HIV prevalence and trends in different regions of China

HIV/AIDS prevention in China

Partly because of the national failure to educate Chinese citizens about AIDS in the 1980s and 1990s, stigma and discrimination towards those living with HIV in China is still a major problem⁵³. Stigma, fear and discrimination constitute a vicious circle which fuels a hidden epidemic, presenting serious obstacles to the design and implementation of effective HIV prevention programmes⁵⁴.

In 2003 China initiated an ambitious programme to raise awareness of the disease, reduce stigma and prevent a generalised HIV epidemic in the country. It includes educational campaigns, HIV testing outreach projects, targeting high-risk groups and prevention of mother-to-child transmission.

AIDS education

The Chinese Education Ministry formulated the Basic Requirements for Health Education as early as 1990. These documents state that sexual morality and self-discipline should be taught in order to prevent HIV/AIDS and STDs⁵⁵.

In 2004 "State Council Document Number 7" instructed local governments to:

"integrate HIV/AIDS into the routine government agenda as an important item ... and urgently and effectively respond to HIV/AIDS, which is a priority linked to the interest and benefit of China and its people".⁵⁶.

Among the recommendations were mass education campaigns among the general population, to teach people how to avoid infection and to counter stigma and discrimination⁵⁷.

However, despite the central government’s frequent educational policies, it is unclear how much HIV/AIDS education local authorities are actually implementing. A lack of qualified teachers for HIV/AIDS prevention education (especially in rural areas) and the lack of appropriate teaching materials on HIV/AIDS prevention in minority languages may be hindering educational efforts.

There is clearly still an urgent need for public HIV/AIDS education in China. A 2008 survey of over 6000 residents in six large cities found that more than 48% of respondents thought they could become infected from mosquito bites, with 18% believing they could become infected by being sneezed or coughed on by someone living with HIV. Negative attitudes towards those with HIV were also revealed. Nearly 32% of interviewees thought people with HIV/AIDS deserved their disease because of their drug use or sexual behaviour; almost 48% would not eat with someone with HIV; and 30% thought children with HIV should not attend the same schools as uninfected children.⁵⁸

Condoms

China's first condom advertisement was banned just two days after its release in 1999, as government officials said that the cartoon condom fighting with HIV was illegally promoting sex products⁵⁹.

This ban was lifted on World AIDS Day 2002, and condoms were reclassified by the Ministry of Health as "a medical device" rather than a sexual commodity. The State Family Planning Commission also changed the Chinese term for "condom", from biyuntao, literally meaning "sheath to avoid pregnancy", to anquantao, or "safety sheath"⁶⁰.

Nevertheless, China’s first major television campaign to promote condom use was not launched until 2007. The campaign targeted the young and mobile, and comprised of short public service announcements on public transport, using slogans such as “Life is too good, please protect yourself”⁶¹.

Despite free condom programmes amongst target groups, condom use in China remains low, both amongst sex workers, men who have sex with men, and the general population⁶². Many Chinese people continue to associate condoms with promiscuity and considerable education is required for an effective safer sex campaign. One survey revealed that of people who had sex in the last six months with someone other than their spouse or boyfriend/girlfriend, 42% had not used a condom during their last two acts of sexual intercourse. Nearly 30% of all respondents did not know how to correctly use a condom.⁶³

China is facing a challenge not just to educate people about proper condom use but also to provide enough quality condoms. Annually, 2.5 billion condoms are manufactured in China, of which 0.5 billion are distributed nationally (this is roughly one condom per man, per year). There are over 1,000 condom brands on the Chinese market, with only 70% of the condoms passing the minimum quality standard⁶⁴.

Prevention of mother to child transmission of HIV (PMTCT)

China currently has relatively few HIV cases related to mother-to-child transmission and an overall low prevalence of HIV infection in pregnant women⁶⁵. However, as the AIDS epidemic spreads to the general population, the percentage of women infected with HIV will rise, as will mother-to-child-transmission. The Chinese government has developed national guidelines and trained a number of health workers in preventing mother-to-child-transmission. It aims to ensure all pregnant women in high prevalence areas have access to testing, counselling and HIV-preventive services⁶⁶.

Although these are positive steps, in 2008 only 980 HIV-positive pregnant women in China received treatment to prevent mother-to-child-transmission, and only 10% of pregnant women were tested for HIV⁶⁷

HIV testing

One of the main barriers to effective HIV prevention is that the majority of people infected with HIV in China are not aware of their positive status. HIV testing is important so that those found to be infected with the virus can seek treatment and take measures to prevent transmission to others. Little over a quarter of those questioned in a 2008 survey knew where they could get tested.⁶⁸

Until recently people in China were only tested for HIV through voluntary counselling and testing (VCT) schemes. Although these VCT sites still exist, in 2004 the government launched a national programme of ‘active testing’ to seek out certain high-risk groups. Under the new policy, community health leaders initiate outreach schemes to invite members of the targeted groups to be tested⁶⁹. The new policy was launched in Yunnan province in 2004 and found that of the 424,000 people targeted, only 1.3% refused the test. 13,486 people (3.2%) were found to be HIV positive⁷⁰.

Although the Chinese government consider outreach ‘active testing’ to be successful for the increased number of people identified as HIV positive (in Yunnan the number of people found to have HIV was equivalent to the total number identified through voluntary testing in the previous 18 years) some experts have voiced concern over the human rights of those being tested. There is unease that ‘active testing’ may be placing community protection over individual rights. The tests may not be entirely voluntary due to the significant social pressure to be tested. Additionally social marketing campaigns promoting HIV awareness and addressing misconceptions are often used in place of individual pre- and post test counselling⁷¹.

Routine testing (whereby people are tested as part of an annual medical check up) has also been introduced in institutional settings such as prisons and government offices⁷². This method of HIV testing has also provoked criticism as individuals consent to health examinations that include an HIV test, rather than directly agreeing to the test itself⁷³.

HIV/AIDS treatment in China

Prior to 2003 few people with HIV/AIDS in China had access to antiretroviral treatment, and clinical expertise about the virus was limited. This changed when the Chinese government launched China CARES (China Comprehensive AIDS Response) in 2003, a community-based HIV treatment, care and prevention programme⁷⁴. Pilot programmes were started in seven central Chinese provinces and provided more than 5,000 HIV/AIDS patients with free, domestically produced antiretroviral drugs⁷⁵. The "Four Frees and One Care" policy was announced at the end of the same year stating that free HIV treatment would become available to poor people in urban areas and to everyone in rural areas.

According to the Ministry of Health, between 2003 and 2007, China provided free antiretroviral therapy to 37,497 people living with AIDS including 771 HIV positive children⁷⁶. The WHO estimated that in 2007 China was supplying 19% of those in need of treatment with antiretroviral therapy⁷⁷. In reality, although the treatment itself is free, patients often have to pay for associated clinical tests⁷⁸.

Funding for treatment programmes comes from central and national programmes, as well as international donors. In 2003, the Global Fund to Fight AIDS, Tuberculosis and Malaria awarded China a five-year grant to strengthen the operational system of the free antiretroviral treatment programme⁷⁹. Funding from central government increased from very little in 2000 to US$185 million in 2006⁸⁰.

Amongst the most affected groups, 45% of IDUs and 25% of sex workers were receiving HIV/AIDS treatment in 2006⁸¹. Challenges in treating these populations remain and include stigma and discrimination in the community and in the health care system, migratory work patterns, and commonly chaotic social circumstances. Additionally many IDUs spend time in drug detention centres where antiretroviral therapy is currently not available. This means that those people that are already receiving antiretrovirals risk interruption of their therapy and consequent resistance if they are incarcerated or otherwise detained⁸².

Migrant workers have been identified as a population who are under-served by treatment programmes, as people are only usually allowed to access medical care in their official area of residency⁸³.

Inadequate human and physical resources significantly affect the capacity of China's health system to treat those with HIV. Since the late 1970s government funding for health service providers has decreased with less money going to local providers. Local governments are mandated to support medical care for HIV/ADS patients, but inadequate funding discourages local governments from identifying and treating HIV/AIDS patients, as the more patients they identify the more expenditure they have⁸⁴.

Another serious limitation to HIV treatment in China is the lack of access to second-line therapy for people living with HIV who have become resistant to their treatment regime or who are experiencing particularly bad side effects. A study of China's national treatment programme found that 50% of patients failed first-line therapy after five years.⁸⁵ It is essential that alternative treatment options are made available to patients who are not responding to first-line therapy, in order to prevent HIV rapidly developing into AIDS.

The Chinese government, NGOs and AIDS activists

International public health experts, including UNAIDS and the WHO, have commended the Chinese government for its recently implemented HIV prevention and treatment programmes⁸⁶.

Although it cannot be denied that there has been an encouraging turn around in policy towards HIV/AIDS in China, there are still a number of political problems that are hampering the response to the epidemic.

China’s continuing restrictions on civil society, free expression and free association mean that HIV-related NGO’s and AIDS activists face repression and harassment from the Chinese authorities.

Although senior Chinese officials have shown an increased tolerance of non governmental AIDS organizations in recent years, local officials often hold more repressive views. Authorities in wealthy coastal provinces tend to be more lenient and supportive of the efforts of AIDS activists, whereas inland, rural areas are reported to be more oppressive of public discussion of AIDS. The old Chinese saying tiangao diyuan (“Heaven is high, and the emperor is far away”) is apt here. Local authorities in remote regions do not always implement AIDS policies made by the central government⁸⁷.

Human Rights Watch (HRW) have reported numerous examples of harassment and surveillance of AIDS activists and support groups, including the detainment of prominent AIDS and human rights campaigners, such as Hu Jia ⁸⁸.

This shows a contradiction in the Chinese government's commitment to combating AIDS in the country. The experience of other countries show that some of the most effective responses to the crisis in many parts of the world have been led by people living with HIV/AIDS and their families and friends. In many parts of the world government openness to civil society’s involvement in the AIDS struggle has led to diverse, vigorous and often successful anti-AIDS efforts⁸⁹.

“The government should recognize that grass-roots organizations can be its ‘right hand’ and can be its partners. It should recognize that NGOs are ‘nongovernmental organizations,’ not ‘anti-government organizations.’” A member of the Information Clearinghouse for Chinese Gays and Lesbians⁹⁰

Conclusion

During the first years of the new millennium China woke up to the very real prospect of a generalised AIDS epidemic in the country. The government has since radically turned around its response to HIV/AIDS and has implemented a wide range of strategies to target high prevalence groups, as well as educating the general population about HIV prevention.

Although a concerted effort to battle the epidemic is under way, the fight has by no means been won. Given the size and complexity of the country’s epidemic many challenges remain and well-coordinated efforts will be needed for continued progress.

In 2007, for the first time ever, unsafe sex overtook drug use as the main cause of new HIV infections in the country⁹¹. This confirms fears that the epidemic is moving outwards from the high prevalence groups traditionally associated with the HIV epidemic in China.

It is vitally important for China to take steps to make their strategies to combat AIDS more than rhetoric: to ensure programme implementation at a regional and local level and to respect the human rights of those living with HIV in China.

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