There are currently an estimated 740,000 people living with HIV in China, including about 105,000 AIDS patients.¹ During 2007 around 39,000 people died from AIDS.² These numbers must be considered in the context of China's extremely large population which is estimated at around 1.3 billion.³ Although China’s HIV epidemic remains one of low prevalence overall (0.057%), there are pockets of high infection among specific sub-populations and the danger of the epidemic spreading further into the general population persists.⁴ This became particularly evident in 2009 when China reported that AIDS had become the country’s leading cause of death among infectious diseases for the first time ever, surpassing both tuberculosis and rabies.⁵

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 and men who have sex with men.

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 1985.⁶ In the following five years a small number of cases were reported among foreigners and Chinese, who were infected overseas or by imported blood products.⁷

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.⁸

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 in China, as homosexuality and "abnormal" sexuality (thought to be the main causes of the spread of HIV), were a "limited" problem.⁹

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 foreigners.¹⁰ 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".¹¹

By late 1994 it was clear 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 100,000¹² - 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 infections.¹³

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 infections.¹⁴

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 and a television drama about AIDS, reflected a far greater willingness to discuss the emerging epidemic.¹⁵

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.¹⁶

On World AIDS Day 2003, Wen Jiabao became the first Chinese premier to shake hands with an HIV-positive person.¹⁷ 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.”¹⁸

The current situation

An estimated 740,000 people were living with HIV in China in 2009.¹⁹ 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 Control²⁰

Yunnan, Guangxi, Henan, Sichuan, Xingiang and Guangdong are provinces with the highest number of reported cases of HIV and AIDS. In total they represent around 70 to 80 percent of the national total.²¹

HIV transmission in China

Traditionally HIV transmission has been particularly high among injecting drugs users, men who have sex with men and former plasma donors. However, in recent years HIV has bridged to the general population, and now heterosexual sex has become the dominant transmission route.^{22 23}

Injecting drug use

In 1989 HIV was detected amongst injecting drug users (IDUs) in Yunnan province.²⁴ 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 IDUs may have been the core source for all later sub-epidemics in China.²⁵

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 users.²⁶ 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 regions.²⁷ By 2007, China had more drug replacement clinics and needle social marketing programmes than any other country in Asia.²⁸

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 areas.²⁹ 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 2006³⁰

By 2009, around 38.5 percent of IDUs were covered by HIV prevention programmes, an increase from 24.8 percent in 2007. Almost three quarters of drug users in 2009 were using sterile injection equipment the last time they injected drugs, compared to just under half two years earlier.³¹

Blood donation and transfusion

Following a ban on imported blood products in the 1980s, thousands of blood and plasma donation sites were established across China. Most operated illegally and collected blood from rural, impoverished areas where there would be less interference from authorities.³² The sites offered around 50 Yuan ($7) for plasma and 200 Yuan ($29) for blood.³³

“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 Province³⁴

The collected blood was pooled together and the plasma removed. The remaining red blood cells were then injected back into the donors to speed recovery time. This unsafe collection method, and the reuse of needles and syringes, facilitates the transmission of HIV through blood. It is thought that hundreds of thousands of people, including both the paid donors and those who received blood transfusions, were infected with HIV in this way.³⁵

By September 2003, cases of HIV relating 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 infections.³⁶ In the same year UNAIDS estimated that of the 75,000 people living with AIDS, approximately 22,000 had been infected in this way.³⁷

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. In 2008 almost all the blood collected at blood stations in China were from voluntary, unpaid donors, and in 2010 the government claimed that all collected blood products were screened for HIV.³⁸

Sex between men

HIV prevalence among men who have sex with men (MSM) in China is estimated at 5%.³⁹ High rates of unprotected anal sex between men are leading to concerns that prevalence among this high risk group is rising.⁴⁰ Among the new HIV infections in 2009, 32.5 percent were as a result of sex between men, a significant increase from 12.2 percent in 2007.⁴¹

The epidemic among MSM in China is complex and still understudied. It is thought to play an important role in transmission to other segments of society⁴² as most gay men in China are married and under social pressure to hide their sexual orientation.⁴³

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 adopted.⁴⁴

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 initiatives.⁴⁵

However, by the beginning of 2010 the reach of government initiatives into the gay community were still limited. This has been attributed to disengagement with health authorities due to continued discrimination and fears of stigma.⁴⁶ The former vice-health minister Wang Longde identified the need for more to be done. He warned:

"The low intervention rate seriously undermines the nation's efforts to curb HIV/AIDS from spreading among the entire population, particularly when sex has become the primary means of new infections in the nation" - Former vice-health minister Wang Longde⁴⁷

Heterosexual sex

In 2007 it was reported that heterosexual sex had overtaken injecting drug use as the main route of HIV transmission in China.⁴⁸ In 2009 around 42 percent of people newly infected with HIV became infected through heterosexual sex.⁴⁹ Groups particularly at risk from HIV infection through heterosexual transmission in China are migrant workers and female sex workers and their clients.

Various studies have found that relative to non-migrants, migrants are at greater risk of becoming infected with, and transmitting, HIV.⁵⁰ Migrants’ perceived risk, knowledge of HIV, and rates of condom use are low and they face barriers to accessing education and healthcare.⁵¹

“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.”⁵²

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 networks.⁵³

Although HIV prevalence among female sex workers in China is relatively low (0.6 percent), several studies have indicated towards high HIV risk factors among this group.^{54 55} In addition, there are fears that the government's attempts to crackdown on China's sex industry will severely hinder HIV prevention efforts among this high risk group.⁵⁶

HIV 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 problem.⁵⁷ 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 programmes.⁵⁸

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 STDs.⁵⁹

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".⁶⁰

One recommendation was to conduct a mass education campaign among the general population, to teach people how to avoid infection and to counter stigma and discrimination.⁶¹

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

There is clearly still an urgent need for public AIDS education in China. A 2008 survey of over 6,000 residents in six large cities found that more than 48 percent of respondents thought they could become infected from mosquito bites, with 18 percent 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 percent of interviewees thought people with HIV and AIDS deserved their condition because of their drug use or sexual behaviour; almost 48 percent would not eat with someone who had HIV; and 30 percent thought children with HIV should not attend the same schools as uninfected children.⁶²

Condoms

China's first condom advertisement was banned just two days after its release in 1999 because government officials had said it was illegally promoting sex products.⁶³

This ban was lifted on World AIDS Day in 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".⁶⁴

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”.⁶⁵

In 2009 it was reported that condom use in China had 'ballooned', and by early 2010 there had been a notable increase in condom sales.⁶⁶

"Several years ago, when consumers were selecting condoms, they did it in a most covert way. Now, there are couples overtly selecting condoms together". - Su Ding, a saleswoman at a Beijing pharmacy⁶⁷

China's 2010 HIV/AIDS progress report shows that 85 percent of female sex workers used a condom with their most recent client. Of MSM who had been tested for HIV and were aware of their result, 73 percent had used a condom during the last time they had anal sex with a male partner. Only 36 percent of injecting drug users used a condom during the last time they had sexual intercourse.⁶⁸ Data was unavailable for condom use outside of these high risk groups.

Prevention of mother-to-child transmission of HIV (PMTCT)

In 2005 it was reported that China had relatively few HIV cases caused by mother-to-child transmission and an overall low prevalence of HIV infection in pregnant women.⁶⁹ 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 has 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 services.⁷⁰

Although these are positive steps, in 2008 only 10% of pregnant women were tested for HIV,⁷¹ and in 2009 one in four HIV-infected pregnant women did not receive antiretroviral drugs to prevent mother-to-child transmission.⁷² In the same year, around 1 in 5 babies born to HIV-infected mothers were infected with HIV.⁷³

HIV testing

In 2004 the Chinese government implemented a large-scale HIV testing programme to identify the hundreds of thousands of people estimated to be unknowingly infected with HIV.⁷⁴ By targeting key populations, the screening programme led to a significant increase in the number of people diagnosed with the virus.⁷⁵

Although the Chinese government considered the outreach 'active testing' to be successful, they received criticism from the international community. It was thought that by actively seeking out high-risk populations, the testing was not always entirely voluntary and was therefore violating individual human rights.⁷⁶ The routine testing (individuals are tested as part of an annual health check) that was introduced in institutional settings, such as prisons and government offices, was also criticised.⁷⁷

In recent years the availability of voluntary counselling and testing (VCT) has been scaled-up. By the end of 2009, 7335 VCT clinics had been established across China and each county had at least one or two free VCT centres. Despite this progress, a quarter of people questioned in a 2008 survey did not know where they could get tested for HIV.⁷⁸ In addition, in a 2009 stigma index report, nearly one sixth of respondents said that a healthcare professional had told other people about their HIV status without their permission.⁷⁹

HIV and 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 programme.⁸⁰ Pilot programmes were started in seven central Chinese provinces and provided more than 5,000 HIV/AIDS patients with free, domestically produced antiretroviral drugs.⁸¹ 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. In reality, although the treatment itself is free, patients often have to pay for associated clinical tests.⁸²

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 children.⁸³ WHO estimated that in 2007 China was supplying 19% of those in need of treatment with antiretroviral therapy.⁸⁴ By the end of 2009 an estimated 65,481 were receiving treatment, which, according to the Chinese government, is only 34 percent of those in need.⁸⁵

The obstacles that are preventing thousands of people from accessing treatment include stigma and discrimination, a shortage of healthcare system funding and migratory work patterns. Migrant workers in particular 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 residency.⁸⁶

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.⁸⁷ The government started second-line treatment roll-out in 2009 and by the end of the year, 2,155 adults and 85 children had been initiated.⁸⁸

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 programmes. 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 NGOs and AIDS activists face repression and harassment from the Chinese authorities.

Although senior Chinese officials have shown an increased tolerance of non governmental AIDS organisations 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 government.⁸⁹ Human Rights Watch 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.⁹⁰

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. Often, government openness to civil society’s involvement in the AIDS struggle has led to diverse, vigorous and often successful anti-AIDS efforts.⁹¹

“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 Lesbians⁹²

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 risk groups, as well as educating the general population about HIV prevention. It also lifted a travel ban that had barred people with HIV or AIDS from entering the country.⁹³

Although a concerted effort to tackle 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. 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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