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HIV & AIDS in China
There are currently an estimated 780,000 people living with HIV in China.1 During 2011 around 28,000 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 (less than 0.1 percent among adults,4 there are pockets of high infection among specific sub-populations and the danger of the epidemic spreading further into the general population persists.5 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.6
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.
Most of the nearly one million people living with HIV in China, live within six of China’s thirty-three provinces*; Yunnan, Guangxi, Henan, Sichuan, Xingiang and Guangdong. These provinces report the highest number of HIV and AIDS cases, representing around 70 to 80 percent of the national total.7 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.8 Nearly half of all people living with HIV at the end of 2011 were infected through heterosexual transmission, whilst injecting drug use and sex between men accounted for just over 1 in 4 and nearly 1 in 5 infections, respectively.9 Other transmission routes included former blood donors or transfusion recipients (6.6 percent) and mother-to-child transmission (1.1 percent).
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.10 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.11
HIV/AIDS education in China
HIV and AIDS education in China has improved since the 1990s, when the Chinese Education Ministry formulated health education guidelines that stated that sexual morality and self-discipline should be taught in order to prevent HIV, AIDS and STDs.12 In 2004, a State Council document recommended conducting a mass education campaign among the general population, to teach people how to avoid infection and to counter stigma and discrimination.13 It stated that the interests of China and its people were dependent on an effective HIV response. Despite frequent implementation of educational policies by central government 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. However, in 2011, reports indicated that basic HIV knowledge was high among young students.
Nevertheless, a study of over 6,000 residents in 2008 found that wider knowledge and stigma remains a problem.15 It found:
- 48 percent of respondents thought they could become infected from mosquito bites
- 18 percent believed they could become infected from a sneezing or coughing person with HIV
- 32 percent of interviewees thought people with HIV and AIDS deserved their condition because of their drug use or sexual behaviour
- 48 percent would not eat with someone who had HIV
- 30 percent thought children with HIV should not attend the same schools as uninfected children.
“The Chinese term for "condom" changed from biyuntao, literally meaning "sheath to avoid pregnancy", to anquantao, or "safety sheath".”
Condoms in China
Condoms used to be considered a sex product, rather than something to protect ones health. In 1999, 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.17 Following the lifting of this ban in 2002 and the reclassification of condoms as a "medical device", rather than a sexual commodity, the government began endorsing the use of condoms as part of the HIV response.
“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 pharmacy18
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”.19 By 2009, it was reported that condom use had ballooned, with a notable increase in condom sales in early 2010.20 Overall condom use in China has now reached relatively high levels among certain groups at a high risk of HIV infection.
Preventing mother-to-child transmission of HIV (PMTCT)
PMTCT is a core part of China's national HIV strategy and in recent years, greater numbers of HIV-positive pregnant women have been reached by PMTCT services.
- The number of pregnant women tested for HIV increased from 64 percent in 2010, to 92 percent in 2011.21 22
- Three quarters of pregnant women, known to be HIV-positive, received antiretroviral therapy to prevent mother-to-child transmission in 2011.23
Voluntary HIV testing and counselling (VCT) in China
VCT was first implemented across health centres in 2003.26 27 VCT enables individuals to request free HIV testing and counselling from a health care provider. However, this form of delivering HIV testing services requires the individual to have knowledge of HIV, actively seek testing and to overcome barriers such as the fear of a positive test result; factors that have been found to deter individuals from actively seeking testing.28 In 2005 China introduced provider initiated testing and counselling (PCT) whereby the health provider offers testing to individuals with HIV related signs and symptoms or those who report high-risk behavior.29 There are concerns that instead of provider initiated testing, some sex workers and injecting drug users are being forced to undergo mandatory testing whilst detained in ‘rehabilitation’ centers.30The fear of mandatory testing, continued stigma and discrimination of people with HIV, and a lack of confidentiality around testing act as deterrents to HIV testing.
- By the end of 2011, 14,571 medical facilities provided HIV testing and counselling across China, compared with 9,475 in 2010.31 32
- A quarter of people questioned in a 2008 survey of six Chinese cities, did not know where they could get tested for HIV.33
- A 2009 stigma index reported that nearly one sixth of respondents said a health care professional had told other people about their HIV status without their permission.34
HIV among high-risk groups in China
Injecting drug users
In 1989 HIV was detected amongst injecting drug users (IDUs) in Yunnan province.35 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.36 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.37 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.38
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.39
- 2.5 million people inject drugs in China
- HIV prevalence is 6.4 percent amongst this group – 3 percent lower than in 2009
- 900 NSPs exist in China
- 60,000 people who use drugs are accessing NSPs
- 12 million needles and syringes are distributed, each year
- 600 methadone maintenance clinics exist in China
- 140,100 people who use drugs are accessing substitution treatment
- 38.5 percent of IDUs reached by HIV prevention programmes in 2011. Compared to 24.8 percent in 2007
- More than three quarters of drug users used sterile injection equipment the last time they injected drugs in 2011. Compared with more than three quarters in 2009
- Two thirds of people who inject drugs still used contaminated injecting equipment in 2011
- 40 percent of people who use drugs, used a condom at last sexual intercourse in 2011. Compared with over one third of people in 2009
Whilst the number of NSPs and OSTs have notably increased in China, access to these services is still difficult for many injecting drug users due to government restrictions. These include the widespread practice of rehabilitating IDUs by forcibly detaining them and restrictions on the use of drug substitution treatments like methadone and buprenorphine.
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.45 The sites offered around 50 Yuan ($7) for plasma and 200 Yuan ($29) for blood.46 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.47
““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 Province48
By September 2003, cases of HIV relating to blood or plasma donation had been reported in all provinces, autonomous regions and municipalities, except Tibet. HIV transmission through infected blood products accounted for 10 percent of HIV infections in 2005.49
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.50
Men who have sex with men
After previous years of being overlooked by China’s national AIDS strategies, greater action to address the epidemic among men who have sex with men (MSM) is now evident in China.51 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.
High levels of stigma surrounding MSM in Chinese society made early 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.52
- HIV prevalence among MSM in 2011 was 6.3 percent. Compared with 5 percent in 2009
- 1 in 6 people living with HIV were infected through sex between men
- More than three quarters of men surveyed were reached by prevention programmes
- Three out of four men reported using a condom the last time they had anal sex with a man
- More than half of MSM do not use condoms consistently or know their HIV status53 54 55
Whilst stigma is evidently declining and greater acceptance of MSM in Chinese society can be seen in the rising numbers of gay bars and clubs, and community action, barriers remain. Laws that prohibit homosexuality from being discussed on TV, in the media or other cultural productions and the censoring of homosexuality on the Internet suggests that stigmatisation of men who have sex with men continues to hinder effective HIV prevention.56 57
It is hoped the recent scale up of HIV prevention interventions will be reflected by a decline in new HIV infections among this group. However, consistent condom use and knowledge of ones HIV status remain key areas in need of improvement.
Whilst the epidemic among MSM in China is complex and in need of greater research, studies have found that overlaps between MSM and other high-risk groups do exist; with many MSM reporting sex with women or having sex in exchange for money, making this a key bridging population.58 59
Making a tangible and lasting impact on the epidemic among MSM in China relies on greater involvement and collaboration with this group, particularly when designing community prevention interventions.61 Greater governmental support for community-based HIV and LGBT organisations will be key to increasing the participation of MSM in the planning of HIV prevention interventions and to successfully lowering new HIV infections among this group.
Initially few cases of HIV were reported as being through heterosexual sex. However, by 2007 it was reported that heterosexual sex had overtaken injecting drug use as the main route of HIV transmission in China.62 Heterosexual sex has remained the main route of transmission, with increasing numbers of people reporting HIV infection through this route. Groups particularly at risk from HIV infection through heterosexual transmission in China are migrant workers and female sex workers and their clients.63 64 65
- In 2011 around 52 percent of people newly infected with HIV reported heterosexual sex as the route of transmission, compared with 42 percent in 2009.66
- HIV prevalence was low among sex workers in 2011, at 0.3 percent.67
- Low knowledge of HIV, low condom use and barriers accessing education and healthcare are key risk factors for HIV among migrants.68
- Migrant female sex workers report high levels of client refusal to use condoms, unsafe sex with both clients and non-paying partners, high STD prevalence.69
- Up to 80 percent of sex workers report being reached by prevention programmes and 87.5 percent report using a condom at last sex.70
- Only a third of female sex workers received an HIV test in the last 12 months.71
- 75 percent of male migrant workers, surveyed, have basic knowledge around HIV.72
- Injecting drug use is associated with high HIV prevalence among female sex workers; In Yunnan province, 38 percent of drug using female sex workers were HIV-positive, compared with 4 percent among non-injecting drug.73
Reducing the number of HIV infections that occur through heterosexual sex relies on improving knowledge about HIV and STDs among sex workers and migrants.74 Targeted interventions are needed to ensure migrant workers and sex workers are reached. Young rural-to-urban male migrants, in particular, 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.75
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.78 Pilot programmes were started in seven central Chinese provinces and provided more than 5,000 HIV/AIDS patients with free, domestically produced antiretroviral drugs.79 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.80
Although initially slow to scale up antiretroviral treatment, WHO estimated that only 19 percent of those in need of HIV treatment in China had access in 2007, improvements in treatment coverage are evident.81 Only 65,481 people, or 34 percent of those in need, accessed HIV treatment in 2009.82 Reassuringly, by 2011 this figure had almost doubled, with 126,448 people, or 76 percent, of people accessing HIV treatment.83
A study of 2,513 treatment sites over seven years, found that HIV-related mortality declined as ART coverage for patients with advanced HIV-infection increased. This signifies the importance of continuing the recent scale-up of treatment delivery across China.84
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.85
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 percent of patients failed first-line therapy after five years.86 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;87 increasing to 18,703 adults and 216 children by the end of 2011.88
Limited availability and choice of drug combinations due to a lengthy licensing process means that HIV positive patients in China find it difficult to access the most effective treatment.
Whilst improvements in China’s delivery of antiretroviral treatment can be seen, some areas of need remain. Notably, the decline in the number of people, co-infected with HIV and TB, receiving treatment from around 45 percent in 2010 to 36 percent in 2011 suggests the need for greater resources in this area.90
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. On an official visit, the UNAIDS Executive Director particularly praised China's commitment to fully fund the country's AIDS response following the withdrawal of major donors.91 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.92 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.93
This shows a contradiction in the Chinese government's commitment to combating AIDS in the country.94 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.95
“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 Lesbians96
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.97 It also lifted a travel ban that had barred people with HIV or AIDS from entering the country.98
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.
The history of AIDS in China
1985 - 1990
- China’s first AIDS case is reported in a traveller from abroad who subsequently dies in Beijing.99 A small number of cases are reported, among foreigners and Chinese, over the next five years100
- Health Ministry concentrates on preventing HIV risk from abroad. All foreign students must comply with a mandatory AIDS screening programme101
- China's first National Programme for AIDS Prevention and Control' is developed
- Public Health Authorities report that AIDS will not become established in China, as homosexuality and "abnormal" sexuality (thought to be the main route of transmission), were a "limited" problem.102
- 146 injecting drug users (IDUs) in Southwest Yunnan identified as HIV positive. Total number of infected people is reported as 153 Chinese and 41 foreigners103
- AIDS and drug addiction seen as consequences of contact with the West, and AIDS is known as aizibing, the "loving capitalism disease"104
- Reports of people infected through blood donation105
- AIDS cases amongst IDUs in Yunnan signal the beginning of an epidemic amongst drug users106
- Minister of Health, Chen Min-Zhang, puts the number of infections, in Yunnan, at between 50,000 and 100,000 with new cases being reported in other regions107
- HIV infections are reported in all 31 provinces, autonomous regions and municipalities
- Drug users account for 60-70 percent of reported infections108
- It becomes clear that extremely large numbers of people have been infected through blood donation109
“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 ”
- Peter Piot, the Executive Director of UNAIDS110
- World AIDS Day events reflects a far greater willingness to discuss the emerging epidemic111
- It is widely felt that the 2003 SARS epidemic has prompted a change in government attitude towards HIV, as it demonstrates the impact public health can have on social and economic stability. China's Health Minister describes the fight against AIDS as a "long-term war" and requests that China’s AIDS budget of US$12.5 million be doubled.112
- World AIDS Day. Wen Jiabao becomes the first Chinese Premier to shake hands with an HIV-positive person.113
- UNAIDS estimated that of the 75,000 people living with AIDS, approximately 22,000 have been infected through blood.114
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