China has made substantial progress in tackling their HIV epidemic. China’s HIV history has been anything but steady, with national negligence a critical factor in the spread of HIV in the early 1990s. However, significant progress in the last decade and increased national response have greatly decreased the epidemic across the country as well increasing the quality of life for people living with HIV.
The HIV epidemic in China is largely characterised by low national prevalence (specific figure known) but with certain regions having higher and more severe HIV prevalence rates.1 China is also faced with the increasing challenge of providing more targeted prevention programmes to key affected populations such as men who have sex with men (MSM), people who inject drugs (PWID) and young people.
Treatment, care and support challenges prevail in China. In 2013 alone, 28,000 people died from AIDS-related causes.2 The number of people living with HIV receiving treatment has steadily increased across the country. However, progress in reducing mother to child transmission (MTCT) rates is still regarded as slow as well as addressing the high levels of stigma and discrimination people living with HIV experience across the country.3
China has made substantial progress with regards to funding their HIV response. 88% of funding comes from domestic sources.4 This is very encouraging when considering the sustainability and longevity of many of the national HIV and AIDS commitments.
Key affected populations in China
China has a relatively low national HIV prevalence rate, however the HIV epidemic is still a major concern for some of the key affected populations within the country. Targeted prevention strategies are critical to curb the epidemic amongst these vulnerable groups as well as addressing the stigma and discrimination that many of these groups face on a daily basis, preventing them from accessing vital HIV services.
Men who have sex with men (MSM)
HIV prevalence among men who have sex with men (MSM) has been rising in China with a prevalence rate of 7.3% in 2013.5 It has been estimated that MSM represent over a quarter of new reported infections,6 however very limited studies exist that aim to understand the epidemic among this population. Stigma and marginalisation are key factors that are preventing a greater understanding of the epidemic in China among MSM. As like many countries in the world, homosexuality is still met with large levels of discrimination.7
The epidemic is not contained to MSM, with research showing that in some regions around 26% of MSM have had female partners in the last six months.8 Unawareness of HIV status is a major factor in the rising epidemic amongst MSM and needs to be greatly considered, focusing on HIV testing services for these vulnerable populations. One study in Chongqing City, which has a high HIV prevalence among MSM, found that HIV testing was actually higher for MSM (58%) than average populations (44%). This is encouraging, however HIV testing among this group remains much lower than other countries in the Global North.9
Strategies such as self-testing have also been explored in China amongst MSM. One study found that 20% of MSM had used self-testing kits for HIV. The increased use of self-testing kits was also greatly correlated with factors such as the individual being married, having a recent HIV test and if they had engaged in anal sex.10 It is clear that the HIV epidemic among MSM is concerning in China but more targeted prevention strategies for this affected population will enable a more effective response that meets this groups’ needs.
One of the growing key affected populations in China is young people. Between 2008 and 2012, the prevalence among 15-24 year olds doubled from 0.9% to 1.7%.11 Despite these figures still being relatively low, there is increasing concern about the impact of the HIV epidemic on younger generations. Understanding the main mode of transmission amongst this population is crucial to providing effective support and services. It has been found that the majority of young people infected are male (95%), and 70% of those infections have been among young MSM.12 It is therefore vital that HIV services and education are tailored to younger generations and key affected groups within these younger populations.
Including young people in the design and formulation of HIV and AIDS policies and programmes will be important in tackling the epidemic amongst this population in China. Research has found that youth HIV and AIDS policy in China is limited and that more holistic approaches, including young people in policy development is an important step in tackling the epidemic.13 This will also challenge stigma and discrimination and also increase knowledge of HIV and AIDS and reduce risk-taking behaviour.
People who inject drugs (PWID)
Blood sharing through drug taking equipment has increased the spread of HIV in China. HIV prevalence among PWID is 3.6%.14 The first cases of HIV among people who inject drugs were recorded in 1989 and since then people living with HIV has steadily risen amongst illicit drug users. Both Yunnan and Guangxi provinces have the highest recorded HIV prevalence rates in the country. In Guangxi alone, 69% of the PLHIV were infected through injecting drugs.15 Providing targeted intervention programmes for these populations is vital for effectively supporting PWID and their risk to HIV.
In Guangxi province, an extensive prevention programme was launched in 2009 funded largely by external donors. The programme provides a variety of support for PWID including needle and syringe programmes (NSPs), HIV and AIDS education and HIV comprehensive education programmes through drop-in centres and peer-led outreach. These services have shown to be effective in promoting safe injecting practices as well as increasing understanding of HIV and AIDS.16 NSPs have increased across China, with over 60,000 PWID using the programmes.17
HIV testing and counselling (VCT) in China
Since the beginning of the millennium, China has intensified HIV testing efforts, tailoring the approach depending on the type of group or population they are aiming to reach.18
An active-testing approach has largely been adopted across the country, inviting high-risk groups such as PWID, pregnant woman and MSM to take an HIV test. This approach has showed a low refusal rate in certain provinces. In 2004, active testing was initiated in Yunnan province, 424,000 were invited to be tested and only 1.3% refused. Active testing is therefore been found to be an effective approach for key affected populations however there have been concerns that with HIV testing comes great social pressure, often leaving people unable to refuse a test.19
VCT services have continued to develop in China. In 2013, there was a recorded 18,367 health service facilities providing and conducting HIV testing and counseling, which has been crucial in diagnosing more people with HIV than ever before.20 China has also put significant effort into establishing and developing HIV and AIDS labs, which a crucial for both prevention and treatment programmes.21
HIV prevention in China
Sexual transmission is the main mode of HIV transmission in China and reducing this transmission has been of critical concern in China’s HIV response.22
HIV prevention programmes have consistently developed across the country in last decade.23 Reducing sexual transmission of HIV has largely been tailored to the key affected populations at greater risk to HIV. National prevention efforts have also focused on serodiscordant couples, providing treatment for the infected spouse, condom promotion and HIV testing. Between 2010 and 2013, the level of transmission between serodiscordant couples dropped by 57%.24
HIV prevention programmes in schools have showed differing results. With the HIV epidemic in China greatly affecting young people, it is crucial that comprehensive HIV education is provided to young people in schools and colleges. One study that analysed HIV prevention programmes in secondary schools across China, found that there was a large amount of young people who despite understanding how HIV was transmitted, did not show a good understanding of misconceptions relating to HIV.25 Sources such as the internet and television have been crucial in providing young people with HIV and AIDS information, however it is unclear how much these sources increase their understanding of HIV and AIDS.26
Public HIV campaigns have been important in China’s response to the HIV epidemic. Targeting key affected populations, different events have been held around the country. The Youth Red Ribbon is one such project providing HIV education for young people and adolescents. A further example of these mass HIV campaigns can be seen in China’s “100 universities going into 1000 enterprises”. The campaign involved utilising university students who have been educated by HIV prevention programmes to go to different organisations and businesses and educate workers in HIV prevention. The programme provided over 300,000 workers with HIV and AIDS education.27
Prevention of mother-to-child transmission (PMTCT)
China’s PMTCT programme has substantially developed in recent years, with MTCT a critical concern of the national HIV response. This has resulted in a reduction in HIV-infected newborns from 7.4% in 2001 to 6.7% in 2013.28 Despite this, some studies in different Chinese provinces have found that even if PMTCT programmes exist, there is a lower availability of PMTCT interventions such as provision of antiretroviral medicines.29 In one province, Guangdong, PMTCT programme failed to meet their objectives due to a shortage of antiretroviral drugs for HIV positive mothers, with 60.2% receiving antiretroviral drugs and only 48.2% receiving these during pregnancy. Research has suggested that in many cases pregnant women were unaware or lacked knowledge of HIV antenatal health services. Factors such as early HIV testing for pregnant women are one method of raising awareness of PMTCT programmes and lowering the overall MTCT in China.30
Prevention of infected blood donation and transfusion
China’s HIV epidemic was profoundly marked by negligent blood donation activities in the early 1990s, which led to a dramatic increase in the spread of HIV across China.31 Following a ban on imported blood products in the 1980s, thousands of blood and plasma sites were established across China. Most operated illegally and collected blood from rural, impoverished areas where there would be less interference from authorities. People sold their blood to make money and the collected blood was pooled together and the plasma removed. The remaining blood was then injected back into the donors.32
Blood or plasma donation had been reported in all provinces across China by 2003 and it was estimated that HIV transmission through blood products accounted for 10% of infections in 2005.33
Serious efforts have been made to prevent these incidences from ever happening again. In 2008 almost all the blood stations in China were from voluntary, unpaid donors and in 2010 the government claimed that all collected blood products were screened for HIV.34 Preventing the risk of HIV transmission through blood products has been significantly funded, with the government providing over 80 million Yuan to improve the services and HIV testing in blood donation services.35
Antiretroviral treatment (ART) in China
The number of people living with HIV who have received antiretroviral treatment in China has significantly increased in the last few years. People on treatment has risen from 126,448 people in 2011 to 227,489 in 2013, with 2013 exhibiting the highest figures for new people accessing treatment.36
China implemented the 2013 World Health Organisation (WHO) guidelines for HIV treatment, providing HIV treatment for all PLHIV with a CD4 count of 500 or less.37 This has naturally increased the pressure on treatment centres and antiretroviral drug supplies but has also had a tremendous effect in reducing AIDS-related mortality.38 Figures for the percentage of people eligible for treatment remain unavailable,39 limiting understanding of treatment progress in China. However PMTCT treatment is still insufficient, with treatment coverage for pregnant mothers equating to just over 60%.40
It is apparent that HIV treatment across China has been significantly scaled-up, sustaining and developing this further will ensure even more people are able to access treatment. However, limited data is impacting upon a clear and informative understanding of treatment progress across the country.
Barriers to HIV prevention in China
HIV and AIDS activism in China has not been as widely celebrated and encouraged in comparison to many countries in other parts of world. Significant progress has been made in tackling the HIV and AIDS epidemic, yet many voices in the epidemic are still being suppressed, including HIV and AIDS activists, NGOs and projects.41 This has had significant repercussions for one group in particular, people living with HIV.
The government has remained cautious regarding the majority of human rights groups and non-governmental organisations, which limits their capacity quite profoundly. Harassment, detention and censorship are just some of the challenges HIV and AIDS activist groups have faced in the past.42
In 2007, the Guardian reported on a serious human rights violation in the Henan province of China. PLHIV were placed under house arrest in some villages to prevent them disclosing the reality of living with HIV in China to Chinese officials.43 Incidences such as this are seemingly not all that rare across China and have often led to increased stigma and discrimination towards PLHIV.
Despite policies in place to protect PLHIV, these policies are all too frequently undermined by state authorities such as the police.44 This also leads to increased stigma and discrimination across Chinese society. In 2014, a village was reported signing a petition to isolate and remove a young HIV-positive boy from their community.45 Attitudes and the understanding of HIV and AIDS needs to be readdressed and efforts to help raise awareness of HIV promoted if the stigma and discrimination that many face within China’s HIV epidemic is to be reduced.
Legal and punitive barriers
Major barriers to HIV prevention work concerns key affected populations. HIV programmes are severely limited by the criminalisation of the activities that many of these groups engage in. It is illegal in China to engage in sex work, often resulting to compulsory detention of sex workers for re-education and punishment. Sex workers are one of China’s key affected populations within the epidemic, with HIV prevalence at around 0.3% in 2013. HIV programmes to increase awareness and provide support are therefore severely limited by the punitive laws surrounding their work.46
China has however made progress in lifting the restrictions on entry, stay and residence.47 Laws limiting movement within and entering the country were lifted in 2010 and the Chinese government has been greatly commended following these actions, taking a positive step in reducing HIV stigma and discrimination.48
The future of HIV and AIDS in China
It is clear that China’s epidemic significantly affects key populations around the country, namely MSM and PWID. Greater effort will be required for providing more targeted interventions that adequately and effectively support these groups. Greater coordination between community level HIV organisations and national level services will crucial for the curbing the HIV epidemic in China for the future.49
It is clear that the Chinese government has made a serious commitment to the HIV epidemic across the country with 88% of the funding from domestic sources. The challenge however remains that as HIV testing and treatment continues to be scaled-up, the national response will need to effectively budget and finance it, preventing drug and resource shortages and enabling those most in need of treatment to access it.
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- 30. Li, B et al (2013) ‘Effectiveness of a prevention of mother-to-child HIV transmission program in Guangdong province from 2007 to 2010’, BMC Public Health, Vol 13: 591
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- 44. Human Rights Watch, (2010) ‘The truth of China’s response to HIV/AIDS’
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