HIV/AIDS in China

HIV/AIDS in China can be traced to an initial outbreak of the human immunodeficiency virus (HIV) first recognized in 1989 among injecting drug users along China's southern border. Figures from the Chinese Center for Disease Control and Prevention, World Health Organization, and UNAIDS estimate that there were 1.25 million people living with HIV/AIDS in China at the end of 2018, with 135,000 new infections from 2017. The reported incidence of HIV/AIDS in China is relatively low, but the Chinese government anticipates that the number of individuals infected annually will continue to increase.

While HIV is a type sexually transmitted infection, the first years of the epidemic in China were dominated by non-sexual transmission routes, particularly among users of intravenous drugs through practices such as needle sharing. By 2005, 50% of new HIV cases were due to sexual transmission, with heterosexual sex gradually becoming the most common means of new infections in the 2000s. New infections among men who have sex with men (MSMs) grew rapidly thereafter, representing 26% of all new cases in 2014, up from 2.5% in 2006. Another major, non-sexual channel of infection was the Plasma Economy of the 1990s, wherein large numbers of blood donors, primarily in poor, rural areas, were infected with HIV as a result of systematically dangerous practices by state and private blood collection clinics.

History

Chronology of major HIV/AIDS developments in China
In June 1985, China records its first death of an AIDS patient, a foreigner.
In September 1985, HIV was found in blood products imported from the United States, which indicates that the virus had been imported into mainland China with the blood products as early as in 1982. The products started to be used since 1983, marking the initial year of the HIV transmission in mainland China. Further tests found four Chinese hemophilia patients transfused with the blood product HIV positive. Shortly, China banned importation of blood products.
In 1987, a 13-year-old Chinese hemophiliac, who was infected with HIV after transfusion of foreign blood products, dies of AIDS.
In December 1989, China records its first HIV outbreak in drug users.
In 1990, the Ministry of Health sets up the National AIDS Committee.
In 1992, the National Health Education Institute sets up the country's first HIV/AIDS counseling hotline.
In 1992, the government confirms that it has recorded 11 AIDS patients and announces a medium-term plan on the prevention and control of HIV/AIDS.
In January 1995, China records its first HIV outbreak in plasma donors.
Also in January 1995, China sets up its HIV/AIDS sentinel surveillance system.
In May 1995, China shuts down all blood/plasma collection stations.
In September 1996, China launches its first condom trials.
In November 1997, China begins its first workshop on effective intervention strategies.
In July 1998, HIV is found in all 31 Chinese provinces for the first time.
In 1998, China's first 'Law on Blood Donation' takes effect on October 1. The law requires health authorities to standardize blood collection. Illegal blood collection for commercial purposes is banned.
In 1998, on November 30, the government issues a 13-year plan (1998–2010) on the prevention and control of HIV/AIDS, which sets a target to keep the HIV positive population below 1.5 million, called Medium-long Term Plan on Prevention and Control of HIV/AIDS (1998–2010).
In 1999, the Ministry of Health issues an administrative guideline, emphasizing the protection of the legitimate rights of people infected with HIV.
In October 1999, China runs its first needle-exchange program (NEP) trials.
In June 2001, the government issues its Action Plan on HIV/AIDS Prevention and Containment (2001–2005).
In August 2002, for the first time, an official of the government of China acknowledges that the country is facing an AIDS epidemic and discloses that HIV infections in China rose 67.4% in the first six months of 2001 compared with the first six months of 2000.
In December 2002, China conducts its first antiretroviral therapy (ART) and prevention of mother-to-child transmission (PMTCT) trials.
In 2003, in September, Vice Health Minister Gao Qiang pledges a set of anti-HIV measures at the 58th UN Assembly's special session on AIDS. The measures mean a larger range of government responsibility on AIDS prevention and control, including free HIV treatment for poor sufferers, establishment of AIDS control centers, the legislation of AIDS-related laws and international cooperation.
In 2003, Premier Wen Jiabao visits AIDS patients in a Beijing hospital and becomes the first premier of China to publicly shake hands with AIDS patients in a bid to eliminate social discrimination.
In December 2003, China initiates its 'Four Free and One Care' policy: free ARV drugs, free prevention of mother-to-child transmission, free voluntary counseling and testing, free schooling for children orphaned by AIDS, and care to people living with HIV/AIDS. It has since expanded to more than 120 sites nationwide.
In 2003, the Ministry of Health and the United Nations Theme Group on HIV/AIDS in China jointly issue an assessment report on December 1, which estimates that China has 840,000 HIV positive people, of whom 80,000 have AIDS. The assessment says that despite the overall low prevalence rate (an adult infection rate of less than 0.1 percent), the epidemic has spread to 31 provinces. In China the government estimated that up to 850,000 people had contracted HIV by 2000 — more than half of them having acquired the virus since 1997.
In February 2004, the State Council AIDS Working Committee is established.
In March 2004, methadone maintenance treatment (MMT) trials begin.
In 2004, Vice Premier Wu Yi openly advocates behavior intervention to the high risk population at a national working meeting on HIV/AIDS in April, marking an unprecedented step forward in the fight against the disease.
In 2004, on November 30, CPC General Secretary Hu Jintao visits AIDS patients in Beijing for face-to-face talks.
In 2006, the Ministry of Health, UNAIDS and the World Health Organization jointly issue an assessment in January in Beijing, lowering the estimated number of HIV/AIDS cases in China to 650,000, nearly 200,000 less than the 2003 estimate. The assessment also estimates that China has 75,000 AIDS patients.
In 2006, new regulations and a second five-year plan issued by the State Council on the prevention and control of HIV/AIDS took effect on March 1.

Global Background 

HIV evolved from the simian immunodeficiency virus (SIV), present in numerous species of primates in West Africa and Central Africa, in the early 20th century. SIV jumped from primates to humans several times, although the primary strain of HIV responsible for the global pandemic, HIV-1 group M, is traceable to the region surrounding Kinshasha, likely having initially crossed from chimpanzees around 1920. From there, it spread to the Caribbean around 1967, proceeding to establish itself in New York City and San Francisco circa 1971 and 1976, respectively.

The Centers for Disease Control and Prevention (CDC) recognized unusual outbreaks of opportunistic infections among gay men in 1981, and the disease was initially referred to as Gay-related immune deficiency (GRID), although it was quickly understood to also infect heterosexuals as well. In 1982, the CDC adopted the name "acquired immune deficiency syndrome" (AIDS). By the end of 1984, 7,699 cases of AIDS and 3,665 deaths had been recorded in America, with an additional cases 762 in Europe. By the end following year, over 20,000 cases were recorded globally, reaching every inhabited region in the world.

Early stages of the epidemic in China
The first recorded death due to AIDS was a male Argentine-American tourist and California resident who died in Beijing on 6 June 1985. The Chinese government focused initially on preventing foreigners from transmitting the disease to its citizens, viewing it primarily as a consequence of a Western lifestyle.

By 1998, HIV/AIDS was present in all 31 provinces and administrative regions of China, and government statistics indicated between 60% and 70% of those infected were drug users. Other major modes of transmission included infected blood spread through blood donation clinics across the country and the sex trade. Before either of these routes of infection were identified, however, a handful of people contracted HIV after receiving transfusions of contaminated hemophilia blood products from the United States.

Contaminated blood imports
Through the early 1980s, multiple American pharmaceutical firms exported medical blood products contaminated with HIV to East Asia. Bayer Corporation exported plasma knowing the risks of HIV transmission, resulting in over one hundred infections in Taiwan and Hong Kong. Factorate, a Factor VIII product of Armour Pharmaceuticals Company, was imported to China and used in blood transfusions in 19 people in Zhejiang province between 1983 and 1985. Four of the recipients, all hemophiliacs, were infected with HIV, making them at the time the first identified cases of native Chinese infected within the country's borders. Armour had been aware that original sterilization methods for Factorate were inadequate since at least 1985.

The Chinese government reacted to the threat of HIV in the blood supply before any confirmed cases of infection had occurred. In September 1984, the Chinese Ministry of Health, in conjunction with the Ministry of Foreign Economic Relations and Trade (now the Ministry of Commerce) and the General Administration of Customs, issued a notice restricting imports on foreign blood products, including a complete ban on blood coagulation factors, specifically to prevent HIV/AIDS from entering the country. The bans were poorly enforced by some local governments, prompting central authorities in August 1985 to issue another notice nationwide, reiterating the ban and ordering all sub-national governments to comply. On 30 January 1986, all blood products, with the sole exception of human serum albumin, were banned from import into China for both organizational and personal use.

Southern intravenous drug users

In 1989, central authorities became aware of a large outbreak of HIV/AIDS in western Yunnan province, in the border city of Ruili. 146 cases had been identified, mostly in injection drug users (IDUs). The outbreak was the first instance of a widespread, native infection in China, and stunned officials previously concerned mainly with preventing infection through sexual contact with foreigners. 

Yunnan borders the Golden Triangle region of Southeast Asia and has been a major hub for drug trafficking. HIV likely crossed into China along heroin trafficking routes from Myanmar. As heroin grew in popularity in Chinese border regions, injections with used needles became more common, greatly accelerating the rate of infection. The disease spread over the next several years, confined mainly to drug using populations of ethnic minorities in poorer, rural areas, reaching other high-risk groups and provinces by 1995. 

Additionally, an independent outbreak among IDUs began in 1997 in the city of Pingxiang, Guangxi. Drug users crossed the border into northern Vietnam, where heroin was similarly smuggled in from Myanmar, and shared needles with Vietnamese dealers and users to test purchases before returning to China.

Bloodhead controversy

Unique to China was the large-scale transmission of HIV through blood donation centers in the early to mid-1990s. The ban on blood product imports from the preceding decade restricted China's blood supply, making blood donation more lucrative, particularly for inadequately funded rural healthcare systems already weakened by privatization. Additionally, medicines containing blood plasma became popular among Chinese consumers, also contributing to demand for blood. By 1990, thousands of public and commercial blood and blood plasma collection centers had been established across China, attracting donors with payments that could equal over a month's worth of income for some farmers. A significant grey market of  poorly regulated "bloodheads" (Simplified Chinese: 血头, Traditional: 血頭, xuètóu, coll. xiětóu) concurrently arose. 

The unsanitary practices in the blood market led to massive propagation of the HIV virus among rural populations. Donation centers frequently recycled needles, mixed blood donations without screening, and failed to adequately sterilize equipment, spreading blood-borne disease to both donors and recipients. For plasma donations, blood was often mixed with other donors' samples and reinjected after plasma extraction. Wu, Rou, and Detels (2001) found that 12.5% of plasma donors in eastern China tested positive for HIV, compared to 1.3% of non-donors; infected donors spread the disease to marital and other sexual partners.  In 2004, official estimates put the range of people infected via unsafe blood donation practices across the most heavily impacted provinces--Henan, Hebei, Anhui, Shaanxi, and Shanxi--at between 200,000 and 300,000. Gansu and Qinghai also reported infections stemming from the commercial blood trade during the same time period. Overall, 24% of all HIV/AIDS cases in China in 2004 had been attributed to blood donation and related activities.

The phenomenon was especially prevalent in Henan, where it was promoted by local officials, including Henan Ministry of Health director Liu Quanxi and provincial Communist Party Secretary Li Changchun, to promote economic growth. An internal report compiled in August 2002 by the Henan Ministry of Health, leaked by prominent AIDS activist Wan Yanhai, estimated that 35-45% of blood donors in some areas of the province had been infected due to poor safety precautions in clinics. 

The Chinese government was slow to admit and respond to the problem after it was identified, and initially repressed efforts to expose it. Shuping Wang and Gao Yaojie, two female doctors from Henan, mounted campaigns to expose the dangerous practices they saw in the early 1990s that put donors at risk for HIV infection. The central government eventually ordered commercial clinics to be shut down in 1995, reopening them in 1997 after stronger regulations on blood donation practices were instituted, although there is evidence that dangerous and unhygienic practices were not completely eliminated. Both Gao and Wang eventually left China for the United States, citing apparent government harassment and intimidation resulting from their advocacy efforts. Even after acknowledging the issue, central and local government bodies sought to suppress discussion or coverage. Wan Yanhai was arrested in 2003 for attempting to screen a movie about the scandal in Beijing. In 2004, while acknowledging some victims had contracted HIV because of inadequate hygiene in blood donation centers and agreeing to provide compensation, authorities still sought to classify such infections as resultant of use of drugs or prostitution in official records.

Sex trade
While the majority of early infections occurred as a result of intravenous injection transmission or tainted blood supplies, prostitution also played a role spreading HIV/AIDS. China's economy rapidly grew as a result of Reform and Opening Up policies, and patronage of commercial sex workers, many of whom were injecting drug users, grew among both wealthy businessman and migrant worker populations, bringing HIV back to their hometowns and other cities.

Epidemiology
Estimates from the Chinese Center for Disease Control and Prevention, World Health Organization, and UNAIDS calculated approximately 1.25 million people living with HIV/AIDS in China at the end of 2018, with 135,000 new infections over the previous year. It was by far the deadliest notifiable disease of 2018, killing 18,780 individuals, compared to 3,149 for tuberculosis, the second-most deadly. The government expects infections to continue to accelerate.

Data collection
The Chinese government did not begin active surveillance of the spread of HIV/AIDS through systematic data collection until 1995, when 42 surveillance sites were established in 23 provinces, expanding to 247 sites nationwide in 2004. Passive surveillance methods that mandated reporting of confirmed HIV/AIDS cases were implemented in 1986. Data from this period suffered a number of shortcomings, including minimal coverage of the general population due to focus on high-risk groups, poor data on men who have sex with men (MSM), stovepiping among different government entities, and difficulties obtaining data from private healthcare providers. Accordingly, estimates varied greatly; in 2004, official and unofficial assessments of total HIV/AIDS cases ranged from 430,000 to 1.5 million in 2004. Through the early 2000s, the Chinese government limited discussion of data and statistics of HIV/AIDS in the country, and media only reported numbers approved by the government. 

The Chinese government greatly expanded the scope and number of HIV surveillance sites beginning in 2010, increasing coverage of all groups and expanding to cover larger portions of the population. Data gathered through the system was generally reliable, although issues with standardized protocols across different sites and coordination among different levels of government were identified in independent studies.

Transmission
HIV in China is primarily transmitted through sexual contact, which accounts for over 90% of new infections. Sexual transmission gradually began to overtake the originally predominant routes of transmission, injection drug use and unsafe blood donation practices, throughout the 1990s and into the mid-2000s. In 2005, sexual transmission accounted for 50% of all new infections, and by 2007, the majority of HIV/AIDS cases were related to sexual transmission pathways.

Primary high-risk groups for HIV infection include intravenous drug users, men who have sex with men (MSM), and sex workers. The Chinese government has additionally established data collection and monitoring sites targeting male migrant workers, long-distance truck drivers, male STI clinic patients, antenatal care clinic patients, and college students. 

MSM in particular have seen a significant increase in transmission rates since epidemiological studies examining began in 2000. They represented 26% of new reported cases in 2014, up from 2.5% in 2006. Hypothesized causes of this increase include: increased migration from poorer regions with high HIV prevalence to urban areas and somewhat liberalized attitude towards homosexuality in China over the last two decades. MSM are also generally at a higher risk for contracting STIs, including syphilis, which may form a coinfection with HIV. Drug use contributes little to HIV infection among MSM, with the overwhelming majority of new cases being the result of sexual activity. More than one-fifth of MSM are married to women, which might speed the transmission of HIV to the general population, and outreach to this subgroup in particular can be difficult.

Predictions
Predictions of the size of the HIV/AIDS epidemic in China have been made by several expert bodies. Notable examples include:
In 2002, a UN-commissioned report, emotively entitled China's Titanic peril, estimated that China had about 1 million cases of HIV, and that it was on the brink of an "explosive HIV/AIDS epidemic... with an imminent risk to widespread dissemination to the general population". The report continued: "a potential HIV/AIDS disaster of unimaginable proportion now lies in wait."
In September 2002, the US National Intelligence Council estimated that 1–2 million people were living with HIV in China, and predicted 10–15 million cases by 2010. The National Intelligence Council claimed that these figures were more reliable than previous estimates because they did not rely on official Chinese sources, which the National Intelligence Council asserted "systematically understate the actual figures", but rather incorporated assessments by academics and non-governmental organizations working in the field.
The number of people infected with HIV/AIDS in China "could rise to 10 million in the next six years unless the government acts urgently and effectively to prevent an epidemic", the Joint United Nations Programme on HIV/AIDS said in its 2004 biennial report on the global AIDS epidemic. The virus has spread to all provinces of China but with no distinct pattern of infection, and there are "extremely serious" epidemics in parts of the country despite a low rate of the disease nationwide of about 0.1 percent, the report said.

These estimates assumed substantial spread of the virus from high-risk groups to the general population. Yet, trends from sentinel surveillance of pregnant women in high-risk areas might indicate that such spread may not have occurred. Another study showed, however, that 43% of the tested infected people were from low-risk groups. More recently, China AIDS Info reported that "HIV infection has caused a 75% increase in the worldwide mortality rate for newborns" and quoted a case in China. It is discussed, whether these predictions may have been made on unfounded assumptions. Some have argued that the effect of the high predictions have drawn attention and resources away from areas of greater need. For example, China's burden of disease from tobacco use is enormous. Others argue that due to the large number of cases of undiagnosed infections HIV testing must be introduced via "anonymous surveillance and voluntary counseling and testing in order to reduce transmission".

Control and prevention
The Chinese government has been widely criticized for its failure to respond to the HIV/AIDS threat and for systematic suppression of information about the size of the problem.

Overview
Early efforts to control the HIV/AIDS epidemic emphasized enforcement of laws against high-risk behavior. Later lessons from effective interventions in pilot programs and in other countries (e.g., needle exchange programs in Australia and condom campaigns for sex workers in Thailand) have led to a more evidence-based approach.

The process of policy development have not been tidy because of tensions arising particularly from those between public health officials and the police and those within public security over the management of illegal drug use and prostitution. However, the 2006 AIDS Prevention and Control Regulations are an example of evidence-based policy, even if their implementation is highly variable across China.

In 2003, in response to the ever-growing spread of HIV/AIDS, the Chinese government declared a strong commitment to its prevention. Long- and medium-term plans for controlling and preventing HIV/AIDS have been developed, and a central government coordinating committee has been formed among 33 ministries.

Additionally, research is being done to explore optimizing testing programs within target populations. SESH, a research partnership dedicated to developing creative, equitable, and effective solutions to sexual health dilemmas, has looked extensively into ways to improve HIV detection among MSM. Research suggests that testing can be optimized by offering rapid STD testing at MSM-focused centers, improving confidentiality, and ensuring test accuracy.

Treatment programs

Current treatment plan
The government now provides free AIDS drugs to rural residents and city-dwellers without insurance. Other measures include:
Free voluntary counseling and testing.
Free drugs to HIV-infected pregnant women to prevent mother-to-child transmission, and HIV testing of newborn babies.
Free schooling for AIDS orphans.
Care and economic assistance to the households of people living with HIV/AIDS.

Pilot programs
The government has recently approved a series of pilot programs, such as:
a needle exchange program for drug users who have gone through detoxification
a methadone maintenance treatment program
vending machines selling condoms have been set up in public places.

Health promotion
A national program has been launched to combat the stigma and discrimination against people with HIV/AIDS.

In 2006, 5,000 Beijing taxi drivers handed out HIV/AIDS information leaflets to passengers in the first 10 days of December.
Officials in the southwestern province of Yunnan announced in 2006 that, starting on January 1, 2007, Yunnan residents will be required by law to take an HIV test before marriage. There would be no charge for the test, the results of which are to be shared with prospective spouses. Yunnan, home to 25% of the country's HIV cases, borders the opium-rich Golden Triangle of Vietnam, Laos and Myanmar. The virus has been found in 128 of its 129 counties, the provincial government has said.

Future treatment options

In China, a distant hope for HIV prevention is the development of an effective vaccine that can offer long-term protection against the wide spectrum of HIV variants that exist. Despite the fact that there are now more than 30 vaccine candidates in clinical trials (in the world), and three of these are in advance stage testing (phase IIb and phase III), many obstacles still lie in the way of the development of a truly effective HIV preventive vaccine.

Funding

Private sector and NGO involvement
Since 2003, the central government showed an increasing openness on AIDS issues, making several public statements encouraging the participation of the private sector and, to some extent, NGOs. This was due, in part, to the SARS epidemic, which helped change the way in which government dealt with public health issues. For a prolonged period, the authorities did not admit to having a serious outbreak of SARS until it was a devastating problem and only then did they decide to come forward and acknowledge the real scale of the epidemic. The new-found frankness helped the government win back some credibility before the international community.

Currently, there are dozens of different projects sponsored by the private sector targeting the problem around the country, from education and awareness programmes to increasing the capacity of local NGOs. Notable cases include:
Merck, a US pharmaceutical company, is spending about US$30m over a period of five years. The program involves training for healthcare professionals, condom distribution and identifying high-risk groups.
Bayer, a German pharmaceutical company, has set up a training course in HIV/AIDS issues for journalists. About 300 reporters have completed the course so far at Tsinghua University in Beijing.
Standard Chartered Bank has introduced some of the approaches it has learned from its operations in southern Africa, including awareness programs for new employees and encouraging staff to be tested.

Traditional Chinese Medicine
There is some evidence that traditional Chinese medicine may help in relieving symptoms of AIDS, but there is no evidence TCM has a significant effect on a patient's HIV status.

Public awareness and education
Public ignorance about AIDS is a major problem in China. A 2001 survey found 20 percent of people had never heard of the disease.

Criticisms and control problems

Government policies
Health officials say there are plenty of problems in China's approach to AIDS. There are frequent reports of police crack-downs on local NGOs involved in AIDS prevention. There have also been reports of police using the presence of a condom in a sex worker's handbag to justify detention. This has been partially blamed on policy incoordination, and contradictions and conflicts between laws and regulations.

In addition, there are concerns that provincial governments have enough autonomy to sometimes stall the implementation of central government-set guidelines and some officials say there has been a reluctance from many state-owned companies to get involved in AIDS programs.

Discrimination and stigma
Many Chinese businesses have been reluctant to make voluntary commitments to non-discriminatory treatment of HIV-positive employees, often because they fear lawsuits and because they are unable to recoup the cost of HIV/AIDS related health care from company insurance policies.

Population movement and urban-rural inequality

Challenges ahead
China has made impressive progress in the development and implementation of effective intervention strategies, especially since 2004. The country is currently in a transition stage in its HIV policy development. It is increasingly adopting approaches that are based on scientific evidence and has encouraged the pilot testing of controversial methods of risk reduction (e.g., methadone maintenance treatment, needle exchange programmes, and the targeting of men who have sex with men and sex workers).

Failures in scaling-up HIV prevention programmes have not been caused by an absence of policy, but rather, as with other countries, by there being no policy enforcement and timely scale-up. Although China has a strong central government, provincial and lower levels of government enjoy a great deal of autonomy, which has resulted in a mixed response and inconsistent enforcement of HIV/AIDS policy. For example, Yunnan province has shown strong support for implementation and advocacy of harm-reduction strategies that reduce HIV transmission in its many drug users, whereas Henan province had been slower to respond to the needs of former plasma donors in the early stages of the epidemic. Moreover, the distribution of HIV in China is not even, and is concentrated in areas with high drug use (e.g., Yunnan, Guangxi, Xinjiang, and Sichuan) and in areas where people were infected through unsafe blood or plasma donation (e.g., Henan, Anhui, Hebei, Shanxi, and Hubei). The number of cases ranges dramatically between provinces, with, for example, just 20 cases reported from Tibet but well over 40,000 in neighboring Yunnan. In provinces with an extremely low prevalence, it can be difficult for officials to see the need for HIV prevention and control.

Conflicts of interest between departments, such as those responsible for health and public security, have also made coordination of services to reach high-risk groups that engage in illegal behavior difficult. The central government has called for greater cooperation between relevant departments – including Public Security, Justice, Education, Civil Affairs, and Health – but implementation of this policy at the local level varies.

The problem is further exacerbated by inadequate resources and trained personnel. Many rural areas – where most of China's HIV-positive population resides – do not have the capacity to monitor patients' CD4+ cell counts and viral load. In some cases, the physical infrastructure exists, but staff do not have the skills or reagents to use it. Human resource capacity is a major constraint on China's ability to deliver HIV prevention and care. Many health workers and educators have poor knowledge of HIV and hold their own biases and stigmas towards those at risk or infected with HIV. A substantial proportion of the funds allocated to HIV prevention and control is being spent on establishing training centers and in building the capacity of health workers so that they can deliver better services. But many of those willing to work in rural areas do not have formal medical qualifications to begin with, which limits their abilities to understand the complexities of treating HIV patients. Furthermore, health services rely heavily on user fees, which often encourages health workers to do additional, chargeable services that many people living with HIV/AIDS cannot afford.

With an estimated 650,000 people living with HIV/AIDS and an ever-greater number of people at risk of infection, the government has embarked upon a formidable task. The provision of accessible testing and treatment services not only requires financial resources, but also, in many cases, reorganization and supplementary funding of existing local health services infrastructure, especially in rural areas where most of Chinese HIV-positive individuals reside. In particular, rural areas do not have adequately trained staff capable of providing effective treatment and prevention services, as well as the laboratory and clinical infrastructure necessary to monitor treatment. The problem of inadequate human resources is not restricted to health departments – in rural areas, there are few adequately trained technical and management personnel at all levels and across all sectors. The combination of insufficiently trained staff, inadequate technical resources, and a largely remote, poorly educated, rural population represents a challenge to the implementation of effective programmes.

A major step has been the government's promotion of NGOs, which are a new concept in China. Many of the larger domestic groups are actually government funded, and those not affiliated with the government are required to go through a complicated registration procedure to be officially endorsed, although there might be a relaxation of these policies in the future. The presence of international NGOs is also increasing. The ability of NGOs to work with high-risk groups, especially those that engage in behaviors deemed to be illegal or immoral, and to provide care and outreach where overstretched health services cannot, is recognized. The private sector is also being encouraged to undertake prevention and education activities.

The mobilization of multiple sectors within China occurred over a 15-year period when there was a long series of educational workshops, conferences, collaborative projects, and networking between members at a number of levels of the government and administrative structural hierarchies. At local, national, and international forums, officials from many sectors were able to meet one another, share a common knowledge base, and debate the appropriateness of different interventions. Personal relationships were formed that facilitated the consideration and examination of previously unrecognised policy options for detection, prevention, and care. In a non-linear process, a consensus slowly evolved, identifying policy options.

Political officials, policymakers, administrators, and service providers were increasingly willing to recognize the relevance of a substantial body of scientific research that suggested effective intervention strategies that could change the course of the epidemic. Also, major policy recommendations with regard to behavioral interventions were preceded by small pilot projects that showed feasibility or efficacy in those populations at highest risk. Once the evidence base was documented, both the policymakers and politicians publicly showed their support for HIV prevention and care, as well as passing legislation to enforce and broadly disseminate health practices (e.g., routine HIV testing and access to care).

These processes occurred in a context of ongoing influences from the media and international donor agencies, with some contribution from advocacy groups within China. The SARS epidemic showed the potentially disastrous effect of a fast-moving infectious disease and, simultaneously, allowed the HIV community to acquire new methods to fight the epidemic (e.g., real-time data collection of new cases). However, mobilisation of resources, scientific evidence, and administrative drive did not occur until there was enthusiastic political commitment. The pace of implementation of innovative strategies for HIV detection, prevention, and care, accelerated with the commitments made by the government of Hu Jintao, starting in 2003.

After a slow start and reluctance to recognize the existence of risk activities in its population and of the HIV epidemic, China has responded to international influences, media coverage, and scientific evidence to take bold steps to control the epidemic, using scientifically validated strategies. The country now faces the challenge of scaling up these programmes and of convincing all levels of government to implement these innovative strategies and policies. This vigorous response, incorporating research findings into policy formulation, can be informative to other countries that face similar challenges in responding to the HIV/AIDS epidemic.

Activism
In China, like elsewhere, HIV/AIDS activists have played and continue to play an essential role in promoting public awareness and education about the disease, helping to prevent discrimination against people living with HIV/AIDS and highlighting factors which may impede efforts to check the spread of the disease.

It has been claimed by some international human rights groups that HIV/AIDS activists in China continue to face serious obstacles in their work, including arbitrary detention, harassment and intimidation, and other human rights violations. Restrictions on travel by Dr. Gao Yaojie, a Henan activist, have been cited in news reports.

The country's best-known AIDS activist, Wan Yanhai, believes China suffers 10 times the number of HIV cases – 650,000 – estimated by health officials.

Socioeconomic effect
The process of the effect of HIV/AIDS can be described as having three key stages: first, the effect experienced at the micro level; second, at the sectoral level; and finally, at the macro level. The effect began to be observed in China at the micro, or household level, and will most certainly be observed in the future at the sectoral level. Individuals and families have been bearing both the economic and social costs of the disease, and the poverty of those affected have increased and will further increase substantially. Expenditures for the health sector will increase, for both treatment and prevention interventions. The macro level has been mostly unaffected . But if without effective preventive action, the HIV spread in the general population at large will affect the macro level as have happened in some countries in sub-Saharan Africa.

Severe acute respiratory syndrome
The challenge of managing the severe acute respiratory syndrome (SARS) epidemic (November 2002 to June 2003) is often credited with further motivating the government to take aggressive policy action on HIV-related issues. SARS showed not only how infectious diseases could threaten economic and social stability but also the effect of China's policies on international health problems. Policymakers announced a change of focus from purely economic goals to increasing the focus on health and social wellbeing and, as a result, increased support for public health agencies. In controlling SARS, contact between the government and international agencies such as WHO, UN, and the US Centers for Disease Control and Prevention was essential and further stimulated stronger international collaboration for HIV/AIDS prevention and treatment. Intervention strategies necessary for SARS control have been translated into HIV/AIDS prevention – e.g., real-time electronic case reporting.

Media
The media have exerted substantial influence over the timing and course of HIV control in China by bringing news of HIV to the attention of the public, administrators, and policymakers. In 1996, the Southern Weekend newspaper ran a front-page story and devoted another two pages to AIDS in China. This coverage was the first time any comprehensive exposure of the HIV/AIDS epidemic in China had been published by the Chinese press. From 1999, the international and subsequently the national media reported on the thousands of infected plasma donors in Henan and neighbouring provinces who did not have access to services. Although the government had acted quickly when the tragedy became apparent in 1995 by shutting down collection stations and, later, introducing new laws and regulations on the collection and management of blood and blood products, provision of HIV testing, prevention, and care for donors in the local areas was slower. Progress was stimulated by the media's attention to the plight of the infected plasma donors. Since these initial reports, the HIV/AIDS situation in China has received much attention from the local and international media.

Documentaries
Chinese-American director Ruby Yang has recently made a documentary about AIDS in rural China, which premiered on 14 June 2006, entitled The Blood of Yingzhou District.

An abridged version of Robert Bilheimer's acclaimed US-made 2003 documentary A Closer Walk was shown on China Central Television (CCTV) on World AIDS Day, December 1 (Friday), 2006, and was rerun Sunday and Monday. It was viewed by around 400 million people. The 75-minute-long documentary, narrated by actors Will Smith and Glenn Close, had premiered in the United States in 2003.

See also
The Blood of Yingzhou District
Plasma Economy
Hu Jia (activist)
Gao Yaojie
Wangdu (activist)
Wan Yanhai
HIV/AIDS in Yunnan
Zeng Jinyan

Notes and references

Further reading

Gill B and Okie S. China and HIV — A Window of Opportunity. N Engl J Med 2007; 356(18): 1801–05.
Chen HT, Liang S, Liao Q, Wang S, Schumacher JE, Creger TN, Wilson CM, Dong B, Vermund SH. HIV Voluntary Counseling and Testing among Injection Drug Users in South China: A Study of a Non-Government Organization Based Program. AIDS Behav Mar 9, 2007.

Wu Z. Sustainability of effective STD/HIV prevention intervention targeting female prostitutes and their clients at five different settings in China. Final Report to the World AIDS Foundation. Beijing, China: Chinese Academy of Preventive Medicine, 2002.

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External links

External links
National Center for STD and AIDS Prevention Control, China CDC
 List of HIV/AIDS Research Centers in China—compiled by the Hong Kong AIDS Information Network.
AIDS Concern HK
China HIV/AIDS Information Network
UNICEF China - HIV/AIDS

 
China