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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”


   


 

AIDS in China: From Drugs to Blood to Sex

A December 2000 report from U.S. Embassy Beijing

http://www.usembassy-china.org.cn/sandt/hivsextrans.htm

Summary: Timely intervention may still be able to slow the spread of HIV from current high-risk groups -- such as intravenous drug users and paid blood donors -- to the general population, where it will spread rapidly via sexual relations, according to Chinese experts. China's flourishing sex trade and ever-increasing rates of sexually transmitted diseases, especially syphillis, are creating conditions that allow HIV to spread more easily. In Yunnan Province, where the HIV/AIDS epidemic is oldest and most serious, the Provincial government's epidemiological station estimates that 28% of intravenous drug users, two percent of Yunnan Province prostitutes, and one percent of those who patronize prostitutes were infected with HIV as of the end of 1999. Meanwhile, large reservoirs of HIV in intravenous drug users and paid blood donors (reportedly 10,000 in one Henan county alone) increase the likelihood that HIV will spread rapidly from these groups to the general population through heterosexual transmission.

Interventions among commercial sex workers will become increasingly important. Some NGO's teach IV drug users and prostitutes risk reduction behaviors such as condom use, but still need to be very cautious in their work with people on the margins of society and the law. A wider strategy addressing social, political and economic issues, already adopted in some Southeast Asian countries, may be more successful. Some foreign and Chinese experts propose working with at least the tacit consent of police and local governments to appeal to the business interests of "entertainment house" operators that condoms should be used by sex workers, since STD's and HIV are bad for business. And some Chinese epidemiologists and social scientists openly argue that greater toleration of marginalized groups and the legalization of prostitution will be needed to defeat the HIV/AIDS epidemic in China.

  


 

How Much HIV? Nobody Knows (or They're Not Saying)

Chinese experts emphasize that there is no reliable information on how far HIV has actually spread in China. The government estimates that 75% of HIV-infected people in China are intravenous drug users, but many epidemiologists, both foreign and Chinese, do not consider this data to be reliable.  Surveillance in China focuses on publicly acknowledged high-risk populations such as drug users.  But some Chinese officials believe that the numbers of people infected through selling or receiving blood transfusions is much higher than is commonly stated publicly.  In addition, China's sex trade, which flourishes even in rural areas, greatly boosts the risk of the rapid spread of HIV beyond current acknowledged high-risk groups such as intravenous drug users.

Further complicating the question of how many people in China carry HIV, many of China's HIV-infected are among the nation's 100 million migrant workers, a group that is relatively difficult to study.  The Shanxi Province Epidemiological Station reported in an October 2000 article that of 176 HIV cases reported (very likely only a very small fraction of the actual number), two-thirds were migrant workers.  Nearly one-half of the migrant workers were from outside Shanxi, and five percent of the HIV-infected persons were paid blood donors.

As a result, some Chinese experts now estimate the number of Chinese infected with HIV to be as high as one million, with the total figure increasing by about 30% annually.  Aside from Yunnan Province, the "birthplace" of AIDS in China, the regions of Henan, Sichuan, Xinjiang, and Guangxi have been especially hard hit with HIV/AIDS.  The sexual transmission of HIV seems already well-established in Yunnan, and perhaps soon will become prominent in some of the southeast coastal provinces that suffer high STD rates.  (Yunnan Province is reported to be home to about half of China's HIV-infected population, and 44% of its AIDS cases. But Yunnan has the most monitoring stations, so it is possible that its high HIV ranking is also related to its relatively effective monitoring, in addition to the relative seriousness of the HIV problem.)

Despite the rapid spread of HIV throughout China, some local governments still do not want their own people or the central government to know how many people are infected with HIV.  Information about the spread of HIV among paid blood donors, in particular, is often suppressed.  Reports in local newspapers concerning paid blood donations and the spread of HIV almost always report on problems in other provinces, not the home province of the media outlet.  For example, a Chengdu newspaper in December 1999 broke the story of the Wenlou AIDS village in Shangcai County, Henan Province.  (See the Spring 2000 Embassy Beijing reports PRC Blood Donors and the Spread of Rural AIDS and  PRC Henan Rural County: No AIDS Here?, as well as recent stories in Time magazine and the New York Times.  In addition, the November 30 edition of the national Chinese newspaper Southern Weekend quoted an unamed Shangcai County epidemiological station worker as saying that Shangsai County has nearly 10,000 HIV-infected people.  The worker asked to remain anonymous for fear of reprisals.)

Some officials consider public discussion of the blood donor/HIV connection to be a threat to social stability, since Chinese people might well blame the problem on official negligence, and therefore believe that denial is the best course.  Physicians in some areas are actively discouraged from speaking out about HIV among paid blood donors.  One Chinese physician was in fact accused recently of helping "spies and anti-China forces" by giving interviews to foreign journalists.

Blood Donors an Important Transmission Channel

There are HIV-infected paid blood donor villages not only in Henan but also in Hubei, Hebei, Shanxi and other provinces. The plight of the hundreds of HIV-infected paid blood donors of Shangcai County is far from unique.  One hundred kilometers away is another blood donor village where 96 out of 155 (or 62%) of the paid blood donors tested HIV positive.  The Kaifeng, Shangqiu, Zhoukou, and Zhumadian regions of Henan Province are also reportedly home to numerous HIV-infected blood donor villages.

An October 1998 law banning paid blood donations has helped reduce the scale of this activity.  But chronic blood shortages, and the strong economic incentive for migrants to sell their blood, have made it difficult to entirely eliminate paid blood donations.  In October, Southern Weekend reported on high rates of blood-borne disease among several thousand illegally-organized paid blood donors in Gansu (see Beijing EST Update November 3, 2000) .  According to Chinese officials, authorities in one other Chinese province have found several illegal blood plasma collection stations over the past two years.  When nearly 100 paid donors found at the blood plasma collection stations were tested for HIV, some 75 tested positive.

Prostitution a Key Factor in Widening Reach of HIV

Chinese HIV researchers explain that one reason China's HIV/AIDS prevalence in China is still fairly low (perhaps one million persons out of a total of 1.3 billion) is that drug users and prostitutes have have begun to mingle only in recent years.  Formerly, drug users were generally located in ethnic minority and rural areas such as Yunnan and Xinjiang, and were usually poor and less mobile.  Prostitutes, on the other hand, were more mobile and generally resided in urban areas.  This situation is changing rapidly.

In recent years, China's rapidly expanding prostitution trade is increasing the risk of HIV infection for urban populations.  (See the overview  A Close Look at China's Sex Industry  in Singapore's United Morning News as one illustration of the growth of prostitution in China, which fits well with what Embassy Beijing has heard from some Chinese epidemiologists and seen reported in the Chinese press.)  The Yunnan Provincial Government Health and Epidemiology Center, reporting in the October 2000 edition of the "Journal for China AIDS/STD Prevention and Control," stated that about 2% of prostitutes and 2% of STD patients in Yunnan Province have HIV.  In addition, about 1% of those who patronize prostitutes are infected.  (Although these percentages seem low, the numbers of people involved is quite high.  The big tourist boom in Yunnan of the past few years, in particular, has increased sex tourism and prostitution there.  One informed Yunnan observer said that Public Security in Yunnan often turns a blind eye to prostitution to the region's sex industry.)

Most experts agree that some prostitutes are IV drug users, and that the two populations have begun to intermingle. Commercial sex workers have many different sexual partners and so spread HIV much more widely and more rapidly than IV drug users (who transmit HIV only within their circle of fellow drug users).

If more HIV continues to spread from the IV drug-using population to prostitutes, the speed of transmission will increase, and HIV could easily spread from high-risk populations to the general population.  However, suppression of information about the widespread HIV problem in rural China means that many people are not told they have HIV.  Hospitals often simply tell people with AIDS "we can't help you here" or say cryptically "you have number four."  In this atmosphere, people with HIV bounce from hospital to hospital, HIV-infected prostitutes keep working, and HIV-infected blood donors keep selling blood.  Although there is more voluntary blood donations being made in China since the passage of the October 1998 law, voluntary donations are still far to few to meet the great demand for blood.

In addition, sexually-transmitted diseases (STD's), and especially syphillis, greatly increase the likelihood of transmission of HIV through sexual intercourse.  And STD infections in China continue to grow at roughly 30% each year -- a long-term trend.  (STD infections climbed 32% nationally in 1999, according to the Chinese National Center for STD and Leprosy Control.)  Mother-to-child congenital syphillis rates, meanwhile, doubled during 1999.  Shanghai, Zhejiang, Beijing, Jiangsu, Guangdong and Hainan report the highest incidence of STD's, although Shanghai, Guangdong and Hainan reported increases of 10% or less.
 

Government Policies Often Complicate HIV Prevention

Harm reduction strategies aim to persuade people in high-risk groups to protect themselves against HIV, even if they are unwilling to stop the risky behavior.  IV drug users can be encouraged to use clean needles, and prostitutes to use condoms and have regular medical check-ups.  However, because drug use and commercial sex work are illegal, interventions to prevent HIV are often constrained by state policies designed to prevent drug use and prostitution.  According to Chinese law, for example, a person may be arrested for drug abuse if carrying an injection needle.  Thus, fear of arrest may discourage many IV drug users from participating in needle exchange programs or carrying clean needles themselves (instead using those provided by the drug sellers).  This creates greater risk for HIV transmission, according to drug abuse experts.  Similarly, programs to reduce risk of HIV transmission among commercial sex workers may elicit harsh criticism or even a crackdown from Public Security officials, who in turn fear attracting attention to rapidly expanding commercial sex activity.

Yunnan provincial health officials assert that, often, Public Security officials (as well as the general population) fear that HIV prevention efforts among drug users and commercial sex workers might lead to an even more rapid expansion in drug abuse and prostitution.  Thus, efforts focus on eradicating the illegal behavior, rather than on preventing HIV transmission.  This policy complicates the work of HIV prevention, say health officials.  If prevention efforts are to succeed, these officials emphasize, behavior change programs to prevent HIV transmission must be implemented, even if IV drug use and commercial sex work persists.

  


 

Some Call for Social Toleration to Help Beat AIDS

Wang Yanguang of the Chinese Academy of Social Sciences Institute of Philosophy, in his April 2000 article titled "Strategy of Tolerance and HIV/AIDS Prevention in China," argued that only by adopting harm reduction strategies, and combined those strategies with tolerance for people who have different beliefs and behaviors, can China beat the HIV/AIDS epidemic.  Wang wrote, "AIDS must be controlled so that the Chinese nation can survive ... AIDS control policies are hard to implement because of the different interests of socially marginal groups that have different beliefs, morals, values and behaviors.  Yet all people share a common interest in controlling AIDS."  Wang went on to criticize the Cuban practice of putting HIV-infected people in concentration camps, calling that approach an ineffective way to combat HIV given the large numbers of people involved, and the fact that such policies might just drive infected people underground.

In China, Wang argued, prostitution is widespread and takes many different forms.  Neither the "strike hard" approach of the Chinese police nor the "red light district" strategy suggested by some Chinese scholars can be successful, he believes.  Wang wrote: "The rapid growth of China's sex industry is not simply a matter of the moral fall of those women who sell themselves.  The context of this problem includes rapid economic development, a growing gap between rich and the poor in both cities and the countryside, unemployment, poverty and relative poverty, and a big buyer's market.  Under these conditions, there are no simple solutions that could make the sex trade disappear in a short time.  The only solution is for the health authorities and public security to work together to see that prostitutes use condoms ... and get regular medical care.  Only in this way can we ensure that the chances of HIV being transmitted by prostitutes can be reduced."

Wang uses similar arguments concerning tolerance for drug abusers and homosexuals, noting that Chinese officials are now more tolerant of homosexuals than ever before, but the Chinese public is still very intolerant.  Wang wrote that treatment must be offered to drug addicts and, without changing the laws, measures should be taken to minimize those aspects of law enforcement that make epidemic control more difficult.  Chinese AIDS researchers have suggested a tolerance strategy to China's leaders, but the legalization of prostitution appears difficult for them to accept.

Behavioral Intervention Too Expensive For Government?

Intervention strategies are expensive.  Chinese Ministry of Health AIDS Prevention and Control researcher Wu Zunyou told the November 30 edition of Southern Weekend that the lowest estimate of the cost of HIV prevention education and behavioral intervention for China's four million prostitutes and six million drug addicts would be roughly USD 1 billion. In this context, the Chinese central government will continue to look to other governments and NGOs for help -- both financial and technical.

Some Yunnan health officials have said that small- scale grass roots pilot projects could succeed, as long as the HIV prevention goals were made clear from the outset.  Winning the trust and support of the local Public Security office would be essential, however.  At the same time, Chinese specialists note that behavioral and attitude intervention is not just for high-risk groups -- it should be aimed at government and Party leaders as well, because changes in awareness, ideas, and attitudes among the leadership can help improve existing policies.  Even if officials do not come to support HIV intervention, they may desist from blocking it.

Current government efforts to eradicate drug abuse include mandatory detoxification and treatment centers, but concurrent rehabilitation programs are relatively rare.  As in the U.S., Chinese heroin addicts have a very high relapse rate -- in Yunnan it is about 90%.  Some Yunnan drug abuse experts plan to include more programs on HIV prevention through harm reduction, when conducting educational programs for drug abusers.

In August 2000, an Embassy officer visited an intervention project in a Yunnan resort town with a flourishing sex industry, which targets sex workers (although provincial officials prefer to call them "entertainment workers").  The project began in April 1999 with two years of funding from the World Health Organization (WHO).  The clinic is housed in a hospital that offers medical care as well as counseling.  All clinic staff are trained at the nearby Kunming City STD hospital, and outreach work includes visits to local entertainment establishments, the distribution of free education materials to sex workers (both written and video materials), and training peer educators among the women.  Mid-course evaluations indicated that the project had been quite successful in raising HIV awareness among female sex workers.  Positive behavior changes such as increased HIV awareness and somewhat higher condom use were also realized.

Local officials noted that the pilot project has been successful because it had earned local financial and policy support.  Many factors that make this intervention successful, however, are apparently difficult to replicate in other parts of Yunnan:

  The project is located close to Kunming City, a major source of expertise, opportunities for training and skilled professionals;

  The township involved is fairly prosperous;

  The hospital is the only high-level hospital in the area, so many women would go there anyways, making the target population easier to access.

  Most important, the project has good relations with the local Public Security office.  Project staff explained the project to Public Security and persuaded the police that public health and public security goals coincide.  The attitude of local public security officials toward HIV work with prostitutes or IV drug users can vary widely in different parts of Yunnan, as well as in different parts of China.

Comment

When local governments deny that HIV exists, it greatly complicates intervention efforts to prevent the spread of HIV.  But effective intervention is now urgent business, or many millions of Chinese people could die unnecessarily from HIV.  Many types of intervention focus on individuals, but ignore the social and economic context -- especially in the case of prostitution and its increasingly important role in spreading HIV.  For example, prostitutes may want to use condoms, but their customers resist.  In this context, many experts believe that the best approach is to argue with local governments that HIV and other STD's "are bad for business."  Bar managers don't want their bar to get a bad reputation -- and if all bars or entertainment establishments implement similar requirements for condom use and health check-ups, then no one will be at a competitive disadvantage.

An appeal to the economic interests of those who control prostitution has been a viable strategy in some Southeast Asian countries, notably Thailand.  A similar approach could possibly work in some areas of China, if the leadership would take the plunge of admitting that prostitution is common, and difficult to combat in absolute terms.  Local governments, for example, might be able to compel bars to agree to mandatory condoms and health check-ups by using harassment (for example incessant health inspections) as a penalty.  However, since many prostitutes in China have been kidnapped or impressed into prostitution and many are poor migrants from the countryside, the interest of the bar operators in the prostitutes as an economic asset may be less than in some other countries.  Moreover, many prostitutes are migrants who work outside entertainment establishments or who work occasionally as prostitutes to supplement their income.  Therefore an approach to China's sex industry managers cannot be completely successful by itself.  Since China is a very decentralized country, this strategy may well succeed in some areas and fail in others.  All that said, however, harm reduction intervention among prostitutes and IV drug users may be China's best chance to stem its rapidly growing AIDS epidemic.


References: HIV/AIDS in China Series

Previous reports on HIV/AIDS in China and summary/translations from the Chinese press on HIV/AIDS are available on the U.S. Embassy Beijing webpage at http://www.usembassy-china.org.cn/english/sandt/index.html

Summary translations of many articles on HIV/AIDS and health from the Chinese media can also be found there. Health and HIV/AIDS news items are sometimes reported in  Beijing Environment, Science and Technology Update .



An English summary of "Red Light District" by Renmin University Sociology Professor Pan Suiming is available on the UNAIDS Beijing website at http://www.unchina.org/unaids/enews5.html
Pan is director of the Institute for Research on Sexuality and Gender at Renmin University in Beijing.