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.
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